David - S Comprehensive Handbook of Laboratory Tests With Nur PDF

00Van Leewan(F)-FM 12/15/05 8:33 PM Page i
Davis’s Comprehensive
Handbook of Laboratory
and Diagnostic Tests—
with Nursing Implications
00Van Leewan(F)-FM 12/15/05 8:33 PM Page ii
This page left intentionally blank.

00Van Leewan(F)-FM 12/15/05 8:33 PM Page iii
Davis’s Comprehensive
Handbook of Laboratory
and Diagnostic Tests—
with Nursing
Implications
Second Edition
Anne M. Van Leeuwen, MA, BS, MT (ASCP)

Todd R. Kranpitz, MS, BS, ARRT (R) (N),
NM (NMTCB), ASCP (N)
Lynette S. Smith, FNP-BC, MSN, RN, MLT (ASCP)
F. A. DAVIS COMPANY • PHILADELPHIA

00Van Leewan(F)-FM 12/15/05 8:33 PM Page iv
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2006 by F. A. Davis Company
All rights reserved. This book is protected by copyright. No part of it may be reproduced,
stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without written permission from the publisher.
Printed in the United States of America
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
Acquisitions Editor: Lisa B. Deitch

Production Manager: Robert C. Butler
As new scientific information becomes available through basic and clinical research,
recommended treatments and drug therapies undergo changes. The authors and publisher have
done everything possible to make this book accurate, up to date, and in accord with accepted
standards at the time of publication. The authors, editors, and publisher are not responsible for
errors or omissions or for consequences from application of the book, and make no warranty,
expressed or implied, in regard to the contents of the book. Any practice described in this
book should be applied by the reader in accordance with professional standards of care used in
regard to the unique circumstances that may apply in each situation. The reader is advised
always to check product information (package inserts) for changes and new information
regarding dose and contraindications before administering any drug. Caution is especially
urged when using new or infrequently ordered drugs.
Library of Congress Cataloging-in-Publication Data
Van Leeuwen, Anne M.

Davis’s comprehensive handbook of laboratory and diagnostic tests : with nursing implications
/ Anne M. Van Leeuwen, Todd R. Kranpitz, Lynette Smith.— 2nd ed.
p. ; cm.
Rev. ed. of: Davis’s comprehensive handbook of laboratory and diagnostic tests / Zoanne
Burgess Schnell, Anne M. Van Leeuwen, Todd R. Kranpitz. c2003.
Includes bibliographical references and index.
ISBN 0-8036-1464-0
1. Diagnosis, Laboratory—Handbooks, manuals, etc. 2. Nursing—Handbooks, manuals, etc.
[DNLM: 1. Laboratory Techniques and Procedures—Handbooks. 2. Laboratory Techniques
and Procedures—Nurses’ Instruction. 3. Nursing Diagnosis—methods. 4. Diagnostic
Techniques and Procedures—Handbooks. 5. Diagnostic Techniques and Procedures—Nurses’
Instruction. QY 39 V217d 2006] I. Title: Comprehensive handbook of laboratory and diag-
nostic tests. II. Kranpitz, Todd R. III. Smith, Lynette. IV. Schnell, Zoanne Burgess. Davis’s
comprehensive handbook of laboratory and diagnostic tests. V. Title.
RB38.2.S37 2006
616.07′5—dc22
2005053757
Authorization to photocopy items for internal or personal use, or the internal or personal
use of specific clients, is granted by F. A. Davis Company for users registered with the
Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee
of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For
those organizations that have been granted a photocopy license by CCC, a separate system of
payment has been arranged. The fee code for users of the Transactional Reporting Service is:
8036-1042/03 0 $.10
00Van Leewan(F)-FM 12/15/05 8:33 PM Page v
-Aminolevulinic Acid v
DEDICATION
I
nspiration springs from Passion.… Passion is born from unconstrained love, commit-
ment, and a vision no one else can own. Thank you Lynda, Mom & Dad, Adele, Gram,
Regina & Mark, Helen & Ricky, Todd, Kent & Cathy, JT, Bev, Cathy, Ev, Ruth, and
Lois…I am truly blessed by your friendship, love, and support. A huge hug for my daugh-
ters, Sarah and Margaret—I love you very much. To my puppies, Maggie and Tayor, for
their endless and unconditional love. With appreciation and in recognition of Stacey for her
assistance with this edition. My thanks and welcome to Lynette for her contributions to this
second edition; I look forward to our continued collaboration. Very special thanks to Lisa
Deitch, Acquisitions Editor, for her friendship, excellent direction, and unwavering encour-
agement.
Anne M. Van Leeuwen, MA, BS, MT (ASCP)
Chief Technologist
Highlands Regional Medical Center
Sebring, Florida
To my wife, Mindy, for her never ending support, and my son, Jake, for his demonstration
of commitment to a goal. I could not have done this book without them. To my coauthors,
for their dedication, endless commitment, and organizational skills. To Lisa Deitch, for her
continued faith in us, and support.
Todd R. Kranpitz, MS, BS, ARRT (R) (N), NM (NMTCB), ASCP (N)
Director of Imaging Services
King’s Daughters Medical Center
Ashland, Kentucky
To my husband, Steve, whose unconditional love, support, and encouragement holds me
steadfast in all my endeavors. To my sons, Eric and Michael, for their wisdom and humor
beyond their ages, you rock my world. To Anne, Todd, and Lisa, humble thanks for taking
this novice writer under your wings and believing in what I had to offer for this edition. I
look forward to future editions with this great team. And lastly, I wish to thank Dr. Mary
Bennett for her years of friendship and look forward to our continual mentoring of minds
in years to come.
Lynette S. Smith, FNP-BC, MSN, RN, MLT (ASCP)
Family Nurse Practitioner
Office of Lynette Smith FNP
Clinton, Indiana
Adjunct Faculty, Family Nurse Practitioner Program
College of Nursing, Indiana State University
Terre Haute, Indiana
v
00Van Leewan(F)-FM 12/15/05 8:33 PM Page vi

00Van Leewan(F)-FM 12/15/05 8:33 PM Page vii
-Aminolevulinic Acid vii
ABOUT THIS BOOK
L
aboratory and diagnostic studies are essential components of a complete patient
assessment. Examined in conjunction with an individual’s history and physical exam-
ination, laboratory and diagnostic data provide clues about health status. Nurses
are increasingly expected to integrate an understanding of laboratory and diagnostic proce-
dures and expected outcomes in assessment, planning, implementation, and evaluation of
nursing care. The data help develop and support nursing diagnoses, interventions, and
outcomes.
Nurses may interface with laboratory and diagnostic testing on several levels,
including:
• Interacting with patients and families of patients undergoing diagnostic tests
or procedures, and providing pretest, intratest, and post-test information and
support
• Maintaining quality control to prevent or eliminate problems that may inter-
fere with the accuracy and reliability of test results
• Ensuring completion of testing in a timely and accurate manner
• Collaborating with other health care professionals in interpreting findings as
they relate to planning and implementing total patient care
• Communicating significant alterations in test outcomes to other appropriate
health care team members
• Coordinating interdisciplinary efforts
Whether the nurse’s role at each level is direct or indirect, the underlying responsi-
bility to the patient, family, and community remains the same.
This book is a reference for nurses, nursing students, and other health care profes-
sionals. It is useful as a clinical tool as well as a supportive text to supplement clinical
courses. It guides the nurse in planning what needs to be assessed, monitored, treated,
and taught regarding pretest requirements, intratest procedures, and post-test care. It
can be used by nursing students at all levels as a textbook in theory classes, integrating
laboratory and diagnostic data as one aspect of nursing care; by practicing nurses, to
update information; and in clinical settings as a quick reference. Designed for use in
academic and clinical settings, Davis’s Comprehensive Handbook of Laboratory and
Diagnostic Procedures—with Nursing Implications provides the user with a comprehen-
sive reference that allows easy access to information about laboratory and diagnostic
tests and procedures. A general overview of how all the tests and procedures included
in this book relate to body systems can be found in tables at the end of the mono-
vii
00Van Leewan(F)-FM 12/15/05 8:33 PM Page viii
viii About This Book
graphs. All tests and procedures are listed in alphabetical order by their complete
name, allowing the user to locate information quickly without having to place tests in
a specific category or body system. Each monograph is presented in a consistent format
for easy identification of specific information at a glance. The following information
is provided for each laboratory and diagnostic test:
• Test Name for each monograph is given as a commonly used designation, and
all test monographs in the book are organized in alphabetical order by name.
• Synonyms/Acronyms for each test are listed where appropriate.
• Specimen Type includes the amount of specimen usually collected and, where
appropriate, the type of collection tube or container commonly recom-
mended. Specimen requirements vary from laboratory to laboratory. The
amount of specimen collected is usually more than what is minimally
required so that additional specimen is available, if needed, for repeat testing
(quality control failure, dilutions, or confirmation of unexpected results). In
the case of diagnostic tests, the type of test procedure (e.g., nuclear medicine,
x-ray) is given.
• Reference Values for each monograph include age-specific and gender-specific
variations, when indicated. It is important to give consideration to the
normal variation of laboratory values over the life span and across cultures;
sometimes what might be considered an abnormal value in one circumstance
is actually what is expected in another. Reference values for laboratory tests
are given in conventional and standard international (SI) units. The factor
used to convert conventional to SI units is also given. Because laboratory
values can vary by method, each laboratory reference range is listed along
with the associated methodology.
• Description & Rationale of the study’s purpose and insight into how and why
the test results can affect health are included.
• Indications are a list of what the test is used for in terms of assessment, evalu-
ation, monitoring, screening, identifying, or assisting in the diagnosis of a
clinical condition.
• Results present a list of conditions in which values may be increased or
decreased and, in some cases, an explanation of variations that may be
encountered.
• Critical Values, or findings that may be life-threatening or for which particu-
lar concern may be indicated, are given along with age span considerations
where applicable. This section also includes signs and symptoms associated
with a critical value as well as possible nursing interventions.
• Interfering Factors are substances or circumstances that may influence the
results of the test, rendering the results invalid or unreliable. Knowledge of
interfering factors is an important aspect of quality assurance and includes
pharmaceuticals, foods, natural and additive therapies, timing of test in rela-
tion to other tests or procedures, collection site, handling of specimen, and
underlying patient conditions.
• Nursing Implications and Procedure provides an outline of pretest, intratest,
and post-test concerns.
• Pretest section addresses the need to:
00Van Leewan(F)-FM 12/15/05 8:33 PM Page ix
About This Book ix
• Obtain pertinent clinical, laboratory, dietary, and therapeutic history of

the patient, especially as it pertains to comparison of previous test
results, preparation for the test, and identification of potentially interfer-
ing factors.
• Understand the interrelationship between various body systems. In this
section, the reader is informed of the body systems that may be involved
in the study of interest and is referred to system tables where related
studies are alphabetically cross-referenced.
• Explain the requirements and restrictions related to the procedure as well
as what to expect; provide the education necessary for the patient to be
properly informed.
• Anticipate and allay patient concerns or anxieties.
• Provide for patient safety.
• Intratest section can be used in a quality control assessment by the nurse or as
a guide to the nurse who may be called on to participate in specimen collec-
tion or perform preparatory procedures and gives:
• Specific directions for specimen collection and test performance.
• Important information such as patient sensation and expected duration
of the procedure.
• Precautions to be taken by the nurse and patient.
• Post-test section provides guidelines regarding:
• Specific monitoring and therapeutic measures that should be performed
after the procedure (e.g., maintaining bed rest, obtaining vital signs to
compare with baseline values, signs and symptoms of complications).
• Specific instructions for the patient and family, such as when to resume
usual diet, medications, and activity.
• General nutritional guidelines related to excess or deficit as well as
common food sources for dietary replacement.
• Indications for interventions from public health representatives or for
special counseling related to test outcomes.
• Indications for follow-up testing that may be required within specific
time frames.
• Related tests for consideration and evaluation, an alphabetical listing of
related laboratory and/or diagnostic tests that is intended to provoke a
deeper and broader investigation of multiple pieces of information; the
tests provide related data that, when combined, can form a more
complete picture of health or illness.
Color and icons have been used to facilitate locating critical information at a glance.
The nursing process is evident throughout the laboratory and diagnostic mono-
graphs. Within each phase of the testing procedure, the nurse has certain potential
roles and responsibilities. These should be evident in reading each monograph.
Information provided in the appendices includes a summary of specimen collection
procedures and materials, describing specific tube tops used for various blood tests and
their recommended order of draw; a summary chart of transfusion reactions, their
signs and symptoms, associated laboratory findings, and potential nursing interven-
tions; an introduction to CLIA with an explanantion of the different levels of testing
00Van Leewan(F)-FM 12/15/05 8:33 PM Page x
x About This Book
complexity; a summary chart that details suggested approaches to persons at various

developmental stages to assist the provider in facilitating cooperation and understand-
ing; a list of some of the herbs and nutraceuticals that have been associated with
adverse clinical reactions or have been associated with drug interactions related to the
affected body system; and guidelines for Standard and Universal Precautions.
Finally, additional supportive materials are provided for the instructor and student
in an Instructor’s Guide. Presentations and case studies with emphasis on laboratory and
diagnostic test–related information and nursing implications have been developed for
selected conditions and body systems. Open-ended and NCLEX-type, multiple-choice
questions are provided as well as suggested critical thinking activities. This supple-
mental material will aid the instructor in integrating laboratory and diagnostic mate-
rials in assessment and clinical courses and provide examples of activities to enhance
student learning.
00Van Leewan(F)-FM 12/15/05 8:33 PM Page xi
-Aminolevulinic Acid xi
PREFACE
L
aboratory and diagnostic testing. The words themselves often conjure up cold and
impersonal images of needles, specimens lined up in collection containers, and high-
tech electronic equipment. But they do not stand alone. They are tied to, bound with,
and tell of health or disease in the blood and tissue of a person. Laboratory and diagnostic
studies augment the health care provider’s assessment of the quality of an individual’s phys-
ical being. Test results guide the plans and interventions geared toward strengthening life’s
quality and endurance. Beyond the pounding noise of the MRI, the cold steel of the x-ray
table, the sting of the needle, the invasive collection of fluids and tissue, and the probing
and inspection is the gathering of evidence that supports the health care provider’s ability
to discern the course of a disease and the progression of its treatment. Laboratory and diag-
nostic data must be viewed with thought and compassion, however, as well as with micro-
scopes and machines. We must remember that behind the specimen and test result is the
person from whom it came, a person who is someone’s son, daughter, mother, father,
husband, wife, friend.
This book is written to help health care providers in their understanding and inter-
pretation of laboratory and diagnostic procedures and their outcomes. Just as impor-
tant, it is dedicated to all health care professionals who experience the wonders in the
science of laboratory and diagnostic testing, performed and interpreted in a caring and
efficient manner.
xi
00Van Leewan(F)-FM 12/15/05 8:33 PM Page xii

00Van Leewan(F)-FM 12/15/05 8:33 PM Page xiii
-Aminolevulinic Acid xiii
CONSULTANTS
Connie J. Frisch, RN, MA Deborah Little, MSN, RN, CCRN, CNRN,

Nursing Instructor APRN, BC
Central Lakes College Faculty Instructor
Brainerd, Minnesota Mountainside Hospital School of Nursing
Montclair, New Jersey
Mary K. Gerepka, MS, APRN, BC
Instructor Brooke C. Martin, RN, MSN, CNM,
Mountainside Hospital School of Nursing ARNP
Montclair, New Jersey Associate Professor Practical Nursing Program
Ivy Tech State College
Peggy L. Hawkins, RN, MSN, PHD, BC Indianapolis, Indiana
Professor of Nursing, Nursing Programs
Director Patricia A. Parsons RN, MSN, MS
College of Saint Mary Director of Associate Degree Nursing
Omaha, Nebraska Program
Riverland Community College
Beth Langlois, RN, MSN, APRN, BC Austin, Minnesota
CCU and Heart Failure Center Coordinator
Overlook Hospital, Atlantic Health System
Summit, New Jersey
xiii
00Van Leewan(F)-FM 12/15/05 8:33 PM Page xiv

00Van Leewan(F)-FM 12/15/05 8:33 PM Page xv
-Aminolevulinic Acid xv
CONTENTS
DEDICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
ABOUT THIS BOOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
MONOGRAPHS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
SYSTEM TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1387
APPENDIX A
Patient Preparation and Specimen Collection 1403

APPENDIX B
Potential Nursing Diagnoses Associated with Laboratory

and Diagnostic Testing 1416
APPENDIX C
Guidelines for Age-Specific Communication 1418

APPENDIX D
Transfusion Reactions: Laboratory Findings and Potential

Nursing Interventions 1422
APPENDIX E
Introduction to CLIA 1988 & 1992 1427

APPENDIX F
Effects of Natural Products on Laboratory Values 1428
APPENDIX G
Standard Precautions (CDC Isolation Precautions) 1431
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1453
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1459
xv
00Van Leewan(F)-FM 12/15/05 8:33 PM Page xvi

01Van Leewan(F) (1-188) 12/15/05 8:34 PM Page 1
ACETYLCHOLINE RECEPTOR
ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: AChR.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay) Less than 0.03 nmol/L.
DESCRIPTION & RATIONALE: Nor- moma. The relationship between the

mally when impulses travel down a thymus gland and MG is not com-
nerve, the nerve ending releases a neu- pletely understood. It is believed that
rotransmitter called acetylcholine. miscommunication in the thymus
Acetylcholine binds to receptor sites gland directed at developing immune
in the neuromuscular junction, which cells may trigger the development of
eventually results in muscle contrac- autoantibodies responsible for MG.
tion. When present, acetylcholine Remission after thymectomy is associ-
receptor (AChR) antibodies block ated with a progressive decrease in
acetylcholine from binding to recep- antibody level. Other markers used in
tor sites on the muscle membrane. the study of MG include muscle
AChR antibodies also destroy acetyl- AChR binding antibodies, muscle
choline receptor sites, interfering with AChR blocking antibodies, muscle
neuromuscular transmission and caus- AChR modulating antibodies, stria-
ing muscle weakness. Antibodies to tional antibodies, thyroglobulin,
AChR sites are present in 90% of HLA-B8, and HLA-DR3. These anti-
patients with generalized myasthenia bodies are often undetectable in the
gravis (MG) and in 55% to 70% of early stages of MG. ■
patients who either have ocular forms
of MG or are in remission. MG is an INDICATIONS:
acquired autoimmune disorder that • Confirm the presence, but not the
can occur at any age. It seems to strike severity, of MG
women between the ages of 20 and 40 • Monitor the effectiveness of immuno-
years; men appear to be affected later suppressive therapy for MG
in life than women. It can affect any • Monitor the remission stage of MG
voluntary muscle, but muscles that
control eye, eyelid, and facial move-
ment and swallowing are most fre- RESULT
quently affected. Antibodies may not Increased in:
be detected in the first six to twelve • Generalized MG
months, after the first appearance of • Thymoma associated with MG
symptoms. MG is the most common
complication associated with thy- Decreased in: Post-thymectomy
1
2 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications
CRITICAL VALUES: N/A ➤ Obtain a history of the patient’s mus-

culoskeletal system and results of
previously performed laboratory
INTERFERING FACTORS: tests, surgical procedures, and other
• Drugs that may increase AChR levels diagnostic procedures. For related
include penicillamine. tests, refer to the Musculoskeletal
System table.
• Biologic false-positive results may be ➤ Note any recent procedures that can
associated with amyotrophic lateral scle- interfere with test results.
rosis, autoimmune hepatitis, patients ➤ Obtain a list of the medications the
who have had a bone marrow trans- patient is taking, especially immuno-
plant, Eaton-Lambert myasthenic syn- suppressive drugs or prednisone.
drome, first-degree relatives of patients Include herbs, nutritional supple-
with MG (rare), thymoma with no evi- ments, and nutraceuticals. The
dence of MG, primary biliary cirrhosis, requesting health care practitioner
and laboratory should be advised if
encephalomyeloneuropathies associ-
the patient regularly uses these prod-
ated with carcinoma of the lung, and ucts so that their effects can be taken
elderly patients prone to autoimmune into consideration when reviewing
disorders. results.
• Immunosuppressive therapy is the rec- ➤ Review the procedure with the
ommended treatment for MG; prior patient. Inform the patient that spec-
imen collection takes approximately
immunosuppressive drug administra- 5 to 10 minutes. Address concerns
tion may result in negative test results. about pain related to the procedure.
• Recent radioactive scans or radiation Explain to the patient that there may
be some discomfort during the
within 1 week of the test can interfere
venipuncture.
with test results when radioimmunoas-
say is the test method. ➤ There are no food, fluid, or medica-
tion restrictions unless by medical
• Inability of the patient to cooperate or direction.
remain still during the procedure
because of age, significant pain, or Intratest:
mental status may interfere with the ➤ If the patient has a history of severe
test results. allergic reaction to latex, care should
be taken to avoid the use of equip-
ment containing latex.
Nursing Implications and ➤ Instruct the patient to cooperate fully
Procedure ● ● ● ● ● ● ● ● ● ● ●
and to follow directions. Direct the
patient to breathe normally and to
Pretest: avoid unnecessary movement.
➤ Observe standard precautions, and
➤ Inform the patient that the test is follow the general guidelines in
used to identify antibodies responsi- Appendix A. Positively identify the
ble for decreased neuromuscular patient, and label the appropriate
transmission and associated muscle tubes with the corresponding patient
weakness. demographics, date, and time of
➤ Obtain a history of the patient’s com- collection. Perform a venipuncture;
plaints, including a list of known collect the specimen in a 5-mL red-
allergens (especially allergies or sen- top tube.
sitivities to latex) and any prior com- ➤ Remove the needle, place gauze
plications with general anesthesia, over the puncture site and apply gen-
and inform the appropriate health tle pressure to stop bleeding.
care practitioner accordingly. Observe venipuncture site for bleed-
Acid Phosphatase, Prostatic 3
ing or hematoma formation. Apply implications of the test results as

paper tape to hold gauze in place or appropriate. Educate the patient
replace with adhesive bandage. regarding access to counseling serv-
➤ Promptly transport the specimen to ices. Provide contact information, if
the laboratory for processing and desired, for the Myasthenia Gravis
analysis. Foundation of America (http://www.
myasthenia.org) and Muscular
➤ The results are recorded manually or Dystrophy Association (http://www.
in a computerized system for recall mdausa.org).
and postprocedure interpretation by
the appropriate health care practi- ➤ Reinforce information given by the
tioner. patient’s health care provider regard-
ing further testing, treatment, or
referral to another health care
Post-test: provider. Answer any questions or
address any concerns voiced by the
➤ A written report of the examination
patient or family.
will be sent to the requesting health
care practitioner, who will discuss ➤ Depending on the results of this pro-
the results with the patient. cedure, additional testing may be
performed to evaluate or monitor
➤ Recognize anxiety related to test progression of the disease process
results, and be supportive of impai- and determine the need for a change
red activity related to lack of neuro- in therapy. If a diagnosis of MG is
muscular control, perceived loss of made, a computed tomography scan
independence, and fear of shortened of the chest should be performed to
life expectancy. Discuss the implica- rule out thymoma. Evaluate test
tions of positive test results on the results in relation to the patient’s
patient’s lifestyle. It is important to symptoms and other tests per-
note that a diagnosis of MG should formed.
be based on positive results from
two different diagnostic tests. These Related laboratory tests:
tests include AChR antibody assay,
edrophonium test, repetitive nerve ➤ Related laboratory tests include anti-
stimulation, and single-fiber elec- nuclear antibodies, antithyroglobulin
tromyography. Evaluate test results and antithyroid peroxidase antibod-
in relationship to a future general ies, myoglobin, rheumatoid factor,
anesthesia. Provide teaching and thyroid-stimulating hormone, and
information regarding the clinical thyroxine.
ACID PHOSPHATASE, PROSTATIC

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Prostatic acid phosphatase, o-phosphoric monoester

phosphohydrolase, AcP.

A swab with vaginal secretions may be submitted in the appropriate trans-

fer container. Other material such as clothing may be submitted for analysis.
Consult the laboratory or emergency services department for the proper
specimen collection instructions and containers.
REFERENCE VALUE: (Method: Spectrophotometric)
Conventional & SI Units

Less than 2.5 ng/mL
effective treatment. Rising levels are

DESCRIPTION & RATIONALE: Acid associated with a poor prognosis.
phosphatases are enzymes found in
many tissues, including the prostate • Investigate or evaluate an enlarged
gland, bone, spleen, liver, and kidney, prostate gland, especially if prostatic
as well as in red blood cells and carcinoma is suspected.
platelets. Seminal fluid also contains
RESULT
high concentrations of acid phos-
phatase, and detection of this enzyme Increased in:
in vaginal swabs or from other physi- • Acute myelogenous leukemia
cal evidence is used to investigate rape. • After prostate surgery or biopsy
Acid phosphatase activity is highest in
• Benign prostatic hypertrophy
the prostate gland; however, prostatic
acid phosphatase (AcP) levels are not • Gaucher’s disease
significantly increased in the early • Liver disease
stages of prostatic cancer, so this test is • Metastatic bone cancer
not recommended as a screening • Niemann-Pick disease
tool. Prostate-specific antigen has • Paget’s disease
replaced AcP for the staging of carci-
• Prostatic cancer
noma of the prostate and diagnosis of
metastatic adenocarcinoma of the • Prostatic infarct
prostate. ■ • Prostatitis
• Sickle cell crisis
INDICATIONS: • Thrombocytosis
• Assist in the investigation of sexual
assault and rape. Decreased in: N/A
• Assist with differential diagnosis of

other disorders associated with elevated CRITICAL VALUES: N/A
AcP of nonprostatic origin.
INTERFERING FACTORS:
• Evaluate the effectiveness of treatment • Drugs that may increase AcP levels
for prostatic cancer (recurrence after include androgens (females), and clofi-
prostatectomy). Levels decrease with brate.
Acid Phosphatase, Prostatic 5
• Drugs that may decrease AcP levels can be taken into consideration
include alcohol, ketoconazole, busere- when reviewing results.
lin and leuprolide. ➤ Review the procedure with the
patient. Inform the patient that spec-
• There is growing evidence that rectal imen collection takes approximately
palpation does not cause elevated AcP. 5 to 10 minutes. Address concerns
However, increases can occur due to about pain related to the procedure.
prostatic needle biopsy, cytoscopy, pro- Explain to the patient that there may
static infarction either by undergoing be some discomfort during the
catheterization or the presence of an venipuncture.
indwelling catheter, and rupture of a ➤ There are no food, fluid, or medica-
prostatic cyst (rare). tion restrictions unless by medical
direction.
• Specimens should be drawn in the
morning because AcP exhibits diurnal Intratest:
variation.
➤ If the patient has a history of severe
• Hemolysis interferes with the test allergic reaction to latex, care should
methodology. be taken to avoid the use of equip-
➤ Instruct the patient to cooperate fully
Nursing Implications and and to follow directions. Direct the
Procedure ● ● ● ● ● ● ● ● ● ● ●
avoid unnecessary movement.
Pretest:
follow the general guidelines in
➤ Inform the patient that the test is pri- Appendix A. Positively identify the
marily used to assist in monitoring patient, and label the appropriate
treatment for prostate cancer. tubes with the corresponding patient
demographics, date, and time of
➤ Obtain a history of the patient’s com-
collection. Perform a venipuncture;
plaints, especially alterations in uri-
collect the specimen in a 5-mL red-
nary elimination. Obtain a list of
top tube.
known allergens, especially allergies
or sensitivities to latex, and inform ➤ Remove the needle, place gauze
the appropriate health care practi- over the puncture site and apply gen-
tioner accordingly. tle pressure to stop bleeding.
Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s gen-
ing or hematoma formation. Apply
itourinary, immune, and reproductive
paper tape over gauze or replace
systems and results of previously
with adhesive bandage.
performed laboratory tests, surgical
procedures, and other diagnostic ➤ Promptly transport the specimen to
procedures. For related laboratory the laboratory for processing and
tests, refer to the Genitourinary, analysis. AcP is very labile. Imme-
Immune, and Reproductive System diate seperation from blood cells and
tables. freezing of the serum stabilizes AcP.
➤ Note any recent procedures that can ➤ The results are recorded manually or
interfere with test results. in a computerized system for recall
➤ Obtain a list of the medications the the appropriate health care practi-
patient is taking, including herbs, tioner.
nutritional supplements, and nutra-
ceuticals. The requesting health care Post-test:
practitioner and laboratory should be
advised if the patient regularly uses ➤ A written report of the examination
these products so that their effects will be sent to the requesting health
care practitioner, who will discuss guilt, depression, anger) as a victim

the results with the patient. of rape or sexual assault.
➤ Social and cultural considerations: ➤ Reinforce information given by the
Recognize anxiety related to test patient’s health care provider re-
results, and offer support. Provide garding further testing, treatment,
teaching and disease information, as or referral to another health care
appropriate. Counsel the male provider. Answer any questions or
patient, as appropriate, that sexual address any concerns voiced by the
dysfunction related to altered body patient or family.
function, drugs, or radiation may
➤ Depending on the results of this pro-
occur. Educate the patient regard-
cedure, additional testing may be
ing counseling services, as appro-
priate.
progression of the disease process
➤ Social and cultural considerations: and determine the need for a change
Offer support, as appropriate, to in therapy. Evaluate test results in
patients who may be the victim of relation to the patient’s symptoms
rape or sexual assault. Educate the and other tests performed.
patient regarding access to counsel-
ing services. Provide a nonjudgmen- Related laboratory tests:
tal, nonthreatening atmosphere for
discussing the risks of sexually trans- ➤ Related laboratory tests include
mitted diseases. Discuss problems prostate biopsy, prostate-specific
the patient may experience (e.g., antigen, and semen analysis.
ADRENAL GLAND SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Adrenal scintiscan.

AREA OF APPLICATION: Adrenal gland.
CONTRAST: Intravenous radioactive NP-59 (iodomethyl-19-norcholesterol)
or metaiodobenzylguanidine (MIBG).
DESCRIPTION & RATIONALE: This adenoma in primary aldosteronism

nuclear medicine study evaluates func- when computed tomography (CT)
tion of the adrenal glands. The secre- and magnetic resonance imaging
tory function of the adrenal glands is (MRI) findings are equivocal. High
controlled primarily by the anterior concentrations of cholesterol (the
pituitary, which produces adrenocorti- precursor in the synthesis of adreno-
cotropic hormone (ACTH). ACTH corticosteroids, including aldosterone)
stimulates the adrenal cortex to pro- are stored in the adrenal cortex.
duce cortisone and secrete aldos- This allows the radionuclide, which
terone. Adrenal imaging is most useful attaches to the cholesterol, to be used
in differentiation of hyperplasia versus in identifying pathology in the secre-
Adrenal Gland Scan 7
tory function of the adrenal cortex. • Adrenal tumor

The uptake of the radionuclide occurs • Hyperplasia
gradually over time; imaging is per- • Infection
formed within 24 to 48 hours of injec-
tion of the radionuclide dose and • Pheochromocytoma
continued daily for 3 to 5 days.
Imaging reveals increased uptake, uni- INTERFERING FACTORS
lateral or bilateral uptake, or absence
This procedure is
of uptake in the detection of patho- contraindicated for:
logic processes. Following prescanning
• Patients who are pregnant or suspected
treatment with corticosteroids, sup- of being pregnant, unless the potential
pression studies can be done to differ- benefits of the procedure far outweigh
entiate the presence of tumor from the risks to the fetus and mother.
hyperplasia of the glands. ■
Factors that may impair
clear imaging:
INDICATIONS:
• Aid in the diagnosis of Cushing’s syn- • Inability of the patient to cooperate or
drome and aldosteronism remain still during the procedure
because of age, significant pain, or
• Aid in the diagnosis of gland tissue mental status
destruction caused by infection, infarc-
tion, neoplasm, or suppression • Retained barium from a previous radi-
ologic procedure
• Aid in locating adrenergic tumors
• Obesity, because patients may exceed
• Determine adrenal suppressibility with the weight limit for the equipment
prescan administration of corticos- • Incorrect positioning of the patient,
teroid to diagnose and localize adrenal which may produce poor visualization
adenoma, aldosteronomas, androgen of the area to be examined
excess, and low-renin hypertension
• Differentiate between asymmetric Other considerations:
hyperplasia and asymmetry from aldos- • Improper injection of the radionuclide
teronism with dexamethasone suppres- may allow the tracer to seep deep into
sion test the muscle tissue, producing erroneous
hot spots.
RESULT • Consultation with a physician should
occur before the procedure for radia-
Normal Findings: tion safety concerns regarding youn-
• No evidence of tumors, infection, ger patients or patients who are lactat-
infarction, or suppression ing.
• Normal bilateral uptake of radionuclide • Risks associated with radiologic overex-
and secretory function of adrenal cortex posure can result from frequent x-ray
procedures. Personnel in the room with
• Normal salivary glands and urinary
the patient should wear a protective
bladder; vague shape of the liver and
lead apron, stand behind a shield, or
spleen sometimes seen
leave the area while the examination is
Abnormal Findings: being done. Badges that reveal the level
of exposure to radiation should be
• Adrenal gland suppression
worn by persons working in the area
• Adrenal infarction where the examination is being done.
➤ Make sure a written and informed

Nursing Implications and consent has been signed prior to the
Procedure ● ● ● ● ● ● ● ● ● ● ● procedure and before administering
any medications.
Pretest:
➤ Inform the patient that the procedure Intratest:
detects adrenal gland function.
➤ Ensure that the patient has removed
➤ Obtain a history of the patient’s com- jewelry, dentures, all external metal-
plaints and symptoms, including a lic objects, and the like prior to the
list of known allergens. procedure.
➤ Obtain a history of results of previ- ➤ Have emergency equipment readily
ously performed diagnostic proce- available.
dures, surgical procedures, and
laboratory tests. All adrenal blood ➤ Patients are given a gown, robe, and
tests should be done before doing foot coverings to wear and instructed
this test. For related tests, refer to to void prior to the procedure.
the Endocrine System table. ➤ Insert an intravenous line, and inject
➤ Record the date of last menstrual the radionuclide intravenously on day
period and determine the possibility 1; images are taken on days 1, 2, and
of pregnancy in perimenopausal 3. Imaging is done from the urinary
women. bladder to the base of the skull to
scan for a primary tumor. Each image
➤ Obtain a list of the patient’s current
takes 20 minutes, and total imaging
medications.
time is 1 to 2 hours per day.
➤ Review the procedure with the
patient. Address concerns about pain ➤ Instruct the patient to cooperate fully
related to the procedure. Explain to and to follow directions. Instruct the
the patient that some pain may be patient to remain still throughout the
experienced during the test, and procedure because movement pro-
there may be moments of discom- duces unreliable results.
fort. Inform the patient that the pro- ➤ Observe standard precautions, and
cedure is performed in a nuclear follow the general guidelines in
medicine department, usually by a Appendix A.
nuclear medicine technologist with
➤ The images are recorded on film or
support staff, and takes approx-
stored electronically for recall and
imately 60 minutes to 120 minutes
postprocedure interpretation by a
each day. Inform the patient the test
health care practitioner specializing
usually involves a prolonged scan-
in this branch of medicine.
ning schedule over a period of days.
➤ Administer saturated solution of Post-test:
potassium iodide (SSKI) 24 hours
before the study to prevent thyroid ➤ Unless contraindicated, advise pati-
uptake of the free radioactive iodine. ent to drink increased amounts of
➤ Sensitivity to cultural and social fluids for 24 to 48 hours to eliminate
issues, as well as concern for mod- the radionuclide from the body. Tell
esty, is important in providing psy- the patient that radionuclide is elimi-
chological support before, during, nated from the body within 24 to 48
and after the procedure. hours.
➤ There are no food, fluid, or medica- ➤ No other radionuclide tests should
tion restrictions unless by medical be scheduled for 24 to 48 hours after
direction. this procedure.
➤ Instruct the patient to remove den- ➤ Instruct the patient in the care and
tures, jewelry (including watches), assessment of the injection site;
hairpins, credit cards, and other observe for bleeding, hematoma for-
metallic objects. mation, and inflammation.
Adrenocorticotropic Hormone (and Challenge Tests) 9
➤ If a woman who is breast-feeding practitioner, who will discuss the

must have a nuclear scan, she results with the patient.
should not breast-feed the infant ➤ Reinforce information given by the
until the radionuclide has been elimi- patient’s health care provider regard-
nated. This could take as long as ing further testing, treatment, or
3 days. She should be instructed to referral to another health care pro-
express the milk and discard it dur- vider. Advise the patient that SSKI
ing the 3-day period to prevent ces- (120 mg/day) will be administered for
sation of milk production. 10 days after the injection of the
➤ Instruct the patient to immediately radionuclide. Answer any questions
flush the toilet and to meticulously or address any concerns voiced by
wash hands with soap and water the patient or family.
after each voiding for 48 hours after
the procedure.
➤ Instruct all caregivers to wear gloves needed to evaluate or monitor pro-
when discarding urine for 48 hours gression of the disease process and
after the procedure. Wash gloved determine the need for a change in
hands with soap and water before therapy. Evaluate test results in rela-
removing gloves. Then wash ung- tion to the patient’s symptoms and
loved hands after the gloves are other tests performed.
removed.
➤ A written report of the examination Related diagnostic tests:
will be completed by a health care
practitioner specializing in this ➤ Computed tomography of the abdo-
branch of medicine. The report will men and magnetic resonance imag-
be sent to the requesting health care ing of the abdomen.
ADRENOCORTICOTROPIC HORMONE
(AND CHALLENGE TESTS)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Corticotropin, ACTH.

SPECIMEN: Plasma (2 mL) from lavender-top (EDTA) tube for adrenocorti-
cotropic hormone (ACTH), and serum (1 mL) from a red-top tube for cor-
tisol. Collect specimens in a prechilled heparinized plastic syringe, and
carefully transfer into collection containers by gentle injection to avoid
hemolysis. Alternatively, specimens can be collected in prechilled lavender-
and red-top tubes. Tiger- and green-top (heparin) tubes are also acceptable
for cortisol, but take care to use the same type of collection container for
serial measurements. Immediately transport specimen tightly capped and
in an ice slurry to the laboratory. The specimens should be immediately
processed. Plasma for ACTH analysis should be transferred to a plastic
container.
Medication
Administered, Recommended
Procedure Adult Dosage Collection Times
ACTH stimulation, 1 g (low-dose 3 cortisol levels: baseline
rapid test protocol) cosyntropin immediately before bolus,
IM 30 min after bolus, and
60 min after bolus
Corticotropin- IV dose of 1 g/kg 8 cortisol and 8 ACTH levels:
releasing ovine CRH at 9 a.m. baseline collected 15 min
hormone (CRH) or 8 p.m. before injection, 0 minutes
stimulation before injection, and then
5, 15, 30, 60, 120, and 180
min after injection
Dexamethasone Oral dose of 1 mg Collect cortisol at 8 a.m. on
suppression dexamethasone the morning after the
(overnight) (Decadron) at 11 p.m. dexamethasone dose
Metyrapone Oral dose of 30 mg/kg Collect cortisol and ACTH at
stimulation metyrapone with 8 a.m. on the morning
(overnight) snack at midnight after the metyrapone dose
IM intramuscular, IV intravenous.
REFERENCE VALUE: (Method: Immunoradiometric assay)

ACTH
Conventional SI Units (Conventional

Age Units Units 0.22)
Cord blood 50–570 pg/mL 11–125 pmol/L
Newborn 10–185 pg/mL 2–41 pmol/L
Adult supine specimen 9–52 pg/mL 2–11 pmol/L
collected in morning
Women on oral 5–29 pg/mL 1–6 pmol/L
contraceptives
ACTH Challenge Tests
ACTH (Cosyntropin) SI Units

Stimulated, (Conversion
Rapid Test Conventional Units Factor 27.6)
Baseline Cortisol greater than Greater than 138
5 g/dL nmol/L
30- or 60-min Cortisol 18–20 g/dL 496–552 nmol/L
response or incremental
increase of 7 g/dL
over baseline value
Corticotropin- SI Units
Releasing Hormone (Conventional
Stimulated Conventional Units Units 27.6)
Cortisol 10 a.m. 359 nmol/L or
13 g/dL or 470 nmol/L
9 p.m. 17 g/dL
ACTH 9:30 a.m. 17.6 pmol/L or
80 pg/ml or 6.4 pmol/L
8:30 p.m. 29pg/ml
Dexamethasone SI Units
Suppressed (Conventional
Overnight Test Conventional Units Units 27.6)
Cortisol less than Less than 83
3 g/dL next day nmol/L
Metyrapone SI Units
Stimulated (Conventional
Overnight Test Conventional Units Units 0.22)
ACTH greater than Greater than
75 pg/mL 16.5 pmol/L
Cortisol less than Less than

3 g/dL next day 83 nmol/L
DESCRIPTION & RATIONALE: source is termed Cushing syndrome.

Hypothalamic-releasing factor stimu- Cortisol excess resulting from ACTH
lates the release of adrenocorticotropin excess produced by the pituitary is
hormone (ACTH) from the anterior termed Cushing disease. ACTH levels
pituitary gland. This hormone stimu- exhibit a diurnal variation, peaking
lates adrenal cortex secretion of gluco- between 6 and 8 a.m. and reaching the
corticoids, androgens, and, to a lesser lowest point between 6 and 11 p.m.
degree, mineralocorticoids. Angioten- Evening levels are generally one-half to
sin II is the other primary adrenal cor- two-thirds lower than morning levels.
tex stimulant. Cortisol is the major Cortisol levels also vary diurnally, with
glucocorticoid secreted by the adrenal the lowest values occurring during the
cortex. ACTH and cortisol test results morning hours and peak levels occur-
are evaluated together because nor- ring in the evening. ■
mally a change in one causes a change
in the other. ACTH secretion is stim- INDICATIONS:
ulated by insulin, metyrapone, and • Determine adequacy of replacement
vasopressin. It is decreased by dexam- therapy in congenital adrenal hyper-
ethasone. Cortisol excess from any plasia
• Determine adrenocortical dysfunction is secreted ectopically (e.g., tumors not

located in the pituitary gland that secrete
• Differentiate between increased ACTH ACTH). Patients with pituitary tumors
release with decreased cortisol levels tend to respond to CRH stimula-
and decreased ACTH release with tion, whereas those with ectopic tumors
increased cortisol levels do not. Patients with adrenal insuffi-
ciency demonstrate one of three patterns
RESULT: depending on the underlying cause:
ACTH Result: • Primary adrenal insufficiency—high
baseline ACTH (in response to intra-
Because ACTH and cortisol secretion
venous [IV] ACTH) and low cortisol
exhibits diurnal variation with values
levels pre- and post-IV ACTH.
being highest in the morning, a lack of
change in values from morning to • Secondary adrenal insufficiency (pitu-
evening is clinically significant. Decreased itary)—low baseline ACTH that does
concentrations of hormones secreted by not respond to ACTH stimulation.
the pituitary gland and its target organs Cortisol levels do not increase after
are observed in hypopituitarism. In pri- stimulation.
mary adrenal insufficiency (Addison’s dis-
• Tertiary adrenal insufficiency (hypo-
ease) due to adrenal gland destruction by
thalmic)—low baseline ACTH with an
tumor, infectious process, or immune
exaggerated and prolonged response to
reaction, ACTH levels are elevated while
stimulation. Cortisol levels usually do
cortisol levels are decreased. Both ACTH
not reach 20 g/dL.
and cortisol levels are decreased in sec-
ondary adrenal insufficiency (i.e., second- The DST is useful in differentiating
ary to pituitary insufficiency). Excess the causes of increased cortisol levels.
ACTH can be produced ectopically by Dexamethasone is a synthetic glucocorti-
various lung cancers such as oat cell carci- coid that is 64 times more potent than
noma and large-cell carcinoma of the cortisol. It works by negative feedback. It
lung and by benign bronchial carcinoid suppresses the release of ACTH in
tumor. patients with a normal hypothalamus. A
cortisol level less than 3.0 g/dL usually
excludes Cushing’s syndrome. With the
Challenge Tests and Results:
DST, a baseline morning cortisol level is
The ACTH (cosyntropin) stimulated rapid collected, and the patient is given a 1-mg
test directly evaluates adrenal gland func- dose of dexamethasone at bedtime. A
tion and indirectly evaluates pituitary second specimen is collected the follow-
gland and hypothalmus function. Cosyn- ing morning. If cortisol levels have not
tropin is a synthetic form of ACTH. A been suppressed, adrenal adenoma is
baseline cortisol level is collected before suspected. The DST also produces abnor-
the injection of cosyntropin. Specimens mal results in the presence of certain
are subsequently collected at 30- and 60- psychiatric illnesses (e.g., endogenous
minute intervals. If the adrenal glands depression).
function normally, cortisol levels rise sig- The metyrapone stimulation test is used
nificantly after administration of cosyn- to distinguish corticotropin-dependent
tropin. causes (pituitary Cushing’s disease and
The CRH stimulation test works as ectopic Cushing’s disease) from corti-
well as the dexamethasone suppression cotropin-independent causes (e.g., carci-
test (DST) in distinguishing Cushing’s noma of the lung or thyroid) of increased
disease from conditions in which ACTH cortisol levels. Metyrapone inhibits the
conversion of 11-deoxycortisol to corti- CRITICAL VALUES: N/A

sol. Cortisol levels should decrease to less
than 3 g/dL if normal pituitary stimula- INTERFERING FACTORS:
tion by ACTH occurs after an oral dose • Drugs that may increase ACTH levels
of metyrapone. Specimen collection and include aminoglutethimide, ampheta-
administration of the medication are per- mines, calcium gluconate, estrogens,
formed as with the overnight dexametha- insulin, levodopa, metoclopramide,
sone test. metyrapone, mifepristone (RU 486),
pyrogens, spironolactone, and vaso-
ACTH Increased in: pressin.
• Addison’s disease (primary adrenocorti- • Drugs that may decrease ACTH levels
cal hypofunction) include adrenal corticosteroids, dexam-
• Carcinoid syndrome ethasone, ethanol, and lithium carbon-
ate.
• Congenital adrenal hyperplasia
• Test results are affected by the time the
• Cushing’s disease (pituitary dependent) test is done because ACTH levels vary
• Depression diurnally, with the highest values
occurring between 6 and 8 a.m. and
• Ectopic ACTH-producing tumors the lowest values occurring at night.
• Lung cancer Samples should be collected at the
same time of day, between 6 and 8 a.m.
• Menstruation
• Excessive physical activity can produce
• Nelson’s syndrome (ACTH-producing elevated levels.
pituitary tumors)
• Recent radioactive scans or radiation
• Non–insulin-dependent diabetes within 1 week before the test can inter-
• Pregnancy fere with test results when immunora-
diometric assay is the test method.
• Sepsis
• The metyrapone stimulation test
• Septic shock is contraindicated in patients with
• Stress suspected adrenal insufficiency.
• Metyrapone may cause gastroin-
ACTH Decreased in:
testinal distress and/or confusion.
• Adrenal adenoma Administer oral dose of metyrapone
• Adrenal cancer with milk and snack.
• Adrenal cortical hyperfunction • Rapid clearance of metyrapone,

resulting in falsely increased corti-
• Glucocorticoid excess (in Cushing sol levels, may occur if the patient is
patients with primary adrenocortical taking drugs that enhance steroid
tumor) metabolism (e.g., phenytoin, rifam-
• Hemochromatosis pin, phenobarbital, mitotane, and
corticosteroids). The primary care prac-
• Hypopituitarism titioner should be consulted prior to
• Major depressive order a metyrapone stimulation test regarding
a decision to withhold these medica-
• Secondary adrenocortical insufficiency tions.
some discomfort during the venipu-

Nursing Implications and ncture.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ There are no food, fluid, or medica-
Pretest: direction.
➤ Inform the patient that the test is ➤ Drugs that enhance steroid metabo-
used to assess for pituitary hormone lism may be withheld by medical
deficiency. direction prior to metyrapone stimu-
lation testing.
plaints, including a list of known ➤ Instruct the patient to refrain from
allergens (especially allergies or sen- strenuous exercise for 12 hours
sitivities to latex), and inform the before the test and to remain in bed
appropriate health care practitioner or at rest for 1 hour immediately
accordingly. before the test. Avoid smoking and
ETOH use.
➤ Weigh patient and report weight to
➤ Prepare an ice slurry in a cup or plas-
lab for 30 mg/kg dosing of metyra-
tic bag to have on hand for immedi-
pone.
ate transport of the specimen to the
➤ Obtain a history of the patient’s laboratory.
endocrine system and results of pre-
viously performed laboratory tests, Intratest:
surgical procedures, and other diag-
nostic procedures. For related tests, ➤ Ensure that strenuous exercise was
refer to the Endocrine System table. avoided for 12 hours before the test
and that 1 hour of bed rest was
➤ Note any recent procedures that can
taken immediately before the test.
interfere with test results.
Samples should be collected bet-
➤ Obtain a list of the medications the ween 6 and 8 a.m.
patient is taking, especially drugs ➤ Have emergency equipment readily
that enhance steroid metabolism available in case of adverse reaction
and include herbs, nutritional supple- to metyrapone.
ments, and nutraceuticals. The
requesting health care practitioner ➤ If the patient has a history of severe
and laboratory should be advised if allergic reaction to latex, care should
the patient regularly uses these be taken to avoid the use of equip-
products so that their effects can be ment containing latex.
taken into consideration when ➤ Instruct the patient to cooperate fully
reviewing results. and to follow directions. Direct the
➤ Review the procedure with the pati- avoid unnecessary movement.
ent. When ACTH hypersecretion is
suspected, a second sample may be ➤ Observe standard precautions, and
requested between 6 and 8 p.m. to follow the general guidelines in
determine if changes are the result Appendix A. Positively identify the
of diurnal variation in ACTH levels. patient, and label the appropriate
Inform the patient that more than tubes with the corresponding patient
one sample may be necessary to demographics, date, and time of col-
ensure accurate results and that the lection. Perform a venipuncture; col-
samples are obtained at specific lect the specimen in a prechilled
times to determine high and low lev- plastic heparinized syringe or in
els of the hormone. Inform the prechilled collection containers as
patient that each specimen collec- listed under “Specimen.”
tion takes approximately 5 to 10 min- ➤ Adverse reactions to metyrapone
utes. Address concerns about pain include nausea and vomiting (N/V),
related to the procedure. Explain abdominal pain, headache, dizziness,
to the patient that there may be sedation, allergic rash, decreased
Alanine Aminotransferase 15
white blood cell count, or bone ➤ A written report of the examination

marrow depression. Signs and sym- will be sent to the requesting health
ptoms of overdose or acute adreno- care practitioner, who will discuss
cortical insuffiency include cardiac the results with the patient.
arrhythmias, hypotension, dehydra-
➤ Reinforce information given by the
tion, anxiety, confusion, weakness,
patient’s health care provider regard-
impairment of consciousness, N/V,
epigastric pain, diarrhea, hypona-
referral to another health care pro-
tremia, and hyperkalemia.
vider. Answer any questions or
➤ Remove the needle, place a gauze address any concerns voiced by the
over the puncture site and apply gen- patient or family.
tle pressure. Observe venipuncture
site for bleeding or hematoma for- ➤ Depending on the results of this pro-
mation. Apply paper tape over gauze cedure, additional testing may be
or replace with adhesive bandage. performed to evaluate or monitor
➤ Promptly transport the specimen to and determine the need for a change
the laboratory for processing and in therapy. If a diagnosis of Cushing’s
analysis. The tightly capped sample disease is made, pituitary computed
should be placed in an ice slurry tomography (CT) or magnetic reso-
immediately after collection. Infor- nance imaging (MRI) may be indi-
mation on the specimen label can be cated prior to surgery. If a diagnosis
protected from water in the ice of ectopic corticotropin syndrome is
slurry if the specimen is first placed made, abdominal CT or MRI may be
in a protective plastic bag. indicated prior to surgery. Evaluate
➤ The results are recorded manually or test results in relation to the patient’s
in a computerized system for recall symptoms and other tests per-
and postprocedure interpretation by formed.
the appropriate health care practi-
tioner.
Related laboratory tests:
Post-test: ➤ Related laboratory tests include cor-

tisol, follicle-stimulating hormone,
➤ Instruct the patient to resume nor- growth hormone, luteinizing hor-
mal activity as directed by the health mone, testosterone, thyroid-stimu-
care practitioner. lating hormone, and thyroxine.
ALANINE AMINOTRANSFERASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Serum glutamic pyruvic transaminase

(SGPT), ALT.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma

(1 mL) collected in a green-top (heparin) tube is also acceptable.
REFERENCE VALUE: (Method: Spectrophotometry)
Conventional
than 1.5 times the upper limits of nor-
Age & SI Units
mal.
Newborn–1 y 13–45 U/L

2 y–adult
RESULT
Male 10–40 U/L
Increased in:
Female 7–35 U/L
• Acute pancreatitis
• Biliary tract obstruction
• Burns (severe)
DESCRIPTION & RATIONALE: Alanine • Chronic alcohol abuse
aminotransferase (ALT), formerly
known as serum glutamic pyruvic • Cirrhosis
transaminase (SGPT), is an enzyme • Fatty liver
produced by the liver. It acts as a cata-
• Hepatic carcinoma
lyst in the reversible transfer of an
amino group between alanine and - • Hepatitis
ketoglutarate. The highest concentra- • Infectious mononucleosis
tion of ALT is found in liver cells,
moderate amounts are found in kid- • Muscle injury from intramuscular injec-
tions, trauma, infection, and seizures
ney cells, and smaller amounts are
(recent)
found in heart and skeletal muscle
cells. When liver damage occurs, • Muscular dystrophy
serum levels of ALT rise to 50 times • Myocardial infarction
normal, making this a useful test in
• Myositis
evaluating liver injury. ALT is also
used to screen donated blood before • Pre-eclampsia
transfusion because the enzyme may • Shock (severe)
be elevated in the absence of detectable
serologic markers of hepatitis. ■ Decreased in:
• Pyridoxal phosphate deficiency
INDICATIONS:
• Compare serially with aspartate amino-
transferase (AST) levels to track the CRITICAL VALUES: N/A
course of liver disease.
Interfering Factors
• Monitor liver damage resulting from • Drugs that may increase ALT levels by
hepatotoxic drugs. causing cholestasis include amitripty-
• Monitor response to treatment of liver line, anabolic steroids, androgens,
disease, with tissue repair indicated by benzodiazepines, chlorothiazide, chlor-
gradually declining levels. propamide, dapsone, erythromycin,
estrogens, ethionamide, gold salts,
• In blood banks, use as a routine screen imipramine, mercaptopurine, nitrofu-
for hepatitis in donor blood samples. rans, oral contraceptives, penicillins,
Samples are rejected if levels are greater phenothiazines, progesterone, propoxy-
Alanine Aminotransferase 17
phene, sulfonamides, tamoxifen, and these products so that their effects

tolbutamide. can be taken into consideration
when reviewing results.
• Drugs that may increase ALT levels by
causing hepatocellular damage include
acetaminophen (toxic), acetylsalicylic imen collection takes approximately
acid, allopurinol, amiodarone, anabolic 5 to 10 minutes. Address concerns
steroids, anticonvulsants, asparaginase, about pain related to the procedure.
azithromycin, bromocriptine, capto- Explain to the patient that there may
pril, cephalosporins, chloramphenicol, be some discomfort during the
clindamycin, clofibrate, danazol, enflu- venipuncture.
rane, ethambutol, ethionamide, fenofi- ➤ There are no food, fluid, or medica-
brate, fluconazole, fluoroquinolones, tion restrictions unless by medical
foscarnet, gentamicin, indomethacin, direction.
interferon, interleukin-2, levamisole,
levodopa, lincomycin, low-molecular- Intratest:
weight heparin, methyldopa, mono- ➤ If the patient has a history of severe
amine oxidase inhibitors, naproxen, allergic reaction to latex, care should
nifedipine, nitrofurans, oral contra- be taken to avoid the use of equip-
ceptives, probenecid, procainamide, ment containing latex.
quinine, ranitidine, retinol, ritodrine, ➤ Instruct the patient to cooperate fully
sulfonylureas, tetracyclines, tobramy- and to follow directions. Direct the
cin, and verapamil. patient to breathe normally and to
• Drugs that may decrease ALT levels
include cyclosporine and interferon. follow the general guidelines in
Appendix A. Positively identify the
Nursing Implications and patient, and label the appropriate
Procedure ● ● ● ● ● ● ● ● ● ● ● tubes with the corresponding patient
demographics, date, and time of col-
Pretest: lection. Perform a venipuncture; col-
lect the specimen in a 5-mL red- or
➤ Inform the patient that the test is tiger-top tube.
used to assess liver function.
➤ Remove the needle, place a gauze
➤ Obtain a history of the patient’s com- over the puncture site and apply gen-
plaints, including a list of known tle pressure to stop bleeding.
allergens (especially allergies or sen- Observe venipuncture site for bleed-
sitivities to latex), and inform the ing and hematoma formation. Apply
appropriate health care practitioner paper tape over gauze or replace
accordingly. with adhesive bandage.
➤ Obtain a history of the patient’s ➤ Promptly transport the specimen to
hepatobiliary system and results of the laboratory for processing and
previously performed laboratory analysis.
tests, surgical procedures, and other
diagnostic procedures. For related ➤ The results are recorded manually or
laboratory tests, refer to the Hepa- in a computerized system for recall
tobiliary System table. and postprocedure interpretation by
➤ Obtain a list of the medications the tioner.
patient is taking, including herbs,
nutritional supplements, and nutra- Post-test:
ceuticals. The requesting health care
practitioner and laboratory should be ➤ Instruct the patient to resume usual
advised if the patient regularly uses diet, fluids, medications, or activity,
as directed by the health care practi- ➤ A written report of the examination

tioner. will be sent to the requesting health
➤ Nutritional considerations: Increased care practitioner, who will discuss
ALT levels may be associated with the results with the patient.
liver disease. Dietary recommenda- ➤ Reinforce information given by the
tions may be indicated and vary patient’s health care provider regard-
depending on the severity of the ing further testing, treatment, or
condition. A low-protein diet may be referral to another health care pro-
in order if the patient’s liver has lost vider. Answer any questions or
the ability to process the end prod- address any concerns voiced by the
ucts of protein metabolism. A diet of patient or family.
soft foods may be required if
esophageal varices have developed. ➤ Depending on the results of this pro-
Ammonia levels may be used to cedure, additional testing may be
determine whether protein should performed to evaluate or monitor
be added to or reduced from the progression of the disease process
diet. Patients should be encouraged and determine the need for a change
to eat simple carbohydrates and in therapy. Evaluate test results in
emulsified fats (as in homogenized relation to the patient’s symptoms
milk or eggs), as opposed to com- and other tests performed.
plex carbohydrates (e.g., starch,
fiber, and glycogen [animal carbohy-
drates]) and complex fats, which Related laboratory tests:
would require additional bile to emul-
sify them so that they can be used. ➤ Related laboratory tests include acet-
The cirrhotic patient should be care- aminophen, ammonia, AST, bilirubin,
fully observed for the development electrolytes, -glutamyl transpepti-
of ascites, in which case fluid and dase, hepatitis antigens and antibod-
electrolyte balance requires strict ies, lactate dehydrogenase, and liver
attention. biopsy.
ALBUMIN AND ALBUMIN/

GLOBULIN RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Alb, A/G ratio.

REFERENCE VALUE: (Method: Spectrophotometry) Normally the

albumin/globulin (A/G) ratio is greater than 1.
Albumin and Albumin/Globulin Ratio 19

Age Units Units 10)
Newborn–4 d 2.8–4.4 g/dL 28–44 g/L
5 d–14 y 3.8–5.4 g/dL 38–54 g/L
15–18 y 3.2–4.5 g/dL 32–45 g/L
19–60 y 3.4–4.8 g/dL 34–48 g/L
61–90 y 3.2–4.6 g/dL 32–46 g/L
Greater than 90 y 2.9–4.5 g/dL 29–45 g/L
INDICATIONS:
DESCRIPTION & RATIONALE: Most
• Assess nutritional status of hospital-
of the body’s total protein is a com-
ized patients, especially geriatric pati-
bination of albumin and globulins. ents
Albumin, the protein present in
• Evaluate chronic illness
the highest concentrations, is the
main transport protein in the body. • Evaluate liver disease
Albumin also maintains plasma
oncotic pressure. Serum albumin RESULT
values are affected by the process of
synthesis, distribution, and degrada- Increased in:
tion. Low levels may be the result of • Any condition that results in a decrease
either inadequate production or exces- of plasma water (e.g., dehydration);
sive loss. Albumin levels are more use- look for increase in hemoglobin and
ful as an indicator of chronic hematocrit
deficiency than of short-term defi-
• Hyperinfusion of albumin
ciency.
Albumin levels are affected by pos-
ture. Results from specimens collected Decreased in:
in an upright posture are higher than • Insufficient intake:
results from specimens collected in a Malabsorption
supine position. Malnutrition
The A/G ratio is useful in the eval- • Decreased synthesis by the liver:
uation of liver and kidney disease. The Acute and chronic liver disease
ratio is calculated using the following (e.g., alcoholism, cirrhosis,
formula: hepatitis)
albumin/(total protein – albumin) Genetic analbuminemia
where globulin is the difference • Inflammation and chronic diseases:

between the total protein value and Amyloidosis
the albumin value. For example, with Bacterial infections
a total protein of 7 g/dL and albumin Monoclonal gammopathies (e.g.,
of 4 g/dL, the A/G ratio is calculated multiple myeloma,
as 4/(7 – 4) or 4/3 1.33. A reversal Waldenström’s
in the ratio, where globulin exceeds macroglobulinemia)
albumin (i.e., ratio less than 1.0), is Neoplasm
clinically significant. ■ Parasitic infestations
Peptic ulcer
Nursing Implications and
Prolonged immobilization
Procedure ● ● ● ● ● ● ● ● ● ● ●
Rheumatic diseases
Severe skin disease Pretest:
• Increased loss over body surface: ➤ Inform the patient that the test is
Burns used as a general indicator of nutri-
Enteropathies related to sensitivity tional status, hydration, and chronic
to ingested substances (e.g., disease.
gluten sensitivity, Crohn’s ➤ Obtain a history of the patient’s com-
disease, ulcerative colitis) plaints, including a list of known
Fistula (gastrointestinal or allergens (especially allergies or sen-
lymphatic) sitivities to latex), and inform the
appropriate health care practitioner
Hemorrhage accordingly.
Kidney disease ➤ Obtain a history of the patient’s gas-
Rapid hydration or overhydration trointestinal, genitourinary, and
Repeated thoracentesis or hepatobiliary systems and results of
paracentesis previously performed laboratory
Trauma and crush injuries
diagnostic procedures. For related
• Increased catabolism: tests, refer to the Gastrointestinal,
Genitourinary, and Hepatobiliary
Fever
System and Therapeutic/Toxicology
Cushing’s disease tables.
Pre-eclampsia ➤ Obtain a list of the medications the
Thyroid dysfunction patient is taking, including herbs,
• Increased blood volume (hyperv- ceuticals. The requesting health care
olemia): practitioner and laboratory should be
Congestive heart failure advised if the patient regularly uses
these products so that their effects
Monoclonal gammopathies
can be taken into consideration
(Waldenström’s disease, when reviewing results.
myeloma)
Pregnancy patient. Inform the patient that spec-
CRITICAL VALUES: N/A 5 to 10 minutes. Address concerns
about pain related to the procedure.
Explain to the patient that there may
INTERFERING FACTORS: be some discomfort during the
• Drugs that may increase albumin levels venipuncture.
include enalapril. ➤ There are no food, fluid, or medica-
• Drugs that may decrease albumin levels tion restrictions unless by medical
include acetaminophen (poisoning), direction.
dapsone, dextran, estrogens, ibuprofen,
nitrofurantoin, oral contraceptives, Intratest:
phenytoin, prednisone (high doses),
trazodone, and valproic acid. ➤ If the patient has a history of severe
allergic reaction to latex, care should
• Availability of administered drugs is be taken to avoid the use of equip-
affected by variations in albumin levels. ment containing latex.
Aldolase 21
➤ Instruct the patient to cooperate fully may be used to determine whether

and to follow directions.Direct the protein should be added to or
patient to breathe normally and to reduced from the diet.
➤ Observe standard precautions, and will be sent to the requesting health
follow the general guidelines in care practitioner, who will discuss
Appendix A. Positively identify the the results with the patient.
patient, and label the appropriate
tubes with the corresponding patient ➤ Reinforce information given by the
demographics, date, and time of col- patient’s health care provider regard-
lection. Perform a venipuncture; col- ing further testing, treatment, or
lect the specimen in a 5-mL red- or referral to another health care pro-
tiger-top tube. vider. Answer any questions or
➤ Remove the needle, place a gauze patient or family.
over the puncture site and apply gen-
tle pressure to stop bleeding. ➤ Depending on the results of this
Observe venipuncture site for bleed- procedure, additional testing may be
ing or hematoma formation. Apply performed to evaluate or monitor
paper tape over gauze or replace progression of the disease process
with adhesive bandage. and determine the need for a change
in therapy. Evaluate test results in
➤ Promptly transport the specimen to
relation to the patient’s symptoms
the laboratory for processing and
and other tests performed.
analysis.
➤ The results are recorded manually or Related laboratory tests:
in a computerized system for recall
and postprocedure interpretation by ➤ Related laboratory tests include ala-
the appropriate health care practi- nine aminotransferase, alkaline phos-
tioner. phatase, ammonia, anti-aspartate
aminotransferase, bilirubin, elec-
Post-test: trolytes, -glutamyl transpeptidase,
hematocrit, hemoglobin, hepatitis
➤ Nutritional considerations: Dietary antibodies and antigens, liver biopsy,
recommendations may be indicated osmolality, prealbumin, protein, pro-
and vary depending on the severity tein electrophoresis, and smooth
of the condition. Ammonia levels muscle antibody.
ALDOLASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: ALD.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
Conventional
• Hemolytic anemias
Age & SI Units • Hepatitis (acute viral or toxic)
Newborn–2 y 3.4–11.8 U/L • Infectious mononucleosis
25 m–16 y 1.2–8.8 U/L • Leukemia (granulocytic and megalob-
Adult Less than 7.4 U/L lastic)
• Limb girdle muscular dystrophy
• Myocardial infarction
DESCRIPTION & RATIONALE: • Pancreatitis (acute)
Aldolase (ALD), an enzyme found • Polymyositis
throughout the body, catalyzes the
• Psychoses and schizophrenia (acute)
breakdown of glucose to lactate.
Highest concentrations of this enzyme • Severe crush injuries
are found in skeletal and cardiac mus- • Tetanus
cle, liver, and pancreas. When trauma • Trichinosis
or disease causes cellular breakdown
of these muscles or organs, large Decreased in:
amounts of ALD are released into the • Hereditary fructose intolerance
blood. Measuring serum levels helps
to determine the presence, and in CRITICAL VALUES: N/A
some cases the progress, of disease.
This test is not commonly requested INTERFERING FACTORS:
because the assay of other liver • Drugs that may increase aldolase
enzymes and creatine kinase is gener- levels include aminocaproic acid, car-
ally sufficient to provide the necessary benoxolone, chlorinated and organo-
phosphorus insecticides, clofibrate,
information. ■
labetalol, and thiabendazole.
INDICATIONS: • Drugs that may decrease aldolase levels
• Assist in the diagnosis of Duchenne’s include phenothiazines (in schizo-
muscular dystrophy phrenic patients with high initial val-
ues) and probucol.
• Differentiate neuromuscular disorders
from neurologic disorders, such as mul- • Intramuscular injections may increase
tiple sclerosis or myasthenia gravis aldolase levels as a result of muscle
trauma.
RESULT • Red blood cells contain aldolase;
hemolysis may cause a false elevation in
Increased in: values.
• Carcinoma (lung, breast, and geni-
tourinary tract, and metastasis to liver)
• Central nervous system tumors
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Delirium tremens
Pretest:
• Dermatomyositis
➤ Inform the patient that the test is
• Duchenne’s muscular dystrophy
used to assess general liver, pancre-
• Gangrene atic, and musculoskeletal function.
Aldolase 23
➤ Obtain a history of the patient’s tubes with the corresponding patient

complaints, including a list of known demographics, date, and time of col-
allergens (especially allergies or sen- lection. Perform a venipuncture; col-
sitivities to latex), and inform the lect the specimen in a 5-mL red- or
appropriate health care practitioner tiger-top tube.
accordingly. ➤ Remove the needle, place a gauze
➤ Obtain a history of neuromuscular over the puncture site and apply gen-
disorders, related treatments, and tle pressure to stop bleeding.
complaints of muscle fatigue or loss Observe venipuncture site for bleed-
of strength. ing or hematoma formation. Apply
➤ Obtain a history of the patient’s paper tape over gauze or replace
hepatobiliary and musculoskeletal with adhesive bandage.
system and results of previously ➤ Promptly transport the specimen to
performed laboratory tests, surgical the laboratory for processing and
procedures, and other diagnostic analysis.
procedures. For related laboratory ➤ The results are recorded manually or
tests, refer to the Hepatobiliary and in a computerized system for recall
Musculoskeletal System tables. and postprocedure interpretation by
can be taken into consideration care practitioner, who will discuss
when reviewing results. the results with the patient.
➤ Review the procedure with the ➤ Reinforce information given by the
patient. Inform the patient that spec- patient’s health care provider regard-
imen collection takes approximately ing further testing, treatment, or
5 to 10 minutes. Address concerns referral to another health care pro-
about pain related to the procedure. vider. Answer any questions or
Explain to the patient that there address any concerns voiced by the
may be some discomfort during the patient or family.
venipuncture.
➤ There are no food, fluid, or medica- cedure, additional testing may be
tion restrictions unless by medical performed to evaluate or monitor
direction. progression of the disease process
and determine the need for a change
Intratest: in therapy. Evaluate test results in
➤ If the patient has a history of severe and other tests performed.
ment containing latex. Related laboratory tests:
➤ Instruct the patient to cooperate fully ➤ Related laboratory tests include
and to follow directions. Direct the alkaline phosphatase, antimitochon-
patient to breathe normally and to drial antibody, aspartate amino-
avoid unnecessary movement. transferase, creatine kinase and
➤ Observe standard precautions, and isoenzymes, Jo-1 antibody, lactate
follow the general guidelines in dehydrogenase and isoenzymes,
Appendix A. Positively identify the liver biopsy, muscle biopsy, and myo-
patient, and label the appropriate globin.
ALDOSTERONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
(1 mL) collected in green-top (heparin) or lavender-top (EDTA) tube is also
acceptable.
REFERENCE VALUE: (Method: Radioimmunoassay)

Cord blood 40–200 ng/dL 1.11–5.54 nmol/L
3 d–1 wk 7–184 ng/dL 0.19–5.10 nmol/L
1 mo–1 y 5–90 ng/dL 0.14–2.49 nmol/L
13–23 mo 7–54 ng/dL 0.19–1.50 nmol/L
2–10 y
Supine 3–35 ng/dL 0.08–0.97 nmol/L
Upright 5–80 ng/dL 0.14–2.22 nmol/L
11–15 y
Adult
These values reflect a normal-sodium diet. Values for a low-sodium diet are three to five
times higher.
DESCRIPTION & RATIONALE: Aldos- sodium intake, certain medications,

terone is a mineralocorticoid secreted and activity. This test is of little diag-
by the zona glomerulosa of the adrenal nostic value unless plasma renin activ-
cortex in response to decreased serum ity is measured simultaneously (see
sodium, decreased blood volume, and monograph titled “Renin”). Patients
increased serum potassium. Aldos- with serum potassium less than 3.6
terone increases sodium reabsorption mEq/L and 24-hour urine potassium
in the renal tubules, resulting in potas- greater than 40 mEq/L fit the general
sium excretion and increased water criteria to test for aldosteronism.
retention, blood volume, and blood Renin is low in primary aldosteronism
pressure. A variety of factors influence and high in secondary aldosteronism.
serum aldosterone levels, including A ratio of plasma aldosterone to
Aldosterone 25
plasma renin activity greater than 50 is • Hypoaldosteronism secondary to renin

significant. ■ deficiency
• Isolated aldosterone deficiency
INDICATIONS:
• Evaluate hypertension of unknown With hypertension:
cause, especially with hypokalemia not • Acute alcohol intoxication
induced by diuretics • Diabetes
• Investigate suspected hyperaldostero-
• Excess secretion of deoxycorticosterone
nism, as indicated by elevated levels
• Investigate suspected hypoaldostero- • Turner’s syndrome (25% of cases)
nism, as indicated by decreased levels
CRITICAL VALUES: N/A
RESULT INTERFERING FACTORS:
Increased with Decreased • Drugs that may increase aldosterone
Renin Levels levels include amiloride, ammonium
chloride, angiotensin, angiotensin II,
Primary hyperaldosteronism:
dobutamine, dopamine, endralazine,
• Adenomas (Conn’s syndrome) fenoldopam, hydralazine, hydrochloro-
• Bilateral hyperplasia of the aldos- thiazide, laxatives (abuse), metoclopra-
terone-secreting zona glomerulosa cells mide, nifedipine, opiates, potassium,
spironolactone, and zacopride.
Increased with Increased • Drugs that may decrease aldosterone
Renin Levels levels include atenolol, captopril, car-
Secondary hyperaldosteronism: vedilol, cilazapril, enalapril, fadrozole,
• Bartter’s syndrome glycyrrhiza, ibopamine, indomethacin,
lisinopril, nicardipine, nonsteroidal
• Cardiac failure anti-inflammatory drugs, perindopril,
ranitidine, saline, sinorphan, and vera-
• Chronic obstructive pulmonary disease pamil. Prolonged heparin therapy also
• Cirrhosis with ascites formation decreases aldosterone levels.
• Diuretic abuse • Upright body posture, stress, strenuous

exercise, and late pregnancy can lead to
• Hypovolemia secondary to hemor- increased levels.
rhage and transudation
• Laxative abuse within 1 week before the test can inter-
fere with test results when radioim-
• Nephrotic syndrome munoassay is the test method.
• Starvation (after 10 days) • Diet can significantly affect results. A
• Thermal stress low-sodium diet can increase serum
aldosterone, whereas a high-sodium
• Toxemia of pregnancy diet can decrease levels. Decreased
serum sodium and elevated serum
Decreased potassium increase aldosterone secre-
Without hypertension:
tion. Elevated serum sodium and
decreased serum potassium suppress
• Addison’s disease aldosterone secretion.
tained for 2 hours before specimen

Nursing Implications and collection.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ The patient should be on a normal-
sodium diet (1 to 2 g of sodium
Pretest: per day) for 2 to 4 weeks before the
test.
used to evaluate hypertension and ➤ Under medical direction, the patient
possible hyperaldosteronism. should avoid diuretics, antihyperten-
sive drugs and herbals, and cyclic
➤ Obtain a history of the patient’s com- progestogens and estrogens for 2 to
plaints, including a list of known 4 weeks before the test.
allergens (especially allergies or sen-
sitivities to latex), and inform the Intratest:
accordingly. ➤ Ensure that the patient has complied
➤ Obtain a history of known or sus- with dietary, medication, and pretes-
pected fluid or electrolyte imbalance, ting preparations regarding activity.
hypertension, renal function, or stage ➤ If the patient has a history of severe
of pregnancy. Note the amount of allergic reaction to latex, care should
sodium ingested in the diet over the be taken to avoid the use of equip-
past 2 weeks. ment containing latex.
➤ Obtain a history of the patient’s ➤ Instruct the patient to cooperate fully
endocrine and genitourinary sys- and to follow directions. Direct the
tems and results of previously patient to breathe normally and to
performed laboratory tests, surgical avoid unnecessary movement.
procedures, and other diagnostic ➤ Observe standard precautions, and
procedures. For related laboratory follow the general guidelines in
tests, refer to the Endocrine and Appendix A. Positively identify the
Genitourinary System tables. patient, and label the appropriate
➤ Note any recent procedures that can tubes with the corresponding patient
interfere with test results. demographics, date, time of collec-
➤ Obtain a list of the medications the tion, patient position (upright or
patient is taking, including herbs, supine), and exact source of speci-
nutritional supplements, and nutra- men (peripheral versus arterial).
ceuticals. The requesting health Perform a venipuncture after the
care practitioner and laboratory patient has been in the upright (sit-
should be advised if the patient is ting or standing) position for 2 hours.
regularly using these products so If a supine specimen is requested on
that their effects can be taken into an inpatient, the specimen should be
consideration when reviewing collected early in the morning before
results. rising. Collect the specimen in a 5-
mL red- or tiger-top tube.
patient. Inform the patient that spec- ➤ Remove the needle, place gauze
imen collection takes approximately over the puncture site and apply gen-
5 to 10 minutes. Inform the patient tle pressure to stop bleeding.
that multiple specimens may be Observe venipuncture site for bleed-
required. Address concerns about ing or hematoma formation. Apply
pain related to the procedure. Explain paper tape over gauze or replace
to the patient that there may be with adhesive bandage.
some discomfort during the veni- ➤ Promptly transport the specimen on
puncture. ice to the laboratory for processing
➤ Inform the patient that the required and analysis.
position, supine/lying down or ➤ The results are recorded manually or
upright/sitting up, must be main- in a computerized system for recall
Aldosterone 27
and postprocedure interpretation by sodium diets should avoid beverages

the appropriate health care practi- such as colas, ginger ale, Gatorade,
tioner. lemon-lime sodas, and root beer.
Many over-the-counter medications,
Post-test: including antacids, laxatives, anal-
gesics, sedatives, and antitussives,
➤ Instruct the patient to resume usual contain significant amounts of
diet, medication, and activity as sodium. The best advice is to empha-
directed by the health care practi- size the importance of reading all
tioner. food, beverage, and medicine labels.
➤ A written report of the examination In 1989, the Subcommittee on the
will be sent to the requesting health 10th Edition of the RDAs established
care practitioner, who will discuss 500 mg as the recommended
the results with the patient. minimum limit for dietary intake
of sodium. There are no RDAs estab-
➤ Instruct the patient to notify the lished for potassium, but the esti-
health care practitioner of any signs mated minimum intake for adults
and symptoms of dehydration or is 200 mEq/d. Potassium is present
fluid overload related to elevated in all plant and animal cells, mak-
aldosterone levels or compromised ing dietary replacement simple. A
sodium regulatory mechanisms. health care practitioner or nutritionist
➤ Nutritional considerations: Aldos- should be consulted before consider-
terone levels are involved in the reg- ing the use of salt substitutes.
ulation of body fluid volume. Educate ➤ Reinforce information given by the
patients about the importance of patient’s health care provider regard-
proper water balance. Although ing further testing, treatment, or
there is no recommended dietary referral to another health care pro-
allowance (RDA) for water, adults vider. Answer any questions or
need 1 mL/kcal per day. Infants need address any concerns voiced by the
more water because their basal patient or family.
metabolic heat production is much
higher than in adults. Tap water may ➤ Depending on the results of this pro-
also contain other nutrients. Water- cedure, additional testing may be
softening systems replace minerals performed to evaluate or monitor
(e.g., calcium, magnesium, iron) with progression of the disease process
sodium, so caution should be used if and determine the need for a change
a low-sodium diet is prescribed. in therapy. Evaluate test results in
➤ Nutritional considerations: Because and other tests performed.
aldosterone levels have an effect on
sodium levels, some consideration
may be given to dietary adjustment if Related laboratory tests:
sodium allowances need to be regu-
lated. Educate patients with low ➤ Related laboratory tests include cat-
sodium levels that the major source echolamines (blood and urine), corti-
of dietary sodium is table salt. Many sol, creatinine (blood and urine),
foods, such as milk and other dairy glucose, kidney biopsy, magne-
products, are also good sources of sium (blood and urine), osmolality
dietary sodium. Most other dietary (blood and urine), potassium (blood
sodium is available through con- and urine), renin, sodium (blood and
sumption of processed foods. urine), urea nitrogen, urinalysis, and
Patients who need to follow low- urine protein.
ALKALINE PHOSPHATASE
AND ISOENZYMES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Alk Phos, ALP and fractionation, heat-stabile ALP.

REFERENCE VALUE: (Method: Spectrophotometry for total alkaline phos-

phatase, inhibition/electrophoresis for fractionation)
Total Conventional
ALP & SI Units Bone Fraction Liver Fraction
1–5 y
Male 56–350 U/L 39–308 U/L Less than 8–101 U/L
Female 73–378 U/L 56–300 U/L Less than 8–53 U/L
6–7 y
8y
9–12 y
13 y
14 y
15 y
16 y
17 y
Alkaline Phosphatase and Isoenzymes 29
Total Conventional
ALP & SI Units Bone Fraction Liver Fraction
18 y
19 y
20 y
Adult
Male 35–142 U/L 11–73 U/L 0–93 U/L
Female 25–125 U/L 11–73 U/L 0–93 U/L
DESCRIPTION & RATIONALE: ALP is in children are higher than in adults

an enzyme found in the liver, in because of the level of bone growth
Kupffer cells lining the biliary tract, and development. An immunoassay
and in bones, intestines, and placenta. method is available for measur-
Additional sources of ALP include the ing bone specific ALP as an indicator
proximal tubules of the kidneys, pul- of increased bone turnover and estro-
monary alveolar cells, germ cells, vas- gen deficiency in post-menopausal
cular bed, lactating mammary glands, women. ■
and granulocytes of circulating blood.
ALP is referred to as alkaline because
it functions optimally at a pH of 9.0. INDICATIONS:
This test is most useful for determin- • Evaluate signs and symptoms of various
ing the presence of liver or bone dis- disorders associated with elevated ALP
ease. levels, such as biliary obstruction, hepa-
Isoelectric focusing methods can iden- tobiliary disease, and bone disease,
tify 12 isoenzymes of ALP. Certain including malignant processes
cancers produce small amounts of dis-
• Differentiate obstructive hepatobiliary
tinctive Regan and Nagao ALP isoen-
tract disorders from hepatocellular dis-
zymes. Four main ALP isoenzymes, ease; greater elevations of ALP are seen
however, are of clinical significance: in the former
ALP1 of liver origin, ALP2 of bone
origin, ALP3 of intestinal origin (occa- • Determine effects of renal disease on
sionally present in individuals with bone metabolism
blood type O and B), and ALP4 of • Determine bone growth or destruction
placental origin (third trimester). ALP in children with abnormal growth pat-
levels vary by age and gender. Values terns
RESULT Hodgkin’s disease

Hyperparathyroidism (primary or
Increased in: secondary to chronic renal
• Liver disease: disease)
Biliary atresia Perforated bowel
Biliary obstruction (acute Pneumonia
cholecystitis, cholelithisis, Pulmonary and myocardial
intrahepatic cholestasis of infarctions
pregnancy, primary biliary Pulmonary embolism
cirrhosis) Sarcoidosis
Cancer Ulcerative colitis
Chronic active hepatitis
Cirrhosis Decreased in:
Diabetes (diabetic hepatic lipidosis) • Anemia (severe)
Extrahepatic duct obstruction • Celiac disease
Granulomatous or infiltrative liver
diseases • Cretinism
Infectious mononucleosis • Folic acid deficiency
Intrahepatic biliary hypoplasia
Toxic hepatitis • HIV-1 infection
Viral hepatitis • Hypervitaminosis D
• Bone disease: • Hypophosphatasia (congenital, rare)
Healing fractures
• Hypothyroidism (characteristic in
Metabolic bone diseases (rickets, infantile and juvenile cases)
osteomalacia)
Metastatic tumors in bone • Milk alkali syndrome
Osteogenic sarcoma • Kwashiorkor
Osteoporosis
Paget’s disease (osteitis • Nutritional deficiency of zinc or mag-
deformans) nesium
Parasitic infections (histoplasmosis, • Pernicious anemia
leptospirosis, malaria,
schistosomiasis) • Scurvy
• Other conditions: • Vitamin C deficiency
Adrenal cortical hyperfunction • Whipple’s disease (indication of vita-
Advanced pregnancy min D and calcium malabsorption)
Amyloidosis
• Zollinger-Ellison syndrome (indication
Atherosclerosis
of vitamin D and calcium malabsorp-
Cancer of the breast, colon, tion)
gallbladder, lung, or pancreas
Cancer of the lung or pancreas
Chronic renal failure
Congestive heart failure INTERFERING FACTORS:
Familial hyperphosphatemia • Drugs that may increase ALP levels by
Galactosemia causing cholestasis include amitripty-
Alkaline Phosphatase and Isoenzymes 31
line, anabolic steroids, androgens, plaints, including a list of known

benzodiazepines, chlorothiazide, chlor- allergens (especially allergies or sen-
propamide, dapsone, erythromycin, sitivities to latex), and inform the
estrogens, ethionamide, gold salts, appropriate health care practitioner
accordingly.
imipramine, mercaptopurine, nitrofu-
rans, oral contraceptives, penicillins, ➤ Obtain a history of the patient’s
phenothiazines, progesterone, pro- hepatobiliary and musculoskeletal
poxyphene, sulfonamides, tamoxifen, systems and results of previously
and tolbutamide. procedures, and other diagnostic
• Drugs that may increase ALP levels by procedures. For related tests, refer
causing hepatocellular damage include to the Hepatobiliary and Musculo-
acetaminophen (toxic), acetylsalicylic skeletal System tables.
acid, allopurinol, amiodarone, anabolic ➤ Obtain a list of the medications the
steroids, anticonvulsants, asparaginase, patient is taking, including herbs,
azithromycin, bromocriptine, capto- nutritional supplements, and nutra-
pril, cephalosporins, chloramphenicol, ceuticals. The requesting health care
clindamycin, clofibrate, danazol, enflu-
advised if the patient is regularly
rane, ethambutol, ethionamide, fenofi- using these products so that their
brate, fluconazole, fluoroquinolones, effects can be taken into considera-
foscarnet, gentamicin, indomethacin, tion when reviewing results.
interferon, interleukin-2, levamisole,
levodopa, lincomycin, low-molecular- patient. Inform the patient that spec-
weight heparin, methyldopa, mono- imen collection takes approximately
amine oxidase inhibitors, naproxen, 5 to 10 minutes. Address concerns
nifedipine, nitrofurans, oral contracep- about pain related to the procedure.
tives, probenecid, procainamide, qui- Explain to the patient that there may
nine, ranitidine, retinol, ritodrine, be some discomfort during the
sulfonylureas, tetracyclines, tobramy- venipuncture.
cin, and verapamil. ➤ There are no food, fluid, or medica-
• Drugs that may cause an overall direction.
decrease in ALP levels include alendro-
late, clofibrate, and theophylline.
Intratest:
• Hemolyzed specimens may cause
falsely elevated results. ➤ If the patient has a history of severe
• Elevations of ALP may occur if the be taken to avoid the use of equip-
patient is nonfasting, usually 2 to 4 h ment containing latex.
after a fatty meal, and especially if the ➤ Instruct the patient to cooperate fully
patient is a Lewis-positive secretor of and to follow directions. Direct the
blood group B or O. patient to breathe normally and to
Nursing Implications and follow the general guidelines in
Procedure ● ● ● ● ● ● ● ● ● ● ● Appendix A. Positively identify the
Pretest: tubes with the corresponding patient
➤ Inform the patient that the test is lection. Perform a venipuncture; col-
used to assess liver function. lect the specimen in a 5-mL red- or
➤ Obtain a history of the patient’s com- tiger-top tube.
➤ Remove the needle, place a gauze of ascites, in which case fluid and
over the puncture site and apply gen- electrolyte balance requires strict
tle pressure to stop bleeding. attention.
Observe venipuncture site for bleed- ➤ A written report of the examination
ing and hematoma formation. Apply will be sent to the requesting health
paper tape over gauze or replace care practitioner, who will discuss
with adhesive bandage. the results with the patient.
➤ Promptly transport the specimen to ➤ Reinforce information given by the
the laboratory for processing and patient’s health care provider regard-
analysis. ing further testing, treatment, or
➤ The results are recorded manually or referral to another health care pro-
in a computerized system for recall vider. Answer any questions or add-
and postprocedure interpretation by ress any concerns voiced by the
the appropriate health care practi- patient or family.
tioner. ➤ Depending on the results of this pro-
Post-test: performed to evaluate or monitor
➤ Nutritional considerations: Increased and determine the need for a change
ALP levels may be associated with in therapy. Evaluate test results in
liver disease. Dietary recommenda- relation to the patient’s symptoms
tions may be indicated and vary and other tests performed.
depending on the severity of the
condition. A low-protein diet may be Related laboratory tests:
in order if the patient’s liver has lost
the ability to process the end prod- ➤ Related laboratory tests include
ucts of protein metabolism. A diet acetaminophen, alanine aminotrans-
of soft foods may be required if ferase, albumin, ammonia, anti-
esophageal varices have developed. DNA antibodies, antimitochondrial
Ammonia levels may be used to antibodies, antinuclear antibodies,
determine whether protein should anti–smooth muscle antibodies, a1-
be added to or reduced from the antitrypsin, 1-antitrypsin phenotyp-
diet. Patients should be encouraged ing, aspartate aminotransferase,
to eat simple carbohydrates and bilirubin (total, direct, and indirect),
emulsified fats (as in homogenized bone biopsy, calcium, ceruloplasmin,
milk or eggs), as opposed to com- C3 complement, C4 complement,
plex carbohydrates (e.g., starch, copper, electrolytes, -glutamyl tran-
fiber, and glycogen [animal carbohy- speptidase, hepatitis antigens and
drates]) and complex fats, which antibodies, liver biopsy, magnesium,
would require additional bile to emul- parathyroid hormone, phosphorus,
sify them so that they can be used. protein, protein electrophoresis, pro-
The cirrhotic patient should be care- thrombin time, salicylate, vitamin D,
fully observed for the development and zinc.
Allergen-Specific Immunoglobulin E 33
ALLERGEN-SPECIFIC
IMMUNOGLOBULIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Allergen profile, radioallergosorbent test (RAST).

SPECIMEN: Serum (2 mL per group of six allergens, 0.5 mL for each addi-
tional individual allergen) collected in a red- or tiger-top tube.
Alternate Scoring
RAST Scoring Method (ASM): Increasing
Method Levels of Allergy Sensitivity
Specific IgE
Antibody Level kIU/L ASM Class ASM % Reference
Absent or Less than 0.35 0 Less than 70
undetectable
Low 0.35–0.70 1 70–109
Moderate 0.71–3.50 2 110–219
High 3.51–17.50 3 220–599
Very high Greater than 17.50 4 600–1999
5 2000–5999
6 Greater than 5999
DESCRIPTION & RATIONALE: antibiotics, dust, foods, grasses,

Allergen-specific immunoglobulin E insects, trees, mites, molds, venom,
(IgE) or a radioallergosorbent test and weeds. Allergen testing is useful
(RAST) is generally requested for for evaluating the cause of hay fever,
groups of allergens commonly known extrinsic asthma, atopic eczema, respi-
to incite an allergic response in the ratory allergies, and potentially fatal
affected individual. The test is based reactions to insect venom, penicillin,
on the use of a radiolabeled anti-IgE and other drugs or chemicals. RAST
reagent to detect IgE in the patient’s has largely replaced skin tests and
serum, produced in response to spe- provocation procedures, which were
cific allergens. The panels include inconvenient, painful, and potentially
allergens such as animal dander, hazardous to patients. ■
INDICATIONS: Nursing Implications and

• Evaluate patients who refuse to submit
to skin testing or who have generalized Procedure ● ● ● ● ● ● ● ● ● ● ●
dermatitis or other dermatopathic con-

Pretest:
ditions
• Monitor response to desensitization ➤ Inform the patient that the test is
used to identify types of allergens
procedures that may be responsible for causing
• Test for allergens when skin testing is an allergic response.
inappropriate, such as in infants ➤ Obtain a history of the patient’s com-
• Test for allergens when there is a known plaints, including a list of known
history of severe allergic reaction to skin allergens (especially allergies or sen-
sitivities to latex), and inform the
testing appropriate health care practitioner
• Test for specific allergic sensitivity accordingly.
before initiating immunotherapy or ➤ Obtain a history of the patient’s
desensitization shots immune and respiratory system and
• Test for specific allergic sensitivity results of previously performed labo-
ratory tests, surgical procedures,
when skin testing is unreliable and other diagnostic procedures. For
related tests, refer to the Immune
RESULT: Different scoring systems are and Respiratory System tables.
used in the interpretation of RAST
results.
Increased in: ➤ Obtain a list of the medications the
• Allergic rhinitis patient is taking, including herbs,
• Anaphylaxis ceuticals. The requesting health care
• Asthma (exogenous) advised if the patient regularly uses
• Atopic dermatitis these products so that their effects
• Echinococcus infection when reviewing results.
• Eczema ➤ Review the procedure with the
• Hay fever patient. Inform the patient that spec-
• Hookworm infection 5 to 10 minutes. Address concerns
• Schistosomiasis Explain to the patient that there may
• Visceral larva migrans be some discomfort during the
venipuncture.
Decreased in: ➤ There are no food, fluid, or medica-
• Asthma (endogenous) tion restrictions unless by medical
direction.
• Pregnancy
• Radiation therapy Intratest:
CRITICAL VALUES: N/A allergic reaction to latex, care should
INTERFERING FACTORS: Recent radioac- ment containing latex.
tive scans or radiation within 1 week ➤ Instruct the patient to cooperate fully
of the test can interfere with test results and to follow directions. Direct the
when radioimmunoassay is the test patient to breathe normally and to
method. avoid unnecessary movement.
➤ Observe standard precautions, and present. Lifestyle adjustments may

follow the general guidelines in be necessary depending on the spe-
Appendix A. Positively identify the cific allergens identified.
patient, and label the appropriate ➤ A written report of the examination
tubes with the corresponding patient will be sent to the requesting health
demographics, date, and time of col- care practitioner, who will discuss
lection. Indicate the specific allergen the results with the patient.
group to be tested on the specimen
requisition. Perform a venipuncture; ➤ Reinforce information given by the
collect the specimen in a 5-mL red- patient’s health care provider regard-
or tiger-top tube. ing further testing, treatment, or
provider. Answer any questions or
tle pressure to stop bleeding.
patient or family.
ing and hematoma formation. Apply ➤ Depending on the results of this pro-
paper tape over gauze or replace cedure, additional testing may be
with adhesive bandage. performed to evaluate or monitor
➤ Promptly transport the specimen to progression of the disease process
the laboratory for processing and and determine the need for a change
analysis. in therapy. Evaluate test results in
➤ The results are recorded manually or and other tests performed.
and postprocedure interpretation by Related laboratory tests:
➤ Related laboratory tests include
tioner.
arterial/alveolar oxygen ratio, blood
Post-test: gases, complete blood count,
eosinophil count, hypersensitivity
➤ Nutritional considerations should be pneumonitis, IgE, ova and parasites,
given to diet if food allergies are and theophylline.
ALVEOLAR/ARTERIAL GRADIENT AND

ARTERIAL/ALVEOLAR OXYGEN RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYMS: Alveolar-arterial difference, A/a gradient, a/A ratio.

SPECIMEN: Arterial blood (1 mL) collected in a heparinized syringe.
Specimen should be transported tightly capped and in an ice slurry.
REFERENCE VALUE: (Method: Selective electrodes that measure pO2 and

pCO2)
Alveolar/arterial gradient Less than 10 mm Hg at rest (room air)

20–30 mm Hg at maximum exercise
activity (room air)
Arterial/alveolar oxygen ratio Greater than 0.75 (75%)
35
DESCRIPTION & RATIONALE: A test a/A paO2/ pAO2

of the ability of oxygen to diffuse from The A/a gradient increases as the
the alveoli into the lungs is of use concentration of oxygen the patient
when assessing a patient’s level of oxy- inspires increases. If the gradient is
genation. This test can help identify abnormally high, either there is a
the cause of hypoxemia (low oxygen problem with the ability of oxygen to
levels in the blood) and intrapul- pass across the alveolar membrane or
monary shunting that might result oxygenated blood is being mixed with
from one of the following three situa- nonoxygenated blood. The a/A ratio is
tions: ventilated alveoli without not dependent on FIO2; it does not
perfusion, unventilated alveoli with increase with a corresponding increase
perfusion, or collapse of alveoli and in inhaled oxygen. For patients on a
associated blood vessels. Information mechanical ventilator with a changing
regarding the alveolar/arterial (A/a) FIO2, the a/A ratio can be used to
gradient can be estimated indirectly determine if oxygen diffusion is
using the partial pressure of oxygen improving. ■
(pO2) (obtained from blood gas
analysis) in a simple mathematical INDICATIONS:
formula: • Assess intrapulmonary or coronary
artery shunting
A/a gradient pO2 in alveolar air
(estimated) – pO2 in arterial blood • Assist in identifying the cause of
(measured) hypoxemia
An estimate of alveolar pO2 is RESULT
accomplished by subtracting the water
vapor pressure from the barometric Increased in:
pressure, multiplying the resulting • Acute respiratory distress syndrome
pressure by the fraction of inspired • Atelectasis
oxygen (FIO2; percentage of oxygen
the patient is breathing), and subtract- • Atrial-venous shunts
ing this from 1.25 times the arterial • Bronchospasm
partial pressure of carbon dioxide • Chronic obstructive pulmonary disease
(pCO2). The gradient is obtained by
subtracting the patient’s arterial pO2 • Congenital cardiac septal defects
from the calculated alveolar pO2: • Underventilated alveoli (mucus plugs)
Alveolar pO2 [(barometric pres- • Pneumothorax
sure – water vapor pressure) FIO2] • Pulmonary edema
– [1.25 pCO2]
• Pulmonary embolus
A/a gradient arterial pO2 (meas-
ured) – alveolar pO2 (estimated) • Pulmonary fibrosis
The arterial/alveolar (a/A) ratio CRITICAL VALUES: N/A

reflects the percentage of alveolar pO2
that is contained in arterial pO2. It is INTERFERING FACTORS:
calculated by dividing the arterial pO2 • Specimens should be collected before
by the alveolar pO2 administration of oxygen therapy.
Alveolar/Arterial Gradient and Arterial/Alveolar Oxygen Ratio 37
• The temperature of the patient should time. For related laboratory tests,
be noted and reported to the laboratory refer to the Cardiovascular, Geni-
if significantly elevated or depressed so tourinary, and Respiratory System
that measured values can be corrected tables.
to actual body temperature. ➤ Note any recent procedures that can
• Exposure of sample to room air affects ➤ Obtain a list of medications the
test results. patient is taking, especially medica-
• Values normally increase with increas- tions known to affect bleeding,
ing age (see monograph titled “Blood including anticoagulants, aspirin and
other salicylates, herbals, and nutra-
Gases”).
ceuticals (see Appendix F: Effects of
• Samples for A/a gradient evalua- Natural Products on Laboratory
tion are obtained by arterial Tests). It is recommended that use of
puncture, which carries a risk of bleed- such products be discontinued 14
ing, especially in patients with bleeding days before dental or surgical proce-
dures. The requesting health care
disorders or who are taking medica-
tions for a bleeding disorder. advised if the patient regularly uses
• Prompt and proper specimen process- these products so that their effects
ing, storage, and analysis are important can be taken into consideration when
to achieve accurate results. Specimens reviewing results.
should always be transported to the ➤ Indicate the type of oxygen, mode of
laboratory as quickly as possible after oxygen delivery, and delivery rate as
collection. Delay in transport of the part of the test requisition process.
Wait 30 minutes after a change in
sample or transportation without ice type or mode of oxygen delivery or
may affect test results. rate for specimen collection.
patient, and advise rest for 30 min-
Nursing Implications and utes before specimen collection.
Procedure ● ● ● ● ● ● ● ● ● ● ● Address concerns about pain related
to the procedure. Be sure to explain
Pretest: to the patient that an arterial punc-
ture may be painful. The site may be
➤ Inform the patient that the test is anesthetized with 1% to 2% lido-
used to assess effective delivery of caine before puncture. Inform the
oxygen by comparing the difference patient that specimen collection usu-
between oxygen levels in the arter- ally takes 10 to 15 minutes.
ies and the alveoli of the lungs.
➤ If the sample is to be collected
➤ Obtain a history of the patient’s com- by radial artery puncture, per-
plaints, including a list of known form an Allen test before puncture to
allergens (especially allergies or sen- ensure that the patient has adequate
sitivities to latex or anesthetics), and collateral circulation to the hand. The
inform the appropriate health care modified Allen test is performed as
practitioner accordingly. follows: extend the patient’s wrist
➤ Obtain a history of the patient’s res- over a rolled towel. Ask the patient
piratory system and any bleeding to make a fist with the hand
disorders as well as results of previ- extended over the towel. Use the
ously performed laboratory tests, second and third fingers to locate
surgical procedures, and other diag- the pulses of the ulnar and radial
nostic procedures, especially bleed- arteries on the palmar surface of the
ing time, coagulation time, complete wrist. (The thumb should not be
blood count, platelets, partial throm- used to locate these arteries
boplastin time, and prothrombin because it has a pulse.) Compress
both arteries, and ask the patient to puncture site. Apply a pressure
open and close the fist several times dressing over the puncture site.
until the palm turns pale. Release Samples should be mixed by gentle
pressure on the ulnar artery only. rolling of the syringe to ensure
Color should return to the palm proper mixing of the heparin with the
within 5 seconds if the ulnar artery sample, which will prevent the for-
is functioning. This is a positive Allen mation of small clots leading to
test, and blood gases may be rejection of the sample. The tightly
drawn from the radial artery site. The capped sample should be placed in
Allen test should then be perfor- an ice slurry immediately after col-
med on the opposite hand. The lection. Information on the specimen
hand to which color is restored label can be protected from water in
fastest has better circulation and the ice slurry by first placing the
should be selected for specimen col- specimen in a protective plastic bag.
lection. Promptly transport the specimen to
➤ There are no food, fluid, or medica- the laboratory for processing and
tion restrictions unless by medical analysis.
direction. ➤ The results are recorded manually or
➤ Prepare an ice slurry in a cup or plas- in a computerized system for recall
tic bag to have ready for immediate and postprocedure interpretation by
transport of the specimen to the the appropriate health care practi-
laboratory. tioner.
Post-test:
Intratest:
➤ Pressure should be applied to the
➤ If the patient has a history of severe puncture site for at least 5 minutes in
allergic reaction to latex, care should the unanticoagulated patient and for
be taken to avoid the use of equip- at least 15 minutes in the case of a
ment containing latex. patient receiving anticoagulant ther-
➤ Instruct the patient to cooperate apy. Observe puncture site for bleed-
fully and to follow directions. ing or hematoma formation. Apply
Direct the patient to breathe nor- pressure bandage.
mally and to avoid unnecessary
➤ Teach the patient breathing exer-
movement.
cises to assist with the appropriate
➤ Observe standard precautions, and exchange of oxygen and carbon
follow the general guidelines in dioxide.
patient, and label the appropriate ➤ Administer oxygen, if appropriate.
tubes with the corresponding patient ➤ Teach the patient how to properly
demographics, date, and time of col- use incentive spirometry or nebu-
lection. lizer, if ordered.
➤ Perform an arterial puncture, and col- ➤ Intervene appropriately for hypoxia
lect the specimen in an air-free and ventilatory disturbances.
heparinized syringe. There is no
demonstrable difference in results ➤ A written report of the examination
between samples collected in plastic will be sent to the requesting health
syringes and samples collected in care practitioner, who will discuss
glass syringes. It is very important the results with the patient.
that no room air be introduced into ➤ Reinforce information given by the
the collection container, because the patient’s health care provider regard-
gases in the room and in the sample ing further testing, treatment, or
will begin equilibrating immediately. referral to another health care
The end of the syringe must be stop- provider. Answer any questions or
pered immediately after the needle address any concerns voiced by the
is withdrawn and removed from the patient or family.
Alzheimer’s Disease Markers 39
➤ Depending on the results of this Related laboratory tests:

procedure, additional testing may
be performed to evaluate or moni- ➤ Related laboratory tests include
tor progression of the disease allergen-specific immunoglobulin E
process and determine the need for (IgE), 1-antitrypsin, 1-antitrypsin
a change in therapy. Evaluate test phenotyping, blood gases, D-dimer,
results in relation to the patient’s electrolytes, eosinophil count, fib-
symptoms and other tests per- rinogen, hypersensitivity pneumoni-
formed. tis, IgE, and theophylline.
ALZHEIMER’S DISEASE MARKERS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: CSF tau protein and -amyloid-42, AD.

SPECIMEN: Cerebrospinal fluid (CSF) (1 to 2 mL) collected in a plain plas-
tic conical tube.
REFERENCE VALUE: (Method: Enzyme-linked immunosorbent assay)

Simultaneous tau protein and -amyloid-42 measurements in CSF are used
in conjunction as biochemical markers of Alzheimer’s disease (AD). Scientific
studies indicate that a combination of elevated tau protein and decreased -
amyloid-42 protein levels are consistent with the presence of AD. Values are
highly dependent on the reagents and standards used in the assay. Ranges
vary among laboratories; the testing laboratory should be consulted for inter-
pretation of results.
DESCRIPTION & RATIONALE: AD is the main component of the classic

the most common cause of dementia neurofibrillary tangles found in
in the elderly population. AD is a dis- patients with AD. Tau protein concen-
order of the central nervous system tration is believed to reflect the num-
that results in progressive and pro- ber of neurofibrillary tangles and may
found memory loss followed by loss of be an indication of the severity of the
cognitive abilities and death. It may disease. -Amyloid-42 is a free-float-
follow years of progressive formation ing protein normally present in CSF. It
of amyloid plaques and brain tangles, is believed to accumulate in the central
or it may appear as an early-onset form nervous system of patients with AD,
of the disease. Two recognized patho- causing the formation of amyloid
logic features of AD are neurofibrillary plaques on brain tissue. The result is
tangles and amyloid plaques found in that these patients have lower CSF val-
the brain. Abnormal forms of the ues compared to age-matched non-
microtubule-associated tau protein are AD control subjects. ■
INDICATIONS: can be taken into consideration

• Assist in establishing a diagnosis of AD when reviewing results.
patient. Inform the patient that the
RESULT procedure will be performed by a
health care practitioner and takes
Increased in: approximately 20 minutes. Address
• Acquired immunodeficiency syndrome concerns about pain related to the
procedure. Explain to the patient that
• AD there may be some discomfort dur-
ing the lumbar puncture. Inform the
• Cerebrovascular disease patient that a stinging sensation may
• Creutzfeldt-Jakob disease be felt as the local anesthetic is
injected. Tell the patient to report any
• Meningoencephalitis pain or other sensations that may
require repositioning of the spinal
• Pick’s disease needle.
➤ Inform the patient that the position
CRITICAL VALUES: N/A required for the lumbar puncture
may be awkward but that some-
INTERFERING FACTORS: one will assist. Stress the impor-
• Some patients with AD may have nor- tance of remaining still and breath-
mal levels of tau protein because of an ing normally throughout the proce-
insufficient number of neurofibrillary dure.
tangles. ➤ Sensitivity to social and cultural
issues, as well as concern for mod-
esty, is important in providing psy-
Nursing Implications and chological support before, during,
Procedure ● ● ● ● ● ● ● ● ● ● ●
and after the procedure.
Pretest: tion restrictions unless by medical
direction.
used to assist in predictive testing ➤ Make sure a written and informed
for or confirmation of Alzheimer’s consent has been signed prior to the
disease, and to monitor progression procedure and before administering
of and therapy for the disease. any medications.
➤ Obtain a history of the patient’s com- Intratest:
plaints, including a list of known
allergens (especially allergies or sen- ➤ If the patient has a history of severe
sitivities to latex or anesthetics), and allergic reaction to latex, care should
inform the appropriate health care be taken to avoid the use of equip-
practitioner accordingly. ment containing latex.
➤ Obtain a history of the patient’s neu- ➤ Instruct the patient to cooperate fully
rologic system and results of previ- and to follow directions. Direct the
ously performed laboratory tests, patient to breathe normally and to
surgical procedures, and other diag- avoid unnecessary movement.
nostic procedures. ➤ Observe standard precautions, and
➤ Obtain a list of the medications the follow the general guidelines in
patient is taking, including herbs, Appendix A. Positively identify the
nutritional supplements, and nutra- patient, and label the appropriate
ceuticals. The requesting health care tubes with the corresponding patient
practitioner and laboratory should be demographics, date, and time of col-
advised if the patient regularly uses lection.
these products so that their effects ➤ Record baseline vital signs, and
Alzheimer’s Disease Markers 41
assess neurologic status. Protocols minutes for 1 hour, then every 2

may vary from facility to facility. hours for 4 hours, and as ordered.
➤ To perform a lumbar puncture, posi- Take the temperature every 4 hours
tion the patient in the knee-chest for 24 hours. Compare with baseline
position at the side of the bed. values. Protocols may vary from
Provide pillows to support the spine facility to facility.
or for the patient to grasp. The sitting ➤ Administer fluids, if permitted, to
position is an alternative. In this posi- replace lost CSF and help prevent or
tion, the patient must bend the neck relieve headache, which is a side
and chest to the knees. effect of lumbar puncture.
➤ Prepare the site (usually between L3 ➤ Check the puncture site for leakage,
and L4 or L4 and L5) with povidone- and frequently monitor body signs,
iodine, and drape the area. such as temperature and blood pres-
➤ A local anesthetic is injected. Using sure.
sterile technique, the health care
practitioner inserts the spinal needle ➤ Position the patient flat, either on the
through the spinous processes of back or abdomen, although some
the vertebrae and into the subarach- health care practitioners allow 30
noid space. The stylet is removed. degrees of elevation. Maintain this
CSF drips from the needle if it is position for 8 hours. Changing posi-
properly placed. tion is acceptable as long as the
body remains horizontal.
➤ Attach the stopcock and manometer,
and measure initial CSF pressure. ➤ Observe the patient for neurologic
Normal pressure for an adult in the changes, such as altered level of con-
lateral recumbent position is 90 to sciousness, change in pupils, reports
180 mm H2O. These values depend of tingling or numbness, and irritabil-
on the body position and are differ- ity.
ent in a horizontal or sitting position. ➤ Recognize anxiety related to test
➤ If the initial pressure is elevated, the results, and be supportive of per-
health care practitioner may perform ceived loss of independence and
Queckenstedt’s test. To perform this fear of shortened life expectancy.
test, apply pressure to the jugular Discuss the implications of abnormal
vein for about 10 seconds. CSF pres- test results on the patient’s lifestyle.
sure usually rises in response to the Provide teaching and information
occlusion, then rapidly returns to nor- regarding the clinical implications
mal within 10 seconds after the pres- of the test results, as appropriate.
sure is released. Sluggish response Educate the patient and family
may indicate CSF obstruction. members regarding access to
➤ Obtain CSF, and place in specimen counseling and other supportive
tubes. Take a final pressure reading, services.
and remove the needle. Clean the ➤ Reinforce information given by the
puncture site with an antiseptic solu- patient’s health care provider regard-
tion, and apply a small bandage. ing further testing, treatment, or
➤ Promptly transport the specimen to referral to another health care
the laboratory for processing and provider. Answer any questions or
analysis. address any concerns voiced by the
➤ The results are recorded manually or patient or family.
in a computerized system for recall ➤ Depending on the results of this pro-
and postprocedure interpretation by cedure, additional testing may be
the appropriate health care practi- performed to evaluate or monitor
tioner. progression of the disease process
Post-test: and determine the need for a change
➤ After lumbar puncture, monitor vital relation to the patient’s symptoms
signs and neurologic status every 15 and other tests performed.
AMINO ACID SCREEN, BLOOD

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
REFERENCE VALUE: (Method: Chromatography) There are numerous amino

acids. The following table includes those most frequently screened. All units
are nanomoles per milliliter (nmol/mL).
-Amino-
-Amino N-butyric
Age Alanine -Alanine Anserine adipic Acid Acid
Premature 212–504 0 — 0 14–52
Newborn–1 131–710 0–10 0 0 8–24
mo
2 mo–2 y 143–439 0–7 0 0 3–26
2–18 y 152–547 0–7 0 0 4–31
Adult 177–583 0–12 0 0–6 5–41
-Amino- -Aminoiso- Aspartic
Age butyric Acid butyric Acid Arginine Asparagine Acid
Premature 0 0 34–96 90–295 24–50
Newborn–1 0–2 0 6–140 29–132 20–129
mo
2 mo–2 y 0 0 12–133 21–95 0–23
2–18 y 0 0 10–140 23–112 1–24
Adult 0 0 15–128 35–74 1–25
Cysta- Ethanol-
Age Carnosine Citrulline thionine Cystine amine
Premature — 20–87 5–10 15–70 —
Newborn–1 0–19 10–45 0–3 17–98 0–115
mo
2 mo-2 y 0 3–35 0–5 16–84 0–4
2–18 y 0 1–46 0–3 5–45 0–7
Adult 0 12–55 0–3 5–82 0–153
Amino Acid Screen, Blood 43
Glutamic Homo-
Age Acid Glutamine Glycine Histidine cystine
Premature 107–276 248–850 298–602 72–134 3–20
Newborn–1 62–620 376–709 232–740 30–138 0
mo
2 mo–2 y 10–133 246–1182 81–436 41–101 0
2–18 y 5–150 254–823 127–341 41–125 0–5
Adult 10–131 205–756 151–490 72–124 0
Hydroxy- Hydroxy-
Age lysine proline Isoleucine Leucine Lysine
Premature 0 0–80 23–85 151–220 128–255
Newborn–1 0–7 0–91 26–91 48–160 92–325
mo
2 mo–2 y 0–7 0–63 31–86 47–155 52–196
2–18 y 0–2 3–45 22–107 49–216 48–284
Adult 0 0–53 30–108 72–201 116–296
1-Methyl- 3-Methyl- Phenyl-
Age Methionine histidine histidine Ornithine alanine
Premature 37–91 4–28 5–33 77–212 98–213
Newborn–1 10–60 0–43 0–5 48–211 38–137
mo
2 mo–2 y 9–42 0–44 0–5 22–103 31–75
2–18 y 7–47 0–42 0–5 10–163 26–91
Adult 10–42 0–39 0–8 48–195 35–85
Phospho- Phospho-
Age ethanolamine serine Proline Sarcosine Serine
Premature 5–35 10–45 92–310 0 127–248
Newborn–1 3–27 7–47 110–417 0–625 99–395
mo
2 mo–2 y 0–6 1–20 52–298 0 71–186
2–18 y 0–69 1–30 59–369 0–9 69–187
Adult 0–40 2–14 97–329 0 58–181
Age Taurine Threonine Tryptophan Tyrosine Valine
Premature 151–411 150–330 28–136 147–420 99–220

Newborn–1 46–492 90–329 0–60 55–147 86–190
mo
2 mo–2 y 15–143 24–174 23–71 22–108 64–294
2–18 y 10–170 35–226 0–79 24–115 74–321
Adult 54–210 60–225 10–140 34–112 119–336
• Glomerulonephritis
DESCRIPTION & RATIONALE: Screen-
ing for inborn errors of amino acid • Hartnup disease
metabolism is generally performed on • Huntington’s chorea
infants after an initial blood test with
• Malnutrition
abnormal results. Certain congenital
enzyme deficiencies interfere with nor- • Nephrotic syndrome
mal amino acid metabolism and cause
• Pancreatitis (acute)
excessive accumulation of or deficien-
cies in amino acid levels. Reduced • Polycystic kidney disease
growth rates, mental retardation, or • Rheumatoid arthritis
various unexplained symptoms can
result unless the abnormality is identi-
fied and corrected early in life. ■ CRITICAL VALUES: N/A
Interfering factors:
INDICATIONS:
• Assist in the detection of noninherited • Drugs that may increase plasma amino
disorders evidenced by elevated amino acid levels include bismuth salts, gluco-
acid levels corticoids, levarterenol, 11-oxysteroids,
and testosterone (elderly).
• Detect inborn errors of amino acid
metabolism • Drugs that may decrease plasma amino
acid levels include cerulein, epineph-
RESULT rine, estrogens (males), glucose, oral
contraceptives, progesterone (males),
Increased (total amino acids) in: and secretin.
• Aminoacidopathies (usually inherited; • Amino acids exhibit a strong circadian
specific amino acids are implicated) rhythm; values are highest in the after-
• Brain damage (severe) noon and lowest in the morning.
Protein intake does not influence diur-
• Burns nal variation but significantly affects
• Diabetes absolute concentrations.
• Eclampsia • Failure to follow dietary restrictions
before the procedure may cause the
• Fructose intolerance (hereditary) procedure to be canceled or repeated.
• Malabsorption
• Renal failure (acute or chronic)
• Reye’s syndrome Procedure ● ● ● ● ● ● ● ● ● ● ●
• Severe liver damage

Pretest:
• Shock ➤ Inform the patient (and/or caregiver)
that the test is used to screen for
Decreased (total amino acids) in: congenital errors of protein metabo-
• Adrenocortical hyperfunction lism and transport.
• Carcinoid syndrome ➤ Obtain a history of the patient’s
complaints, including a list of known
• Fever allergens (especially allergies or sen-
Amino Acid Screen, Blood 45
sitivities to latex), and inform the normally and to avoid unnecessary

appropriate health care practitioner movement. The caregiver may assist
accordingly. in preventing unnecessary move-
ment.
➤ Obtain a history of the patient’s or
parents’ reproductive system as it ➤ Observe standard precautions, and
relates to genetic disease, as well follow the general guidelines in
as results of previously performed Appendix A. Positively identify the
laboratory tests, surgical proce- patient, and label the appropriate
dures, and other diagnostic proce- tubes with the corresponding patient
dures. For related laboratory tests, demographics, date, and time of col-
refer to the Reproductive System lection. Perform a venipuncture; col-
table. lect the specimen in a 5-mL red-top
tube.
➤ Obtain a list of the medications the
patient is taking, including herbs, ➤ Remove the needle, place a gauze
nutritional supplements, and nutra- over the puncture site and apply
ceuticals. The requesting health care gentle pressure to stop bleeding.
practitioner and laboratory should be Observe venipuncture site for bleed-
advised if the patient regularly uses ing or hematoma formation. Apply
these products so that their effects paper tape over gauze or replace
can be taken into consideration adhesive plastic bandage.
when reviewing results. ➤ Promptly transport the specimen to
➤ Review the procedure with the the laboratory for processing and
patient (and/or caregiver). Inform the analysis.
patient (and/or caregiver) that ➤ The results are recorded manually or
specimen collection takes approxi- in a computerized system for recall
mately 5 to 10 minutes. Address and postprocedure interpretation by
concerns about pain related to the the appropriate health care practi-
procedure. Explain to the patient tioner.
(and/or caregiver) that there may
venipuncture. Post-test:
➤ Sensitivity to social and cultural ➤ Instruct the patient to resume usual
issues is important in providing psy- diet as directed by the health care
chological support before, during, practitioner.
and after the procedure. ➤ Nutritional considerations: Instruct
➤ There are no food, fluid or medica- the patient (and/or caregiver) in spe-
tion restrictions unless by medical cial dietary modifications, as appro-
direction. priate to treat deficiency, or refer
caregiver to a qualified nutritionist.
Amino acids are classified as essen-
Intratest: tial (i.e., must be present simultane-
➤ Ensure that the patient has complied ously in sufficient quantities);
with dietary and other pretesting conditionally or acquired essential
preparations; assure that food has (i.e., under certain stressful condi-
been restricted for at least 12 hours tions, they become essential); and
prior to the procedure. nonessential (i.e., can be produced
by the body, when needed, if diet
➤ If the patient has a history of severe does not provide them). Essential
allergic reaction to latex, care should amino acids include lysine, threo-
be taken to avoid the use of equip- nine, histidine, isoleucine, methion-
ment containing latex. ine, phenylalanine, tryptophan, and
➤ Instruct the patient (and/or caregiver) valine. Conditionally essential amino
to cooperate fully and to follow direc- acids include cysteine, tyrosine, argi-
tions. Direct the patient to breathe nine, citrulline, taurine, and carnitine.
Nonessential amino acids include giver) regarding access to genetic or

alanine, glutamic acid, aspartic other counseling services.
acid, glycine, serine, proline, gluta- ➤ Reinforce information given by the
mine, and asparagine. A high intake patient’s health care provider regard-
of specific amino acids can cause ing further testing, treatment, or
other amino acids to become essen- referral to another health care provi-
tial. der. Answer any questions or add-
➤ A written report of the examination ress any concerns voiced by the
will be sent to the requesting health patient or family.
the results with the patient (and/or cedure, additional testing may be
caregiver). performed to evaluate or monitor
results, and be supportive of per- and determine the need for a change
ceived loss of independence and in therapy. Evaluate test results in
fear of shortened life expectancy. relation to the patient’s symptoms
Discuss the implications of abnormal and other tests performed.
test results on the patient’s lifestyle.
Provide teaching and information
regarding the clinical implications of ➤ Related laboratory tests include
the test results, as appropriate. ammonia and urine amino acid
Educate the patient (and/or care- screen.
AMINO ACID SCREEN, URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Urine (10 mL) from a random or timed specimen collected in a
clean plastic collection container with hydrochloric acid as a preservative.
REFERENCE VALUE: (Method: Chromatography) There are numerous amino

acids. The following table includes those most frequently screened. All units
are nanomoles per milligram (nmol/mg) creatinine.
Amino Acid Screen, Urine 47
a-Amino- a-Amino-
adipic N-butyric
Age Alanine -Alanine Anserine Acid Acid
Premature 1320–4040 1020–3500 — 70–460 50–710
Newborn– 982–3055 25–288 0–3 0–180 8–65
1 mo
2 mo–2 y 767–6090 0–297 0–5 45–268 30–136
2–18 y 231–915 0–65 0 2–88 0–77
Adult 240–670 0–130 0 40–110 0–90
-Amino- -Aminoiso- Aspartic
Age butyric Acid butyric Acid Arginine Asparagine Acid
Premature 20–260 50–470 190–820 1350–5250 580–1520
Newborn– 0–15 421–3133 35–214 185–1550 336–810
1 mo
2 mo–2 y 0–105 802–4160 38–165 252–1280 230–685
2–18 y 15–30 291–1482 31–109 72–332 0–120
Adult 15–30 10–510 10–90 99–470 60–240
Cystath- Ethano
Age Carnosine Citrulline ionine Cystine amine
Premature 260–370 240–1320 260–1160 480–1690 —
Newborn– 97–665 27–181 16–147 212–668 840–3400
1 mo
2 mo–2 y 203–635 22–180 33–470 68–710 0–2230
2–18 y 72–402 10–99 0–26 25–125 0–530
Adult 10–90 8–50 20–50 43–210 0–520
Glutamic Homo-
Age Acid Glutamine Glycine Histidine cystine
Premature 380–3760 520–1700 7840– 1240–7240 580–2230
23,600
Newborn– 70–1058 393–1042 5749– 908–2528 0–88
1 mo 16,423
2 mo–2 y 54–590 670–1562 3023– 815–7090 6–67
11,148
2–18 y 0–176 369–1014 897–4500 644–2430 0–32
Adult 39–330 190–510 730–4160 460–1430 0–32
Hydroxy- Hydroxy-
Age lysine proline Isoleucine Leucine Lysine
Premature — 560–5640 250–640 190–790 1860–15,460
Newborn– 10–125 40–440 125–390 78–195 270–1850
1 mo
2 mo–2 y 0–97 0–4010 38–342 70–570 189–850
2–18 y 40–102 0–3300 10–126 30–500 153–634
Adult 40–90 0–26 16–180 30–150 145–634
(Continued on the following page)

1-Methyl- 3-Methyl- Phenyl-

Age Methionine histidine histidine Ornithine alanine
Premature 500–1230 170–880 420–1340 260–3350 920–2280
Newborn– 342–880 96–499 189–680 118–554 91–457
1 mo
2 mo–2 y 174–1090 106–1275 147–391 55–364 175–1340
2–18 y 16–114 170–1688 182–365 31–91 61–314
Adult 38–210 170–1680 160–520 20–80 51–250
Phospho- Phospho-
Age ethanolamine serine Proline Sarcosine Serine
Premature 80–340 500–1690 1350– 0 1680–6000
10,460
Newborn– 0–155 150–339 370–2323 0–56 1444–3661
1 mo
2 mo–2 y 108–533 112–304 254–2195 30–358 845–3190
2–18 y 18–150 70–138 0 0–26 362–1100
Adult 20–100 40–510 0 0–80 240–670
Age Taurine Threonine Tryptophan Tyrosine Valine
Premature 5190– 840–5700 0 1090–6780 180–890
23,620
Newborn– 1650–6220 445–1122 0 220–1650 113–369
1 mo
2 mo–2 y 545–3790 252–1528 0–93 333–1550 99–316
2–18 y 639–1866 121–389 0–108 122–517 58–143
Adult 380–1850 130–370 0–70 90–290 27–260
DESCRIPTION & RATIONALE: Urine rates, and various unexplained symp-

amino acid testing is used in the initial toms. Values are age dependent. A
screening for congenital defects and positive screen on a random sample
disorders of amino acid metabolism. should be followed up with a timed
The major genetic disorders include collection. Amino acid concentrations
phenylketonuria, tyrosinuria, and demonstrate a significant circadian
alcaptonuria, a defect in the phenyl- rhythm with values being lowest in
alanine-tyrosine conversion pathway. the morning and highest in midafter-
Renal aminoaciduria is also associated noon. ■
with conditions marked by defective
tubular reabsorption from congenital INDICATIONS:
disorders, such as hereditary fructose • Assist in the detection of noninherited
intolerance, cystinuria, and Hartnup disorders evidenced by elevated amino
disease. Early diagnosis and treatment acid levels
of certain aminoacidurias can prevent • Screen for inborn errors of amino acid
mental retardation, reduced growth metabolism

• Drugs that may increase urine amino
Increased (total amino acids) in: acid levels include acetaminophen,
• Primary causes (inherited): acetosalicylic acid, amikacin, amino-
Aminoaciduria (specific) caproic acid, amphetamine, bismuth,
Cystinosis (may be masked cephalosporins, colistin, corticotropin,
because of decreased glomerular dopamine, ephedrine, epinephrine,
filtration rate, so values may be erythromycin, ethylenediamine, gen-
in normal range) tamicin, hydrocortisone, hydroxyami-
Fanconi’s syndrome nobutyric acid, insulin, kanamycin,
Fructose intolerance levarterenol, levodopa, mafenide, meta-
nephrine, methamphetamine, methyl-
Galactosemia
dopa, neomycin, normetanephrine,
Hartnup disease penicillins, phenacetin, phenobarbital,
Lactose intolerance phenylephrine, phenylpropanolamine,
Lowe’s syndrome polymixin, polythiazide, primidone,
Maple syrup urine disease proSobee, pseudoephedrine, strepto-
Tyrosinemia type I zocin, tetracycline, triamcinolone, val-
proic acid, and vigabatrin.
Tyrosinosis
Wilson’s disease • Drugs that may decrease urine amino
• Secondary causes (noninherited): acid levels include antihistamines.
Acute leukemia • Amino acids exhibit a strong circadian
Chronic renal failure (reduced GFR) rhythm; values are highest in the after-
Chronic renal failure noon and lowest in the morning.
Diabetic ketosis Protein intake does not influence diur-
nal variation but significantly affects
Epilepsy (transient increase due to
disturbed renal function during absolute concentrations.
grand mal seizure) • Dilute urine (specific gravity less than
Folic acid deficiency 1.010) should be rejected for analysis.
Hyperparathyroidism
Liver necrosis and cirrhosis • Failure to follow dietary restrictions
Multiple myeloma
procedure to be canceled or repeated.
Muscular dystrophy (progressive)
Osteomalacia (secondary to
parathyroid hormone excess)
Pernicious anemia
Procedure ● ● ● ● ● ● ● ● ● ● ●
Thalassemia major
Vitamin deficiency (B, C, and D;
vitamin D–deficiency rickets, Pretest:
vitamin D–resistant rickets)
➤ Inform the patient (and/or caregiver)
Viral hepatitis (reflects the degree that the test is used to screen for
of hepatic involvement) congenital errors of protein metabo-
lism and transport.
Decreased in: N/A ➤ Obtain a history of the patient’s com-
CRITICAL VALUES: N/A allergens (especially allergies or sen-
sitivities to latex), and inform the contamination of the specimen.

appropriate health care practitioner Place a sign in the bathroom to
accordingly. remind the patient to save all urine.
➤ Obtain a history of the patient’s and ➤ Instruct the patient to void all urine
parents’ reproductive system as it into the collection device and pour
relates to genetic disease, as well as the urine into the laboratory collec-
results of previously performed labo- tion container. Alternatively, the
ratory tests, surgical procedures, specimen can be left in the collection
and other diagnostic procedures. For device for a health care staff mem-
related laboratory tests, refer to the ber to add to the laboratory collec-
Reproductive System table. tion container.
patient is taking, including herbs, Intratest:
ceuticals. The requesting health care ➤ Ensure that the patient has complied
practitioner and laboratory should be with dietary and other pretesting
advised if the patient regularly uses preparations; assure that food has
these products so that their effects been restricted for at least 12 hours
can be taken into consideration prior to the procedure.
when reviewing results. ➤ Observe standard precautions, and
➤ Review the procedure with the follow the general guidelines in
patient (and/or caregiver). Inform the Appendix A. Positively identify the
patient and caregiver that random patient, and label the appropriate
urine specimen collection takes specimen container with the corre-
approximately 5 minutes. Address sponding patient demographics,
concerns about pain related to the date, and time of collection. Include
procedure. Explain to the patient on the timed specimen label the
(and/or caregiver) that no pain will be amount of urine and test start and
experienced during the test. stop times.
➤ Sensitivity to social and cultural ➤ Promptly transport the specimen to
issues is important in providing psy- the laboratory for processing and
chological support before, during, analysis.
and after the procedure. ➤ The results are recorded manually or
➤ There are no fluid or medication in a computerized system for recall
restrictions unless by medical direc- and postprocedure interpretation by
tion. the appropriate health care practi-
tioner.
➤ The patient should avoid excessive
exercise and stress during the 24-
hour collection of urine. Random specimen (collect
in early morning):
patient (and/or caregiver). Provide a ➤ Infant: Clean and dry the genital
nonmetallic urinal, bedpan, or toilet- area, attach the collection device
mounted collection device. securely to prevent leakage, and
➤ If a timed collection is requested, observe for voiding. Remove collec-
inform the patient that all urine col- tion device carefully from the skin to
lected over a 24-hour period must be prevent irritation. Transfer the urine
saved; if a preservative has been into a specimen container. For dip-
added to the container, instruct the stick method, place dipstick or
patient not to discard the preserva- reagent pad into the urine specimen
tive. Instruct the patient not to void or on the diaper saturated with urine.
directly into the laboratory collection Remove, compare with color chart,
container. Instruct the patient to and record results.
avoid defecating in the collection ➤ Adult: Instruct the patient to obtain a
device and to keep toilet tissue out clean-catch specimen as described
of the collection device to prevent in Appendix A. If an indwelling
catheter is in place, it may be neces- Amino acids are classified as essen-

sary to clamp off the catheter for 15 tial (i.e., must be present simultane-
to 30 minutes before specimen col- ously in sufficient quantities);
lection. Cleanse specimen port with conditionally or acquired essential
antiseptic swab, and then aspirate 5 (i.e., under certain stressful condi-
mL of urine with a 21- to 25-gauge tions, they become essential); and
needle and syringe. Transfer urine to nonessential (i.e., can be produced
a properly labeled plastic container. by the body, when needed, if diet
does not provide them). Essential
Timed specimen: amino acids include lysine, threo-
nine, histidine, isoleucine, methion-
➤ Obtain a clean 3-L urine specimen
ine, phenylalanine, tryptophan, and
container, toilet-mounted collection
valine. Conditionally essential amino
device, and plastic bag (for transport
acids include cysteine, tyrosine, argi-
of the specimen container). The
nine, citrulline, taurine, and carnitine.
specimen must be refrigerated or
Nonessential amino acids include
kept on ice throughout the entire col-
alanine, glutamic acid, aspartic acid,
lection period. If an indwelling uri-
glycine, serine, proline, glutamine,
nary catheter is in place, the
and asparagine. A high intake of spe-
drainage bag must be kept on ice.
cific amino acids can cause other
➤ Begin the test between 6 and 8 a.m., amino acids to become essential.
if possible. Collect first voiding and
discard. Record the time the speci- ➤ A written report of the examination
men was discarded as the beginning will be sent to the requesting health
of the timed collection period. The care practitioner, who will discuss
next morning, ask the patient to void the results with the patient (and/or
at the same time the collection was caregiver).
started, and add this last voiding to ➤ Recognize anxiety related to test
the container. results, and be supportive of per-
➤ If an indwelling catheter is in place, ceived loss of independence and fear
replace the tubing and container sys- of shortened life expectancy. Discuss
tem at the start of the collection the implications of abnormal test
time. Keep the container system on results on the patient’s lifestyle.
ice during the collection period, or Provide teaching and information
empty the urine into a larger con- regarding the clinical implications of
tainer periodically during the collec- the test results, as appropriate. Edu-
tion period; monitor to ensure cate the patient regarding access to
continued drainage, and conclude genetic or other counseling services.
the test the next morning at the ➤ Reinforce information given by the
same hour the collection started. patient’s health care provider regard-
➤ At the conclusion of the test, com- ing further testing, treatment, or
pare the quantity of urine with the referral to another health care
urinary output record for the collec- provider. Answer any questions or
tion. If the specimen contains less address any concerns voiced by the
than what was recorded as output, patient or family.
some urine may have been dis- ➤ Depending on the results of this pro-
carded, invalidating the test. cedure, additional testing may be
Post-test: progression of the disease process
➤ Instruct the patient to resume usual and determine the need for a change
diet as directed by the health care in therapy. Evaluate test results in
practitioner. relation to the patient’s symptoms
➤ Nutritional considerations: Instruct
the patient (and/or caregiver) in spe- Related laboratory tests:
cial dietary modifications, as appro-
priate to treat deficiency, or refer ➤ Related laboratory tests include am-
caregiver to a qualified nutritionist. monia and blood amino acid screen.
-AMINOLEVULINIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: -ALA.
SPECIMEN: Urine (25 mL) from a timed specimen collected in a dark plastic
container with hydrochloric acid as a preservative.
Conventional Units SI Units (Conventional Units 7.626)

1.5–7.5 mg/24 h 11.4–57.2 mol/24 h
Decreased in:
DESCRIPTION & RATIONALE: - • Liver disease (alcoholic)
Aminolevulinic acid (-ALA) is
involved in the formation of por- CRITICAL VALUES: N/A
phyrins. Disturbances in porphyrin
metabolism can cause an increase in
-ALA excretion in urine. Although
• Drugs that may increase -ALA levels
lead poisoning can cause increased include ammonia, glucosamine, and
urinary excretion, the measurement of penicillins.
-ALA is not useful to indicate lead
toxicity because it is not detectable in • Cisplatin may decrease -ALA levels.
the urine until the blood lead level • Numerous drugs are suspected as
approaches and exceeds 40 g/dL. ■ potential initiators of attacks of acute
porphyria, but those classified as unsafe
for high-risk individuals include
INDICATIONS: aminoglutethimide, aminopyrine, anti-
• Assist in the diagnosis of porphyrias pyrine, barbiturates, carbamazepine,
carbromal, chlorpropamide, danazol,
RESULT dapsone, diclofenac, diphenylhydan-
toin, ergot preparations, ethchlorvynol,
Increased in: ethinamate, glutethimide, griseofulvin,
• Acute porphyrias mephenytoin, meprobamate, methy-
prylone, N-isopropyl meprobamate,
• Aminolevulinic acid dehydrase defi- novobiocin, phenylbutazone, primi-
ciency done, pyrazolone preparations, succin-
• Hereditary tyrosinemia imides, sulfomethane, sulfonamides,
sulfonethylmethane, synthetic estro-
• Lead poisoning gens and progestins, tolazamide, tolbu-
-Aminolevulinic Acid 53
tamide, trimethadione, and valproic lection container. Alternatively, the

acid. specimen can be left in the collection
device for a health care staff mem-
ber to add to the laboratory collec-
Nursing Implications and tion container.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Sensitivity to social and cultural
Pretest: esty, is important in providing psy-
➤ Inform the patient that the test is pri- chological support before, during,
marily used to diagnose porphyrias. and after the procedure.
➤ Obtain a history of the patient’s com- ➤ There are no food, fluid, or medica-
plaints, including a list of known tion restrictions unless by medical
allergens (especially allergies or sen- direction.
appropriate health care practitioner Intratest:
accordingly.
➤ Obtain a history of the patient’s allergic reaction to latex, care should
hematopoietic system and results of be taken to avoid the use of equip-
previously performed laboratory ment containing latex.
diagnostic procedures. For related ➤ Instruct the patient to cooperate fully
laboratory tests, refer to the Hema- and to follow directions.
topoietic System table. ➤ Observe standard precautions, and
patient is taking, including herbs, Appendix A. Positively identify the
nutritional supplements, and nutra- patient, and label the appropriate col-
ceuticals. The requesting health care lection container with the correspon-
practitioner and laboratory should be ding patient demographics, date, and
advised if the patient regularly uses time of collection.
can be taken into consideration Timed specimen:
when reviewing results. ➤ Obtain a clean 3-L urine specimen
➤ Review the procedure with the container, toilet-mounted collection
patient. Provide a nonmetallic urinal, device, and plastic bag (for transport
bedpan, or toilet-mounted collection of the specimen container). The
device. Address concerns about pain specimen must be refrigerated or
related to the procedure. Explain to kept on ice throughout the entire
the patient that there should be no collection period. If an indwelling
discomfort during the procedure. urinary catheter is in place, the
➤ Usually a 24-hour time frame for drainage bag must be kept on ice.
urine collection is ordered. Inform ➤ Begin the test between 6 and 8 a.m.,
the patient that all urine must be if possible. Collect first voiding and
saved during that 24-hour period. discard. Record the time the speci-
Instruct the patient not to void men was discarded as the beginning
directly into the laboratory collection of the timed collection period. The
container. Instruct the patient to next morning, ask the patient to void
avoid defacating in the collection at the same time the collection was
device and to keep toilet tissue out started, and add this last voiding to
of the collection device to prevent the container.
contamination of the specimen. ➤ If an indwelling catheter is in place,
Place a sign in the bathroom to replace the tubing and container sys-
remind the patient to save all urine. tem at the start of the collection
➤ Instruct the patient to void all urine time. Keep the container system on
into the collection device and then to ice during the collection period, or
pour the urine into the laboratory col- empty the urine into a larger con-
tainer periodically during the collec- care practitioner, who will discuss
tion period. Monitor to ensure con- the results with the patient.
tinued drainage, and conclude the ➤ Recognize anxiety related to test
test the next morning at the same results. Discuss the implications of
hour the collection was begun. abnormal test results on the
➤ At the conclusion of the test, com- patient’s lifestyle. Provide teaching
pare the quantity of urine with the and information regarding the clinical
urinary output record for the collec- implications of the test results, as
tion. If the specimen contains less appropriate.
than what was recorded as output,
some urine may have been dis- ➤ Reinforce information given by the
carded, invalidating the test. patient’s health care provider regard-
➤ Include on the specimen collection referral to another health care pro-
container’s label the amount of urine vider. Answer any questions or
as well as test start and stop times. address any concerns voiced by the
Note the ingestion of any medica- patient or family.
tions that may affect test results.
➤ Promptly transport the specimen to ➤ Depending on the results of this pro-
the laboratory for processing and cedure, additional testing may be
analysis. performed to evaluate or monitor
➤ The results are recorded manually or and determine the need for a change
in a computerized system for recall in therapy. Evaluate test results in
and postprocedure interpretation by relation to the patient’s symptoms
the appropriate health care practi- and other tests performed.
tioner.
Post-test: Related laboratory tests:
➤ A written report of the examination ➤ Related laboratory tests include lead
will be sent to the requesting health and urine porphyrins.
AMMONIA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: NH3.
SPECIMEN: Plasma (1 mL) collected in completely filled green-top (heparin)
tube. Specimen should be transported tightly capped and in an ice slurry.
SI Units (Conventional
Age Conventional Units Units 0.714)
Newborn 90–150 g/dL 64–107 mol/L
Adult Male 27–102 g/dL 19–73 mol/L
Adult Female 19–87 g/dL 14–62 mol/L
Ammonia 55
nase, barbiturates, diuretics, ethanol,

DESCRIPTION & RATIONALE: Blood fibrin hydrolysate, fluorides, furose-
ammonia (NH3) comes from two mide, thiazides, and valproic acid.
sources: deamination of amino acids • Drugs/organisms that may decrease
during protein metabolism and degra- ammonia levels include diphenhy-
dation of proteins by colon bacteria. dramine, kanamycin, neomycin, tetra-
The liver converts ammonia in the cycline, and Lactobacillus acidophilus.
portal blood to urea, which is excreted • Hemolysis falsely increases ammonia
by the kidneys. When liver function is levels.
severely compromised, especially in
situations in which decreased hepato- • Prompt and proper specimen process-
ing, storage, and analysis are important
cellular function is combined with
to achieve accurate results. The speci-
impaired portal blood flow, ammonia men should be collected on ice; the
levels rise. Ammonia is potentially collection tube should be filled com-
toxic to the central nervous system. ■ pletely, and then kept tightly stop-
pered. Ammonia increases rapidly in
INDICATIONS: the collected specimen, so analysis
• Evaluate advanced liver disease or other should be performed within 20 min-
disorders associated with altered serum utes of collection.
ammonia levels
• Identify impending hepatic enceph-
alopathy with known liver disease Nursing Implications and
• Monitor the effectiveness of treatment Procedure ● ● ● ● ● ● ● ● ● ● ●
for hepatic encephalopathy, indicated

by declining levels Pretest:
• Monitor patients receiving hyperali- ➤ Inform the patient that the test is
mentation therapy used to assess liver function, partic-
ularly in the diagnosis of urea cycle
RESULT deficiencies in neonates and the
identification of Reye’s syndrome.
Increased in: ➤ Obtain a history of the patient’s com-
• Gastrointestinal hemorrhage plaints, including a list of known
• Genitourinary tract infection with dis-
tention and stasis appropriate health care practitioner
• Hepatic coma accordingly.
• Inborn enzyme deficiency ➤ Obtain a history of the patient’s gas-
trointestinal, genitourinary, and
• Liver failure, late cirrhosis hepatobiliary systems, as well as
results of previously performed labo-
• Reye’s syndrome
• Total parenteral nutrition and other diagnostic procedures. For
related laboratory tests, refer to the
Decreased in: N/A Gastrointestinal, Genitourinary, and
Hepatobiliary System tables.
CRITICAL VALUES: N/A ➤ Obtain a list of the medications
the patient is taking, including
INTERFERING FACTORS: herbs, nutritional supplements, and
• Drugs that may increase ammonia lev- nutraceuticals. The requesting health
els include ammonium salts, asparagi- care practitioner and laboratory
should be advised if the patient in a computerized system for recall

regularly uses these products so and postprocedure interpretation by
that their effects can be taken into the appropriate health care practi-
consideration when reviewing tioner.
results.
Post-test:
imen collection takes approximately ➤ Nutritional considerations: Increased
5 to 10 minutes. Address concerns ammonia levels may be associated
about pain related to the procedure. with liver disease. Dietary recom-
Explain to the patient that there may mendations may be indicated,
be some discomfort during the depending on the severity of the
venipuncture. condition. A low-protein diet may be
➤ There are no food, fluid, or medica- in order if the patient’s liver has lost
tion restrictions unless by medical the ability to process the end prod-
direction. ucts of protein metabolism. A diet of
soft foods may be required if
Intratest: esophageal varices have developed.
Ammonia levels may be used to
➤ If the patient has a history of severe determine whether protein should
allergic reaction to latex, care should be added to or reduced from the
be taken to avoid the use of equip- diet. Patients should be encouraged
ment containing latex. to eat simple carbohydrates and
➤ Instruct the patient to cooperate fully emulsified fats (as in homogenized
and to follow directions. Direct the milk or eggs), as opposed to com-
patient to breathe normally and to plex carbohydrates (e.g., starch,
avoid unnecessary movement. fiber, and glycogen [animal carbohy-
drates]) and complex fats, which
➤ Observe standard precautions, and would require additional bile to emul-
follow the general guidelines in sify them so that they could be used.
Appendix A. Positively identify the The cirrhotic patient should be care-
patient, and label the appropriate fully observed for the development
tubes with the corresponding patient of ascites, in which case fluid and
demographics, date, and time of electrolyte balance requires strict
collection. Perform a venipuncture; attention.
collect the specimen in a 5-mL
green-top tube.
➤ Remove the needle, place a gauze care practitioner, who will discuss
over the puncture site and apply the results with the patient.
gentle pressure to stop bleeding.
Observe the venipuncture site for
bleeding or hematoma formation.
Apply paper tape over gauze or
replace with adhesive bandage.
➤ Promptly transport the specimen to address any concerns voiced by the
the laboratory for processing and patient or family.
analysis. The tightly capped sample ➤ Depending on the results of this pro-
should be placed in an ice slurry cedure, additional testing may be
immediately after collection. Infor- performed to evaluate or monitor
mation on the specimen label can be progression of the disease process
protected from water in the ice and determine the need for a change
slurry by first placing the specimen in therapy. Evaluate test results in
in a protective plastic bag. relation to the patient’s symptoms
Amniotic Fluid Analysis 57
ses, blood calcium, complete blood

count, electrolytes, glucose, ketones,
➤ Related laboratory tests include acet- lactic acid, osmolality, protein, pro-
aminophen, alanine aminotransfe- thrombin time, urea nitrogen, and uric
rase, albumin, anion gap, aspartate acid.
aminotransferase, bilirubin, blood ga-
AMNIOTIC FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Amniotic fluid (10 to 20 mL) collected in a clean amber glass or
plastic container.
REFERENCE VALUE: (Method: Macroscopic observation of fluid for color and

appearance, immunochemiluminometric assay [ZCMA] for 1-fetoprotein,
electrophoresis for acetylcholinesterase, spectrophotometry for creatinine and
bilirubin, chromatography for lecithin/sphingomyelin [L/S] ratio and phos-
phatidylglycerol, tissue culture for chromosome analysis, dipstick for leuko-
cyte esterase, and automated cell counter for white blood cell count and
lamellar bodies)
Test Reference Value

Color Colorless to pale yellow
Appearance Clear
1-Fetoprotein Less than 2.0 MoM
Acetylcholinesterase Absent
Creatinine 1.8–4.0 mg/dL at term
Bilirubin Less than 0.075 mg/dL in early
pregnancy
Less than 0.025 mg/dL at term
L/S ratio Greater than 2:1 at term
Phosphatidylglycerol Present at term
Chromosome analysis Normal karyotype
White blood cell count None seen
Leukocyte esterase Negative
Lamellar bodies 30,000–50,000 platelet equivalents
MoM multiples of the median.

maternal age (some of the aforemen-

DESCRIPTION & RATIONALE: Amni- tioned tests are routinely requested in
otic fluid is formed in the membra- mothers age 35 years and older).
nous sac that surrounds the fetus. The • Evaluate fetus in mothers with a history
total volume of fluid at term is 500 to of miscarriage or stillbirth.
2500 mL. In amniocentesis, fluid is
obtained by ultrasound-guided needle • Evaluate known or suspected hemolytic
disease involving the fetus in an Rh-
aspiration from the amniotic sac. This
sensitized pregnancy, indicated by ris-
procedure is generally performed ing bilirubin levels, especially after the
between 14 and 16 weeks’ gestation, 30th week of gestation.
but it also can be done between 26
and 35 weeks’ gestation if fetal distress • Evaluate suspected neural tube defects,
such as spina bifida or myelomeningo-
is suspected. Amniotic fluid is tested
cele, as indicated by elevated 1-
to identify genetic and neural tube fetoprotein (see monograph titled
defects, hemolytic diseases of the new- “1-Fetoprotein” for information re-
born, fetal infection, fetal renal mal- lated to triple-marker testing).
function, or maturity of the fetal lungs
(see monograph titled “Lecithin/ RESULT:
Sphingomyelin Ratio”). ■ • Yellow, green, red, or brown fluid indi-
cates the presence of bilirubin, blood
INDICATIONS: (fetal or maternal), or meconium,
• Assist in the diagnosis of (in utero) which indicate fetal distress or death,
metabolic disorders, such as cystic hemolytic disease, or growth retar-
fibrosis; or errors of lipid, carbohy- dation.
drate, or amino acid metabolism. • Elevated bilirubin levels indicate fetal
• Detect infection secondary to ruptured hemolytic disease or intestinal obstruc-
membranes. tion. Measurement of bilirubin is not
usually performed before 20 to 24
• Detect fetal ventral wall defects.
weeks’ gestation because no action can
• Determine fetal maturity when preterm be taken before then. The severity of
delivery is being considered. Fetal hemolytic disease is graded by optical
maturity is indicated by an L/S ratio of density (OD) zones: A value of 0.28 to
2:1 or greater (see monograph titled 0.46 OD at 28 to 31 weeks’ gestation
“Lecithin/Sphingomyelin Ratio”). indicates mild hemolytic disease, which
• Determine fetal sex when the mother is probably will not affect the fetus; 0.47
a known carrier of a sex-linked abnor- to 0.90 OD indicates a moderate effect
mal gene that could be transmitted to on the fetus; and 0.91 to 1.0 OD indi-
male offspring, such as hemophilia or cates a significant effect on the fetus. A
Duchenne’s muscular dystrophy. trend of increasing values with serial
measurements may indicate the need
• Determine the presence of fetal distress for intrauterine transfusion or early
in late-stage pregnancy. delivery, depending on the fetal age.
• Evaluate fetus in families with a history After 32 to 33 weeks’ gestation, early
of genetic disorders, such as Down syn- delivery is preferred over intrauterine
drome, Tay-Sachs disease, chromosome transfusion, because early delivery is
or enzyme anomalies, or inherited more effective in providing the
hemoglobinopathies. required care to the neonate.
• Evaluate fetus in mothers of advanced • Creatinine concentration greater than
2.0 mg/dL indicates fetal maturity (at • Maternal serum creatinine should be
36 to 37 weeks) if maternal creatinine measured simultaneously for compari-
is also within the expected range. This son with amniotic fluid creatinine for
value should be interpreted in conjunc- proper interpretation. Even in circum-
tion with other parameters evaluated in stances in which the maternal serum
amniotic fluid and especially with the value is normal, the results of the amni-
L/S ratio, because normal lung devel- otic fluid creatinine may be misleading.
opment depends on normal kidney A high fluid creatinine value in the
development. fetus of a diabetic mother may reflect
• An L/S ratio less than 2:1 and absence the increased muscle mass of a larger
of phosphatidylglycerol at term indi- fetus. If the fetus is big, the creatinine
cate fetal lung immaturity and possible may be high, and the fetus may still
respiratory distress syndrome. The have immature kidneys.
expected L/S ratio for the fetus of an • Contamination of the sample with
insulin-dependent diabetic mother is blood or meconium or complications
higher (3.5:1). (See monograph titled in pregnancy may yield inaccurate L/S
“Lecithin/Sphingomyelin Ratio.”) ratios.
• Lamellar bodies are specialized alveolar • 1-Fetoprotein and acetylcholines-
cells in which lung surfactant is stored. terase may be falsely elevated if the
They are approximately the size of sample is contaminated with fetal
platelets. Their presence in sufficient blood.
quantities is an indicator of fetal lung
maturity. • Karyotyping cannot be performed
under the following conditions: (1)
• Elevated 1-fetoprotein levels and pres- failure to promptly deliver samples for
ence of acetylcholinesterase indicate a chromosomal analysis to the laboratory
neural tube defect (see monograph performing the test, or (2) improper
titled “1-Fetoprotein”). incubation of the sample, which causes
• Abnormal karyotype indicates genetic cell death.
abnormality (e.g., Tay-Sachs disease, • Amniocentesis is contraindicated in
mental retardation, chromosome or women with a history of premature
enzyme anomalies, and inherited labor or incompetent cervix. It is also
hemoglobinopathies). (See monograph contraindicated in the presence of pla-
titled “Chromosome Analysis, Blood.”) centa previa or abruptio placentae.
• Elevated white blood cell count and
positive leukocyte esterase are indica-
tors of infection. Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
INTERFERING FACTORS: Pretest:
• Bilirubin may be falsely elevated if
maternal hemoglobin or meconium is ➤ Inform the patient that the test is
present in the sample; fetal acidosis used to evaluate fetal well-being.
may also lead to falsely elevated biliru- ➤ Obtain a history of the patient’s com-
bin levels. plaints, including a list of known
• Bilirubin may be falsely decreased if the sitivities to latex or anesthetics), and
sample is exposed to light or if amni- inform the appropriate health care
otic fluid volume is excessive. practitioner accordingly.
➤ Obtain a history of the patient’s weeks’ gestation or beyond do not

reproductive system, previous preg- need to drink extra fluids and should
nancies, and results of previously void before the test, because an
performed laboratory tests, surgical empty bladder is less likely to be
procedures, and other diagnostic accidentally punctured during speci-
procedures. Include any family his- men collection. Encourage relaxation
tory of genetic disorders such as cys- and controlled breathing during the
tic fibrosis, Duchenne’s muscular procedure to aid in reducing any mild
dystrophy, hemophilia, sickle cell discomfort. Inform the patient that
disease, Tay-Sachs disease, tha- specimen collection is performed by
lassemia, and trisomy 21. Obtain a health care provider specializing in
maternal Rh type. If Rh-negative, this procedure and usually takes
check for prior sensitization. A stan- approximately 20 to 30 minutes to
dard RhoGAM dose is indicated after complete.
amniocentesis; repeat doses should ➤ Sensitivity to social and cultural
be considered if repeated amnio- issues, as well as concern for mod-
centesis is performed. For related esty, is important in providing psy-
laboratory tests, refer to the Repro- chological support before, during,
ductive System table. and after the procedure.
➤ Note any recent procedures that can ➤ There are no food, fluid, or medica-
interfere with test results. tion restrictions unless by medical
direction.
➤ Record the date of the last menstrual
period and determine the pregnancy ➤ Make sure a written and informed
weeks’ gestation and expected deliv- consent has been signed prior to the
ery date. procedure and before administering
any medications.
patient is taking. Include herbs, nutri- Intratest:
tional supplements, and nutraceuti-
cals. The requesting health care ➤ Ensure that the patient has a full
practitioner and laboratory should be bladder before the procedure if ges-
advised if the patient regularly uses tation is 20 weeks or less; have
these products so that their effects patient void before the procedure if
can be taken into consideration gestation is 21 weeks or more.
when reviewing results. ➤ Positively identify the patient, and
➤ Review the procedure with the label the appropriate collection con-
patient. Warn the patient that normal tainers with the corresponding
results do not guarantee a normal patient demographics, date, time of
fetus. Assure the patient that pre- collection, and site location.
cautions to avoid injury to the fetus ➤ Have patient remove clothes below
will be taken by localizing the fetus the waist. Assist the patient to a
with ultrasound. Address concerns supine position on the exam table
about pain related to the procedure. with the abdomen exposed. Drape
Explain that, during the transabdomi- the patient’s legs, leaving the
nal procedure, any discomfort asso- abdomen exposed. Raise her head
ciated with a needle biopsy will be or legs slightly to promote comfort
minimized with local anesthetics. If and to relax the abdominal muscles.
the patient is less than 20 weeks’ If the uterus is large, place a pillow or
gestation, instruct her to drink extra rolled blanket under the patient’s
fluids 1 hour before the test and to right side to prevent hypertension
refrain from urination. The full blad- caused by great-vessel compres-
der assists in raising the uterus up sion. Instruct the patient to cooper-
and out of the way to provide better ate fully and to follow directions.
visualization during the ultrasound Direct the patient to breathe nor-
procedure. Patients who are at 20 mally and to avoid unnecessary
movement during the local anes- ➤ Place samples in properly labeled

thetic and the procedure. specimen container, and promptly
➤ Record maternal and fetal baseline transport the specimen to the labo-
vital signs, and continue to monitor ratory for processing and analysis.
throughout the procedure. Monitor ➤ The results are recorded manually or
for uterine contractions. Monitor in a computerized system for recall
fetal vital signs using ultrasound. and postprocedure interpretation by
Protocols may vary from facility to the appropriate health care practi-
facility. tioner.
➤ After the administration of local
anesthesia, shave and cleanse the Post-test:
site with an antiseptic solution, and
drape the area with sterile towels. ➤ After the procedure, fetal heart
rate and maternal life signs (i.e.,
➤ Have emergency equipment readily
heart rate, blood pressure, pulse,
available.
and respiration) should be compared
➤ Observe standard precautions, and with baseline values and closely
follow the general guidelines in monitored every 15 minutes for 30
Appendix A. to 60 minutes after the amniocente-
➤ Assess the position of the amniotic sis procedure. Protocols may vary
fluid, fetus, and placenta using ultra- from facility to facility.
sound. ➤ Observe for delayed allergic reac-
➤ Assemble the necessary equipment, tions, such as rash, urticaria, tachy-
including an amniocentesis tray with cardia, hyperpnea, hypertension,
solution for skin preparation, local palpitations, nausea, or vomiting.
anesthetic, 10- or 20-mL syringe, ➤ Observe the amniocentesis site for
needles of various sizes (including a bleeding, inflammation, or hema-
22-gauge, 5-inch spinal needle), ster- toma formation.
ile drapes, sterile gloves, and foil- ➤ Instruct the patient in the care and
covered or amber-colored specimen assessment of the amniocentesis
collection containers. site. Instruct the patient to report any
➤ Cleanse suprapubic area with an redness, edema, bleeding, or pain at
antiseptic solution, and protect with the biopsy site. Instruct the patient
sterile drapes. A local anesthetic is to keep the site clean and change
injected. Explain that this may cause the dressing as needed.
a stinging sensation. ➤ Instruct the patient to expect mild
➤ A 22-gauge, 5-inch spinal needle is cramping, leakage of small amount
inserted through the abdominal and of amniotic fluid, and vaginal spotting
uterine walls. Explain that a sensa- for up to 2 days following the proce-
tion of pressure may be experienced dure. Instruct the patient to report
when the needle is inserted. Explain moderate to severe abdominal pain
to the patient how to use focused or cramps, change in fetal activity,
and controlled breathing for relax- increased or prolonged leaking of
ation during the procedure. amniotic fluid from abdominal needle
➤ After the fluid is collected and the site, vaginal bleeding that is heavier
needle is withdrawn, apply slight than spotting, and either chills or
pressure to the site. If there is no fever.
evidence of bleeding or other ➤ Instruct the patient to rest until all
drainage, apply a sterile adhesive symptoms have disappeared before
bandage to the site. resuming normal levels of activity.
➤ Monitor the patient for complications ➤ Administer standard RhoGAM dose
related to the procedure (e.g., pre- to maternal Rh-negative patients to
mature labor, allergic reaction, ana- prevent maternal Rh sensitization
phylaxis). should the fetus be Rh-positive.
➤ A written report of the examination patient’s health care provider regard-

will be completed by a health care ing further testing, treatment, or
practitioner specializing in this referral to another health care
branch of medicine. A written report provider. Inform the patient that it
of the examination will be sent to the may be 2 to 4 weeks before all
requesting health care practitioner, results are available. Answer any
who will discuss the results with the questions or address any concerns
patient. voiced by the patient or family.
➤ Recognize anxiety related to test ➤ Instruct the patient in the use of any
results. Discuss the implications ordered medications. Explain the
of abnormal test results on the importance of adhering to the ther-
patient’s lifestyle. Provide teaching apy regimen. As appropriate, instruct
and information regarding the clinical the patient in significant side effects
implications of the test results, as and systemic reactions associated
appropriate. Encourage the family to with the prescribed medication.
seek appropriate counseling if con- Encourage her to review correspon-
cerned with pregnancy termination, ding literature provided by a pharma-
and to seek genetic counseling if a cist.
chromosomal abnormality is deter-
mined. Decisions regarding elective ➤ Depending on the results of this pro-
abortion should take place in the cedure, additional testing may be
presence of both parents. Provide performed to evaluate or monitor
a nonjudgmental, nonthreatening progression of the disease process
atmosphere for discussing the risks and determine the need for a change
and difficulties of delivering and rais- in therapy. Evaluate test results in
ing a developmentally challenged relation to the patient’s symptoms
infant, as well as exploring other and other tests performed.
options (termination of pregnancy
or adoption). It is also important to
discuss problems the mother and
father may experience (guilt, depres- ➤ Related laboratory tests include 1-
sion, anger) if fetal abnormalities are fetoprotein, blood groups and anti-
detected. bodies, chromosome analysis, and
➤ Reinforce information given by the L/S ratio.
AMYLASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Amylase 63

• Carcinoma of the head of the pancreas
(advanced)
30–110 U/L
• Common bile duct obstruction
• Diabetic ketoacidosis
• Duodenal obstruction
DESCRIPTION & RATIONALE: Amy-
• Ectopic pregnancy
lase, a digestive enzyme, splits starch
into disaccharides. Although many • Gastric resection
cells have amylase activity (e.g., liver, • Macroamylasemia
small intestine, ovaries, skeletal mus-
• Mumps
cles), circulating amylase is derived
from the parotid glands and the pan- • Pancreatic cyst and pseudocyst
creas. Amylase is a sensitive indicator • Pancreatitis
of pancreatic acinar cell damage and
pancreatic obstruction. Newborns • Parotitis
and children up to 2 years old have • Perforated peptic ulcer involving the
little measurable serum amylase. In pancreas
the early years of life, most of this • Peritonitis
enzyme is produced by the salivary
glands. ■ • Postoperative period
• Some tumors of the lung and ovaries
INDICATIONS: • Viral infections
• Assist in the diagnosis of early acute
pancreatitis; serum amylase begins to Decreased in:
rise within 6 to 24 hours after onset • Cystic fibrosis (advanced)
and returns to normal in 2 to 7 days
• Hepatic disease (severe)
• Assist in the diagnosis of macroamy-
lasemia, a disorder seen in alcoholism, • Pancreatectomy
malabsorption syndrome, and other • Pancreatic insufficiency
digestive problems
• Assist in the diagnosis of pancreatic
duct obstruction, which causes serum
amylase levels to remain elevated
• Drugs and substances that may increase
• Detect blunt trauma or inadvertent
amylase levels include asparaginase,
surgical trauma to the pancreas
captopril, cimetidine, clofibrate, corti-
• Differentiate between acute pancreati- costeroids, estrogens, ethacrynic acid,
tis and other causes of abdominal pain furosemide, ibuprofen, methyldopa,
that require surgery nitrofurantoin, oral contraceptives,
pentamidine, sulfonamides, tetracy-
RESULT cline, thiazide diuretics, valproic acid,
zalcitabine, and alcohol.
Increased in:
• Drugs that may decrease amylase levels
• Abdominal trauma include anabolic steroids, citrates, and
• Alcoholism fluorides.

Nursing Implications and movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: Appendix A. Positively identify the
➤ Inform the patient that the test is pri- tubes with the corresponding patient
marily used to assess pancreatic demographics, date, and time of col-
function. lection. Perform a venipuncture; col-
➤ Obtain a history of the patient’s com- lect the specimen in a 5-mL red- or
plaints, including a list of known tiger-top tube.
allergens (especially allergies or sen- ➤ Remove the needle, place a gauze
sitivities to latex), and inform the over the puncture site and apply gen-
appropriate health care practitioner tle pressure to stop bleeding.
accordingly. Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s ing or hematoma formation. Apply
endocrine, gastrointestinal, and paper tape over gauze or replace with
hepatobiliary systems, as well as adhesive bandage.
results of previously performed labo- ➤ Promptly transport the specimen to
ratory tests, surgical procedures, the laboratory for processing and
and other diagnostic procedures. For analysis.
related laboratory tests, refer to the ➤ The results are recorded manually or
Endocrine, Gastrointestinal, and in a computerized system for recall
Hepatobiliary System tables. and postprocedure interpretation by
advised if the patient regularly uses ➤ Nutritional considerations: Increased
these products so that their effects amylase levels may be associated
can be taken into consideration with gastrointestinal disease or alco-
when reviewing results. holism. Small, frequent meals work
best for patients with gastrointesti-
➤ Review the procedure with the nal disorders. Consideration should
patient. Inform the patient that spec- be given to dietary alterations in the
imen collection takes approximately case of gastrointestinal disorders.
5 to 10 minutes. Address concerns Usually after acute symptoms sub-
about pain related to the procedure. side and bowel sounds return,
Explain to the patient that there may patients are given a clear liquid diet,
be some discomfort during the progressing to a low-fat, high-carbo-
venipuncture. hydrate diet. Vitamin B12 may be
➤ There are no food, fluid, or medica- ordered for parenteral administration
tion restrictions unless by medical to patients with decreased levels,
direction. especially if their disease prevents
adequate absorption of the vitamin.
Intratest: The alcoholic patient should be
encouraged to avoid alcohol and to
➤ If the patient has a history of severe seek appropriate counseling for sub-
allergic reaction to latex, care should stance abuse.
be taken to avoid the use of equip- ➤ A written report of the examination
ment containing latex. will be sent to the requesting health
➤ Instruct the patient to cooperate care practitioner, who will discuss
fully and to follow directions. the results with the patient.
Direct the patient to breathe nor- ➤ Reinforce information given by the
Analgesic and Antipyretic Drugs: Acetaminophen, Acetylsalicylic Acid 65
patient’s health care provider regard- relation to the patient’s symptoms

ing further testing, treatment, or and other tests performed.
provider. Answer any questions or Related laboratory tests:
patient or family.
alanine aminotransferase, alkaline
➤ Depending on the results of this pro- phosphatase, amylase (fluid), aspar-
cedure, additional testing may be tate aminotransferase, bilirubin, CA
performed to evaluate or monitor 19–9, calcium, fecal fat, -glutamyl
progression of the disease process transpeptidase, lipase, magnesium,
and determine the need for a change mumps serology, triglycerides, and
in therapy. Evaluate test results in white blood cell count.
ANALGESIC AND ANTIPYRETIC

DRUGS: ACETAMINOPHEN,
ACETYLSALICYLIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Acetaminophen (Acephen, Apacet, Aspirin Free

Anacin, Banesin, Dapa, Datril, Dorcol, Gebapap, Halenol, Liquiprin, Meda
Cap, Panadol, Redutemp, Tempra, Tylenol, Ty-Pap, Uni-Ace); Acetylsalicylic
acid (salicylate, aspirin, Anacin, Aspergum, Bufferin, Ecotrin, Empirin,
Measurin, Synalgos, ZORprin, ASA).

REFERENCE VALUE: (Method: Immunoassay)
Therapeutic SI Half- Volume of Protein

Drug Dose* Units Life Distribution Binding Excretion
(SI Conventional Units 6.62)
Acetamino- 10–30 66–199 1–3 h 0.95 20–50% 85–95%
phen g/mL mol/L L/kg hepatic,
metabo-
lites, renal
Salicylate 15–20 1.1–1.4 2–3 h 0.1–0.3 90–95% 1 hepatic,
mg/dL mmol/L L/kg metabo-
lites, renal
* Conventional units.
Liver disease
DESCRIPTION & RATIONALE: Aceta- Toxicity
minophen is used for headache, fever,
and pain relief, especially for individ- • ASA
uals unable to take salicylate products Toxicity
or who have bleeding conditions. It is
the analgesic of choice for children Decreased in:
less than 13 years of age; salicylates are • Noncompliance with therapeutic regi-
avoided in this age group because of men
the association between aspirin and
Reye’s syndrome. Acetaminophen is CRITICAL VALUES: Note: The ad-
rapidly absorbed from the gastroin- verse effects of subtherapeutic levels are
testinal tract and reaches peak concen- also important. Care should be taken to
tration within 30 to 60 minutes after investigate signs and symptoms of too lit-
administration of a therapeutic dose. tle and too much medication. Note and
It can be a silent killer because, by the immediately report to the health care
practitioner any critically increased values
time symptoms of intoxication appear
and related symptoms.
24 to 48 hours after ingestion, the
antidote is ineffective. Acetylsalicylic
acid (ASA) is also used for headache, Acetaminophen: Greater
fever, and pain relief. Some patients Than 150 g/mL (4 Hours
with cardiovascular disease take small Postingestion); Greater
prophylactic doses. The main site of Than 50 g/mL (12 Hours
Postingestion)
toxicity for both drugs is the liver, par-
ticularly in the presence of liver dis- Signs and symptoms of acetaminophen
ease or decreased drug metabolism intoxication occur in stages over a period
and excretion. of time. In stage I (0 to 24 hours after
Many factors must be considered in ingestion), symptoms may include gas-
trointestinal irritation, pallor, lethargy,
interpreting drug levels, including
diaphoresis, metabolic acidosis, and possi-
patient age, patient weight, interact- bly coma. In stage II (24 to 48 hours after
ing medications, electrolyte balance, ingestion), signs and symptoms may
protein levels, water balance, condi- include right upper quadrant abdominal
tions that affect absorption and excre- pain; elevated liver enzymes, aspartate
tion, and foods, herbals, vitamins, and aminotransferase (AST), and alanine
minerals that can potentiate or inhibit aminotransferase (ALT); and possible
the intended target concentration. ■ decreased renal function. In stage III (72
to 96 hours after ingestion), signs and
INDICATIONS: symptoms may include nausea, vomiting,
• Suspected overdose jaundice, confusion, coagulation disor-
ders, continued elevation of AST and
• Suspected toxicity ALT, decreased renal function, and
• Therapeutic monitoring coma. Intervention may include gas-
trointestinal decontamination (stomach
RESULT pumping) if the patient presents within 6
hours of ingestion or administration of N-
Increased in: acetylcysteine (Mucomyst) in the case of
• Acetaminophen an acute intoxication in which the patient
Alcoholic cirrhosis presents more than 6 hours after ingestion.
Analgesic and Antipyretic Drugs: Acetaminophen, Acetylsalicylic Acid 67
ASA: Greater Than 50 mg/dL respiratory arrest, and tinnitus. Possible

interventions include administration of
Signs and symptoms of salicylate intoxi- activated charcoal as vomiting ceases,
cation include ketosis, convulsions, dizzi- alkalinization of the urine with bicarbon-
ness, nausea, vomiting, hyperactivity, ate, and a single dose of vitamin K (for
hyperglycemia, hyperpnea, hyperthermia, rare instances of hypoprothrombinemia).
Pediatric Serum Salicylate Level and Acetaminophen Toxicity Nomogram

Severity of Intoxication Single Dose
Acute Ingestion Nomogram 500
180
________________________
160 Probable hepatic toxicity
140 200
Probably Lethal 150
Acetaminophen (µg/mL plasma)
120
Possible
100 100
hepatic toxicity
Serum salicylate (µg/mL)
Severe
80 50
Moderate
unavailable. Image rights unavailable.

60
Image rights
Mild
40
10
Hepatic toxicity unlikely
25%
5
20
Asymptomatic
1
Asymptomatic 4 8 12 16 20 24
10 Hours after ingestion
0 12 24 36 48 60
Hours since ingestion The Rumack-Matthew nomogram, relating expected severity of
liver toxicity to serum acetaminophen concentrations.
Nomogram relating serum salicylate concentration and expected
severity of intoxication at varying intervals following the ingestion From Smilkstein MJ, Bronstein AC, Linden C, et al, "Acetamino-
of a single dose of salicylate. phen Overdose: A 48-Hour Intravenous N-Acetylcysteine Treat-
From Done AK, "Aspirin Overdosage: Incidence, Diagnosis, and ment Protocol," , 1991,20(10):1058, with
Management," ,1978, 62:890-7 with permission. permission.
INTERFERING FACTORS: • Drugs that may increase acetamino-

• Blood drawn in serum separator tubes phen levels include diflunisal, metoclo-
(gel tubes). pramide, and probenecid.
• Drugs that may decrease acetamino-
• Contraindicated in patients with liver phen levels include cholestyramine,
disease, and caution advised in patients iron, oral contraceptives, and propan-
with renal impairment. theline.
• Drugs that increase ASA levels include chological support before, during,
sulfinpyrazone. and after the procedure.
• Drugs and substances that decrease tion restrictions unless by medical
ASA levels include activated charcoal, direction.
antacids (aluminum hydroxide), and
iron.
Intratest:
Nursing Implications and allergic reaction to latex, care should
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
➤ Instruct the patient to cooperate
➤ Inform the patient that the test is fully and to follow directions. Direct
used to monitor therapeutic levels the patient to breathe normally
and detect toxic levels of acetamino- and to avoid unnecessary move-
phen and salicylate. ment.
➤ Obtain a complete history of the ➤ Observe standard precautions, and
time and amount of drug ingested by follow the general guidelines in
the patient. Appendix A. Positively identify the
➤ Obtain a history of the patient’s com- patient, and label the appropriate
plaints, including a list of known tubes with the corresponding patient
allergens (especially allergies or sen- demographics, date, and time of
sitivities to latex), and inform the collection, noting the last dose of
appropriate health care practitioner medication taken. Perform a veni-
accordingly. puncture; collect the specimen in a
➤ Review results of previously per- 5-mL red-top tube.
formed laboratory tests, surgical pro- ➤ Remove the needle, place a gauze
cedures, and other diagnostic over the puncture site and apply gen-
procedures. For related laboratory tle pressure to stop the bleeding.
tests, refer to the Genitourinary, Observe the venipuncture site for
Hepatobiliary, and Therapeutic/Toxi- bleeding and hematoma formation.
cology System tables. Apply paper tape over gauze or
➤ Obtain a list of the medications the replace with adhesive bandage.
patient is taking, including herbs, ➤ Promptly transport the specimen to
nutritional supplements, and nutra- the laboratory for processing and
ceuticals. The requesting health care analysis.
advised if the patient is regularly ➤ The results are recorded manually or
using these products so that their in a computerized system for recall
effects can be taken into considera- and postprocedure interpretation by
tion when reviewing results. the appropriate health care practi-
tioner.
imen collection takes approximately Post-test:
5 to 10 minutes. Address concerns
about pain related to the procedure. ➤ Nutritional considerations include
Explain to the patient that there may the avoidance of alcohol consump-
be some discomfort during the tion.
venipuncture. ➤ A written report of the examination
➤ Sensitivity to cultural and social will be sent to the requesting health
issues, as well as concern for mod- care practitioner, who will discuss
esty, is important in providing psy- the results with the patient.
Angiography, Abdomen 69
➤ Reinforce information given by the ➤ Depending on the results of this pro-

patient’s health care provider regard- cedure, additional testing may be
ing further testing, treatment, or performed to evaluate or monitor
referral to another health care progression of the disease process
provider. Explain to the patient the and determine the need for a change
importance of following the medica- in therapy. Evaluate test results in
tion regimen and instructions regard- relation to the patient’s symptoms
ing food and drug interactions. and other tests performed.
Answer any questions or address
any concerns voiced by the patient Related laboratory tests:
or family.
➤ Related laboratory tests include acti-
➤ Instruct the patient to be prepared to vated partial thromboplastin time,
provide the pharmacist with a list of ALT, AST, bilirubin, blood urea nitro-
other medications he or she is gen, complete blood count, creati-
already taking in the event that the nine, electrolytes, glucose, lactic
requesting health care practitioner acid, liver biopsy, and prothrombin
prescribes a medication. time.
ANGIOGRAPHY, ABDOMEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Abdominal angiogram, abdominal arteriography.

AREA OF APPLICATION: Abdomen.
CONTRAST: Intravenous iodine based.
DESCRIPTION & RATIONALE: Angiog- organ under study and associated ves-
raphy allows x-ray visualization of the sels are displayed on a monitor and
large and small arteries, veins, and recorded on film or stored electroni-
associated branches of the abdominal cally for future viewing and evalua-
vasculature and organ parenchyma tion. Patterns of circulation, organ
after contrast-medium injection. This function, and changes in vessel wall
visualization is accomplished by the appearance can be viewed to help
injection of contrast medium through diagnose the presence of vascular
a catheter, which most commonly has abnormalities, aneurysm, tumor,
been inserted into the femoral artery trauma, or lesions. The catheter used
or vein and advanced through the iliac to administer the contrast medium to
artery and aorta into the organ- confirm the diagnosis of organ lesions
specific artery or vein. Images of the may be used to deliver chemothera-
peutic drugs or different types of RESULT

media to stop bleeding. Catheters
Normal Findings:
with attached inflatable balloons and
wire mesh stents are used to widen • Normal structure, function, and
patency of abdominal organ vessels
areas of stenosis and to keep the ves-
sels open, frequently replacing sur- • Contrast medium normally circulates
gery. Angiography is one of the throughout abdomen symmetrically
definitive tests for organ disease and and without interruption
may be used to evaluate chronic dis- • No evidence of obstruction, variations
ease, evaluate organ failure, treat arte- in number and size of vessels and
rial stenosis, differentiate a vascular organs, malformations, cysts, or tumors
cyst from hypervascular cancers, and
evaluate the effectiveness of medical Abnormal Findings:
or surgical treatment. ■ • Abscess or inflammation
• Arterial aneurysm
INDICATIONS: • Arterial stenosis, dysplasia, or organ
• Aid in angioplasty, atherectomy, or
infarction
stent placement
• Arteriovenous fistula or other abnor-
• Allow infusion of thrombolytic drugs
malities
into an occluded artery
• Congenital anomalies
• Detect arterial occlusion, which may be
evidenced by a transection of the artery • Cysts or tumors
caused by trauma or penetrating injury
• Organ hematoma
• Detect artery stenosis, evidenced by
• Trauma causing tears or other disrup-
vessel dilation, collateral vessels, or
tion
increased vascular pressure
• Detect nonmalignant tumors before INTERFERING FACTORS
surgical resection
This procedure is
• Detect thrombosis, arteriovenous fis- contraindicated for:
tula, aneurysms, or emboli in abdomi-
nal vessels • Patients with allergies to shellfish
or iodinated dye. The contrast
• Detect tumors and arterial supply, medium used may cause a life-threat-
extent of venous invasion, and tumor ening allergic reaction. Patients with a
vascularity known hypersensitivity to contrast
• Differentiate between tumors and cysts medium may benefit from premedica-
tion with corticosteroids or the use of
• Evaluate organ transplantation for nonionic contrast medium.
function or organ rejection
• Patients with bleeding disorders.
• Evaluate placement of a shunt or stent
• Evaluate tumor vascularity before sur- of being pregnant, unless the potential
gery or embolization benefits of the procedure far outweigh
the risks to the fetus and mother.
• Evaluate the vascular system of
prospective organ donors before sur- • Elderly and other patients who
gery are chronically dehydrated before
the test, because of their risk of con- is being done should wear badges
trast-induced renal failure. that reveal their level of exposure to
radiation.
• Patients who are in renal failure.
• Failure to follow dietary restrictions
Factors that may impair and other pretesting preparations may
clear imaging: cause the procedure to be canceled or
• Gas or feces in the gastrointestinal tract repeated.
resulting from inadequate cleansing or
failure to restrict food intake before the
study Nursing Implications and
• Retained barium from a previous radi- Procedure ● ● ● ● ● ● ● ● ● ● ●
ologic procedure
Pretest:
• Metallic objects within the examina-
tion field (e.g., jewelry, body rings), ➤ Inform the patient that the procedure
which may inhibit organ visualization assesses cardiovascular function.
and can produce unclear images ➤ Obtain a history of the patient’s com-
• Improper adjustment of the radi- allergens (especially allergies or sen-
ographic equipment to accommodate sitivities to latex, iodine, seafood,
obese or thin patients, which can cause contrast medium, anesthetics, or
overexposure or underexposure and a dyes), and inform the appropriate
poor-quality study health care practitioner accordingly.
➤ Obtain a history of results of previ-
• Patients who are very obese, who may ously performed diagnostic proce-
exceed the weight limit for the equip- dures, surgical procedures, and
ment laboratory tests. Ensure that the
• Incorrect positioning of the patient, results of blood tests are obtained
and recorded before the procedure,
which may produce poor visualization especially coagulation tests, blood
of the area to be examined urea nitrogen, and creatinine, if con-
• Inability of the patient to cooperate or trast medium is to be used. For
remain still during the procedure related diagnostic tests, refer to the
Cardiovascular System table.
mental status ➤ Note any recent procedures that can
interfere with test results, including
examinations using iodine-based
Other considerations: contrast medium or barium.
• Consultation with a health care practi- ➤ Record the date of the last menstrual
tioner should occur before the proce- period and determine the possibility
dure for radiation safety concerns of pregnancy in perimenopausal
regarding younger patients or patients women.
who are lactating. ➤ Obtain a list of the medications the
• Risks associated with radiographic patient is taking, especially medica-
overexposure can result from frequent tions known to affect bleeding,
x-ray procedures. Personnel in the including anticoagulant therapy,
aspirin and other salicylates. Include
room with the patient should wear a herbs, nutritional supplements, and
protective lead apron, stand behind a nutraceuticals (see Appendix F:
shield, or leave the area while the exam- Effects of Natural Products on
ination is being done. Personnel work- Laboratory Values). It is recom-
ing in the area where the examination mended that use of such products
be discontinued 14 days before sur- ➤ Make sure a written and informed

gical procedures. The requesting consent has been signed prior to the
health care practitioner and labora- procedure and before administering
tory should be advised if the patient any medications.
regularly uses these products so that ➤ This procedure may be terminated if
their effects can be taken into con- chest pain, severe cardiac arrhyth-
sideration when reviewing results. mias, or signs of a cerebrovascular
➤ Patients receiving metformin (glu- accident occur.
cophage) for non–insulin-dependent
(type 2) diabetes should discontinue Intratest:
the drug on the day of the test and
continue to withhold it for 48 hours ➤ Ensure that the patient has complied
after the test. Failure to do so may with dietary and medication restric-
result in lactic acidosis. tions and pretesting preparations;
assure that food and medications
have been restricted for at least 8
patient. Address concerns about pain
hours prior to the procedure. Ensure
related to the procedure. Explain to
that the patient has removed jew-
the patient that some pain may be
elry, dentures, all external metallic
experienced during the test, or there
objects, and the like prior to the pro-
may be moments of discomfort.
cedure.
Inform the patient that the procedure
is performed in a special department, ➤ Have emergency equipment readily
usually in a radiology or vascular available.
suite, by a health care practitioner ➤ If the patient has a history of severe
and support staff and takes approxi- allergic reactions to any substance or
mately 30 to 60 minutes. drug, administer ordered prophylac-
➤ Sensitivity to social and cultural tic steroids or antihistamines before
issues, as well as concern for mod- the procedure. Use nonionic contrast
esty, is important in providing psy- medium for the procedure.
chological support before, during, ➤ Patients are given a gown, robe, and
and after the procedure. foot coverings to wear and ins-
➤ Explain that an intravenous (IV) line tructed to void prior to the proce-
may be inserted to allow infusion of dure.
IV fluids, contrast medium, dye, or ➤ Observe standard precautions, and
sedatives. Usually normal saline is follow the general guidelines in
infused. Appendix A.
➤ Inform the patient that a burning ➤ Record baseline vital signs, and
and flushing sensation may be felt assess neurologic status. Protocols
throughout the body during injection may vary from facility to facility.
of the contrast medium. After injec-
tion of the contrast medium, the ➤ Instruct the patient to cooperate fully
patient may experience an urge to and to follow directions. Instruct the
cough, flushing, nausea, or a salty or patient to remain still throughout the
metallic taste. procedure because movement pro-
duces unreliable results.
➤ The patient should fast and restrict
fluids for 8 hours prior to the proce- ➤ Establish an IV fluid line for the injec-
dure. Instruct the patient to avoid tion of emergency drugs and of
taking anticoagulant medication or to sedatives.
reduce dosage as ordered prior to ➤ Administer an antianxiety agent, as
the procedure. ordered, if the patient has claustro-
➤ Instruct the patient to remove den- phobia. Administer a sedative to a
tures, jewelry (including watches), child or to an uncooperative adult, as
hairpins, credit cards, and other ordered.
metallic objects in the area to be ➤ Place electrocardiographic elec-
examined. trodes on the patient for cardiac
monitoring. Establish a baseline every 4 hours for 24 hours. Compare

rhythm; determine if the patient has with baseline values. Protocols may
ventricular arrhythmias. vary from facility to facility.
➤ Using a pen, mark the site of the ➤ Observe for delayed allergic reac-
patient’s peripheral pulses before tions, such as rash, urticaria, tachy-
angiography; this allows for quicker cardia, hyperpnea, hypertension,
and more consistent assessment of palpitations, nausea, or vomiting.
the pulses after the procedure. ➤ Instruct the patient to immediately
➤ Place the patient in the supine posi- report symptoms such as fast heart
tion on an exam table. Cleanse the rate, difficulty breathing, skin rash,
selected area, and cover with a ster- itching, or decreased urinary output.
ile drape. ➤ Assess extremities for signs of
➤ A local anesthetic is injected at the ischemia or absence of distal pulse
site, and a small incision is made or caused by a catheter-induced throm-
a needle inserted under fluoroscopy. bus.
➤ The contrast medium is injected, and ➤ Observe the needle/catheter inser-
a rapid series of images is taken dur- tion site for bleeding, inflammation,
ing and after the filling of the vessels or hematoma formation.
to be examined. Delayed images ➤ Instruct the patient to apply cold
may be taken to examine the vessels compresses to the puncture site, as
after a time and to monitor the needed, to reduce discomfort or
venous phase of the procedure. edema.
➤ Instruct the patient to inhale deeply ➤ Instruct the patient to maintain bed
and hold his or her breath while the rest for 4 to 6 hours after the proce-
x-ray images are taken, and then to dure or as ordered.
exhale after the images are taken.
➤ Instruct the patient in the care and
➤ Instruct the patient to take slow,
assessment of the site and to
deep breaths if nausea occurs during
observe for bleeding, hematoma for-
the procedure.
mation, bile leakage, and inflamma-
➤ Monitor the patient for complications tion. Note any pleuritic pain,
related to the procedure (e.g., aller- persistent right shoulder pain, or
gic reaction, anaphylaxis, bron- abdominal pain.
chospasm).
➤ Nutritional considerations: A low-fat,
➤ The needle or catheter is removed, low-cholesterol, and low-sodium diet
and a pressure dressing is applied should be consumed to reduce
over the puncture site. current disease processes and/or
➤ The results are recorded on x-ray film decrease risk of hypertension and
or electronically in a computerized coronary artery disease.
system for recall and postprocedure ➤ No other radionuclide tests should
interpretation by the appropriate be scheduled for 24 to 48 hours after
health care practitioner. this procedure.
Post-test: ➤ A written report of the examination
➤ Instruct the patient to resume usual practitioner specializing in this
diet, fluids, medications, or activity, branch of medicine. The report will
as directed by the health care practi- be sent to the requesting health care
tioner. Renal function should be practitioner, who will discuss the
assessed before metformin is results with the patient.
resumed. ➤ Recognize anxiety related to test
➤ Monitor vital signs and neurologic results, and be supportive of per-
status every 15 minutes for 1 hour, ceived loss of independent function.
then every 2 hours for 4 hours, and Discuss the implications of abnormal
as ordered. Take the temperature test results on the patient’s lifestyle.
Provide teaching and information responding literature provided by a

regarding the clinical implications of pharmacist.
the test results, as appropriate. ➤ Depending on the results of this
➤ Reinforce information given by procedure, additional testing may
the patient’s health care provider be performed to evaluate or monitor
regarding further testing, treatment, progression of the disease process
or referral to another health care and determine the need for a change
provider. Answer any questions or in therapy. Evaluate test results in
address any concerns voiced by the relation to the patient’s symptoms
patient or family. and other tests performed.
➤ Instruct the patient in the use of any Related diagnostic tests:
ordered medications. Explain the
importance of adhering to the ther- ➤ Related diagnostic tests include
apy regimen. As appropriate, instruct computed tomography of the
the patient in significant side effects abdomen; kidney, ureter, and bladder
and systemic reactions associated study; magnetic resonance imaging
with the prescribed medication. of the abdomen, and magnetic reso-
Encourage him or her to review cor- nance angiography.
ANGIOGRAPHY, ADRENAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Adrenal angiogram, adrenal arteriography.

AREA OF APPLICATION: Adrenal gland.
DESCRIPTION & RATIONALE: Adrenal may be taken from the vein of each
angiography evaluates adrenal dys- gland to assess cortisol levels in deter-
function by allowing x-ray visualiza- mining a diagnosis of Cushing’s
tion of the large and small arteries of syndrome or the presence of pheo-
the adrenal gland vasculature and chromocytoma. After injection of the
parenchyma. This visualization is contrast medium through the
accomplished by the injection of con- catheter, images of the adrenal glands
trast medium through a catheter that and associated vessels surrounding the
has been inserted into the femoral adrenal tissue are displayed on a mon-
artery for viewing the artery (arterio- itor and are recorded on film or elec-
graphy) or into the femoral vein for tronically. Patterns of circulation,
viewing the veins (venography). After adrenal function, and changes in ves-
the catheter is in place, a blood sample sel wall appearance can be viewed to
Angiography, Adrenal 75
help diagnose the presence of vascular • No evidence of obstruction, variations

abnormalities, trauma, or lesions. This in number and size of vessels and
organs, malformations, cysts, or tumors
definitive test for adrenal disease may
be used to evaluate chronic adrenal Abnormal Findings:
disease, evaluate arterial or venous • Adrenal adenoma
stenosis, differentiate an adrenal cyst
from adrenal tumors, and evaluate • Adrenal carcinoma
medical therapy or surgery of the • Bilateral adrenal hyperplasia
adrenal glands. ■
• Pheochromocytoma
INDICATIONS: INTERFERING FACTORS
• Assist in the infusion of thrombolytic
drugs into an occluded artery
This procedure is
• Assist with the collection of blood contraindicated for:
samples from the vein for laboratory
analysis • Patients with allergies to shellfish
• Detect adrenal hyperplasia medium used may cause a life-threat-
• Detect and determine the location of ening allergic reaction. Patients with a
adrenal tumors evidenced by arterial known hypersensitivity to contrast
supply, extent of venous invasion, and medium may benefit from premedica-
tumor vascularity tion with corticosteroids or the use of
nonionic contrast medium.
• Detect arterial occlusion, evidenced by
a transection of the artery caused by • Patients with bleeding disorders.
trauma or a penetrating injury
• Detect arterial stenosis, evidenced by of being pregnant, unless the potential
vessel dilation, collateral vessels, or benefits of the procedure far outweigh
increased vascular pressure the risks to the fetus and mother.
• Detect nonmalignant tumors before • Elderly and other patients who
surgical resection are chronically dehydrated before
• Detect thrombosis, arteriovenous fis- the test, because of their risk of con-
tula, aneurysms, or emboli in vessels trast-induced renal failure.
• Differentiate between adrenal tumors • Patients who are in renal failure.
and adrenal cysts
Factors that may
• Evaluate tumor vascularity before sur- impair clear imaging:
gery or embolization
• Gas or feces in the gastrointestinal tract
• Perform angioplasty, perform atherec- resulting from inadequate cleansing or
tomy, or place a stent failure to restrict food intake before the
study
RESULT
• Retained barium from a previous radi-
Normal Findings: ologic procedure
• Normal structure, function, and • Metallic objects within the examina-
patency of adrenal vessels tion field (e.g., jewelry, body rings,
• Contrast medium circulating through- dental amalgams), which may inhibit
out the adrenal gland symmetrically organ visualization and can produce
and without interruption unclear images
• Improper adjustment of the radi- allergens (especially allergies or

ographic equipment to accommodate sensitivities to latex, iodine, seafood,
obese or thin patients, which can cause contrast medium, anesthetics, or
overexposure or underexposure and a dyes), and inform the appropriate
health care practitioner accordingly.
poor-quality study
results of blood tests are obtained
• Incorrect positioning of the patient, and recorded before the procedure,
trast medium is to be used. For
• Inability of the patient to cooperate related diagnostic tests, refer to
or remain still during the procedure the Cardiovascular and Endocrine
because of age, significant pain, or System tables.
mental status ➤ Note any recent procedures that can
Other considerations: examinations using iodine-based
• Consultation with a health care practi- contrast medium.
tioner should occur before the proce- ➤ Record the date of the last menstrual
dure for radiation safety concerns period and determine the possibil-
regarding younger patients or patients ity of pregnancy in perimenopausal
who are lactating. women.
• Risks associated with radiographic patient is taking, especially medica-
overexposure can result from frequent tions known to affect bleeding,
x-ray procedures. Personnel in the including anticoagulant therapy,
room with the patient should wear a aspirin and other salicylates, herbs,
protective lead apron, stand behind a nutritional supplements, and nutra-
shield, or leave the area while the exam- ceuticals (see Appendix F: Effects of
ination is being done. Personnel work- Natural Products on Laboratory
ing in the area where the examination Values). It is recommended that use
of such products be discontinued 14
is being done should wear badges
days before surgical procedures. The
that reveal their level of exposure to requesting health care practitioner
radiation. and laboratory should be advised if
• Failure to follow dietary restrictions the patient regularly uses these prod-
ucts so that their effects can be taken
and other pretesting preparations may
into consideration when reviewing
cause the procedure to be canceled or results.
repeated.
➤ Patients receiving metformin (glu-
(type 2) diabetes should discontinue
Nursing Implications and the drug on the day of the test and
Procedure ● ● ● ● ● ● ● ● ● ● ● continue to withhold it for 48 hours
after the test. Failure to do so may
Pretest: result in lactic acidosis.
➤ Inform the patient that the procedure patient. Address concerns about pain
assesses cardiovascular function. related to the procedure. Explain to
➤ Obtain a history of the patient’s com- the patient that some pain may be
plaints, including a list of known experienced during the test, or there
Angiography, Adrenal 77
may be moments of discomfort. elry, dentures, all external metallic

Inform the patient that the procedure objects, and the like prior to the pro-
is performed in a special department, cedure.
usually in a radiology or vascular ➤ Have emergency equipment readily
suite, by a health care practitioner available.
and support staff and takes approxi-
mately 30 to 60 minutes. ➤ If the patient has a history of severe
allergic reactions to any substance or
drug, administer ordered prophylac-
tic steroids or antihistamines before
the procedure. Use nonionic contrast
chological support before, during,
medium for the procedure.
➤ Patients are given a gown, robe,
➤ Explain that an intravenous (IV) line
and foot coverings to wear and
may be inserted to allow infusion of
instructed to void prior to the proce-
IV fluids, contrast medium, dye, or
dure.
sedatives. Usually normal saline is
infused. ➤ Observe standard precautions, and
➤ Inform the patient that a burning and follow the general guidelines in
flushing sensation may be felt Appendix A.
throughout the body during injection ➤ Record baseline vital signs, and
of the contrast medium. After injec- assess neurologic status. Protocols
tion of the contrast medium, the may vary from facility to facility.
patient may experience an urge to
cough, flushing, nausea, or a salty or
and to follow directions. Instruct the
metallic taste.
patient to remain still throughout the
➤ The patient should fast and restrict procedure because movement pro-
fluids for 8 hours prior to the produces unreliable results.
cedure. Instruct the patient to avoid
➤ Establish an IV fluid line for the injec-
taking anticoagulant medication or to
tion of emergency drugs and of
reduce dosage as ordered prior to
sedatives.
the procedure.
➤ Instruct the patient to remove den- ➤ Administer an antianxiety agent, as
tures, jewelry (including watches), ordered, if the patient has claustro-
hairpins, credit cards, and other phobia. Administer a sedative to a
metallic objects in the area to be child or to an uncooperative adult, as
examined. ordered.
➤ Make sure a written and informed ➤ Place electrocardiographic elec-
consent has been signed prior to the trodes on the patient for cardiac
procedure and before administering monitoring. Establish a baseline
any medications. rhythm; determine if the patient has
ventricular arrhythmias.
➤ This procedure may be terminated
if chest pain, severe cardiac arrhy- ➤ Using a pen, mark the site of the
thmias, or signs of a cerebrovascular patient’s peripheral pulses before
accident occur. angiography; this allows for quicker
and more consistent assessment of
Intratest: the pulses after the procedure.
➤ Place the patient in the supine posi-
➤ Ensure that the patient has complied
tion on an exam table. Cleanse the
with dietary and medication restric-
selected area, and cover with a
tions and pretesting preparations;
sterile drape.
assure that food and medications
have been restricted for at least 8 ➤ A local anesthetic is injected at the
hours prior to the procedure. Ensure site, and a small incision is made or
that the patient has removed jew- a needle inserted under fluoroscopy.
➤ The contrast medium is injected, ➤ Observe the needle/catheter inser-

and a rapid series of images is taken tion site for bleeding, inflammation,
during and after the filling of the or hematoma formation.
vessels to be examined. Delayed ➤ Instruct the patient to apply cold
images may be taken to examine the compresses to the puncture site, as
vessels after a time and to monitor needed, to reduce discomfort or
the venous phase of the procedure. edema.
➤ Ask the patient to inhale deeply and ➤ Instruct the patient to maintain bed
hold his or her breath while the x-ray rest for 4 to 6 hours after the proce-
images are taken, and then to exhale dure or as ordered.
after the images are taken.
➤ Instruct the patient to take slow, assessment of the site and to ob-
deep breaths if nausea occurs during serve for bleeding, hematoma forma-
the procedure. tion, bile leakage, and inflammation.
➤ Monitor the patient for complications Note any pleuritic pain, persistent
related to the procedure (e.g., right shoulder pain, or abdominal
allergic reaction, anaphylaxis, bron- pain.
chospasm).
➤ Nutritional considerations: A low-
➤ The needle or catheter is removed, fat, low-cholesterol, and low-sodium
and a pressure dressing is applied diet should be consumed to reduce
over the puncture site. current disease processes and/or
➤ The results are recorded on x-ray film decrease risk of hypertension and
or electronically in a computerized coronary artery disease.
system for recall and postprocedure ➤ No other radionuclide tests should
interpretation by the appropriate be scheduled for 24 to 48 hours after
health care practitioner. this procedure.
Post-test: ➤ A written report of the examina-
tion will be completed by a health
➤ Instruct the patient to resume usual care practitioner specializing in this
as directed by the health care be sent to the requesting health care
practitioner. Renal function should practitioner, who will discuss the
be assessed before metformin is results with the patient.
resumed. ➤ Recognize anxiety related to test
➤ Monitor vital signs and neurologic results, and be supportive of per-
status every 15 minutes for 1 hour, ceived loss of independent function.
then every 2 hours for 4 hours, and Discuss the implications of abnormal
as ordered. Take the temperature test results on the patient’s lifestyle.
every 4 hours for 24 hours. Compare Provide teaching and information
with baseline values. Protocols may regarding the clinical implications of
vary from facility to facility. the test results, as appropriate.
➤ Observe for delayed allergic reac- ➤ Reinforce information given by the
tions, such as rash, urticaria, tachy- patient’s health care provider regard-
cardia, hyperpnea, hypertension, ing further testing, treatment, or
palpitations, nausea, or vomiting. referral to another health care
➤ Advise the patient to immediately provider. Answer any questions or
report symptoms such as fast heart address any concerns voiced by the
rate, difficulty breathing, skin rash, patient or family.
itching, or decreased urinary output. ➤ Instruct the patient in the use of
➤ Assess extremities for signs of any ordered medications. Explain the
ischemia or absence of distal importance of adhering to the ther-
pulse caused by a catheter-induced apy regimen. As appropriate, instruct
thrombus. the patient in significant side effects
Angiography, Carotid 79
and systemic reactions associated in therapy. Evaluate test results in

with the prescribed medication. relation to the patient’s symptoms
Encourage him or her to review cor- and other tests performed.
responding literature provided by a
pharmacist. Related diagnostic tests:
➤ Depending on the results of this pro- ➤ Related diagnostic tests include adre-
cedure, additional testing may be nal gland scan; computed tomogra-
performed to evaluate or monitor phy of the abdomen; kidney, ureter,
progression of the disease process and bladder study; and magnetic res-
and determine the need for a change onance imaging of the abdomen.
ANGIOGRAPHY, CAROTID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carotid angiogram, carotid arteriography.

AREA OF APPLICATION: Neck/cervical spine area.
DESCRIPTION & RATIONALE: The beneath the table on which the patient
test evaluates blood vessels in the neck lies. Over the patient is an image
carrying arterial blood. This visualiza- intensifier that receives the x-rays after
tion is accomplished by the injection they pass through the patient. Patterns
of contrast material through a catheter of circulation or changes in vessel
that has been inserted into the femoral wall appearance can be viewed to help
artery for viewing the artery (arteriog- diagnose the presence of vascular
raphy). The angiographic catheter is a abnormalities, disease, narrowing,
long tube about the size of a strand of enlargement, blockage, trauma, or
spaghetti. After the injection of con- lesions. This definitive test for arterial
trast media through the catheter, x-ray disease may be used to evaluate
images of the carotid artery and asso- chronic vascular disease, arterial or
ciated vessels in surrounding tissue are venous stenosis, and medical therapy
displayed on a monitor and are or surgery of the vasculature. Catheter
recorded on film or electronically. The angiography still is used in patients
x-ray equipment is mounted on a C- who may undergo surgery, angio-
shaped bed with the x-ray device plasty, or stent placement. ■
INDICATIONS: • Congenital anomalies

• Aid in angioplasty, atherectomy, or • Cysts or tumors
stent placement
• Trauma causing tears or other disrup-
• Allow infusion of thrombolytic drugs tion
• Vascular blockage or other disruption
• Detect arterial occlusion, which may be
evidenced by a transection of the artery INTERFERING FACTORS
caused by trauma or penetrating injury
This procedure is
• Detect artery stenosis, evidenced by contraindicated for:
vessel dilation, collateral vessels, or
increased vascular pressure • Patients with allergies to shellfish
• Detect nonmalignant tumors before
medium used may cause a life-threaten-
surgical resection
ing allergic reaction. Patients with a
• Detect tumors and arterial supply, known hypersensitivity to contrast
extent of venous invasion, and tumor medium may benefit from premedica-
vascularity tion with corticosteroids or the use of
• Detect thrombosis, arteriovenous fis- nonionic contrast medium.
tula, aneurysms, or emboli in vessels • Patients with bleeding disorders.
• Differentiate between tumors and cysts • Patients who are pregnant or suspected
of being pregnant, unless the potential
• Evaluate placement of a stent
benefits of the procedure far outweigh
• Evaluate tumor vascularity before sur- the risks to the fetus and mother.
gery or embolization • Elderly and other patients who
• Evaluate the vascular system of prospec- are chronically dehydrated before
tive organ donors before surgery the test, because of their risk of con-
trast-induced renal failure.
RESULT • Patients who are in renal failure.
Factors that may
Normal Findings:
impair clear imaging:
• Normal structure, function, and
patency of carotid vessels
• Contrast medium normally circulates failure to restrict food intake before the
throughout neck symmetrically and study
without interruption • Retained barium from a previous radi-
• No evidence of obstruction, variations ologic procedure
in number and size of vessels, malfor- • Metallic objects within the examina-
mations, cysts, or tumors tion field (e.g., jewelry, body rings,
dental amalgams), which may inhibit
Abnormal Findings: organ visualization and can produce
• Abscess or inflammation unclear images
• Arterial aneurysm • Improper adjustment of the radi-
ographic equipment to accommodate
• Arterial stenosis or dysplasia
obese or thin patients, which can cause
• Arteriovenous fistula or other abnor- overexposure or underexposure and a
malities poor-quality study
results of blood tests are obtained
• Incorrect positioning of the patient, and recorded before the procedure,
• Inability of the patient to cooperate or related diagnostic tests, refer to the
remain still during the procedure Cardiovascular System table.
because of age, significant pain, or ➤ Note any recent procedures that can
mental status interfere with test results, including
Other considerations: contrast medium.
• Consultation with a health care practi- ➤ Record the date of the last menstrual
tioner should occur before the proce- period and determine the possibility
dure for radiation safety concerns of pregnancy in perimenopausal
regarding younger patients or patients women.
who are lactating. ➤ Obtain a list of the medications the
patient is taking, especially medica-
• Risks associated with radiographic tions known to affect bleeding,
overexposure can result from frequent including anticoagulant therapy,
x-ray procedures. Personnel in the aspirin and other salicylates, herbs,
room with the patient should wear a nutritional supplements, and nutra-
protective lead apron, stand behind a ceuticals (see Appendix F: Effects of
shield, or leave the area while the exam- Natural Products on Laboratory
ination is being done. Personnel work- Values). It is recommended that use
ing in the area where the examination is of such products be discontinued 14
being done should wear badges that days before surgical procedures. The
requesting health care practitioner
reveal their level of exposure to radia- and laboratory should be advised if
tion. the patient regularly uses these prod-
• Failure to follow dietary restrictions ucts so that their effects can be taken
and other pretesting preparations may results.
cause the procedure to be canceled or
repeated. ➤ Patients receiving metformin (glu-
Nursing Implications and continue to withhold it for 48 hours
Procedure ● ● ● ● ● ● ● ● ● ● ● after the test. Failure to do so may
result in lactic acidosis.
Pretest: ➤ Review the procedure with the
➤ Inform the patient that the procedure patient. Address concerns about pain
assesses cardiovascular function. related to the procedure. Explain to
➤ Obtain a history of the patient’s com- experienced during the test, or there
plaints, including a list of known may be moments of discomfort.
allergens (especially allergies or sen- Inform the patient that the procedure
sitivities to latex, iodine, seafood, is performed in a special department,
contrast medium, anesthetics, or usually in a radiology or vascular
dyes), and inform the appropriate suite, by a health care practitioner
health care practitioner accordingly. and support staff and takes approxi-
➤ Obtain a history of results of previ- mately 30 to 60 minutes.
➤ Sensitivity to social and cultural drug, administer ordered prophylac-

issues, as well as concern for mod- tic steroids or antihistamines before
esty, is important in providing psy- the procedure. Use nonionic contrast
chological support before, during, medium for the procedure.
and after the procedure. ➤ Patients are given a gown, robe, and
➤ Explain that an intravenous (IV) line foot coverings to wear and instructed
may be inserted to allow infusion of to void prior to the procedure.
IV fluids, contrast medium, dye, or
infused.
Appendix A.
➤ Inform the patient that a burning and
➤ Record baseline vital signs, and
flushing sensation may be felt
assess neurologic status. Protocols
throughout the body during injection
may vary from facility to facility.
➤ The patient should fast and restrict duces unreliable results.
metallic objects in the area to be ➤ Place electrocardiographic electrodes
examined. on the patient for cardiac monitoring.
➤ Make sure a written and informed Establish a baseline rhythm; deter-
consent has been signed prior to the mine if the patient has ventricular
procedure and before administering arrhythmias.
any medications. ➤ Using a pen, mark the site of the
➤ This procedure may be terminated if patient’s peripheral pulses before
chest pain, severe cardiac arrhyth- angiography; this allows for quicker
mias, or signs of a cerebrovascular and more consistent assessment of
accident occur. the pulses after the procedure.
Intratest: tion on an exam table. Cleanse the
➤ Ensure that the patient has complied selected area, and cover with a ster-
with dietary, medication, or activity ile drape.
restrictions and pretesting prepara- ➤ A local anesthetic is injected at the
tions; assure that food and medica- site, and a small incision is made or
tions have been restricted for at least a needle inserted under fluoroscopy.
8 hours prior to the procedure. ➤ The contrast medium is injected, and
Ensure that the patient has removed a rapid series of images is taken dur-
jewelry, dentures, all external metal- ing and after the filling of the vessels
lic objects, and the like prior to the to be examined. Delayed images
procedure. may be taken to examine the vessels
➤ Have emergency equipment readily after a time and to monitor the
available. venous phase of the procedure.
➤ If the patient has a history of severe ➤ Ask the patient to inhale deeply and
allergic reactions to any substance or hold his or her breath while the x-ray
images are taken, and then to exhale ➤ Instruct the patient to maintain bed
after the images are taken. rest for 4 to 6 hours after the proce-
dure or as ordered.
deep breaths if nausea occurs during ➤ Instruct the patient in the care and
the procedure. assessment of the site and to
observe for bleeding, hematoma for-
➤ Monitor the patient for complications
mation, bile leakage, and inflamma-
related to the procedure (e.g., aller-
tion. Note any pleuritic pain,
gic reaction, anaphylaxis, bron-
persistent right shoulder pain, or
chospasm).
abdominal pain.
➤ The needle or catheter is removed,
and a pressure dressing is applied
low-cholesterol, and low-sodium diet
over the puncture site.
should be consumed to reduce cur-
➤ The results are recorded on x-ray film rent disease processes and/or
or electronically in a computerized decrease risk of hypertension and
system for recall and postprocedure coronary artery disease.
interpretation by the appropriate
➤ No other radionuclide tests should
health care practitioner.
be scheduled for 24 to 48 hours after
this procedure.
➤ Instruct the patient to resume usual will be completed by a health care
diet, fluids, medications, or activity, practitioner specializing in this
as directed by the health care practi- branch of medicine. The report will
tioner. Renal function should be be sent to the requesting health care
assessed before metformin is practitioner, who will discuss the
resumed. results with the patient.
➤ Monitor vital signs and neurologic ➤ Recognize anxiety related to test
status every 15 minutes for 1 hour, results, and be supportive of per-
then every 2 hours for 4 hours, and ceived loss of independent func-
as ordered. Take the temperature tion. Discuss the implications of
every 4 hours for 24 hours. Compare abnormal test results on the
with baseline values. Protocols may patient’s lifestyle. Provide teaching
vary from facility to facility. and information regarding the clinical
implications of the test results, as
➤ Observe for delayed allergic reac- appropriate.
tions, such as rash, urticaria, tachy-
cardia, hyperpnea, hypertension, ➤ Reinforce information given by the
palpitations, nausea, or vomiting. patient’s health care provider regard-
➤ Instruct the patient to immediately referral to another health care
report symptoms such as fast heart provider. Answer any questions or
rate, difficulty breathing, skin rash, address any concerns voiced by the
itching, or decreased urinary output. patient or family.
➤ Assess extremities for signs of ➤ Instruct the patient in the use of any
ischemia or absence of distal ordered medications. Explain the
pulse caused by a catheter-induced importance of adhering to the ther-
thrombus. apy regimen. As appropriate, instruct
➤ Observe the needle/catheter inser- the patient in significant side effects
tion site for bleeding, inflammation, and systemic reactions associated
or hematoma formation. with the prescribed medication.
Encourage him or her to review cor-
➤ Instruct the patient to apply cold
compresses to the puncture site, as
pharmacist.
needed, to reduce discomfort or
edema. ➤ Depending on the results of this pro-
cedure, additional testing may be Related diagnostic tests:

progression of the disease process ➤ Related diagnostic tests include com-
and determine the need for a change puted tomography angiography, mag-
in therapy. Evaluate test results in netic resonance angiography, and
relation to the patient’s symptoms ultrasound, arterial Doppler carotid
and other tests performed. studies.
ANGIOGRAPHY, CORONARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Angiocardiography, cardiac angiography, cardiac

catheterization, cineangiocardiography, coronary arteriography.
AREA OF APPLICATION: Heart.

DESCRIPTION & RATIONALE: Angio- abnormalities are seen with left heart
graphy allows x-ray visualization of the views. Coronary angiography is a
heart, aorta, inferior vena cava, pul- definitive test for coronary artery dis-
monary artery and vein, and coronary ease, and it is useful for evaluating
arteries after injection of contrast other types of cardiac abnormalities. ■
medium. Contrast medium is injected
through a catheter, which has been INDICATIONS:
inserted into a peripheral vein for a • Allow infusion of thrombolytic drugs
right heart catheterization or an artery into an occluded coronary artery
for a left heart catheterization; through • Detect narrowing of coronary vessels or
the same catheter, cardiac pressures abnormalities of the great vessels in
are recorded. Images of the heart and patients with angina, syncope, abnor-
mal electrocardiogram, hypercholes-
associated vessels are displayed on a
teremia with chest pain, and persistent
monitor and are recorded on film or chest pain after revascularization
electronically. Patterns of circulation,
cardiac output, cardiac functions, and • Evaluate cardiac muscle function
changes in vessel wall appearance can • Evaluate cardiac valvular and septal
be viewed to help diagnose the pres- defects
ence of vascular abnormalities or • Evaluate disease associated with the
lesions. Pulmonary artery abnormali- aortic arch
ties are seen with right heart views, • Evaluate previous cardiac surgery or
and coronary artery and thoracic aorta other interventional procedures
Angiography, Coronary 85
• Evaluate ventricular aneurysms • Patients who are pregnant or suspected

• Monitor pulmonary pressures and car- of being pregnant, unless the potential
diac output benefits of the procedure far outweigh
the risk of radiation exposure to the
• Perform angioplasty, perform atherec- fetus.
tomy, or place a stent
• Quantify the severity of atherosclerotic, • Elderly and compromised pa-
occlusive coronary artery disease tients who are chronically dehy-
drated before the test, because of their
RESULT risk of contrast-induced renal failure.
Normal Findings:
• Normal great vessels and coronary Factors that may
arteries impair clear imaging:
Abnormal Findings: resulting from inadequate cleansing or
• Aortic atherosclerosis failure to restrict food intake before the
study
• Aortic dissection
• Aortitis ologic procedure
• Aneurysms • Metallic objects within the examina-
• Cardiomyopathy tion field (e.g., jewelry, body rings),
which may inhibit organ visualization
• Congenital anomalies and can produce unclear images
• Coronary artery atherosclerosis and • Improper adjustment of the radi-
degree of obstruction ographic equipment to accommodate
• Graft occlusion obese or thin patients, which can cause
overexposure or underexposure and a
• Pulmonary artery abnormalities poor-quality study
• Septal defects • Patients who are very obese, who may
exceed the weight limit for the equip-
• Trauma causing tears or other dis-
ment
ruption
• Incorrect positioning of the patient,
• Tumors which may produce poor visualization
• Valvular disease of the area to be examined
• Inability of the patient to cooperate or
INTERFERING FACTORS remain still during the procedure
This procedure is
mental status
contraindicated for:
• Patients with allergies to shellfish Other considerations:

or iodinated dye. The contrast • Consultation with a physician should
medium used may cause a life-threat- occur before the procedure for radia-
ening allergic reaction. Patients with a tion safety concerns regarding younger
known hypersensitivity to contrast patients or patients who are lactating.
medium may benefit from premedica- • Risks associated with radiographic over-
tion with corticosteroids or the use of exposure can result from frequent x-ray
nonionic contrast medium. procedures. Personnel in the room with
• Patients with bleeding disorders. the patient should wear a protective
lead apron, stand behind a shield, or Natural Products on Laboratory

leave the area while the examination is Values). It is recommended that use
being done. Personnel working in the of such products be discontinued 14
area where the examination is being days before surgical procedures. The
done should wear badges that reveal and laboratory should be advised if
their level of exposure to radiation. the patient regularly uses these prod-
and other pretesting preparations may into consideration when reviewing
repeated. ➤ Patients receiving metformin (glu-
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: ➤ Review the procedure with the
patient. Address concerns about
➤ Inform the patient that the procedure pain related to the procedure.
assesses cardiovascular function. Explain to the patient that some pain
may be experienced during the test,
or there may be moments of dis-
comfort. Inform the patient that the
procedure is performed in a special
sitivities to latex, iodine, seafood,
department, usually in a radiology
contrast medium, anesthetics, or
or vascular suite, by a physician and
dyes), and inform the appropriate
support staff and takes approxi-
mately 30 to 60 minutes.
➤ Obtain a history of results of previ- ➤ Sensitivity to cultural and social
ously performed diagnostic proce- issues, as well as concern for mod-
dures, surgical procedures, and esty, is important in providing psy-
laboratory tests. Ensure that the chological support before, during,
results of blood tests are obtained and after the procedure.
and recorded before the procedure,
especially coagulation tests, blood
may be inserted to allow infusion
urea nitrogen, and creatinine, if con-
of IV fluids, contrast medium, dye, or
related diagnostic tests, refer to
infused.
the Cardiovascular and Respiratory
System tables. ➤ Inform the patient that a burning and
flushing sensation may be felt
➤ Note any recent procedures that can throughout the body during injection
interfere with test results, including of the contrast medium. After injec-
examinations using iodine-based tion of the contrast medium, the
contrast medium. patient may experience an urge to
➤ Record the date of the last menstrual cough, flushing, nausea, or a salty or
period and determine the possibility metallic taste.
of pregnancy in perimenopausal ➤ The patient should fast and restrict
women. fluids for 8 hours prior to the proce-
➤ Obtain a list of the medications the dure. Instruct the patient to avoid
patient is taking, especially medica- taking anticoagulant medication or to
tions known to affect bleeding, reduce dosage as ordered prior to
including anticoagulant therapy, the procedure.
aspirin and other salicylates, herbs, ➤ Instruct the patient to remove den-
nutritional supplements, and nutra- tures, jewelry (including watches),
ceuticals (see Appendix F: Effects of hairpins, credit cards, and other
Angiography, Coronary 87
metallic objects in the area to be rhythm; determine if the patient has

examined. ventricular arrhythmias.
➤ Make sure a written and informed ➤ Using a pen, mark the site of the
consent has been signed prior to the patient’s peripheral pulses before
procedure and before administering angiography; this allows for quicker
any medications. and more consistent assessment of
➤ This procedure may be terminated if the pulses after the procedure.
chest pain, severe cardiac arrhyth- ➤ Place the patient in the supine posi-
mias, or signs of a cerebrovascular tion on an exam table. Cleanse the
accident occur. selected area, and cover with a ster-
ile drape.
Intratest: ➤ A local anesthetic is injected at the
➤ Ensure that the patient has complied site, and a small incision is made or
with dietary and medication restric- a needle inserted under fluoroscopy.
tions and pretesting preparations; ➤ The contrast medium is injected, and
assure that food and medications a rapid series of images is taken dur-
have been restricted for at least 8 ing and after the filling of the vessels
hours prior to the procedure. Ensure to be examined. Delayed images
that the patient has removed jew- may be taken to examine the vessels
elry, dentures, all external metallic after a time and to monitor the
objects, and the like prior to the pro- venous phase of the procedure.
cedure. ➤ Ask the patient to inhale deeply and
➤ Have emergency equipment readily hold his or her breath while the x-ray
available. images are taken, and then to exhale
➤ If the patient has a history of severe after the images are taken.
allergic reactions to any substance or ➤ Instruct the patient to take slow,
drug, administer ordered prophylac- deep breaths if nausea occurs during
tic steroids or antihistamines before the procedure.
the procedure. Use nonionic contrast ➤ Monitor the patient for complica-
medium for the procedure. tions related to the procedure (e.g.,
➤ Patients are given a gown, robe, and allergic reaction, anaphylaxis, bron-
foot coverings to wear and instructed chospasm).
to void prior to the procedure. ➤ The needle or catheter is removed,
➤ Observe standard precautions, and and a pressure dressing is applied
follow the general guidelines in over the puncture site.
Appendix A. ➤ The results are recorded on x-ray film
➤ Record baseline vital signs, and or electronically in a computerized
assess neurologic status. Protocols system for recall and postprocedure
may vary from facility to facility. interpretation by the appropriate
➤ Instruct the patient to cooperate fully health care practitioner.
patient to remain still throughout Post-test:
the procedure because movement
➤ Instruct the patient to resume usual
produces unreliable results.
diet, fluids, medications, or activity,
➤ Establish an IV fluid line for the injec- as directed by the health care practi-
tion of emergency drugs and of tioner. Renal function should be
sedatives. assessed before metformin is
➤ Administer an antianxiety agent, as resumed.
ordered, if the patient has claustro- ➤ Monitor vital signs and neurologic
phobia. Administer a sedative to a status every 15 minutes for 1 hour,
child or to an uncooperative adult, as then every 2 hours for 4 hours, and
ordered. as ordered. Take the temperature
➤ Place electrocardiographic elec- every 4 hours for 24 hours. Compare
trodes on the patient for cardiac with baseline values. Protocols may
monitoring. Establish a baseline vary from facility to facility.
➤ Observe for delayed allergic reac- Discuss the implications of abnormal

tions, such as rash, urticaria, tachy- test results on the patient’s lifestyle.
cardia, hyperpnea, hypertension, Provide teaching and information
palpitations, nausea, or vomiting. regarding the clinical implications of
➤ Advise the patient to immediately the test results, as appropriate.
report symptoms such as fast heart ➤ Reinforce information given by the
rate, difficulty breathing, skin rash, patient’s health care provider regard-
itching, or decreased urinary output. ing further testing, treatment, or
➤ Assess extremities for signs of
ischemia or absence of distal pulse
caused by a catheter-induced throm-
patient or family.
bus.
➤ Instruct the patient in the use of any
➤ Observe the needle/catheter inser-
tion site for bleeding, inflammation,
importance of adhering to the ther-
or hematoma formation.
apy regimen. As appropriate, instruct
➤ Instruct the patient to apply cold the patient in significant side effects
compresses to the puncture site, as and systemic reactions associated
needed, to reduce discomfort or with the prescribed medication.
edema. Encourage him or her to review cor-
➤ Instruct the patient to maintain bed responding literature provided by a
rest for 4 to 6 hours after the proce- pharmacist.
dure or as ordered. ➤ Depending on the results of this pro-
➤ Instruct the patient in the care and as- cedure, additional testing may be
sessment of the site and to observe performed to evaluate or monitor
for bleeding, hematoma formation, progression of the disease process
bile leakage, and inflammation. Note and determine the need for a change
any pleuritic pain, persistent right in therapy. Evaluate test results in
shoulder pain, or abdominal pain. relation to the patient’s symptoms
practitioner specializing in this Related diagnostic tests:
branch of medicine. The report will ➤ Related diagnostic tests include
be sent to the requesting health care chest x-ray, computed tomography
practitioner, who will discuss the angiography, computed tomogra-
results with the patient. phy cardiac scoring, electrocardio-
➤ Recognize anxiety related to test gram, magnetic resonance angiogra-
results, and be supportive of per- phy, and myocardial perfusion heart
ceived loss of independent function. scan.
ANGIOGRAPHY, PULMONARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Pulmonary angiography, pulmonary arteriography.

AREA OF APPLICATION: Pulmonary vasculature.
Angiography, Pulmonary 89
• Bleeding caused by tuberculosis, bron-

DESCRIPTION & RATIONALE: Pul- chiectasis, sarcoidosis, or aspergilloma
monary angiography allows x-ray visu- • Inflammatory diseases
alization of the pulmonary vasculature
• Pulmonary embolism (acute or chronic)
after injection of an iodinated contrast
medium into the pulmonary artery or • Pulmonary sequestration
a branch of this great vessel. Contrast • Tumors
medium is injected through a catheter
that has been inserted into the vascu- CRITICAL VALUES: N/A
lar system, usually through the
femoral vein. It is one of the definitive INTERFERING FACTORS:
tests for pulmonary embolism, but it
This procedure is
is also useful for evaluating other types
of pulmonary vascular abnormalities.
It is definitive for peripheral pul- • Patients with allergies to shellfish
monary artery stenosis, anomalous or iodinated dye. The contrast
pulmonary venous drainage, and medium used may cause a life-threat-
ening allergic reaction. Patients with a
pulmonary fistulae. Hemodynamic
known hypersensitivity to contrast
measurements during pulmonary medium may benefit from premedica-
angiography can assist in the diagnosis tion with corticosteroids or the use of
of pulmonary hypertension and cor nonionic contrast medium.
pulmonale. ■ • Patients with bleeding disorders.
INDICATIONS: • Patients who are pregnant or suspected
• Detect acute pulmonary embolism of being pregnant, unless the potential
• Detect arteriovenous malformations or the risks to the fetus and mother.
aneurysms
• Elderly and other patients who
• Detect tumors; aneurysms; congenital are chronically dehydrated before
defects; vascular changes associated the test, because of their risk of con-
with emphysema, blebs, and bullae; trast-induced renal failure.
and heart abnormalities
• Determine the cause of recurrent or
severe hemoptysis Factors that may impair
• Evaluate pulmonary circulation clear imaging:
RESULT ologic procedure
Normal Findings: tion field (e.g., jewelry, body rings),
• Normal pulmonary vasculature; radio- which may inhibit organ visualization
paque iodine contrast medium should and can produce unclear images
circulate symmetrically and without • Improper adjustment of the radi-
interruption through the pulmonary ographic equipment to accommodate
circulatory system. obese or thin patients, which can cause
Abnormal Findings:
poor-quality study
• Aneurysms
• Patients who are very obese, who may
• Arterial hypoplasia or stenosis exceed the weight limit for the equip-
• Arteriovenous malformations ment
• Incorrect positioning of the patient, trast medium is to be used. For

which may produce poor visualization related diagnostic tests, refer to the
of the area to be examined Cardiovascular and Respiratory
System tables.
remain still during the procedure ➤ Note any recent procedures that
can interfere with test results,
including examinations using iodine-
mental status based contrast medium.
Other considerations: ➤ Record the date of the last menstrual

period and determine the possibility
• Consultation with a physician should
of pregnancy in perimenopausal
occur before the procedure for radia- women.
tion safety concerns regarding younger
patients or patients who are lactating. ➤ Obtain a list of the medications the
• Risks associated with radiographic over- tions known to affect bleeding,
exposure can result from frequent x-ray including anticoagulant therapy,
procedures. Personnel in the room with aspirin and other salicylates, herbs,
the patient should wear a protective nutritional supplements, and nutra-
lead apron, stand behind a shield, or ceuticals (see Appendix F: Effects of
Natural Products on Laboratory
leave the area while the examination is Values). It is recommended that use
being done. Personnel working in the of such products be discontinued 14
area where the examination is being days before surgical procedures. The
done should wear badges that reveal requesting health care practitioner
their level of exposure to radiation. and laboratory should be advised if
and other pretesting preparations may into consideration when reviewing
repeated.
➤ Patients receiving metformin (glu-
Nursing Implications and the drug on the day of the test and
Procedure ● ● ● ● ● ● ● ● ● ● ● continue to withhold it for 48 hours
Pretest: result in lactic acidosis.
➤ Inform the patient that the procedure ➤ Review the procedure with the
assesses cardiovascular function. patient. Address concerns about pain
➤ Obtain a history of the patient’s com- related to the procedure. Explain to
plaints, including a list of known the patient that some pain may be
allergens (especially allergies or experienced during the test, or there
sensitivities to latex, iodine, sea- may be moments of discomfort.
food, contrast medium, anesthetics, Inform the patient that the procedure
or dyes), and inform the appropriate is performed in a special depart-
health care practitioner accordingly. ment, usually in a radiology or vascu-
lar suite, by a physician and support
➤ Obtain a history of results of previ- staff and takes approximately 30 to
ously performed diagnostic proce- 60 minutes.
laboratory tests. Ensure that the ➤ Sensitivity to cultural and social
results of blood tests are obtained issues, as well as concern for mod-
and recorded before the procedure, esty, is important in providing psy-
especially coagulation tests, blood chological support before, during,
urea nitrogen, and creatinine, if con- and after the procedure.
Angiography, Pulmonary 91
➤ Explain that an intravenous (IV) line ➤ Patients are given a gown, robe, and
may be inserted to allow infusion of foot coverings to wear and instruc-
IV fluids, contrast medium, dye, or ted to void prior to the procedure.
sedatives. Usually normal saline is ➤ Observe standard precautions, and
infused. follow the general guidelines in
➤ Inform the patient that a burning and Appendix A.
flushing sensation may be felt ➤ Record baseline vital signs, and
throughout the body during injection assess neurologic status. Protocols
of the contrast medium. After injec- may vary from facility to facility.
➤ The patient should fast and restrict duces unreliable results.
metallic objects in the area to be ➤ Place electrocardiographic elec-
examined. trodes on the patient for cardiac
➤ Make sure a written and informed monitoring. Establish a baseline
consent has been signed prior to the rhythm; determine if the patient has
procedure and before administering ventricular arrhythmias.
any medications. ➤ Using a pen, mark the site of the
patient’s peripheral pulses before
➤ This procedure may be terminated if
angiography; this allows for quicker
chest pain, severe cardiac arrhyth-
and more consistent assessment of
mias, or signs of a cerebrovascular
the pulses after the procedure.
accident occur.
tion on an exam table. Cleanse the
Intratest: selected area, and cover with a ster-
➤ Ensure that the patient has complied ile drape.
with dietary and medication restric- ➤ A local anesthetic is injected at the
tions and pretesting preparations; site, and a small incision is made or
assure that food and medications a needle inserted under fluoroscopy.
have been restricted for at least 8 ➤ The contrast medium is injected, and
hours prior to the procedure. Ensure a rapid series of images is taken dur-
that the patient has removed jew- ing and after the filling of the vessels
elry, dentures, all external metallic to be examined. Delayed images
objects, and the like prior to the pro- may be taken to examine the vessels
cedure. after a time and to monitor the
➤ Have emergency equipment readily venous phase of the procedure.
available. ➤ Ask the patient to inhale deeply and
➤ If the patient has a history of severe hold his or her breath while the x-ray
allergic reactions to any substance or images are taken, and then to exhale
drug, administer ordered prophylac- after the images are taken.
tic steroids or antihistamines before ➤ Instruct the patient to take slow,
the procedure. Use nonionic contrast deep breaths if nausea occurs during
medium for the procedure. the procedure.
➤ Monitor the patient for complications any pleuritic pain, persistent right
related to the procedure (e.g., aller- shoulder pain, or abdominal pain.
chospasm).
➤ The needle or catheter is removed, practitioner specializing in this
and a pressure dressing is applied branch of medicine. The report will
over the puncture site. be sent to the requesting health care
➤ The results are recorded on x-ray film practitioner, who will discuss the
or electronically in a computerized results with the patient.
system for recall and postprocedure ➤ Recognize anxiety related to test
interpretation by the appropriate results, and be supportive of per-
health care practitioner. ceived loss of independent func-
tion. Discuss the implications of
Post-test: abnormal test results on the pa-
➤ Instruct the patient to resume usual tient’s lifestyle. Provide teaching and
diet, fluids, medications, or activity, information regarding the clinical
as directed by the health care practi- implications of the test results, as
tioner. Renal function should be appropriate.
assessed before metformin is ➤ Reinforce information given by the
resumed. patient’s health care provider regard-
➤ Monitor vital signs and neurologic ing further testing, treatment, or
status every 15 minutes for 1 hour, referral to another health care
then every 2 hours for 4 hours, and provider. Answer any questions or
as ordered. Take the temperature address any concerns voiced by the
every 4 hours for 24 hours. Compare patient or family.
with baseline values. Protocols may ➤ Instruct the patient in the use of any
vary from facility to facility. ordered medications. Explain the
➤ Observe for delayed allergic reac- importance of adhering to the ther-
tions, such as rash, urticaria, tachy- apy regimen. As appropriate, instruct
cardia, hyperpnea, hypertension, the patient in significant side effects
palpitations, nausea, or vomiting. and systemic reactions associated
with the prescribed medication.
➤ Advise the patient to immediately Encourage him or her to review cor-
report symptoms such as fast heart responding literature provided by a
rate, difficulty breathing, skin rash, pharmacist.
itching, or decreased urinary output.
➤ Assess extremities for signs of
ischemia or absence of distal
pulse caused by a catheter-induced
thrombus.
➤ Observe the needle/catheter inser- in therapy. Evaluate test results in
tion site for bleeding, inflammation, relation to the patient’s symptoms
or hematoma formation. and other tests performed.
needed, to reduce discomfort or Related diagnostic tests
edema.
➤ Related diagnostic tests include
➤ Instruct the patient to maintain bed chest x-ray, computed tomography
rest for 4 to 6 hours after the proce- angiography, electrocardiogram, lung
dure or as ordered. perfusion and lung ventilation scans,
➤ Instruct the patient in the care and as- magnetic resonance angiography,
sessment of the site and to observe magnetic resonance imaging of the
for bleeding, hematoma formation, chest, and thoracic computed tomo-
bile leakage, and inflammation. Note graphy.
Angiography, Renal 93
ANGIOGRAPHY, RENAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Renal angiogram, renal arteriography.

AREA OF APPLICATION: Kidney.
caused by trauma or a penetrating

DESCRIPTION & RATIONALE: Renal injury
angiography allows x-ray visualization • Detect nonmalignant tumors before
of the large and small arteries of the surgical resection
renal vasculature and parenchyma or • Detect renal artery stenosis as evi-
the renal veins and their branches. denced by vessel dilation, collateral ves-
Contrast medium is injected through sels, or increased renovascular pressure
a catheter that has been inserted into • Detect renal tumors as evidenced by
the femoral artery or vein and arterial supply, extent of venous inva-
advanced through the iliac artery and sion, and tumor vascularity
aorta into the renal artery or the infe- • Detect small kidney or absence of a
rior vena cava into the renal vein. kidney
Images of the kidneys and associated • Detect thrombosis, arteriovenous fistu-
vessels are displayed on a monitor and lae, aneurysms, or emboli in renal ves-
recorded on film or electronically. sels
Patterns of circulation, renal function, • Differentiate between renal tumors and
or changes in vessel wall appearance renal cysts
can be viewed to help diagnose the • Evaluate postoperative renal transplan-
presence of vascular abnormalities, tation for function or organ rejection
trauma, or lesions. This definitive test • Evaluate renal function in chronic renal
for renal disease may be used to evalu- failure or end-stage renal disease or
ate chronic renal disease, renal failure, hydronephrosis
and renal artery stenosis; differentiate • Evaluate the renal vascular system of
a vascular renal cyst from hypervascu- prospective kidney donors before sur-
lar renal cancers; and evaluate renal gery
transplant donors, recipients, and the • Evaluate tumor vascularity before sur-
kidney after transplantation. ■ gery or embolization
INDICATIONS: • Perform angioplasty, perform atherec-
• Allow infusion of thrombolytic drugs tomy, or place a stent
RESULT
• Assist with the collection of blood sam-
ples from renal vein for renin analysis Normal Findings:
• Detect arterial occlusion as evidenced • Normal structure, function, and
by a transection of the renal artery patency of renal vessels
• Contrast medium circulating through- • Retained barium from a previous radi-

out the kidneys symmetrically and ologic procedure
without interruption • Metallic objects within the examina-
• No evidence of obstruction, variations tion field (e.g., jewelry, body rings,
in number and size of vessels and dental amalgams), which may inhibit
organs, malformations, cysts, or tumors organ visualization and can produce
Abnormal Findings:
unclear images
• Abscess or inflammation • Improper adjustment of the radi-
• Arterial stenosis, dysplasia, or infarction
• Arteriovenous fistula or other abnor- overexposure or underexposure and a
malities poor-quality study
• Congenital anomalies • Patients who are very obese, who may
• Intrarenal hematoma exceed the weight limit for the equip-
• Renal artery aneurysm ment
• Renal cysts or tumors • Incorrect positioning of the patient,
• Trauma causing tears or other disrup- which may produce poor visualization
tion of the area to be examined
CRITICAL VALUES: N/A remain still during the procedure
INTERFERING FACTORS because of age, significant pain, or
mental status
This procedure is
contraindicated for: Other considerations:
• Consultation with a physician should
• Patients with allergies to shellfish occur before the procedure for radia-
or iodinated dye. The contrast tion safety concerns regarding younger
medium used may cause a life-threat- patients or patients who are lactating.
ening allergic reaction. Patients with a • Risks associated with radiographic over-
known hypersensitivity to contrast exposure can result from frequent x-ray
medium may benefit from premedica- procedures. Personnel in the room with
tion with corticosteroids or the use of the patient should wear a protective
nonionic contrast medium. lead apron, stand behind a shield, or
• Patients with bleeding disorders. leave the area while the examination is
• Patients who are pregnant or suspected being done. Personnel working in the
of being pregnant, unless the potential area where the examination is being
benefits of the procedure far outweigh done should wear badges that reveal
the risks to the fetus and mother. their level of exposure to radiation.
• Elderly and other patients who • Failure to follow dietary restrictions
are chronically dehydrated before and other pretesting preparations may
the test, because of their risk of con- cause the procedure to be canceled or
trast-induced renal failure. repeated.
Factors that may Nursing Implications and

impair clear imaging: Procedure ● ● ● ● ● ● ● ● ● ● ●

resulting from inadequate cleansing or Pretest:
failure to restrict food intake before the ➤ Inform the patient that the procedure
study assesses cardiovascular function.
➤ Obtain a history of the patient’s com- the procedure is performed in a spe-

plaints, including a list of known cial department, usually in a radiol-
allergens (especially allergies or sen- ogy or vascular suite, by a physician
sitivities to latex, iodine, seafood, and support staff and takes approxi-
contrast medium, anesthetics, or mately 30 to 60 minutes.
dyes), and inform the appropriate ➤ Sensitivity to cultural and social
health care practitioner accordingly. issues, as well as concern for mod-
➤ Obtain a history of results of previ- esty, is important in providing psy-
ously performed diagnostic proce- chological support before, during,
dures, surgical procedures, and and after the procedure.
laboratory tests. Ensure that the ➤ Explain that an intravenous (IV) line
results of blood tests are obtained may be inserted to allow infusion of
and recorded before the procedure, IV fluids, contrast medium, dye, or
especially coagulation tests, blood sedatives. Usually normal saline is
urea nitrogen, and creatinine, if con- infused.
related diagnostic tests, refer to the ➤ Inform the patient that a burning and
Cardiovascular and Genitourinary flushing sensation may be felt
System tables. throughout the body during injection
tion of the contrast medium, the
patient may experience an urge to
cough, flushing, nausea, or a salty or
contrast medium.
metallic taste.
period and determine the possibility ➤ The patient should fast and restrict
of pregnancy in perimenopausal fluids for 8 hours prior to the proce-
women. dure. Instruct the patient to avoid
taking anticoagulant medication or to
reduce dosage as ordered prior to
the procedure.
tions known to affect bleeding,
including anticoagulant therapy, as- ➤ Instruct the patient to remove den-
pirin and other salicylates, herbs, tures, jewelry (including watches),
nutritional supplements, and nutra- hairpins, credit cards, and other
ceuticals (see Appendix F: Effects of metallic objects in the area to be
Natural Products on Laboratory examined.
Values). It is recommended that use ➤ Make sure a written and informed
of such products be discontinued 14 consent has been signed prior to the
days before surgical procedures. The procedure and before administering
requesting health care practitioner any medications.
the patient regularly uses these prod- ➤ This procedure may be terminated if
ucts so that their effects can be taken chest pain, severe cardiac arrhyth-
into consideration when reviewing mias, or signs of a cerebrovascular
results. accident occur.
➤ Patients receiving metformin (glu- Intratest:
(type 2) diabetes should discontinue ➤ Ensure that the patient has complied
the drug on the day of the test and with dietary and medication restric-
continue to withhold it for 48 hours tions and pretesting preparations;
after the test. Failure to do so may assure that food and medications
result in lactic acidosis. have been restricted for at least 8
➤ Review the procedure with the hours prior to the procedure. Ensure
patient. Address concerns about that the patient has removed jew-
pain related to the procedure. elry, dentures, all external metallic
Explain to the patient that some objects, and the like prior to the pro-
pain may be experienced during the cedure.
test, or there may be moments of ➤ Have emergency equipment readily
discomfort. Inform the patient that available.
95
➤ If the patient has a history of severe images are taken, and then to exhale
allergic reactions to any substance or after the images are taken.
drug, administer ordered prophylac- ➤ Instruct the patient to take slow,
tic steroids or antihistamines before deep breaths if nausea occurs during
the procedure. Use nonionic contrast the procedure.
medium for the procedure. ➤ Monitor the patient for complications
➤ Patients are given a gown, robe, and related to the procedure (e.g.,
foot coverings to wear and instructed allergic reaction, anaphylaxis, bron-
to void prior to the procedure. chospasm).
➤ Observe standard precautions, and ➤ The needle or catheter is removed,
follow the general guidelines in and a pressure dressing is applied
Appendix A. over the puncture site.
➤ Record baseline vital signs, and ➤ The results are recorded on x-ray film
assess neurologic status. Protocols or electronically in a computerized
may vary from facility to facility. system for recall and postprocedure
interpretation by the appropriate
Post-test:
procedure because movement pro-
duces unreliable results. ➤ Instruct the patient to resume usual
➤ Establish an IV fluid line for the injec- diet, fluids, medications, or activity,
tion of emergency drugs and of as directed by the health care
sedatives. practitioner. Renal function should
be assessed before metformin is
➤ Administer an antianxiety agent, as
resumed.
ordered, if the patient has claustro-
phobia. Administer a sedative to a ➤ Monitor vital signs and neurologic
child or to an uncooperative adult, as status every 15 minutes for 1 hour,
ordered. then every 2 hours for 4 hours, and
as ordered. Take the temperature
➤ Place electrocardiographic elec- every 4 hours for 24 hours. Compare
trodes on the patient for cardiac with baseline values. Protocols may
monitoring. Establish a baseline vary from facility to facility.
rhythm; determine if the patient has
➤ Observe for delayed allergic reac-
ventricular arrhythmias.
➤ Using a pen, mark the site of the cardia, hyperpnea, hypertension,
patient’s peripheral pulses before palpitations, nausea, or vomiting.
angiography; this allows for quicker ➤ Advise the patient to immediately
and more consistent assessment of report symptoms such as fast heart
the pulses after the procedure. rate, difficulty breathing, skin rash,
➤ Place the patient in the supine posi- itching, or decreased urinary output.
tion on an exam table. Cleanse the ➤ Assess extremities for signs of
selected area, and cover with a ster- ischemia or absence of distal pulse
ile drape. caused by a catheter-induced throm-
➤ A local anesthetic is injected at the bus.
site, and a small incision is made or ➤ Observe the needle/catheter inser-
a needle inserted under fluoroscopy. tion site for bleeding, inflammation,
➤ The contrast medium is injected, and or hematoma formation.
a rapid series of images is taken dur- ➤ Instruct the patient to apply cold
ing and after the filling of the vessels compresses to the puncture site, as
to be examined. Delayed images needed, to reduce discomfort or
may be taken to examine the vessels edema.
after a time and to monitor the ➤ Instruct the patient to maintain bed
venous phase of the procedure. rest for 4 to 6 hours after the proce-
➤ Ask the patient to inhale deeply and dure or as ordered.
hold his or her breath while the x-ray ➤ Instruct the patient in the care and
Angiotensin-Converting Enzyme 97
assessment of the site and to ➤ Instruct the patient in the use of any
observe for bleeding, hematoma for- ordered medications. Explain the
mation, bile leakage, and inflamma- importance of adhering to the ther-
tion. Note any pleuritic pain, apy regimen. As appropriate, instruct
persistent right shoulder pain, or the patient in significant side effects
abdominal pain. and systemic reactions associated
➤ A written report of the examina- with the prescribed medication.
tion will be completed by a health Encourage him or her to review cor-
care practitioner specializing in this responding literature provided by a
branch of medicine. The report will pharmacist.
be sent to the requesting health care ➤ Depending on the results of this pro-
practitioner, who will discuss the cedure, additional testing may be
results with the patient. performed to evaluate or monitor
results, and be supportive of per- and determine the need for a change
ceived loss of independent function. in therapy. Evaluate test results in
Discuss the implications of abnormal relation to the patient’s symptoms
test results on the patient’s lifestyle. and other tests performed.
regarding the clinical implications of
the test results, as appropriate. Related diagnostic tests
➤ Reinforce information given by the ➤ Related diagnostic tests include
patient’s health care provider regard- computed tomography of the abdo-
ing further testing, treatment, or men; computed tomography angiog-
referral to another health care pro- raphy; kidney, ureter, and bladder
vider. Answer any questions or study; magnetic resonance angiogra-
address any concerns voiced by the phy and magnetic resonance imag-
patient or family. ing of the abdomen.
ANGIOTENSIN-CONVERTING ENZYME
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Angiotensin I–converting enzyme (ACE).

0–2 y 5–83 U/L 0.09–1.41 Kat/L
3–7 y 8–76 U/L 0.14–1.29 Kat/L
8–14 y 6–89 U/L 0.10–1.51 Kat/L
Greater than 14 y 8–52 U/L 0.14–0.88 Kat/L
DESCRIPTION & RATIONALE: useful marker in the evaluation of dis-

Angiotensin-converting enzyme ease for patients less than 20 years of
(ACE) production occurs mainly in age. ■
the epithelial cells of the pulmonary
bed. Smaller amounts are found in INDICATIONS:
blood vessels and renal tissue, where • Assist in establishing a diagnosis of sar-
coidosis
ACE converts angiotensin I to
angiotensin II; this conversion helps • Assist in the evaluation of Gaucher’s
regulate arterial blood pressure. disease
Angiotensin II stimulates the adrenal • Assist in the treatment of sarcoidosis
cortex to produce aldosterone. • Evaluate hypertension
Aldosterone is a hormone that helps • Evaluate the severity and activity of sar-
the kidneys maintain water balance by coidosis
retaining sodium and promoting the
excretion of potassium. RESULT
ACE levels are used primarily in the
Increased in:
evaluation of hypertension and active
• Bronchitis (acute and chronic)
sarcoidosis, a granulomatous disease
that can affect many organs, including • Connective tissue disease
the lungs. Serial levels are useful in • Gaucher’s disease
correlating the therapeutic response to • Hansen’s disease (leprosy)
corticosteroid treatment. Increasing
• Histoplasmosis and other fungal dis-
ACE levels with positive gallium eases
scans in sarcoidosis patients receiving
steroids indicate a poor response to • Hyperthyroidism (untreated)
therapy. Monitoring ACE levels may • Pulmonary fibrosis
also have some utility in assessing the • Rheumatoid arthritis
risk of pulmonary damage in affected • Sarcoidosis
patients receiving antineoplastic
agents. Thyroid hormones may play a Decreased in:
role in regulating ACE levels: • Advanced pulmonary carcinoma
Decreased levels have been noted in • The period following corticosteroid
patients with clinical hypothyroidism therapy for sarcoidosis
and anorexia nervosa, whereas
increased levels have been noted in CRITICAL VALUES: N/A
patients with hyperthyroidism. INTERFERING FACTORS:
Elevations of serum ACE have been • Drugs that may increase serum ACE
reported in 20% to 30% of patients levels include triiodothyronine.
with abnormal 1-antitrypsin vari- • Drugs that may decrease serum ACE
ants. ACE levels are sometimes levels include captopril, cilazapril, enal-
ordered on cerebrospinal fluid to eval- april, fosinopril, lisinopril, nicardipine,
uate patients with neurosarcoidosis. pentopril, perindopril, propranolol,
Results must be interpreted with care quinapril, ramipril, and trandolapril.
because of the nonspecificity of • Prompt and proper specimen process-
increased and decreased ACE levels. ing, storage, and analysis are important
ACE is normally elevated in pediatric to achieve accurate results. Failure to
patients and therefore is not a freeze sample if not tested immediately
Angiotensin-Converting Enzyme 99
may cause falsely decreased values ➤ Instruct the patient to cooperate

because ACE degrades rapidly. fully and to follow directions. Dir-
ect the patient to breathe normally
and to avoid unnecessary move-
Nursing Implications and ment.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Observe standard precautions, and
➤ Inform the patient that the test is pri- tubes with the corresponding patient
marily used to diagnose and monitor demographics, date, and time of col-
treatment of sarcoidosis. lection. Perform a venipuncture; col-
allergens (especially allergies or sen- ➤ Remove the needle, place a gauze
sitivities to latex), and inform the over the puncture site and apply gen-
appropriate health care practitioner tle pressure to stop bleeding.
accordingly. Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s ing or hematoma formation. Apply
endocrine, immune, musculoskele- paper tape over gauze or replace
tal, and respiratory systems, as well with adhesive bandage.
as results of previously performed ➤ Promptly transport the specimen to
laboratory tests, surgical proce- the laboratory for processing and
dures, and other diagnostic proce- analysis.
dures. For related laboratory tests,
refer to the Endocrine, Immune, ➤ The results are recorded manually or
Musculoskeletal, and Respiratory in a computerized system for recall
System tables. and postprocedure interpretation by
nutritional supplements, and
nutraceuticals. The requesting health Post-test:
care practitioner and laboratory
should be advised if the patient reg- ➤ Nutritional considerations: ACE levels
ularly uses these products so that affect the regulation of fluid balance
their effects can be taken into con- and electrolytes. Dietary adjustment
sideration when reviewing results. may be considered if sodium
allowances need to be regulated.
Educate patients with low sodium
patient. Note the patient’s age. This
levels that the major source of
test is rarely ordered on patients
dietary sodium is found in table salt.
less than 20 years old. Inform the
Many foods such as milk and other
patient that specimen collection
dairy products are also good sources
takes approximately 5 to 10 minutes.
of dietary sodium. Most other
Address concerns about pain related
dietary sodium is available through
to the procedure. Explain to the
consumption of processed foods.
patient that there may be some dis-
Patients who need to follow low-
comfort during the venipuncture.
sodium diets should be advised to
➤ There are no food, fluid, or medica- avoid beverages such as colas, gin-
tion restrictions unless by medical ger ale, Gatorade, lemon-lime sodas,
direction. and root beer. Many over-the-counter
medications, including antacids, lax-
Intratest: atives, analgesics, sedatives, and
➤ If the patient has a history of severe antitussives, contain significant
allergic reaction to latex, care should amounts of sodium. The best advice
be taken to avoid the use of equip- is to emphasize the importance
ment containing latex. of reading all food, beverage, and
medicine labels. In 1989, the Sub- address any concerns voiced by the
committee on the 10th Edition of the patient or family.
Recommended Dietary Allowances
(RDAs) established 500 mg as the
recommended minimum limit for
dietary intake of sodium. There are
no RDAs established for potassium,
but the estimated minimum intake
for adults is 200 mEq/d. Potassium is
present in all plant and animal cells,
making dietary replacement fairly
simple. A health care practitioner or Related laboratory tests:
nutritionist should be consulted
before considering the use of salt ➤ Related laboratory tests include
substitutes. aldosterone, alkaline phosphatase,
anion gap, 1-antitrypsin, 1-antit-
rypsin phenotyping, arterial/alveolar
oxygen ratio, blood gases, serum
care practitioner, who will discuss
and urine calcium, electrolytes, ery-
the results with the patient.
throcyte sedimentation rate, liver
➤ Reinforce information given by the biopsy, lymph node biopsy, phospho-
patient’s health care provider regard- rus, potassium, protein electrophore-
ing further testing, treatment, or sis, renin, rheumatoid factor, skin
referral to another health care pro- biopsy, sodium, thyroid hormone lev-
vider. Answer any questions or els, and urine protein.
ANION GAP
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Agap.
SPECIMEN: Serum (1 mL) for electrolytes collected in a red- or tiger-top

tube. Plasma (1 mL) collected in a green-top (heparin) tube is also acceptable.
REFERENCE VALUE: (Method: Anion gap is derived mathematically from the

direct measurement of sodium, chloride, and total carbon dioxide.) There are
differences between serum and plasma values for some electrolytes. The refer-
ence ranges listed are based on serum values.
Age Conventional Units Units 1)
Child 8–16 mEq/L 8–16 mmol/L
Adult 8–16 mEq/L 8–16 mmol/L
Anion Gap 101
high-protein/low-carbohydrate diet,
DESCRIPTION & RATIONALE: The diabetes, and alcoholism
anion gap is used most frequently as a
• Lactic acidosis
clinical indicator of metabolic acido-
sis. It does not include measurement • Poisoning (salicylate, methanol, ethyl-
of important cations, such as calcium, ene glycol, or paraldehyde)
potassium (usually), and magnesium; • Renal failure
or anions, such as proteins, forms
of phosphorus, sulfur, and organic • Uremia
acids. The anion gap is calculated as
Decreased in:
follows:
• Hyperchloremia
(sodium – [chloride HCO3–])
• Hypergammaglobulinemia (multiple
Because bicarbonate (HCO3–) is myeloma)
not directly measured on most chem-
istry analyzers, it is estimated by sub- • Hypoalbuminemia
stitution of the total carbon dioxide • Hyponatremia (hyperviscosity syn-
(TCO2) value in the calculation. Some dromes)
laboratories may include potassium in
TCO2 is commonly substituted for
the calculation of the anion gap. HCO3– in anion gap calculations. It is
Calculations including potassium can important to note the clinical significance
be invalidated because minor amounts of excessive HCO3–, which occurs in
of hemolysis can contribute signifi- renal alkalosis, gastrointestinal alkalosis,
cant levels of potassium leaked into and excessive ingestion of exogenous
the serum as a result of cell rupture. sources of alkali, the effects of which may
The anion gap is also widely used as a not be accurately reflected by the calcu-
laboratory quality control measure lated anion gap.
because low gaps usually indicate a
reagent, calibration, or instrument CRITICAL VALUES: N/A
error. ■
• Drugs that can increase or decrease the
INDICATIONS: anion gap include those listed in the
• Evaluate metabolic acidosis individual electrolyte (i.e., sodium,
• Indicate the need for laboratory instru- chloride, calcium, magnesium, and
ment recalibration or review of elec- total carbon dioxide), total protein,
trolyte reagent preparation and stability lactic acid, and phosphorus mono-
graphs.
• Indicate the presence of a disturbance
• Specimens should never be collected
in electrolyte balance
above an intravenous line because of
the potential for dilution when the
RESULT specimen and the intravenous solution
combine in the collection container,
Increased in: falsely decreasing the result. There is
• Dehydration (severe) also the potential of contaminating the
• Excessive exercise sample with the substance of interest, if
it is present in the intravenous solution,
• Ketoacidosis caused by starvation, falsely increasing the result.

Procedure ● ● ● ● ● ● ● ● ● ● ● patient to breathe normally and to
Pretest: ➤ Observe standard precautions, and
used to assist in the evaluation of Appendix A. Positively identify the
electrolyte balance. patient, and label the appropriate
tubes with the corresponding patient
➤ Obtain a history of the patient’s demographics, date, and time of
complaints, including a list of known collection. Perform a venipuncture;
allergens (especially allergies or sen- collect the specimen in a 5-mL red-
sitivities to latex), and inform the or tiger-top tube.
➤ Obtain a history of the patient’s car- tle pressure to stop bleeding.
diovascular, endocrine, gastrointesti- Observe venipuncture site for bleed-
nal, genitourinary, hematopoietic, ing and hematoma formation. Apply
immune, and respiratory systems, paper tape over gauze or replace
as well as results of previously per- with adhesive bandage.
formed laboratory tests, surgical
procedures, and other diagnostic ➤ Promptly transport the specimen to
procedures. For related laboratory the laboratory for processing and
tests, refer to the Cardiovascular, analysis.
Endocrine, Gastrointestinal, Geni- ➤ The results are recorded manually or
tourinary, Hematopoietic, Immune, in a computerized system for recall
and Respiratory System tables. and postprocedure interpretation by
advised if the patient regularly uses ➤ Nutritional considerations: Specific
these products so that their effects dietary considerations are listed in
can be taken into consideration the monographs on individual elec-
when reviewing results. trolytes (i.e., sodium, chloride, cal-
➤ Review the procedure with the cium, and magnesium), total protein,
patient. Inform the patient that spec- and phosphorus.
imen collection takes approximately ➤ Nutritional considerations: The anion
5 to 10 minutes. Address concerns gap can be used to indicate the pres-
about pain related to the procedure. ence of dehydration. Evaluate the
Explain to the patient that there may patient for signs and symptoms of
be some discomfort during the dehydration. Dehydration is a signifi-
venipuncture. cant and common finding in geriatric
➤ There are no food, fluid, or medica- patients and patients with decreased
tion restrictions unless by medical renal function.
direction. ➤ A written report of the examination
Intratest: care practitioner, who will discuss
allergic reaction to latex, care should ➤ Reinforce information given by the
be taken to avoid the use of equip- patient’s health care provider regard-
ment containing latex. ing further testing, treatment, or re-
Anion Gap 103
ferral to another health care provider. relation to the patient’s symptoms

Answer any questions or address and other tests performed.
any concerns voiced by the patient
or family. Related laboratory tests:
➤ Depending on the results of this pro- ➤ Related laboratory tests include albu-
cedure, additional testing may be min, blood gases, blood urea nitro-
performed to evaluate or monitor gen, creatinine, electrolytes, ethanol,
progression of the disease process glucose, ketones, lactic acid, osmo-
and determine the need for a change lality, protein, protein electrophore-
in therapy. Evaluate test results in sis, salicylate, and urinalysis.
ANTIARRHYTHMIC DRUGS:
DIGOXIN, DISOPYRAMIDE,
FLECAINIDE, LIDOCAINE,
PROCAINAMIDE, QUINIDINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Digoxin (Digitek, Lanoxicaps, Lanoxin); disopyra-

mide (Norpace, Norpace CR); flecainide (flecainide acetate, Tambocor);
lidocaine (Xylocaine); procainamide (Procanbid, Pronestyl, Pronestyl SR);
quinidine (Quinidex Extentabs, quinidine sulface SR, quinidine gluconate
SR).
Route of Recommended
Drug Administration Collection Time
Digoxin Oral Trough: 12–24 h after dose
Never draw peak samples
Disopyramide Oral Trough: immediately before
next dose
Peak: 2–5 h after dose
Flecainide Oral Trough: immediately before
next dose
Peak: 3 h after dose
Lidocaine IV 15 min, 1 h, then every 24 h
Procainamide IV 15 min; 2, 6, 12 hours; then
every 24 h
Procainamide Oral Trough: immediately before
next dose
Peak: 75 min after dose
Quinidine sulfate Oral Trough: immediately before
next dose
Quinidine gluconate Oral Trough: immediately before
next dose
Quinidine polygalac- Oral Trough: immediately before
turonate next dose
IV intravenous.
Drug Therapeutic Volume of Protein
(Indication) Dose* SI Units Half-Life (h) Distribution (L/kg) Binding (%) Excretion
Digoxin 0.5–2.0 ng/mL 0.6–2.6 nmol/L 20–60 7 20–30 1o renal
Disopyramide 2.8–3.2 g/mL 8.3–9.4 mol/L 4–10 0.7–0.9 20–60 1o renal
(atrial
01Van Leewan(F) (1-188)
arrhythmias)
Disopyramide 3.3–5.0 g/mL 9.7–15.0 mol/L 1o renal
(ventricular
arrhythmias)
12/15/05
Flecainide 0.2–1.0 g/mL 0.5–2.4 mol/L 7–19 5–13 40–50 1o renal


8:34 PM
Lidocaine 1.5–5.0 g/mL 6.4–21.4 mol/L 1.5–2 1–1.5 60–80 1o hepatic

Procainamide 4–10 g/mL 17–42 mol/L 2–6 2–4 10–20 1o renal
Page 105

+
Procainamide 10–30 g/mL 36–108 mol/L 8 1o renal
N-acetyl
procainamide
Quinidine 2–5 g/mL 6–15 mol/L 6–8 2–3 70–90 Renal and
hepatic
105
CHF congestive heart failure.
DESCRIPTION & RATIONALE: Cardiac tion. Peak and trough collection times
glycosides are used in the prophylactic should be documented carefully in
management and treatment of heart relation to the time of medication
failure and ventricular and atrial administration. ■
arrhythmias. Because these drugs have
IMPORTANT NOTE: This information
narrow therapeutic windows, they must be communicated clearly and accu-
must be monitored closely. The signs rately to avoid misunderstanding of the
and symptoms of toxicity are often dose time in relation to the collection
difficult to distinguish from those of time. Miscommunication between the
cardiac disease. Patients with toxic lev- individual administering the medication
els may show gastrointestinal, ocular, and the individual collecting the speci-
and central nervous system effects and men is the most frequent cause of sub-
disturbances in potassium balance. therapeutic levels, toxic levels, and
Many factors must be considered in misleading information used in the calcu-
lation of future doses.
effective dosing and monitoring of
therapeutic drugs, including patient INDICATIONS:
age, patient weight, interacting med- • Assist in the diagnosis and prevention
ications, electrolyte balance, protein of toxicity
levels, water balance, conditions that • Monitor compliance with therapeutic
affect absorption and excretion, and regimen
the ingestion of substances (e.g., • Monitor patients who have a pace-
foods, herbals, vitamins, and miner- maker, who have impaired renal or
als) that can either potentiate or hepatic function, or who are taking
inhibit the intended target concentra- interacting drugs
RESULT
Level Result
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Digoxin Renal impairment, CHF, elderly patients
Disopyramide Renal impairment
Flecainide Renal impairment, CHF
Lidocaine Hepatic impairment, CHF
Procainamide Renal impairment
Quinidine Renal and hepatic impairment, CHF,
elderly patients
CHF congestive heart failure.
CRITICAL VALUES: Adverse effects much medication. Note and immediately

of subtherapeutic levels are important. report to the health care practitioner any
Care should be taken to investigate the critically increased values and related
signs and symptoms of too little and too symptoms.
Antiarrhythmic Drugs 107
Digoxin: Greater Than 2.5 ng/mL respiratory, and blood pressure moni-
toring.
Signs and symptoms of digoxin toxicity
include arrhythmias, anorexia, hyper- Lidocaine: Greater Than 6 g/mL
kalemia, nausea, vomiting, diarrhea,
changes in mental status, and visual dis- Signs and symptoms of lidocaine toxicity
turbances (objects appear yellow or have include slurred speech, central nervous
halos around them). Possible interven- system depression, cardiovascular depres-
tions include discontinuing the medica- sion, convulsions, muscle twitches, and
tion, continuous electrocardiographic possible coma. Possible interventions
(ECG) monitoring (prolonged P-R inter- include continuous ECG monitoring,
val, widening QRS interval, lengthening airway support, seizure precautions, and
Q-Tc interval, and atrioventricular hourly monitoring of temperature for
block), transcutaneous pacing, adminis- hyperthermia.
tration of activated charcoal (if the
patient has a gag reflex and central nerv- Procainamide: Greater Than
ous system function), support and treat- 12 g/mL; Procainamide
ment of electrolyte disturbance, and N-acetyl Procainamide:
administration of Digibind (digoxin Greater Than 30 g/mL
immune Fab). The amount of Digibind The active metabolite of procainamide is
given depends on the level of digoxin to N-acetyl procainamide (NAPA). Signs
be neutralized. Digoxin levels must be and symptoms of procainamide toxicity
measured before the administration of include torsades de pointes (ventricular
Digibind. Digoxin levels should not be tachycardia), nausea, vomiting, agranulo-
measured for several days after adminis- cytosis, and hepatic disturbances. Possible
tration of Digibind in patients with nor- interventions include airway protection,
mal renal function (1 week or longer in emesis, gastric lavage, and administration
patients with decreased renal function). of sodium lactate.
Digibind cross-reacts in the digoxin assay
and may provide misleading elevations or Quinidine: Greater Than 8 g/mL
decreases in values depending on the par-
ticular assay in use by the laboratory. Signs and symptoms of quinidine toxicity
include ataxia, nausea, vomiting, diar-
rhea, respiratory system depression, hypo-
Disopyramide: Greater
tension, syncope, anuria, arrhythmias
Than 7 g/mL (heart block, widening of QRS and Q-T
Signs and symptoms of disopyramide intervals), asystole, hallucinations, pares-
toxicity include prolonged Q-T interval, thesia, and irritability. Possible interven-
ventricular tachycardia, hypotension, and tions include airway support, emesis,
heart failure. Possible interventions gastric lavage, administration of activated
include discontinuing the medication, charcoal, administration of sodium lac-
airway support, and ECG and blood tate, and temporary transcutaneous or
pressure monitoring. transvenous pacemaker.
Flecainide: Greater Than 1 g/mL
• Blood drawn in serum separator tubes
Signs and symptoms of flecainide toxi- (gel tubes).
city include exaggerated pharmacologic
effects resulting in arrhythmia. Possible • Contraindicated in patients with liver
interventions include discontinuing the disease, and caution advised in patients
medication as well as continuous ECG, with renal impairment.
• Drugs that may increase digoxin levels immunoreactive substances usually

or increase risk of toxicity include have a condition related to salt and
amiodarone, amphotericin B, fluid retention, such as renal failure,
diclofenac, diltiazem, erythromycin, hepatic failure, low-renin hypertension,
propantheline, quinidine, spironolac- and pregnancy.
tone, tetracycline, and verapamil. • Unexpectedly low digoxin levels may
• Drugs that may decrease digoxin be found in patients with thyroid dis-
levels include aluminum hydroxide ease.
(antacids), cholestyramine, colestipol, • Disopyramide may cause a decrease in
kaolin-pectin, metoclopramide, neo- glucose levels. It may also potentiate
mycin, phenytoin, and sulfasalazine. the anticoagulating effects of warfarin.
• Drugs that may increase disopyramide • Long-term administration of pro-
levels or increase risk of toxicity include cainamide can cause false-positive
amiodarone and troleandomycin. antinuclear antibody results and devel-
opment of a lupus-like syndrome in
• Drugs that may decrease disopyramide some patients.
levels include rifampin.
• Quinidine may potentiate the effects of
• Drugs that may increase flecainide lev- neuromuscular blocking medications
els or increase risk of toxicity include and warfarin anticoagulants.
amiodarone and cimetidine.
• Concomitant administration of quini-
• Drugs that may increase lidocaine lev- dine and digoxin can rapidly raise
els or increase risk of toxicity include digoxin to toxic levels. If both drugs are
anticonvulsants, -blockers, cimeti- to be given together, the digoxin level
dine, metoprolol, nadolol, and propra- should be measured before the first
nolol. dose of quinidine and again in 4 to 6
days.
• Drugs that may increase procainamide
levels or increase risk of toxicity include
amiodarone, cimetidine, other antiar-
rhythmics, ranitidine, and trimetho- Nursing Implications and
prim. Procedure ● ● ● ● ● ● ● ● ● ● ●
• Drugs that may increase quinidine lev- Pretest:

els or increase risk of toxicity include
amiodarone, cimetidine, thiazide ➤ Inform the patient that the test is
diuretics, and verapamil. used to monitor for therapeutic and
toxic drug levels.
• Drugs that may decrease quinidine ➤ Obtain a history of the patient’s
levels include disopyramide, nifedip- complaints, including a list of known
ine, phenobarbital, phenytoin, and allergens (especially allergies or sen-
rifampin. sitivities to latex), and inform the
• Digitoxin cross-reacts with digoxin; accordingly.
results are falsely elevated if digoxin is ➤ Obtain a history of the patient’s gen-
measured when the patient is taking itourinary and hepatobiliary systems
digitoxin. as well as results of previously per-
• Digitalis-like immunoreactive sub- procedures, and other diagnostic
stances are found in the serum of some procedures. For related laboratory
patients who are not taking digoxin, tests, refer to the Genitourinary and
causing false-positive results. Patients Hepatobiliary Systems and Thera-
whose serum contain digitalis-like peutic/ Toxicology tables.
Antiarrhythmic Drugs 109
➤ Obtain a list of the medications the ing or hematoma formation. Apply

patient is taking, including herbs, paper tape over gauze or replace
nutritional supplements, and nutra- with adhesive bandage.
ceuticals. Note the last time and ➤ Promptly transport the specimen to
dose of medication taken. The the laboratory for processing and
requesting health care practitioner analysis.
the patient regularly uses these ➤ The results are recorded manually or
products so that their effects can be in a computerized system for recall
taken into consideration when and postprocedure interpretation by
reviewing results. the appropriate health care practi-
tioner.
➤ Nutritional considerations include
the avoidance of alcohol consump-
tion.
➤ Sensitivity to cultural and social
chological support before, during, ➤ Reinforce information given by the
and after the procedure. patient’s health care provider regard-
provider. Explain to the patient the
direction.
importance of following the medica-
tion regimen and instructions regard-
Intratest: ing drug interactions. Instruct the
patient to immediately report any
➤ If the patient has a history of severe unusual sensations (e.g., dizziness,
allergic reaction to latex, care should changes in vision, loss of appetite,
be taken to avoid the use of equip- nausea, vomiting, diarrhea, weak-
ment containing latex. ness, or irregular heartbeat) to his or
➤ Instruct the patient to cooperate fully her health care practitioner. Instruct
and to follow directions. Direct the the patient not to take medicine
patient to breathe normally and to within 1 hour of food high in fiber.
avoid unnecessary movement. Answer any questions or address
or family.
Appendix A. Consider recommended ➤ Instruct the patient to be prepared to
collection time in relation to the dos- provide the pharmacist with a list of
ing schedule. Positively identify the other medications he or she is
patient, and label the appropriate already taking in the event that the
tubes with the corresponding patient requesting health care practitioner
demographics, date, and time of prescribes a medication.
collection, noting the last dose of ➤ Depending on the results of this pro-
medication taken. Perform a veni- cedure, additional testing may be
puncture; collect the specimen in a performed to evaluate or monitor
5-mL red top tube. progression of the disease process
➤ Remove the needle, place a gauze and determine the need for a change
over the puncture site and apply gen- in therapy. Evaluate test results in
tle pressure to stop bleeding. relation to the patient’s symptoms
Observe venipuncture site for bleed- and other tests performed.
cholesterol (total, HDL, and LDL),

creatine kinase and isoenzymes,
➤ Related laboratory tests include ala- creatinine, glucose, glycated hemo-
nine aminotransferase, albumin, globin, homocysteine, ionized
alkaline phosphatase, apolipoprotein calcium, ketones, lactate dehydroge-
A, apolipoprotein B, aspartate amino- nase and isoenzymes, magnesium,
transferase, atrial natriuretic peptide, myoglobin, platelet count, potas-
B-type natriuretic peptide, blood sium, triglycerides, troponin, and
gases, C-reactive protein, calcium, urea nitrogen.
ANTIBIOTIC DRUGS—
AMINOGLYCOSIDES:
AMIKACIN, GENTAMICIN,
TOBRAMYCIN; TRICYCLIC
GLYCOPEPTIDE: VANCOMYCIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS: Amikacin (Amikin); gentamicin (Garamycin, Genoptic,

Gentacidin, Gentafair, Gentak, Gentamar, Gentrasul, G-myticin, Oco-
Mycin, Spectro-Genta); tobramycin (Nebcin, Tobrex); vancomycin (Lyphocin,
Vancocin, Vancoled).
Antibiotic Type Administration Collection Time*
Aminoglycosides
Amikacin IV, IM Trough: immediately before next dose
Peak: 30 min after the end of a 30-
min IV infusion
Gentamicin IV, IM Trough: immediately before next dose
min IV infusion
Tobramycin IV, IM Trough: immediately before next dose
min IV infusion
Tricyclic glycopeptide
Vancomycin IV, PO Trough: immediately before next dose
Peak: 30-60 min after the end of a 60-
min IV infusion
* Usually after fifth dose if given every 8 hours or third dose if given every 12 hours.
IV intravenous; IM intramuscular; PO by mouth.
Therapeutic Half- Distribution Volume of Protein
Drug Dose* SI Units Life (h) (L/kg) Binding (%) Excretion
Amikacin
Peak 20–30 g/mL 34–51 mol/L 4–8 0.4–1.3 50 1 renal
Trough 1–8 g/mL 2–14 mol/L

Gentamicin
(Standard
Dosing)
12/15/05

Trough 0.5–1.5 g/mL 1–3 mol/L
Tobramycin
8:34 PM

Trough 0.5–1.5 g/mL 1–3 mol/L
Vancomycin
Page 111
Trough 5–10 g/mL 3–7 mol/L

111
DESCRIPTION & RATIONALE: The herbals, vitamins, and minerals) that

aminoglycoside antibiotics amikacin, can either potentiate or inhibit the
gentamicin, and tobramycin are used intended target concentration. The
against many gram-negative (Acineto- most serious side effects of the amino-
bacter, Citrobacter, Enterobacter, glycosides and vancomycin are
Escherichia coli, Klebsiella, Proteus, nephrotoxicity and irreversible oto-
Providencia, Pseudomonas, Salmonella, toxicity (uncommon). Peak and
Serratia, and Shigella) and some trough collection times should be
gram-positive (Staphylococcus aureus) documented carefully in relation to
pathogenic microorganisms. Amino- the time of medication administra-
glycosides are poorly absorbed tion. Creatinine levels should be mon-
through the gastrointestinal tract and itored every 2 to 3 days to detect renal
are most frequently administered impairment due to toxic drug levels. ■
intravenously.
Vancomycin is a tricyclic glycopep- IMPORTANT NOTE: This information
tide antibiotic used against many gram- must be clearly and accurately communi-
cated to avoid misunderstanding of the
positive microorganisms, such as
dose time in relation to the collection
staphylococci, Streptococcus pneumo- time. Miscommunication between the
niae, group A -hemolytic strepto- individual administering the medication
cocci, enterococci, Corynebacterium, and the individual collecting the specimen
and Clostridium. Vancomycin has also is the most frequent cause of subtherapeu-
been used in an oral form for the treat- tic levels, toxic levels, and misleading
ment of pseudomembranous colitis information used in the calculation of
resulting from Clostridium difficile in- future doses. Some pharmacies use a com-
fection. This approach is less frequently puterized pharmacokinetics approach to
used because of the emergence of van- dosing that eliminates the need to be con-
cerned about peak and trough collections;
comycin-resistant enterococci (VRE).
random specimens are adequate.
Many factors must be considered in
effective dosing and monitoring of INDICATIONS:
therapeutic drugs, including patient • Assist in the diagnosis and prevention
age, patient weight, interacting med- of toxicity
ications, electrolyte balance, protein • Monitor renal dialysis patients or
levels, water balance, conditions that patients with rapidly changing renal
affect absorption and excretion, and function
ingestion of substances (e.g., foods, • Monitor therapeutic regimen
RESULT
Level Result
Amikacin Renal, hearing impairment
Gentamicin Renal, hearing impairment
Tobramycin Renal, hearing impairment
Vancomycin Renal, hearing impairment
Antibiotic Drugs 113
CRITICAL VALUES: The adverse Signs and symptoms of toxic levels of

effects of subtherapeutic levels are impor- these antibiotics are similar and include
tant. Care should be taken to investigate loss of hearing and decreased renal
signs and symptoms of too little and too function. The most important interven-
much medication. Note and immediately tion is accurate therapeutic drug moni-
report to the health care practitioner any toring so the medication can be discon-
critically increased or subtherapeutic val- tinued before irreversible damage is
ues and related symptoms. done.
Drug Name Toxic Levels

Amikacin Peak greater than 30 g/mL, trough greater than 8 g/mL
Gentamicin Peak greater than 12 g/mL, trough greater than 2 g/mL
Tobramycin Peak greater than 12 g/mL, trough greater than 2 g/mL
Vancomycin Peak greater than 80 g/mL, trough greater than 20 g/mL
INTERFERING FACTORS: of previously performed laboratory

• Blood drawn in serum separator tubes tests, surgical procedures, and other
(gel tubes).
laboratory tests, refer to the Genito-
• Contraindicated in patients with liver urinary System and Therapeutic/
disease, and caution advised in patients Toxicology tables.
with renal impairment. ➤ Obtain a list of the medications the
• Drugs that may decrease aminoglyco- nutritional supplements, and nutra-
side efficacy include bleomycin, ceuticals. Note the last time and
daunorubicin, doxorubicin, and peni- dose of medication taken. The re-
cillins (e.g., carbenicillin, piperacillin). questing health care practitioner and
laboratory should be advised if the
• Obtain a culture before and after the patient regularly uses such products
first dose of aminoglycosides. so that their effects can be taken into
• The risks of ototoxicity and nephrotox- consideration when reviewing results.
icity are increased by the concomitant ➤ Review the procedure with the
administration of aminoglycosides. patient. Inform the patient that spec-
Nursing Implications and Explain to the patient that there may
Procedure ● ● ● ● ● ● ● ● ● ● ● be some discomfort during the
venipuncture.
Pretest: ➤ Sensitivity to cultural and social
➤ Inform the patient that the test is issues, as well as concern for mod-
used to monitor for therapeutic and esty, is important in providing psy-
toxic drug levels. chological support before, during,
plaints, including a list of known ➤ There are no food, fluid, or medica-
allergens (especially allergies or sen- tion restrictions unless by medical
sitivities to latex), and inform the direction.
accordingly. Intratest:
➤ Obtain a history of the patient’s gen- ➤ If the patient has a history of severe
itourinary system as well as results allergic reaction to latex, care should
be taken to avoid the use of equip- the avoidance of alcohol consump-

ment containing latex. tion.
➤ Instruct the patient to cooperate fully ➤ Administer antibiotic therapy if
and to follow directions. Direct the ordered. Remind the patient of the
patient to breathe normally and to importance of completing the entire
avoid unnecessary movement. course of antibiotic therapy, even if
signs and symptoms disappear
➤ Observe standard precautions, and before completion of therapy.
Appendix A. Consider recommended ➤ A written report of the examination
collection time in relation to the dos- will be sent to the requesting health
ing schedule. Positively identify the care practitioner, who will discuss
patient and label the appropriate the results with the patient.
tubes with the corresponding patient ➤ Reinforce information given by the
demographics, date, and time of patient’s health care provider regard-
collection, noting the last dose of ing further testing, treatment, or
medication taken. Perform a veni- referral to another health care
puncture; collect the specimen in a provider. Explain to the patient the
5-mL red- or tiger-top tube. importance of following the medica-
➤ Remove the needle, place a gauze tion regimen and instructions regard-
over the puncture site and apply gen- ing food and drug interactions.
tle pressure to stop bleeding. Answer any questions or address
Observe venipuncture site for bleed- any concerns voiced by the patient
ing or hematoma formation. Apply or family.
paper tape over gauze or replace ➤ Instruct the patient to be prepared to
with adhesive bandage. provide the pharmacist with a list of
other medications he or she is
already taking in the event that the
analysis.
prescribes a medication.
➤ The results are recorded manually or ➤ Depending on the results of this pro-
in a computerized system for recall cedure, additional testing may be
and postprocedure interpretation by performed to evaluate or monitor
the appropriate health care practi- progression of the disease process
tioner. and determine the need for a change
Post-test:
➤ Instruct the patient receiving amino-
glycosides to immediately report any Related laboratory tests:
unusual symptoms (e.g., hearing ➤ Related laboratory tests include albu-
loss, decreased urinary output) to his min, blood urea nitrogen, creatinine,
or her health care practitioner. creatinine clearance, potassium, and
➤ Nutritional considerations include urinalysis.
Antibodies, Anticytoplasmic Neutrophilic 115
ANTIBODIES, ANTICYTOPLASMIC
NEUTROPHILIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Cytoplasmic antineutrophil cytoplasmic antibody

(c-ANCA), perinuclear antineutrophil cytoplasmic antibody (p-ANCA).

REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative.
• Distinguish between vasculitic disease

DESCRIPTION & RATIONALE: There and the effects of therapy
are two types of cytoplasmic neu-
trophil antibodies (ANCA), identified RESULT
by their cellular staining characteris-
tics. c-ANCA (cytoplasmic) is specific Increased in:
for proteinase 3 in neutrophils and • c-ANCA
monocytes and is found in the sera Wegener’s granulomatosis and its
of patients with Wegener’s granulo- variants
matosis. Wegener’s syndrome includes
• p-ANCA
granulomatous inflammation of the
Alveolar hemorrhage
upper and lower respiratory tract and
Angiitis and polyangiitis
vasculitis. p-ANCA (perinuclear) is
Autoimmune liver disease
specific for myeloperoxidase, elastase,
Capillaritis
and lactoferrin, as well as other
enzymes in neutrophils. p-ANCA is Churg-Strauss syndrome
present in the sera of patients with Felty’s syndrome
pauci-immune necrotizing glomeru- Inflammatory bowel disease
lonephritis. ■ Leukocytoclastic skin vasculitis
Necrotizing-crescentic
glomerulonephritis
INDICATIONS:
Rheumatoid arthritis
• Assist in the diagnosis of Wegener’s
granulomatosis and its variants Vasculitis
• Differential diagnosis of ulcerative colitis Decreased in: N/A

• Distinguish between biliary cirrhosis
and sclerosing cholangitis CRITICAL VALUES: N/A
INTERFERING FACTORS: N/A be taken to avoid the use of equip-

Nursing Implications and fully and to follow directions.
Direct the patient to breathe nor-
Procedure ● ● ● ● ● ● ● ● ● ● ●
movement.
Pretest:
used to assist in the diagnosis and Appendix A. Positively identify the
monitoring of inflammatory activity patient, and label the appropriate
in primary systemic small vessel vas- tubes with the corresponding patient
culitides. demographics, date, and time of col-
➤ Obtain a history of the patient’s com- lection. Perform a venipuncture; col-
plaints, including a list of known lect the specimen in a 5-mL red-top
allergens (especially allergies or sen- tube.
sitivities to latex), and inform the ➤ Remove the needle, place a gauze
appropriate health care practitioner over the puncture site and apply gen-
accordingly. tle pressure to stop bleeding.
➤ Obtain a history of the patient’s gas- Observe venipuncture site for bleed-
trointestinal, genitourinary, hepato- ing or hematoma formation. Apply
biliary, immune, and musculoskeletal paper tape over gauze or replace
systems and results of previously with adhesive bandage.
performed laboratory tests, surgical ➤ Promptly transport the specimen to
procedures, and other diagnostic the laboratory for processing and
procedures. For related laboratory analysis.
tests, refer to the Gastrointestinal,
Genitourinary, Hepatobiliary, Immune, ➤ The results are recorded manually or
and Musculoskeletal System tables. in a computerized system for recall
practitioner and laboratory should be Post-test:
advised if the patient regularly uses
these products so that their effects ➤ A written report of the examination
can be taken into consideration will be sent to the requesting health
when reviewing results. care practitioner, who will discuss
patient. Inform the patient that spec- ➤ Recognize anxiety related to test
imen collection takes approximately results, and be supportive of per-
5 to 10 minutes. Address concerns ceived loss of independence and
about pain related to the procedure. fear of shortened life expectancy.
Explain to the patient that there may Discuss the implications of abnormal
be some discomfort during the test results on the patient’s lifestyle.
venipuncture. Provide teaching and information
the test results, as appropriate.
Educate the patient regarding access
direction.
to counseling services.
Intratest: ➤ Reinforce information given by the

➤ If the patient has a history of severe ing further testing, treatment, or re-
allergic reaction to latex, care should ferral to another health care provider.
Antibodies, Anti–Glomerular Basement Membrane 117
Answer any questions or address relation to the patient’s symptoms

any concerns voiced by the patient and other tests performed.
or family.
cedure, additional testing may be ➤ Related laboratory tests include anti–
performed to evaluate or monitor glomerular basement membrane
progression of the disease process antibody, antimitochondrial antibody,
and determine the need for a change eosinophil count, kidney biopsy,
in therapy. Evaluate test results in rheumatoid factor, and urinalysis.
ANTIBODIES, ANTI–GLOMERULAR
BASEMENT MEMBRANE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Goodpasture’s antibody, anti-GBM.

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Lung or kid-
ney tissue also may be submitted for testing. Refer to related biopsy mono-
graphs for specimen collection instructions.
REFERENCE VALUE: (Method: Direct or indirect immunofluorescence)

Negative.
INDICATIONS:
DESCRIPTION & RATIONALE: Good-
pasture syndrome is a rare hypersensi- • Differentiate glomerulonephritis caus-
tivity condition characterized by the ed by anti-GBM from glomeru-
lonephritis from other causes
presence of circulating anti–glomeru-
lar basement membrane antibodies in
the blood and the deposition of RESULT
immunoglobulin and complement
in renal basement membrane tissue.
Increased in:
Severe and progressive glomeru-
lonephritis can result from the
presence of antibodies to renal • Goodpasture’s syndrome
glomerular basement membrane
(GBM). Autoantibodies may also be • Idiopathic pulmonary hemosiderosis
directed to act against lung tissue in
Goodpasture’s syndrome. ■ Decreased in: N/A
CRITICAL VALUES: N/A be taken to avoid the use of equip-

INTERFERING FACTORS: N/A ➤ Instruct the patient to cooperate
fully and to follow directions.
Nursing Implications and movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
➤ Inform the patient that the test is patient, and label the appropriate
used to assist in detection and tubes with the corresponding patient
monitoring of glomerular basement demographics, date, and time of
membrane antibodies present in collection. Perform a venipuncture;
Goodpasture’s syndrome. collect the specimen in a 5-mL red-
top tube.
plaints, including a list of known ➤ Remove the needle, place a gauze
allergens (especially allergies or sen- over the puncture site and apply gen-
sitivities to latex), and inform the tle pressure to stop bleeding.
appropriate health care practitioner Observe venipuncture site for bleed-
accordingly. ing or hematoma formation. Apply
➤ Obtain a history of the patient’s geni- paper tape over gauze or replace
tourinary, immune, and respiratory with adhesive bandage.
systems and results of previously ➤ Promptly transport the specimen to
performed laboratory tests, surgical the laboratory for processing and
procedures, and other diagnostic pro- analysis.
cedures. For related laboratory tests,
➤ The results are recorded manually or
refer to the Genitourinary, Immune,
and Respiratory System tables.
such products so that their effects will be sent to the requesting health
➤ Review the procedure with the ➤ Recognize anxiety related to test
patient. Inform the patient that spec- results, and be supportive of per-
imen collection takes approximately ceived loss of independence and
5 to 10 minutes. Address concerns fear of shortened life expectancy.
about pain related to the procedure. Discuss the implications of abnormal
Explain to the patient that there may test results on the patient’s lifestyle.
be some discomfort during the Provide teaching and information
venipuncture. regarding the clinical implications of
➤ There are no food, fluid, or medica- Educate the patient regarding access
tion restrictions unless by medical to counseling services.
direction.
Intratest: patient’s health care provider regard-
ing further testing, treatment, or re-
➤ If the patient has a history of severe ferral to another health care provider.
allergic reaction to latex, care should Answer any questions or address
Antibodies, Antinuclear, Anti-DNA, and Anticentromere 119
any concerns voiced by the patient relation to the patient’s symptoms

or family. and other tests performed.
➤ Depending on the results of this pro- Related laboratory tests:
performed to evaluate or monitor ➤ Related laboratory tests include anti-
progression of the disease process neutrophilic anti-cytoplasmic anti-
and determine the need for a change body, kidney biopsy, lung biopsy, and
in therapy. Evaluate test results in urinalysis.
ANTIBODIES, ANTINUCLEAR,
ANTI-DNA, AND ANTICENTROMERE
SYNONYMS/ACRONYMS: Antinuclear antibodies (ANA), anti-DNA
(anti-ds DNA).

REFERENCE VALUE: (Method: Indirect fluorescent antibody for ANA
and anticentromere; enzyme-linked immunosorbent assay [ELISA] for
anti-DNA)
ANA and anticentromere: titer of 1:40 or less
ANTI-DNA:
Negative Less than 24 IU eases. Antibodies against cellular DNA

Borderline 25–30 IU are strongly associated with SLE.
Positive 31–200 IU Anticentromere antibodies are a subset
Strong Greater than of ANA. Their presence is strongly
positive 200 IU associated with CREST syndrome
(calcinosis, Raynaud’s phenomenon,
esophageal dysfunction, sclerodactyly,
and telangiectasia). ANA and anticen-
DESCRIPTION & RATIONALE: Antinu- tromere antibodies are detected using
clear antibodies (ANA) are autoanti- Hep-2 cells (human epithelial cul-
bodies mainly located in the nucleus tured cells). Anti-DNA antibodies can
of affected cells. The presence of ANA be detected using a Crithidia luciliae
indicates systemic lupus erythemato- substrate. Women are much more
sus (SLE), related collagen vascular likely than men to be diagnosed
diseases, and immune complex dis- with SLE. ■
INDICATIONS: • Evaluate suspected immune disorders,

such as rheumatoid arthritis, systemic
• Assist in the diagnosis and evaluation sclerosis, polymyositis, Sjögren’s syn-
of SLE drome, and mixed connective tissue dis-
ease
RESULT
ANA Pattern* Associated Antibody

Rim and/or homogeneous Double-stranded DNA
Single- or double-stranded DNA
Homogeneous Histones
Speckled Sm (Smith) antibody
RNP
SS-B/La, SS-A/Ro
Diffuse speckled with positive Centromere
mitotic figures
Nucleolar Nucleolar, RNP
*ANA patterns are helpful in that certain conditions are frequently associated with
specific patterns, but the patterns are not diagnostic for a particular disease.
RNP ribonucleoprotein.
Increased in: • Inability of the patient to cooperate or

• Drug-induced lupus erythematosus remain still during the procedure
• Lupoid hepatitis mental status may interfere with the
• Mixed connective tissue disease test results.
• Polymyositis
• Progressive systemic sclerosis
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Rheumatoid arthritis
Pretest:
• Sjögren’s syndrome
• SLE used to detect the presence of anti-
nuclear antibodies associated with a
Decreased in: N/A variety of musculoskeletal and con-
nective tissue diseases.
CRITICAL VALUES: N/A ➤ Obtain a history of the patient’s com-
INTERFERING FACTORS: allergens (especially allergies or sen-
• Drugs that may cause positive sitivities to latex), and inform the
results include carbamazepine, chlor- appropriate health care practitioner
promazine, ethosuximide, hydralazine, accordingly.
isoniazid, mephenytoin, methyldopa, ➤ Obtain a history of the patient’s
penicillins, phenytoin, primidone, pro- immune and musculoskeletal sys-
cainamide, and quinidine. tems and results of previously per-
• A patient can have lupus and test ANA procedures, and other diagnostic
negative. procedures. For related laboratory
Antibodies, Antinuclear, Anti-DNA, and Anticentromere 121
tests, refer to the Immune and in a computerized system for recall

Musculoskeletal System tables. and postprocedure interpretation by
➤ Obtain a list of the medications the appropriate health care practi-
the patient is taking, including tioner.
herbs, nutritional supplements, and
care practitioner and laboratory ➤ A written report of the examination
should be advised if the patient reg- will be sent to the requesting health
ularly uses these products so that care practitioner, who will discuss
their effects can be taken into con- the results with the patient.
sideration when reviewing results.
➤ Recognize anxiety related to test
➤ Review the procedure with the results, and be supportive of per-
patient. Inform the patient that spec- ceived loss of independence and fear
imen collection takes approximately of shortened life expectancy. Col-
5 to 10 minutes. Address concerns lagen and connective tissue diseases
about pain related to the procedure. are chronic and, as such, they must
Explain to the patient that there may be addressed on a continuous basis.
be some discomfort during the Discuss the implications of abnormal
venipuncture. test results on the patient’s lifestyle.
➤ There are no food, fluid, or medica- Provide teaching and information
tion restrictions unless by medical regarding the clinical implications of
direction. the test results, as appropriate.
to counseling services.
Intratest: ➤ Educate the patient, as appropriate,
➤ If the patient has a history of severe regarding the importance of prevent-
allergic reaction to latex, care should ing infection, which is a significant
be taken to avoid the use of equip- cause of death in immunosup-
ment containing latex. pressed individuals.
➤ Instruct the patient to cooperate fully patient’s health care provider regard-
and to follow directions. Direct the ing further testing, treatment, or
patient to breathe normally and to referral to another health care
avoid unnecessary movement. provider. Answer any questions or
➤ Observe standard precautions, and address any concerns voiced by the
follow the general guidelines in patient or family.
Appendix A. Positively identify the ➤ Depending on the results of this pro-
patient, and label the appropriate cedure, additional testing may be
tubes with the corresponding patient performed to evaluate or monitor
demographics, date, and time of col- progression of the disease process
lection. Perform a venipuncture; col- and determine the need for a change
lect the specimen in a 5-mL red-top in therapy. Evaluate test results in
tube. relation to the patient’s symptoms
➤ Remove the needle, place a gauze and other tests performed.
tle pressure to stop bleeding. Related laboratory tests:
ing or hematoma formation. Apply ➤ Related laboratory tests include anti-
paper tape over gauze or replace cardiolipin antibody, antisclerodermal
with adhesive bandage. antibodies, C3, C4, erythrocyte sedi-
mentation rate, extractable nuclear
antibodies, Jo-1 antibody, kidney
biopsy, procainamide, rheumatoid
analysis.
factor, skin biopsy, and total com-
➤ The results are recorded manually or plement.
ANTIBODIES, ANTISCLERODERMA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Progressive systemic sclerosis antibody, Scl-70 anti-

body.

REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative.
DESCRIPTION & RATIONALE: Antis- Nursing Implications and

cleroderma antibodies are associated Procedure ● ● ● ● ● ● ● ● ● ● ●
with progressive systemic sclerosis,

Pretest:
a condition that affects multiple
systems, including the skin, gastroin- ➤ Inform the patient that the test is
used in the differential diagnosis of
testinal tract, lungs, blood vessels,
scleroderma and other autoimmune
heart, and kidneys. These antibodies diseases of the musculoskeletal sys-
are present in the sera of patients tem.
with CREST syndrome (calcinosis, ➤ Obtain a history of the patient’s com-
Raynaud’s phenomenon, esophageal plaints, including a list of known
dysfunction, sclerodactyly, and telang- allergens (especially allergies or sen-
iectasia). ■ sitivities to latex), and inform the
accordingly.
INDICATIONS: ➤ Obtain a history of the patient’s
immune and musculoskeletal sys-
• Assist in the diagnosis of scleroderma tems and results of previously per-
RESULT procedures, and other diagnostic
procedures. For related laboratory
tests, refer to the Immune and
Increased in: Musculoskeletal System tables.
• CREST syndrome
➤ Obtain a list of the medications
• Progressive diffuse scleroderma the patient is taking, including
nutraceuticals. The requesting health
Decreased in: N/A care practitioner and laboratory
should be advised if the patient reg-
ularly uses these products so that
CRITICAL VALUES: N/A their effects can be taken into con-
INTERFERING FACTORS: N/A ➤ Review the procedure with the
Antibodies, Antiscleroderma 123
patient. Inform the patient that spec- care practitioner, who will discuss
imen collection takes approximately the results with the patient.
about pain related to the procedure. ➤ Recognize anxiety related to test
Explain to the patient that there may results, and be supportive of per-
be some discomfort during the ceived loss of independence and
venipuncture. fear of shortened life expectancy.
Collagen and connective tissue
➤ There are no food, fluid, or medica- diseases are chronic and, as such,
tion restrictions unless by medical they must be addressed on a con-
direction. tinuous basis. Discuss the impli-
cations of abnormal test results
Intratest: on the patient’s lifestyle. Provide
➤ If the patient has a history of severe teaching and information regarding
allergic reaction to latex, care should the clinical implications of the test
be taken to avoid the use of equip- results, as appropriate. Educate the
ment containing latex. patient regarding access to counsel-
➤ Instruct the patient to cooperate fully ing services.
and to follow directions. Direct the ➤ Educate the patient, as appropriate,
patient to breathe normally and to regarding the importance of prevent-
avoid unnecessary movement. ing infection, which is a significant
➤ Observe standard precautions, and cause of death in immunosup-
follow the general guidelines in pressed individuals.
patient, and label the appropriate ➤ Reinforce information given by the
tubes with the corresponding patient patient’s health care provider regard-
demographics, date, and time of ing further testing, treatment, or
collection. Perform a venipuncture; referral to another health care pro-
collect the specimen in a 5-mL red- vider. Answer any questions or
top tube. address any concerns voiced by the
patient or family.
over the puncture site and apply gen- ➤ Depending on the results of this
tle pressure to stop bleeding. procedure, additional testing may
Observe venipuncture site for bleed- be performed to evaluate or moni-
ing or hematoma formation. Apply tor progression of the disease
paper tape over gauze or replace process and determine the need for
with adhesive bandage. a change in therapy. Evaluate test
➤ Promptly transport the specimen to results in relation to the patient’s
the laboratory for processing and symptoms and other tests per-
analysis. formed.
➤ Related laboratory tests include anti-
tioner.
centromere antibodies, anti-DNA
antibodies, antinuclear antibodies,
Post-test: extractable nuclear antibodies, Jo-1
➤ A written report of the examination antibody, kidney biopsy, rheumatoid
will be sent to the requesting health factor, and skin biopsy.
ANTIBODIES, ANTISPERM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: N/A.
Sperm Bound by CRITICAL VALUES: N/A

Result Immunobead (%)
Negative 0–15 • The patient should not ejaculate for 3
Weak 16–30 to 4 days before specimen collection if
positive semen will be evaluated.
Moderate 31–50
positive • Sperm antibodies have been detected in
Strong positive 51–100 pregnant women and in women with
primary infertility.

DESCRIPTION & RATIONALE: A major
Procedure ● ● ● ● ● ● ● ● ● ● ●
cause of infertility in men is blocked
efferent testicular ducts. As a result of Pretest:
the reabsorption of sperm from the
blocked ducts, antibodies against the ➤ Inform the patient that the test is
used in the evaluation of infertility
sperm may be produced over time and and guidance through assisted repro-
thereby may lower the patient’s fertil- ductive techniques.
ity. Semen and cervical mucus can also ➤ Obtain a history of the patient’s com-
be tested for antisperm antibodies. ■ plaints, including a list of known
INDICATIONS: appropriate health care practitioner
• Evaluation of infertility accordingly.
➤ Obtain a history of the patient’s
RESULT immune and reproductive systems
and results of previously performed
Increased in: laboratory tests, surgical procedures,
• Blocked testicular efferent duct and other diagnostic procedures. For
• Postvasectomy Immune and Reproductive System
tables.
Decreased in: N/A ➤ Obtain a list of the medications the
Antibodies, Antisperm 125

nutritional supplements, and nutra- with adhesive bandage.
ceuticals. The requesting health care ➤ Promptly transport the specimen to
practitioner and laboratory should be the laboratory for processing and
advised if the patient regularly uses analysis.
can be taken into consideration ➤ The results are recorded manually or
when reviewing results. in a computerized system for recall
➤ Review the procedure with the the appropriate health care practi-
patient. Inform the patient that tioner.
specimen collection takes approxi-
mately 5 to 10 minutes and that addi-
Post-test:
tional specimens may be required.
Address concerns about pain rela- ➤ A written report of the examination
ted to the procedure. Explain to will be sent to the requesting health
the patient that there may be some care practitioner, who will discuss
discomfort during the venipuncture. the results with the patient.
➤ Sensitivity to social and cultural ➤ Recognize anxiety related to test
issues, as well as concern for mod- results. Discuss the implications of
esty, is important in providing psy- abnormal test results on the patient’s
chological support before, during, lifestyle. Educate the patient regard-
and after the procedure. ing access to counseling services.
➤ There are no food, fluid, or medica- Provide a supportive, nonjudgmen-
tion restrictions unless by medical tal environment when assisting a
direction. patient through the process of fertil-
ity testing. Educate the patient
Intratest: regarding access to counseling serv-
ices, as appropriate.
➤ If the patient has a history of severe ➤ Reinforce information given by the
allergic reaction to latex, care should patient’s health care provider regard-
be taken to avoid the use of equip- ing further testing, treatment, or re-
ment containing latex. ferral to another health care provider.
➤ Instruct the patient to cooperate fully Answer any questions or address
and to follow directions. Direct the any concerns voiced by the patient
patient to breathe normally and to or family.
avoid unnecessary movement. ➤ Depending on the results of this pro-
➤ Observe standard precautions, and cedure, additional testing may be
follow the general guidelines in performed to evaluate or monitor
Appendix A. Positively identify the progression of the disease process
patient, and label the appropriate and determine the need for a change
tubes with the corresponding patient in therapy. Evaluate test results in
demographics, date, and time of col- relation to the patient’s symptoms
lection. Perform a venipuncture; and other tests performed.
top tube.
over the puncture site and apply gen- ➤ Related laboratory tests include
tle pressure to stop bleeding. human chorionic gonadotropin,
Observe venipuncture site for bleed- luteinizing hormone, progesterone,
ing or hematoma formation. Apply semen analysis, and testosterone.
ANTIBODIES, ANTISTREPTOLYSIN O
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Streptozyme, ASO.

REFERENCE VALUE: (Method: Nephelometry) Less than 200 IU/mL.
DESCRIPTION & RATIONALE: Group Decreased in: N/A

A -hemolytic streptococci secrete the
enzyme streptolysin O, which can CRITICAL VALUES: N/A
destroy red blood cells. The enzyme
acts as an antigen and stimulates the INTERFERING FACTORS:
immune system to develop strep- • Drugs that may decrease ASO titers
tolysin O antibodies. These antistrep- include antibiotics and corticosteroids,
because therapy suppresses antibody
tolysin O (ASO) antibodies occur
response.
within 1 month after the onset of a
streptococcal infection. Detection of
the antibody over several weeks Nursing Implications and
strongly suggests exposure to group A Procedure ● ● ● ● ● ● ● ● ● ● ●
-hemolytic streptococci. ■
Pretest:
INDICATIONS: ➤ Inform the patient that the test is
• Assist in establishing a diagnosis of used to document exposure to group
streptococcal infection A streptococci bacteria.
• Evaluate patients with streptococcal ➤ Obtain a history of the patient’s com-
infections for the development of acute plaints, including a list of known
rheumatic fever or nephritis allergens (especially allergies or sen-
• Monitor response to therapy in strepto- appropriate health care practitioner
coccal illnesses accordingly.
RESULT immune system and results of previ-
ously performed laboratory tests,
Increased in: surgical procedures, and other diag-
• Endocarditis nostic procedures. For related labo-
ratory tests, refer to the Immune
• Glomerulonephritis System table.
• Rheumatic fever ➤ Obtain a list of the medications
• Scarlet fever herbs, nutritional supplements, and
Antibodies, Antistreptolysin O 127
nutraceuticals. The requesting health ➤ Promptly transport the specimen to

care practitioner and laboratory the laboratory for processing and
should be advised if the patient reg- analysis.
ularly uses these products so that ➤ The results are recorded manually or
their effects can be taken into con- in a computerized system for recall
sideration when reviewing results. and postprocedure interpretation by
➤ Review the procedure with the the appropriate health care practi-
patient. Inform the patient that spec- tioner.
5 to 10 minutes. Address concerns Post-test:
Explain to the patient that there may ➤ Administer antibiotics as ordered.
be some discomfort during the Remind the patient of the impor-
venipuncture. tance of completing the entire
➤ There are no food, fluid, or medica- course of antibiotic therapy even if
tion restrictions unless by medical signs and symptoms disappear
direction. before completion of therapy.
Intratest: will be sent to the requesting health
be taken to avoid the use of equip- ➤ Reinforce information given by the
ment containing latex. patient’s health care provider regard-
➤ Instruct the patient to cooperate fully ing further testing, treatment, or
and to follow directions. Direct the referral to another health care
patient to breathe normally and to provider. Answer any questions or
avoid unnecessary movement. address any concerns voiced by the
patient or family.
follow the general guidelines in ➤ Depending on the results of this
Appendix A. Positively identify the procedure, additional testing may be
patient, and label the appropriate performed to evaluate or monitor
tubes with the corresponding patient progression of the disease process
demographics, date, and time of and determine the need for a change
collection. Perform a venipuncture; in therapy. Evaluate test results in
collect the specimen in a 5-mL red- relation to the patient’s symptoms
top tube. and other tests performed.
over the puncture site and apply gen- Related laboratory tests:
Observe venipuncture site for bleed- ➤ Related laboratory tests include
ing or hematoma formation. Apply group A streptococcal screen, strep-
paper tape over gauze or replace tococcal anti-DNAse B, and throat
with adhesive bandage. culture.
ANTIBODIES, ANTITHYROGLOBULIN
AND ANTITHYROID PEROXIDASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Thyroid antibodies, antithyroid peroxidase antibod-

ies (thyroid peroxidase [TPO] antibodies were previously called thyroid
antimicrosomal antibodies).

Conventional SI Units (Conversion

Antibody Units Factor 1)
Antithyroglobulin Less than 0.3 U/mL Less than 0.3 kU/L
antibody
Antiperoxidase Less than 0.3 U/mL Less than 0.3 kU/L
antibody
• Assist in the diagnosis of suspected

DESCRIPTION & RATIONALE: Thyroid hypothyroidism caused by thyroid tis-
antibodies are mainly immunoglobu- sue destruction
lin G–type antibodies. Antithyroid • Assist in the diagnosis of suspected thy-
peroxidase antibodies bind with roid autoimmunity in patients with
microsomal antigens on cells lining other autoimmune disorders
the microsomal membrane. They are
thought to destroy thyroid tissue as a
result of stimulation by lymphocytic RESULT
killer cells. These antibodies are pres- Increased in:
ent in hypothyroid and hyperthyroid
• Autoimmune disorders
conditions. Antithyroglobulin anti-
bodies are autoantibodies directed • Graves’ disease
against thyroglobulin. The function of • Goiter
these antibodies is unclear. Both tests
• Hashimoto’s thyroiditis
are normally requested together. ■
• Idiopathic myxedema
INDICATIONS: • Pernicious anemia
• Assist in confirming suspected inflam-
mation of thyroid gland • Thyroid carcinoma
Antibodies, Antithyroglobulin and Antithyroid Peroxidase 129
Decreased in: N/A Explain to the patient that there may

venipuncture.
INTERFERING FACTORS: tion restrictions unless by medical
direction.
• Lithium may increase thyroid antibody
levels.
Intratest:
within 1 week before the test can inter- ➤ If the patient has a history of severe
fere with test results when radioim- allergic reaction to latex, care should
munoassay is the test method. ment containing latex.
Nursing Implications and patient to breathe normally and to
Procedure ● ● ● ● ● ● ● ● ● ● ● avoid unnecessary movement.
Pretest: follow the general guidelines in
➤ Inform the patient that the test is used Appendix A. Positively identify the
to assess thyroid gland function. patient, and label the appropriate
sitivities to latex), and inform the top tube.
endocrine and immune system and
ratory tests, surgical procedures, and
other diagnostic procedures. For
Endocrine and Immune System ➤ Promptly transport the specimen to
tables. the laboratory for processing and
analysis.
the patient is taking, including ➤ The results are recorded manually or
herbs, nutritional supplements, and in a computerized system for recall
nutraceuticals. The requesting health and postprocedure interpretation by
care practitioner and laboratory the appropriate health care practi-
should be advised if the patient tioner.
regularly uses these products so
that their effects can be taken into
consideration when reviewing
Post-test:
results. ➤ A written report of the examination
➤ Note any recent procedures that can will be sent to the requesting health
interfere with test results. care practitioner, who will discuss
patient. Inform the patient that spec- ➤ Reinforce information given by the
imen collection takes approximately patient’s health care provider regard-
5 to 10 minutes. Address concerns ing further testing, treatment, or re-
about pain related to the procedure. ferral to another health care provider.

or family.
cedure, additional testing may be ➤ Related laboratory tests include com-
performed to evaluate or monitor plete blood count, thyroid biopsy,
progression of the disease process thyroid-stimulating hormone, free
and determine the need for a change thyroxine, thyroxine, and triiodothyro-
in therapy. Evaluate test results in nine.
ANTIBODIES, CARDIOLIPIN,
IMMUNOGLOBULIN G, AND
IMMUNOGLOBULIN M
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Antiphospholipid antibody, lupus anticoagulant,

LA, ACA.

REFERENCE VALUE: (Method: Immunoassay, enzyme-linked immunosorbent
assay [ELISA]) Negative.
DESCRIPTION & RATIONALE: Cardi- Cardiolipin antibodies are often

olipin antibody is one of several iden- found in association with lupus anti-
tified antiphospholipid antibodies. coagulant. Increased antiphospholipid
These antibodies react with proteins antibody levels have been found in
in the blood that are bound to phos- pregnant women with lupus who
pholipid and interfere with normal have had miscarriages. The com-
blood vessel function. The two pri- bination of noninflammatory throm-
mary types of problems they cause are bosis of blood vessels, low platelet
narrowing and irregularity of the count, and history of miscarriage is
blood vessels and blood clots in the termed antiphospholipid antibody syn-
blood vessels. Cardiolipin antibodies drome. ■
are found in individuals with lupus
erythematosus, lupus-related condi- INDICATIONS:
tions, infectious diseases, drug reac- • Assist in the diagnosis of antiphospho-
tions, and sometimes fetal loss. lipid antibody syndrome
Antibodies, Cardiolipin, Immunoglobulin G, and Immunoglobulin M 131
RESULT ➤ Obtain a history of the patient’s

hematopoietic, immune, and repro-
ductive systems and results of pre-
Increased in:
viously performed laboratory tests,
• Antiphospholipid antibody syndrome surgical procedures, and other diag-
nostic procedures. For related labora-
• Chorea
tory tests, refer to the Hematopoietic,
• Drug reactions Immune, and Reproductive System
tables.
• Epilepsy
• Infectious diseases the patient is taking, including
• Mitral valve endocarditis nutraceuticals. The requesting health
• Patients with lupus-like symptoms
should be advised if the patient
(often antinuclear antibody negative) regularly uses these products so
• Placental infarction that their effects can be taken
• Recurrent fetal loss (strong association results.
with two or more occurrences) ➤ Review the procedure with the
• Recurrent venous and arterial throm- patient. Inform the patient that spec-
boses imen collection takes approximately
Decreased in: N/A Explain to the patient that there
may be some discomfort during the
CRITICAL VALUES: N/A venipuncture.
INTERFERING FACTORS: Cardiolipin tion restrictions unless by medical
antibody is partially cross-reactive with direction.
syphilis reagin antibody and lupus anti-
coagulant. False-positive rapid plasma Intratest:
reagin results may occur.
Nursing Implications and ment containing latex.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: patient to breathe normally and to
➤ Inform the patient that the test is avoid unnecessary movement.
used to detect the presence of ➤ Observe standard precautions, and
antiphospholipid antibodies, which follow the general guidelines in
can lead to the development of blood Appendix A. Positively identify the
vessel problems, complications of patient, and label the appropriate
which include stroke, heart attack, tubes with the corresponding patient
and miscarriage. demographics, date, and time of col-
➤ Obtain a history of the patient’s com- lection. Perform a venipuncture;
Observe venipuncture site for bleed- Educate the patient regarding access
ing or hematoma formation. Apply to counseling services. Provide con-
paper tape over gauze or replace tact information, if desired, for the
with adhesive bandage. Lupus Foundation of America (http://
➤ Promptly transport the specimen to www.lupus.org).
the laboratory for processing and ➤ Reinforce information given by
analysis. the patient’s health care provider
➤ The results are recorded manually regarding further testing, treatment,
or in a computerized system for or referral to another health care
recall and postprocedure interpreta- provider. Answer any questions or
tion by the appropriate health care address any concerns voiced by the
practitioner. patient or family.
➤ A written report of the examination progression of the disease process
will be sent to the requesting health and determine the need for a change
care practitioner, who will discuss in therapy. Evaluate test results in
the results with the patient. relation to the patient’s symptoms
results, and be supportive of fear of Related laboratory tests:
shortened life expectancy. Discuss
the implications of abnormal test ➤ Related laboratory tests include anti-
results on the patient’s lifestyle. nuclear antibodies, complete blood
Provide teaching and information count, fibrinogen, lupus anticoagul-
regarding the clinical implications of ant antibodies, platelet count, protein
the test results, as appropriate. C, protein S, and syphilis serology.
ANTIBODIES, GLIADIN
(IMMUNOGLOBULIN G AND
IMMUNOGLOBULIN A)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Endomysial antibodies, gliadin (IgG and IgA)

antibodies, EMA.

Antibodies, Gliadin (Immunoglobulin G, and Immunoglobulin A) 133
Gliadin Conventional INTERFERING FACTORS:

Antibody Units • Conditions other than gluten-sensitive
enteropathy can result in elevated anti-
IgA Less than 5 U body levels without corresponding his-
IgG Less than 57 U tologic evidence. These conditions
include Crohn’s disease, postinfection
malabsorption, and food protein intol-
erance.
DESCRIPTION & RATIONALE: Gliadin • A negative IgA gliadin result, especially
is a water-soluble protein found in the with a positive IgG gliadin result in an
gluten of wheat, rye, oats, and barley. untreated patient, does not rule out
The intestinal mucosa of certain indi- active gluten-sensitive enteropathy.
viduals does not digest gluten, allow-
ing a toxic buildup of gliadin. Nursing Implications and
Antibodies to gliadin form and result Procedure ● ● ● ● ● ● ● ● ● ● ●
in damage to the intestinal mucosa. In

severe cases, intestinal mucosa can be Pretest:
lost. Immunoglobulin G (IgG) and ➤ Inform the patient that the test is
immunoglobulin A (IgA) gliadin anti- used to assist in the diagnosis
bodies are detectable in the serum of and monitoring of gluten-sensitive
patients with gluten-sensitive enter- enteropathies.
opathy. ■ ➤ Obtain a history of the patient’s com-
INDICATIONS: sitivities to latex), and inform the
• Assist in the diagnosis of asymptomatic appropriate health care practitioner
gluten-sensitive enteropathy in some accordingly.
patients with dermatitis herpetiformis ➤ Obtain a history of the patient’s gas-
• Assist in the diagnosis of gluten- trointestinal and immune systems as
well as results of previously per-
sensitive enteropathies formed laboratory tests, surgical
• Assist in the diagnosis of nontropical procedures, and other diagnostic
sprue procedures. For related laboratory
tests, refer to the Gastrointestinal
• Monitor dietary compliance of patients and Immune System tables.
with gluten-sensitive enteropathies ➤ Obtain a list of foods and medica-
tions the patient is taking, including
RESULT herbs, nutritional supplements, and
Increased in:
• Asymptomatic gluten-sensitive entero- ularly uses these products so that
pathy their effects can be taken into con-
• Celiac disease
• Dermatitis herpetiformis patient. Inform the patient that spec-
• Nontropical sprue 5 to 10 minutes. Address concerns
Decreased in: N/A Explain to the patient that there may
➤ There are no food, fluid, or medica- ings to consult with a qualified nutri-
tion restrictions unless by medical tionist to plan a gluten-free diet. This
direction. dietary planning is complex because
patients are often malnourished and
Intratest: have other related nutritional prob-
lems.
and to follow directions. Direct the ➤ Recognize anxiety related to test
patient to breathe normally and to results, and offer support. Discuss
avoid unnecessary movement. the implications of abnormal test
results on the patient’s lifestyle.
➤ Observe standard precautions, and Provide teaching and information
follow the general guidelines in regarding the clinical implications of
Appendix A. Positively identify the the test results, as appropriate.
patient, and label the appropriate Educate the patient regarding access
tubes with the corresponding patient to appropriate counseling services.
lection. Perform a venipuncture; col- ➤ Reinforce information given by the
lect the specimen in a 5-mL red-top patient’s health care provider regard-
tube. ing further testing, treatment, or
➤ Remove the needle, place a gauze referral to another health care
over the puncture site and apply gen- provider. Answer any questions or
tle pressure to stop bleeding. address any concerns voiced by the
Observe venipuncture site for bleed- patient or family.
ing or hematoma formation. Apply ➤ Depending on the results of this
paper tape over gauze or replace procedure, additional testing may be
with adhesive bandage. performed to evaluate or monitor
the appropriate health care practi- Related laboratory tests:
tioner.
➤ Related laboratory tests include albu-
Post-test: min, calcium, D-xylose tolerance
test, electrolytes, fecal analysis,
➤ Nutritional considerations: Encour- fecal fat, folic acid, iron, lactose tol-
age the patient with abnormal find- erance test, and skin biopsy.
ANTIBODY, ANTIMITOCHONDRIAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: AMA.
Antibody, Antimitochondrial 135

REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative or titer
less than 1:20.

DESCRIPTION & RATIONALE: Anti- sitivities to latex), and inform the
mitochondrial antibodies are found in accordingly.
90% of patients with primary biliary
cirrhosis (PBC). PBC is identified hepatobiliary and immune systems,
most frequently in women ages 35 to as well as results of previously
60 years. Testing is useful in the dif- performed laboratory tests, surgical
ferential diagnosis of chronic liver dis- procedures, and other diagnostic
ease as antimitochondrial antibodies procedures. For related laboratory
tests, refer to the Hepatobiliary and
are rarely detected in extrahepatic bil- Immune System tables.
iary obstruction, various forms of
hepatitis, and cirrhosis. ■ patient is taking, including herbs,
INDICATIONS: ceuticals. The requesting health care
• Assist in the diagnosis of PBC practitioner and laboratory should be
• Assist in the differential diagnosis of these products so that their effects
chronic liver disease can be taken into consideration
RESULT ➤ Review the procedure with the
Increased in:
• Hepatitis (alcoholic, viral) 5 to 10 minutes. Address concerns
• PBC about pain related to the procedure.
• Rheumatoid arthritis (occasionally) be some discomfort during the
• Systemic lupus erythematosus (occa- venipuncture.
sionally) ➤ There are no food, fluid, or medica-
• Thyroid disease (occasionally) tion restrictions unless by medical
direction.
Decreased in: N/A
Intratest:
CRITICAL VALUES: N/A ➤ If the patient has a history of severe
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
used in the differential diagnosis of Appendix A. Positively identify the
chronic liver disease. patient, and label the appropriate
➤ Obtain a history of the patient’s com- tubes with the corresponding patient
plaints, including a list of known demographics, date, and time of col-
lection. Perform a venipuncture; plex carbohydrates (e.g., starch,

collect the specimen in a 5-mL red- fiber, and glycogen [animal carbohy-
top tube. drates]) and complex fats, which
➤ Remove the needle, place a gauze would require additional bile to emul-
over the puncture site and apply gen- sify them so that they could be used.
tle pressure to stop bleeding. Observe the cirrhotic patient care-
Observe venipuncture site for bleed- fully for the development of ascites;
ing or hematoma formation. Apply if ascites develops, pay strict atten-
paper tape over gauze or replace tion to fluid and electrolyte balance.
with adhesive bandage. ➤ A written report of the examination
➤ Promptly transport the specimen to will be sent to the requesting health
the laboratory for processing and care practitioner, who will discuss
analysis. the results with the patient.
➤ The results are recorded manually or ➤ Reinforce information given by the
in a computerized system for recall patient’s health care provider regard-
and postprocedure interpretation by ing further testing, treatment, or
the appropriate health care practi- referral to another health care pro-
tioner. vider. Answer any questions or
Post-test: patient or family.
➤ Nutritional considerations: The pres-
ence of antimitochondrial antibodies
may be associated with liver dis-
ease. Dietary recommendations may
be indicated and vary depending on
the severity of the condition. A low-
protein diet may be in order if the
liver cannot process the end prod-
ucts of protein metabolism. A diet of
soft foods may be required if Related laboratory tests:
esophageal varices have developed.
Ammonia levels may be used to ➤ Related laboratory tests include albu-
determine whether protein should min, alkaline phosphatase, ammo-
be added to or reduced from the nia, anticytoplasmic neutrophilic
diet. Patients should be encouraged antibodies, antinuclear antibodies,
to eat simple carbohydrates and anti–smooth muscle antibodies,
emulsified fats (as in homogenized bilirubin, electrolytes, -glutamyl
milk or eggs), as opposed to com- transpeptidase, and liver biopsy.
ANTIBODY, ANTI–SMOOTH MUSCLE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: ASMA.
REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative.
Antibody, Anti–Smooth Muscle 137

DESCRIPTION & RATIONALE: Anti– nutraceuticals. The requesting health
smooth muscle antibodies are autoan- care practitioner and laboratory
tibodies found in high titers in the ularly uses these products so that
sera of patients with autoimmune their effects can be taken into con-
diseases of the liver and bile duct. sideration when reviewing results.
Simultaneous testing for antimito- ➤ Review the procedure with the
chondrial antibodies can be useful in patient. Inform the patient that spec-
the differential diagnosis of chronic imen collection takes approximately
liver diesease. ■
Explain to the patient that there
INDICATIONS: may be some discomfort during the
• Differential diagnosis of liver disease venipuncture.
RESULT tion restrictions unless by medical
direction.
Increased in:
• Autoimmune hepatitis
Intratest:
• Chronic active viral hepatitis
• Infectious mononucleosis allergic reaction to latex, care should
Decreased in: N/A ment containing latex.
CRITICAL VALUES: N/A ➤ Instruct the patient to cooperate fully

INTERFERING FACTORS: N/A patient to breathe normally and to
➤ Inform the patient that the test is lection. Perform a venipuncture;
used in the differential diagnosis of collect the specimen in a 5-mL red-
chronic liver disease. top tube.
accordingly.
➤ Obtain a history of the patient’s with adhesive bandage.
hepatobiliary and immune systems,
as well as results of previously per- ➤ Promptly transport the specimen to
formed laboratory tests, surgical pro- the laboratory for processing and
cedures, and other diagnostic analysis.
procedures. For related laboratory ➤ The results are recorded manually or
tests, refer to the Hepatobiliary and in a computerized system for recall
Immune System tables. and postprocedure interpretation by
➤ Obtain a list of the medications the appropriate health care practi-

➤ Nutritional considerations: The pres- care practitioner, who will discuss
ence of anti–smooth muscle anti- the results with the patient.
bodies may be associated with liver ➤ Reinforce information given by the
disease. Dietary recommendations patient’s health care provider regard-
may be indicated and vary depending further testing, treatment, or
ing on the severity of the condition. referral to another health care pro-
A low-protein diet may be in order if vider. Answer any questions or
the liver cannot process the end address any concerns voiced by the
products of protein metabolism. A patient or family.
diet of soft foods may be required if
esophageal varices have developed. ➤ Depending on the results of this
Ammonia levels may be used to procedure, additional testing may be
determine whether protein should performed to evaluate or monitor
be added to or reduced from the progression of the disease process
diet. Patients should be encouraged and determine the need for a change
to eat simple carbohydrates and in therapy. Evaluate test results in
emulsified fats (as in homogenized relation to the patient’s symptoms
milk or eggs), as opposed to com- and other tests performed.
plex carbohydrates (e.g., starch,
fiber, and glycogen [animal carbohy- Related laboratory tests:
drates]) and complex fats, which
would require additional bile to emul- ➤ Related laboratory tests include
sify them so that they could be alkaline phosphatase, ammonia,
used. Observe the cirrhotic patient antimitochondrial antibody, antinu-
carefully for the development of clear antibody, aspartate aminotrans-
ascites; if ascites develops, pay strict ferase, bilirubin, hepatitis serology,
attention to fluid and electrolyte liver biopsy, prothrombin time, and
balance. serum protein electrophoresis.
ANTIBODY, Jo-1
SYNONYM/ACRONYM: Antihistidyl transfer RNA (tRNA) synthase.
REFERENCE VALUE: (Method: Immunoassay) Negative.
DESCRIPTION & RATIONALE: Jo-1 is ease course and a higher risk of mor-
an autoantibody found in the serum tality. The clinical effects of this
of some antinuclear antibody–positive autoantibody include acute onset,
patients. Compared to the presence fever, dry and cracked skin on the
of other autoantibodies, the presence hands, Raynaud’s phenomenon, and
of Jo-1 suggests a more aggressive dis- arthritis.
Antibody, Jo-1 139
INDICATIONS: 5 to 10 minutes. Address concerns

• Test for idiopathic inflammatory myo- about pain related to the procedure.
pathies
venipuncture.
RESULT
Increased in: tion restrictions unless by medical
• Dermatomyositis direction.
• Polymyositis
Intratest:
Decreased in: N/A ➤ If the patient has a history of severe
INTERFERING FACTORS: N/A ➤ Instruct the patient to cooperate
fully and to follow directions.
Nursing Implications and mally and to avoid unnecessary
Procedure ● ● ● ● ● ● ● ● ● ● ●
movement.
used to identify and monitor idio- tubes with the corresponding patient
pathic myopathies. demographics, date, and time of
➤ Obtain a history of the patient’s collection. Perform a venipuncture;
complaints, including a list of known collect the specimen in a 5-mL red-
➤ Obtain a history of the patient’s Observe venipuncture site for bleed-
immune and musculoskeletal sys- ing or hematoma formation. Apply
tems, as well as results of pre- paper tape over gauze or replace
viously performed laboratory tests, with adhesive bandage..
surgical procedures, and other ➤ Promptly transport the specimen to
diagnostic procedures. For related the laboratory for processing and
laboratory tests, refer to the Im- analysis.
mune and Musculoskeletal System
tables. ➤ The results are recorded manually or
➤ Obtain a list of the medications the and postprocedure interpretation by
patient is taking, including herbs, the appropriate health care practi-
nutritional supplements, and nutra- tioner.
ceuticals. The requesting health
should be advised if the patient Post-test:
that their effects can be taken into ➤ A written report of the examination
consideration when reviewing will be sent to the requesting health
results. care practitioner, who will discuss
➤ Review the procedure with the the results with the patient.
patient. Inform the patient that spec- ➤ Reinforce information given by the
imen collection takes approximately patient’s health care provider regard-
ing further testing, treatment, or Related laboratory tests:

referral to another health care provi-
der. Answer any questions or add- ➤ Related laboratory tests include
ress any concerns voiced by the alanine aminotransferase, aldolase,
patient or family. antinuclear antibody, aspartate
➤ Depending on the results of this aminotransferase, creatine kinase,
procedure, additional testing may be erythrocyte sedimentation rate,
performed to evaluate or monitor extractable nuclear antibodies, lac-
progression of the disease process tate dehydrogenase and isoen-
and determine the need for a change zymes, muscle biopsy, myoglobin,
in therapy. Evaluate test results in rheumatoid factor, anti-scleroderma
relation to the patient’s symptoms antibody, skin biopsy, and urine crea-
and other tests performed. tinine.
ANTICONVULSANT DRUGS:
CARBAMAZEPINE, ETHOSUXIMIDE,
PHENOBARBITAL, PHENYTOIN,
PRIMIDONE, VALPROIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carbamazepine (Carbatrol, Tegretol, Tegretol XR);

Ethosuximide (Zarontin); Phenobarbital (Luminal, Phenobarb); Phenytoin
(Cerebyx, Dilantin, Fenytoin, Phenytek); Primidone (Mysoline); Valproic acid
(Depacon, Depakene, Depakote).
Drug Route of Administration

Carbamazepine* Oral
Ethosuximide* Oral
Phenobarbital* Oral
Phenytoin* Oral
Primidone* Oral
Valproic Acid* Oral
* Recommended collection time trough: immediately before next dose (at steady
state) or at a consistent sampling time.
Therapeutic Volume of Protein
Drug Dose* SI Units Half-Life (h) Distribution (L/kg) Binding (%) Excretion
Carbamazepine 4–12 g/mL 17–51 mol/L 15–40 0.8–1.8 60–80 Hepatic
Ethosuximide 40–100 283–708 25–70 0.7 0–5 Renal

g/mL mol/L
Phenobarbital Adult: 15–40 Adult: 65–172 Adult: 0.5–1.0 L/kg 40–50 80%
12/15/05
g/mL mol/L 50–140 Hepatic

Child: 15–30 Child: 65–129 Child: 20% Renal
g/mL mol/L 40–70

8:34 PM
Phenytoin 10–20 g/mL 40–79 mol/L Adult: 0.6–0.7 85–95 Hepatic

Neonatal: Neonatal: 20–40
6–14 g/mL 24–55 mol/L Child: 10
Page 141
Primidone Adult: 5–12 Adult: 23–55 4–12 0.5–1.0 0–20 Hepatic

g/mL mol/L
Child: 7–10 Child: 32–46
g/mL mol/L

Valproic Acid 50–120 347–832 12–16 0.1–0.5 85–95 Hepatic
g/mL mol/L
141
DESCRIPTION & RATIONALE: Anti- Peak and trough collection times

convulsants are used to reduce the fre- should be documented carefully in
quency and severity of seizures for relation to the time of medication
patients with epilepsy. Carbamazepine administration. ■
is also used for controlling neurogenic
pain in trigeminal neuralgia and dia- must be clearly and accurately communi-
betic neuropathy and for treating for cated to avoid misunderstanding of the
bipolar disease and other neurologic dose time in relation to the collection
and psychiatric conditions. Valproic time. Miscommunication between the
acid is also used for some psychiatric individual administering the medication
conditions like bipolar disease and for and the individual collecting the speci-
prevention of migrane headache. men is the most frequent cause of sub-
Many factors must be considered in therapeutic levels, toxic levels, and
effective dosing and monitoring of misleading information used in calcula-
tion of future doses.
therapeutic drugs, including patient
age, patient weight, interacting med- INDICATIONS:
ications, electrolyte balance, protein • Assist in the diagnosis of and preven-
levels, water balance, conditions that tion of toxicity
affect absorption and excretion, and • Evaluate overdose, especially in combi-
foods, herbals, vitamins, and minerals nation with ethanol
that can either potentiate or inhibit • Monitor compliance with therapeutic
the intended target concentration. regimen
RESULT
Level Response
Carbamazepine Hepatic impairment
Ethosuximide Hepatic impairment
Phenobarbital Hepatic impairment
Phenytoin Hepatic impairment
Primidone Hepatic impairment
Valproic acid Hepatic impairment
CRITICAL VALUES: It is important Carbamazepine: Greater

to note the adverse effects of toxic and Than 12 g/mL
subtherapeutic levels. Care must be taken
to investigate the signs and symptoms of Signs and symptoms of carbamaze-
too little and too much medication. Note pine toxicity include respiratory depres-
and immediately report to the health care sion, seizures, leukopenia, hyponatremia,
practitioner any critically increased values hypotension, stupor, and possible coma.
and related symptoms. Possible interventions include gastric
Anticonvulsant Drugs 143
lavage (contraindicated if ileus is present); administration of saline or sorbitol cathar-

airway protection; administration of flu- tic, and discontinuing the medication.
ids and vasopressors for hypotension;
treatment of seizures with diazepam, phe- Primidone: Greater
nobarbital, or phenytoin; cardiac moni- Than 12 g/mL
toring; monitoring of vital signs; and
discontinuing the medication. Emetics Signs and symptoms of primidone toxic-
are contraindicated. ity include ataxia, anemia, and central
nervous system depression. Possible inter-
Ethosuximide: Greater ventions include airway protection, treat-
ment of anemia with vitamin B12 and
Than 100 g/mL
folate, and discontinuing the medication.
Signs and symptoms of ethosuximide
toxicity include nausea, vomiting, and Valproic Acid: Greater
lethargy. Possible interventions include Than 120 g/mL
administration of activated charcoal,
Signs and symptoms of valproic acid tox-
administration of saline cathartic and gas-
icity include numbness, tingling, weak-
tric lavage (contraindicated if ileus is pres-
ness, loss of appetite, and mental changes.
ent), airway protection, hourly assessment
Possible interventions include adminis-
of neurologic function, and discontinuing
tration of activated charcoal and naloxone
the medication.
and discontinuing the medication.
Phenobarbital: Greater
Than 40 g/mL • Blood drawn in serum separator tubes
Signs and symptoms of phenobarbital (gel tubes).
toxicity include cold, clammy skin; ataxia; • Contraindicated in patients with liver
central nervous system depression; hypo- disease, and caution advised in patients
thermia; hypotension; cyanosis; Cheyne- with renal impairment.
Stokes respiration; tachycardia; possible
• Drugs that may increase carbamaze-
coma; and possible renal impairment.
pine levels or increase risk of toxicity
Possible interventions include gastric
include cimetidine, clozapine, danazol,
lavage, administration of activated char-
diazepam, diltiazem, erythromycin,
coal with cathartic, airway protection,
haloperidol, isoniazid, propoxyphene,
possible intubation and mechanical venti-
risperidone, triacetyloleandomycin,
lation (especially during gastric lavage
tricyclic antidepressants, valproic acid,
if there is no gag reflex), monitoring
and verapamil.
for hypotension, and discontinuing the
medication. • Drugs that may decrease carbamaze-
pine levels include phenobarbital, phe-
Phenytoin: Adults: Greater nytoin, and primidone.
Than 20 g/mL; Neonatal: • Drugs that may increase ethosuximide
Greater Than 14 g/mL levels include isoniazid, ritonavir, and
valproic acid.
Signs and symptoms of phenytoin toxi-
city include double vision, nystagmus, • Drugs that may decrease ethosuximide
lethargy, central nervous system depres- levels include phenobarbital, pheny-
sion, and possible coma. Possible toin, and primidone.
interventions include airway support, • Drugs that may increase phenobarbital
electrocardiographic monitoring, admin- levels or increase risk of toxicity include
istration of activated charcoal, gastric barbital drugs, furosemide, primidone,
lavage with warm saline or tap water, salicylates, and valproic acid.
• Phenobarbital may affect the meta- • Drugs that may increase valproic acid
bolism of other drugs, increasing levels or increase risk of toxicity include
their effectiveness, such as -blockers, dicumarol, phenylbutazone, and high
chloramphenicol, corticosteroids, doxy- doses of salicylate.
cycline, griseofulvin, haloperidol,
• Drugs that may decrease valproic acid
methylphenidate, phenothiazines, phe-
levels include carbamazepine, pheno-
nylbutazone, propoxyphene, quinidine,
barbital, phenytoin, and primidone.
theophylline, tricyclic antidepressants,
and valproic acid.
• Phenobarbital may affect the metabo- Nursing Implications and
lism of other drugs, decreasing their Procedure ● ● ● ● ● ● ● ● ● ● ●
effectiveness, such as chloramphenicol,
cyclosporine, ethosuximide, oral anti- Pretest:
coagulants, oral contraceptives, pheny-
toin, and theophylline. ➤ Inform the patient that the test is
used to monitor for therapeutic and
• Phenobarbital is an active metabolite toxic drug levels.
of primidone, and both drug levels ➤ Obtain a history of the patient’s com-
should be monitored while the patient plaints, including a list of known
is receiving primidone to avoid either allergens (especially allergies or sen-
toxic or subtherapeutic levels of both sitivities to latex), and inform the
medications. appropriate health care practitioner
accordingly.
• Drugs that may increase phenytoin lev- ➤ Obtain a history of the patient’s gen-
els or increase the risk of phenytoin itourinary and hepatobiliary systems
toxicity include amiodarone, azapropa- as well as results of previously per-
zone, carbamazepine, chlorampheni- formed laboratory tests, surgical
col, cimetidine, disulfiram, ethanol, procedures, and other diagnostic
fluconazole, halothane, ibuprofen, procedures. For related laboratory
imipramine, levodopa, metronidazole, tests, refer to the Genitourinary
miconazole, nifedipine, phenylbuta- and Hepatobiliary Systems and
Therapeutic/Toxicology tables.
zone, sulfonamides, trazodone, tricyclic
antidepressants, and trimethoprim. ➤ Obtain a list of medications the
Small changes in formulation (i.e., patient is taking, including herbs,
changes in brand) also may increase ceuticals. Note the last time and
phenytoin levels or increase the risk dose of medication taken. The
of phenytoin toxicity. requesting health care practitioner
• Drugs that may decrease phenytoin the patient regularly uses these
levels include bleomycin, carbamaze- products so that their effects can
pine, cisplatin, disulfiram, folic acid, be taken into consideration when re-
intravenous fluids containing glucose, viewing results.
nitrofurantoin, oxacillin, rifampin, sal- ➤ Review the procedure with the
icylates, and vinblastine. patient. Inform the patient that spec-
• Primidone decreases the effectiveness 5 to 10 minutes. Address concerns
of carbamazepine, ethosuximide, fel- about pain related to the procedure.
bamate, lamotrigine, oral anticoagu- Explain to the patient that there
lants, oxcarbazepine, topiramate, and may be some discomfort during the
valproate. venipuncture.
Anticonvulsant Drugs 145
➤ Sensitivity to cultural and social Post-test:

esty, is important in providing psy- ➤ A written report of the examination
chological support before, during, will be sent to the requesting health
and after the procedure. care practitioner, who will discuss
➤ There are no food, fluid, or medica- the results with the patient.
tion restrictions unless by medical ➤ Reinforce information given by the
direction. patient’s health care provider regard-
Intratest: referral to another health care
➤ If the patient has a history of severe provider. Explain to the patient the
allergic reaction to latex, care should importance of following the medi-
be taken to avoid the use of equip- cation regimen and instructions
ment containing latex. regarding drug interactions. Instruct
the patient to immediately report
➤ Direct the patient to breathe nor- any unusual sensations (e.g., ataxia,
mally and to avoid unnecessary dizziness, dyspnea, lethargy, rash,
movement. tremors, mental changes, weakness,
➤ Observe standard precautions, and or visual disturbances) to his or
follow the general guidelines in her health care practitioner. Answer
Appendix A. Consider recommended any questions or address any con-
collection time in relation to dos- cerns voiced by the patient or family.
ing schedule. Positively identify the
patient, and label the appropriate ➤ Instruct the patient to be prepared
tubes with the corresponding patient to provide the pharmacist with a list
demographics, date, and time of col- of other medications he or she is
lection, noting the last dose of already taking in the event that the
medication taken. Perform a veni- requesting health care practitioner
puncture; collect the specimen in a prescribes a medication.
5-mL red-top tube. ➤ Depending on the results of this
➤ Remove the needle, place a gauze procedure, additional testing may be
over the puncture site and apply gen- performed to evaluate or monitor
tle pressure to stop bleeding. progression of the disease pro-
Observe venipuncture site for bleed- cess and determine the need for a
ing or hematoma formation. Apply change in therapy. Evaluate test
paper tape over gauze or replace results in relation to the patient’s
with adhesive bandage. symptoms and other tests per-
➤ Promptly transport the specimen to formed.
analysis.
➤ The results are recorded manually
or in a computerized system for ➤ Related laboratory tests include albu-
recall and postprocedure interpreta- min, blood urea nitrogen, creatinine,
tion by the appropriate health care complete blood count, electrolytes,
practitioner liver function tests, and total protein.
ANTIDEOXYRIBONUCLEASE-B,
STREPTOCOCCAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: ADNase-B, AntiDNase-B titer, antistreptococcal

DNase-B titer, streptodornase.

Normal CRITICAL VALUES: N/A

Age Results
INTERFERING FACTORS: N/A
Preschoolers Less than 61 U
School-age Less than 171 U
children Nursing Implications and
Adults Less than 86 U
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
DESCRIPTION & RATIONALE: The ➤ Inform the patient that the test is
presence of streptococcal deoxyri- used to document recent strepto-
bonuclease (DNase) antibodies is an coccal infection.
indicator of recent infection, espe- ➤ Obtain a history of the patient’s
cially if a rise in antibody titer can be complaints, including a list of known
shown. This test is more sensitive than sitivities to latex), and inform the
the antistreptolysin O test. A rise in appropriate health care practitioner
titer of two or more dilution incre- accordingly.
ments between acute and convalescent ➤ Obtain a history of the patient’s
specimens is clinically significant. ■ immune system and results of previ-
INDICATIONS: surgical procedures, and other diag-
• Investigate the presence of streptococ- nostic procedures. For related labo-
cal antibodies as a source of recent System table.
infection
RESULT herbs, nutritional supplements, and
Increased in: care practitioner and laboratory
• Streptococcal infections (systemic) should be advised if the patient
Decreased in: N/A that their effects can be taken
Antideoxyribonuclease-B, Streptococcal 147
into consideration when reviewing ➤ The results are recorded manually or

results. in a computerized system for recall
➤ Review the procedure with the and postprocedure interpretation by
patient. Inform the patient that spec- the appropriate health care practi-
imen collection takes approximately tioner.
Explain to the patient that there may Post-test:
be some discomfort during the ➤ Administer analgesics and antibiotics
venipuncture. if ordered. Remind the patient of the
➤ There are no food, fluid, or medica- importance of completing the entire
tion restrictions unless by medical course of antibiotic therapy, even if
direction. signs and symptoms disappear
before completion of therapy.
Intratest: ➤ A written report of the examination
➤ If the patient has a history of severe will be sent to the requesting health
allergic reaction to latex, care should care practitioner, who will discuss
be taken to avoid the use of equip- the results with the patient.
ment containing latex. ➤ Reinforce information given by the
and to follow directions. Direct the ing further testing, treatment, or
patient to breathe normally and to referral to another health care
avoid unnecessary movement. provider. Inform the patient that a
➤ Observe standard precautions, and convalescent specimen may be
follow the general guidelines in requested in 7 to 10 days. Answer
Appendix A. Positively identify the any questions or address any con-
patient, and label the appropriate cerns voiced by the patient or family.
tubes with the corresponding patient ➤ Depending on the results of this
demographics, date, and time of col- procedure, additional testing may be
lection. Perform a venipuncture; performed to evaluate or monitor
collect the specimen in a 5-mL red- progression of the disease process
top tube. and determine the need for a change
➤ Remove the needle, place a gauze in therapy. Evaluate test results in
over the puncture site and apply gen- relation to the patient’s symptoms
tle pressure to stop bleeding. and other tests performed.
paper tape over gauze or replace Related laboratory tests:
with adhesive bandage. ➤ Related laboratory tests include anti-
➤ Promptly transport the specimen to streptolysin O antibody, group A
the laboratory for processing and streptococcal screen, and throat
analysis. culture.
ANTIDEPRESSANT DRUGS (Cyclic):

AMITRIPTYLINE, NORTRIPTYLINE,
DOXEPIN, IMIPRAMINE, DESIPRAMINE
SYNONYMS/ACRONYM: Cyclic antidepressants: amitriptyline (Elavil, Endep,
Etrafon, Limbitrol DS, Triavil); nortriptyline (Aventyl HCL, Pamelor); dox-
epin (Adapin, Sinequan); imipramine (Anafranil, Clomipramine, Imavate,
Presamine, Surmontil, Tofranil PM, Trimipramine); desipramine
(Norpramin, pertofrane).
Amitriptyline Oral Trough: immediately before
next dose (at steady state)
Nortriptyline Oral Trough: immediately before
Doxepin Oral Trough: immediately before
Imipramine Oral Trough: immediately before
Desipramine Oral Trough: immediately before
REFERENCE VALUE: (Method: Chromatography for amitriptyline, nortripty-

line, and doxepin; immunoassay for imipramine and desipramine)
Therapeutic Half- Volume of Protein
Drug Dose* SI Units Life (h) Distribution (L/kg) Binding (%) Excretion
Amitriptyline, 80–200 289–722 17–40 10–36 85–95 Hepatic

alone ng/mL nmol/L
Nortriptyline, alone 50–150 ng/mL 190–570 20–90 15–23 90–95 Hepatic
12/15/05
nmol/L
Combined doxepin and 150–250 540–900 10–25 10–30 75–85 Hepatic
desmethyldoxepin ng/mL nmol/L
8:34 PM

Imipramine 150–250 536–892 6–28 9–23 60–95 Hepatic
ng/mL nmol/L
Page 149
(Conventional Units 3.75)

Desipramine 150–250 562–938 6–28 9–23 60–95 Hepatic
ng/mL nmol/L
149
DESCRIPTION & RATIONALE: Cyclic Trough collection times should be

antidepressants are used in the treat- documented carefully in relation to
ment of major depression. They have the time of medication administra-
also been used effectively to treat tion. ■
bipolar disorder, panic disorder, atten-
tion-deficit hyperactivity disorder
must be clearly and accurately communi-
(ADHD), obsessive-compulsive disor- cated to avoid misunderstanding of the
der (OCD), enuresis, eating disorders dose time in relation to the collection
(bulimia nervosa in particular), time. Miscommunication between the
nicotine dependence (tobacco), and individual administering the medication
cocaine dependence. Numerous drug and the individual collecting the speci-
interactions occur with the cyclic anti- men is the most frequent cause of
depressants. subtherapeutic levels, toxic levels, and
Many factors must be considered in misleading information used in calcula-
effective dosing and monitoring of tion of future doses.
therapeutic drugs, including patient INDICATIONS:
age, patient weight, interacting med- • Assist in the diagnosis and prevention
ications, electrolyte balance, protein of toxicity
levels, water balance, conditions that • Evaluate overdose, especially in combi-
affect absorption and excretion, and nation with ethanol (Note: Doxepin
foods, herbals, vitamins, and minerals abuse is unusual)
that can either potentiate or inhibit • Monitor compliance with therapeutic
the intended target concentration. regimen
RESULT
Level Response
Amitriptyline Hepatic impairment
Nortriptyline Hepatic impairment
Doxepin Hepatic impairment
Imipramine Hepatic impairment
Desipramine Hepatic impairment
CRITICAL VALUES: It is important Cyclic Antidepressants:

to note the adverse effects of toxic and • Amitriptyline: Greater than 300 ng/mL
subtherapeutic levels of antidepressants.
Care must be taken to investigate signs • Combined amitriptyline and nortripty-
and symptoms of too little and too much line: Greater than 250 ng/mL
medication. Note and immediately report • Combined doxepin and desmethyldox-
to the health care practitioner any epin: Greater than 150 ng/mL
critically increased values and related
symptoms. • Desipramine: Greater than 300 ng/mL
Antidepressant Drugs 151
• Imipramine: Greater than 250 ng/mL nutritional supplements, and nutra-

ceuticals. Note the last time and dose
Signs and symptoms of cyclic anti- of medication taken. The requesting
depressant toxicity include agitation, health care practitioner and labora-
hallucinations, confusion, seizures, arrhy- tory should be advised if the patient
thmias, hyperthermia, flushing, dilation regularly uses these products so that
of the pupils, and possible coma. Possi- their effects can be taken into consid-
ble interventions include administration eration when reviewing results.
of activated charcoal; emesis; gastric ➤ Review the procedure with the
lavage with saline; administration of patient. Inform the patient that spec-
physostigmine to counteract seizures, imen collection takes approximately
hypertension, or respiratory depression; 5 to 10 minutes. Address concerns
administration of bicarbonate, propra- Explain to the patient that there may
nolol, lidocaine, or phenytoin to counter- be some discomfort during the
act arrhythmias; and electrocardiographic venipuncture.
monitoring. ➤ Sensitivity to cultural and social
INTERFERING FACTORS: esty, is important in providing psy-
• Blood drawn in serum separator tubes chological support before, during,
(gel tubes). and after the procedure.
• Contraindicated in patients with liver ➤ There are no food, fluid, or medica-
disease, and caution advised in patients tion restrictions unless by medical
direction.
with renal impairment.
• Cyclic antidepressants may potentiate
the effects of oral anticoagulants. Intratest:
Nursing Implications and be taken to avoid the use of equip-
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: and to follow directions. Direct the
toxic drug levels. ➤ Observe standard precautions, and
➤ Obtain a history of the patient’s com- Appendix A. Consider recommended
plaints, including a list of known collection time in relation to dos-
allergens (especially allergies or sen- ing schedule. Positively identify the
sitivities to latex), and inform the patient, and label the appropriate
appropriate health care practitioner tubes with the corresponding patient
accordingly. demographics, date, and time of
➤ Obtain a history of the patient’s gen- collection, noting the last dose
itourinary and hepatobiliary systems of medication taken. Perform a
as well as results of previously venipuncture; collect the specimen
performed laboratory tests, surgical in a 5-mL red-top tube.
procedures, and other diagnos- ➤ Remove the needle, place a gauze
tic procedures. For related laboratory over the puncture site and apply gen-
tests, refer to the Genitourinary tle pressure to stop bleeding.
and Hepatobiliary Systems and Observe venipuncture site for bleed-
Therapeutic/ Toxicology tables. ing or hematoma formation. Apply
➤ Obtain a list of the medications the paper tape over gauze or replace
patient is taking, including herbs, with adhesive bandage.
➤ Promptly transport the specimen to headache, vomiting, sweating, dia-

the laboratory for processing and phoresis, visual disturbances) to his
analysis. or her health care practitioner. Blood
➤ The results are recorded manually pressure should be monitored regu-
or in a computerized system for larly. Answer any questions or
recall and postprocedure interpreta- address any concerns voiced by the
tion by the appropriate health care patient or family.
practitioner ➤ Instruct the patient to be prepared to
provide the pharmacist with a list of
Post-test: other medications he or she is
already taking in the event that the
➤ Nutritional considerations include requesting health care practitioner
the avoidance of alcohol consump- prescribes a medication.
tion.
➤ A written report of the examination cedure, additional testing may be
will be sent to the requesting health performed to evaluate or monitor
care practitioner, who will discuss progression of the disease process
the results with the patient. and determine the need for a change
➤ Reinforce information given by the in therapy. Evaluate test results in
provider. Explain to the patient the Related laboratory tests:
importance of following the medica-
tion regimen and instructions regard- ➤ Related laboratory tests include albu-
ing drug interactions. Instruct the min, blood urea nitrogen, creatinine,
patient to immediately report any complete blood count, electrolytes,
unusual sensations (e.g., severe liver function tests, and total protein.
ANTIDIURETIC HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Vasopressin, arginine vasopressin hormone, ADH.

SPECIMEN: Plasma (1 mL) collected in lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube.

RECOMMENDATION: This test should be ordered and interpreted with results
of a serum osmolality.
Antidiuretic Hormone 153
Serum Antidiuretic SI Units (Conversion

Osmolality* Hormone* Factor 0.926)
270–280 mOsm/kg Less than 1.5 pg/mL Less than 1.4 pmol/L
280–285 mOsm/kg Less than 2.5 pg/mL Less than 2.3 pmol/L
285–290 mOsm/kg 1–5 pg/mL 0.9–4.6 pmol/L
• Differentiate neurogenic (central) dia-

DESCRIPTION & RATIONALE: Anti- betes insipidus from nephrogenic dia-
diuretic hormone (ADH) is formed betes insipidus by decreased ADH
by the hypothalamus and stored in the levels in neurogenic diabetes insipidus
posterior pituitary gland. ADH is or elevated levels in nephrogenic dia-
released in response to increased betes insipidus if normal feedback
serum osmolality or decreased blood mechanisms are intact.
volume. When the hormone is active, • Evaluate polyuria or altered serum
small amounts of concentrated urine osmolality to identify possible alter-
are produced; in its absence, large ations in ADH secretion as the cause.
amounts of dilute urine are produced.
Although a 1% change in serum RESULT
osmolality stimulates ADH secretion,
blood volume must decrease by Increased in:
approximately 10% for ADH secre- • Acute intermittent porphyria
tion to be induced. Psychogenic stim- • Brain tumor
uli, such as stress, pain, and anxiety,
• Disorders involving the central nervous
may also stimulate ADH release, but
system, thyroid gland, and adrenal
the mechanism is unclear. ■ gland
INDICATIONS: • Ectopic production (systemic neo-
• Assist in the diagnosis of known or sus- plasm)
pected malignancy associated with syn-
drome of inappropriate ADH secretion • Guillain-Barré syndrome
(SIADH), such as oat cell lung cancer, • Nephrogenic diabetes insipidus
thymoma, lymphoma, leukemia, pan-
creatic carcinoma, prostate gland • Pain, stress, or exercise
carcinoma, and intestinal carcinoma; • Pneumonia
elevated ADH levels indicate the pres-
ence of this syndrome. • Pulmonary tuberculosis
• Assist in the diagnosis of known or sus- • SIADH

pected pulmonary conditions associ- • Tuberculous meningitis
ated with SIADH, such as tuberculosis,
pneumonia, and positive-pressure Decreased in:
mechanical ventilation. • Nephrotic syndrome
• Detect central nervous system trauma,
• Pituitary (central) diabetes insipidus
surgery, or disease that may lead to
impaired ADH secretion. • Psychogenic polydipsia
CRITICAL VALUES: Effective treatment of ➤ Obtain a history of the patient’s

SIADH depends on identifying and res- endocrine and genitourinary sys-
tems, as well as results of previously
olving the cause of increased ADH pro-
duction. Signs and symptoms of SIADH procedures, and other diagnostic
are the same as those for hyponatremia, procedures. For related laboratory
including irritability, tremors, muscle tests, refer to the Endocrine and
spasms, convulsions, and neurologic Genitourinary System tables.
changes. The patient has enough sodium, ➤ Note any recent procedures that can
but it is diluted in excess retained water. interfere with test results.
INTERFERING FACTORS: the patient is taking, including
• Drugs that may increase ADH levels herbs, nutritional supplements, and
include barbiturates, carbamazepine, nutraceuticals. The requesting health
chlorpropamide, chlorthalidone, cis- care practitioner and laboratory
platin, clofibrate, ether, furosemide, should be advised if the patient reg-
haloperidol, hydrochlorothiazide, lith- ularly uses these products so that
ium, methyclothiazide, narcotic anal- their effects can be taken into con-
gesics, phenothiazides, polythiazide,
tolbutamide, tricyclic antidepressants, ➤ Review the procedure with the
vidarabine, vinblastine, and vincristine. patient. Inform the patient that spec-
• Drugs that may decrease ADH levels 5 to 10 minutes. Address concerns
include clonidine, demeclocycline, about pain related to the procedure.
ethanol, lithium carbonate, and pheny- Explain to the patient that there may
toin. be some discomfort during the
venipuncture.
within 1 week before the test can inter- ➤ There are no food, fluid, or medica-
direction.
munoassay is the test method.
• ADH exhibits diurnal variation, with tic bag to have ready for immediate
highest levels of secretion occurring at transport of the specimen to the lab-
night; first morning collection is rec- oratory. Prechill the lavender-top tube
ommended. in the ice slurry.
• ADH secretion is also affected by pos-
Intratest:
ture, with higher levels measured while
upright. ➤ If the patient has a history of severe
Procedure ● ● ● ● ● ● ● ● ● ● ●
and to follow directions. The patient
Pretest: should be encouraged to be calm
and in a sitting position for specimen
➤ Inform the patient that the test is collection. Direct the patient to
used to assist in the diagnosis of dis- breathe normally and to avoid unnec-
orders affecting urine concentration. essary movement.
➤ Obtain a history of the patient’s ➤ Observe standard precautions, and
complaints, including a list of known follow the general guidelines in
allergens (especially allergies or sen- Appendix A. Positively identify the
accordingly. demographics, date, and time of col-
Antigens/Antibodies, Anti Extractable Nuclear 155
lection. Perform a venipuncture; col- care practitioner, who will discuss

lect the specimen in a prechilled 5- the results with the patient.
mL lavender-top tube. ➤ Reinforce information given by the
➤ Remove the needle, place a gauze patient’s health care provider regard-
over the puncture site and apply gen- ing further testing, treatment, or
tle pressure to stop bleeding. referral to another health care pro-
Observe venipuncture site for bleed- vider. Inform the patient, as appropri-
ing or hematoma formation. Apply ate, that treatment may include
paper tape over gauze or replace diuretic therapy and fluid restriction
with adhesive bandage. to successfully eliminate the excess
water. Answer any questions or
➤ The sample should be placed in an
ice slurry immediately after collec-
patient or family.
tion. Information on the specimen
label can be protected from water in ➤ Depending on the results of this pro-
the ice slurry by first placing the cedure, additional testing may be
specimen in a protective plastic bag. performed to evaluate or monitor
Promptly transport the specimen to progression of the disease process
or in a computerized system for
recall and postprocedure interpreta-
tion by the appropriate health care
practitioner. ➤ Related laboratory tests include
serum and urine electrolytes, serum
Post-test: and urine osmolality, serum and urine
sodium, thyroid-stimulating hor-
➤ A written report of the examination mone, blood urea nitrogen, uric acid,
will be sent to the requesting health and urinalysis.
ANTIGENS/ANTIBODIES,
ANTI–EXTRACTABLE NUCLEAR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: La antibodies, Ro antibodies, SS-A antibodies,

SS-B antibodies, ENA.


DESCRIPTION & RATIONALE: The
extractable nuclear antigens (ENAs)
include ribonucleoprotein (RNP), Nursing Implications and
Smith (Sm), SS-A/Ro, and SS-B/La Procedure ● ● ● ● ● ● ● ● ● ● ●
antigens. ENAs and antibodies to

Pretest:
them are found in various combina-
tions in individuals with combinations ➤ Inform the patient that the test is
of overlapping rheumatologic symp- used to detect the presence of anti-
bodies associated with autoimmune
toms. ■ disorders such as systemic lupus
erythematosus and mixed connec-
INDICATIONS: tive tissue disease.
• Assist in the diagnosis of mixed con- ➤ Obtain a history of the patient’s
nective tissue disease complaints, including a list of known
• Assist in the diagnosis of Sjögren’s syn- allergens (especially allergies or sen-
drome sitivities to latex), and inform the
• Assist in the diagnosis of systemic lupus accordingly.
erythematosus (SLE) ➤ Obtain a history of the patient’s
RESULT tems, as well as results of previously
Increased in: procedures, and other diagnostic pro-
• Anti-RNP is associated with mixed cedures. For related laboratory tests,
refer to the Immune and Muscu-
connective tissue disease.
loskeletal System tables.
• Anti-SS-A and anti-SS-B are helpful in ➤ Obtain a list of medications the
antinuclear antibody (ANA)–negative patient is taking, including herbs,
cases of SLE. nutritional supplements, and nutra-
• Anti-SS-A/ANA–positive, anti-SS- practitioner and laboratory should be
B–negative patients are likely to have advised if the patient regularly uses
nephritis. these products so that their effects
• Anti-SS-A/anti-SS-B–positive sera are when reviewing results.
found in patients with neonatal lupus.
• Anti-SS-A–positive patients may also patient. Inform the patient that spec-
have antibodies associated with anti- imen collection takes approximately
phospholipid syndrome. 5 to 10 minutes. Address concerns
• Anti-SS-A/La is associated with pri- Explain to the patient that there may
mary Sjögren’s syndrome. be some discomfort during the
venipuncture.
• Anti-SS-A/Ro is a predictor of congen-
ital heart block in neonates born to
mothers with SLE. direction.
• Anti-SS-A/Ro–positive patients have
photosensitivity. Intratest:
Decreased in: N/A allergic reaction to latex, care should
CRITICAL VALUES: N/A ment containing latex.
Antigens/Antibodies, Anti Extractable Nuclear 157
➤ Instruct the patient to cooperate fully ence, and fear of shortened life
and to follow directions. Direct the expectancy. Collagen and connective
patient to breathe normally and to tissue diseases are chronic. As such,
avoid unnecessary movement. they must be addressed on a contin-
uous basis and may require signifi-
cant changes in lifestyle. Discuss the
implications of abnormal test results
on the patient’s lifestyle. Provide
teaching and information regarding
the clinical implications of the test
results, as appropriate. Educate the
lection. Perform a venipuncture;
patient in the importance of prevent-
ing infection, which is a significant
top tube.
cause of death in immunosup-
➤ Remove the needle, place a gauze pressed individuals. Educate the
over the puncture site and apply gen- patient regarding access to counsel-
tle pressure to stop bleeding. ing services.
➤ Promptly transport the specimen to vider. Answer any questions or
the laboratory for processing and address any concerns voiced by the
analysis. patient or family.
➤ The results are recorded manually ➤ Depending on the results of this pro-
or in a computerized system for cedure, additional testing may be
recall and postprocedure interpreta- performed to evaluate or monitor
tion by the appropriate health care progression of the disease process
practitioner. and determine the need for a change
Post-test: relation to the patient’s symptoms
care practitioner, who will discuss Related laboratory tests:
the results with the patient. ➤ Related laboratory tests include ANA,
➤ Recognize anxiety related to test re- anticardiolipin antibodies, anti-DNA
sults, and be supportive of impaired antibodies, and anti-scleroderma anti-
activity, perceived loss of independ- body.
ANTIPSYCHOTIC DRUGS
AND ANTIMANIC DRUGS:
HALOPERIDOL, LITHIUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Antipsychotic drugs: haloperidol (Haldol, Haldol

Decanoate, Haldol Lactate); antimanic drugs: lithium (Eskalith, Eskalith-CR,
Lithobid).
Haloperidol Oral Peak: 3–6 h
Lithium Oral Trough: at least 12 h
after last dose
REFERENCE VALUE: (Method: Chromatography for haloperidol; ion-selective

electrode for lithium)
Volume of Protein
Therapeu- Half- Distribu- Binding
Drug tic Dose* SI Units Life (h) tion (L/kg) (%) Excretion
(SI Conventional
Units 2.66)
Haloperidol 4–26 11–69 15–40 18–30 90 Hepatic
ng/mL nmo/L
(SI Conventional
Units 1)
Lithium 0.6–1.4 0.6–1.4 18–24 0.7–1.0 0 Renal
mEq/L mmol/L
DESCRIPTION & RATIONALE: Halo- Tourette’s syndrome, and hyperactive

peridol is an antipsychotic tranquilizer children with severe behavioral prob-
used for the following indications: lems. Lithium is used in the treatment
acute and chronic psychotic disorders, of manic depression.
Antipsychotic Drugs and Antimanic Drugs 159
Many factors must be considered in must be clearly and accurately communi-

cated to avoid misunderstanding of the
dose time in relation to the collection
therapeutic drugs, including patient time. Miscommunication between the
age, patient weight, interacting med- individual administering the medication
ications, electrolyte balance, protein and the individual collecting the speci-
levels, water balance, conditions that men is the most frequent cause of sub-
affect absorption and excretion, and therapeutic levels, toxic levels, and
foods, herbals, vitamins, and minerals misleading information used in calcula-
that can either potentiate or inhibit tion of future doses.
the intended target concentration.
Peak collection times should be docu-
INDICATIONS:
• Assist in the diagnosis and prevention
mented carefully in relation to the of toxicity
time of medication administration. ■
• Monitor compliance with therapeutic
IMPORTANT NOTE: This information regimen
RESULT
Level Response
Haloperidol Hepatic impairment
Lithium Renal impairment
CRITICAL VALUES: It is important Lithium: Greater Than 1.5 mEq/L

to note the adverse effects of toxic and Signs and symptoms of lithium toxicity
subtherapeutic levels. Care must be taken include ataxia, coarse tremors, muscle
to investigate signs and symptoms of weakness, vomiting, diarrhea, confusion,
not enough medication and too much convulsions, stupor, T-wave flattening,
medication. Note and immediately report loss of consciousness, and possible coma.
to the health care practitioner any Possible interventions include adminis-
critically increased values and related tration of activated charcoal, gastric
symptoms. lavage, and administration of intravenous
Haloperidol: Greater fluids with diuresis.
Than 50 ng/mL
Signs and symptoms of haloperidol toxic- • Blood drawn in serum separator tubes
ity include hypotension, respiratory (gel tubes).
depression, and extrapyramidal neuro-
• Contraindicated in patients with liver
muscular reactions. Possible interventions
disease, and caution advised in patients
include emesis (contraindicated in the
with renal impairment.
absence of gag reflex or central nervous
system depression or excitation), and gas- • Haloperidol may increase levels of tri-
tric lavage followed by administration of cyclic antidepressants and increase the
activated charcoal. risk of lithium toxicity.
• Drugs that may increase lithium levels ➤ Sensitivity to cultural and social
include angiotensin-converting enzyme issues, as well as concern for mod-
inhibitors, some nonsteroidal anti- esty, is important in providing psy-
inflammatory drugs, and thiazide chological support before, during,
diuretics.
• Drugs and substances that may decrease tion restrictions unless by medical
lithium levels include acetazolamide, direction.
osmotic diuretics, theophylline, and
caffeine. Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: ➤ Instruct the patient to cooperate fully
➤ Inform the patient that the test is patient to breathe normally and to
used to monitor for therapeutic and avoid unnecessary movement.
toxic drug levels.
➤ Obtain a history of the patient’s com- follow the general guidelines in
plaints, including a list of known Appendix A. Consider recommended
allergens (especially allergies or sen- collection time in relation to dosing
sitivities to latex), and inform the schedule. Positively identify the
appropriate health care practitioner patient, and label the appropriate
accordingly. tubes with the corresponding patient
genitourinary and hepatobiliary sys- collection, noting the last dose
tems as well as results of previously of medication taken. Perform a veni-
performed laboratory tests, surgical puncture; collect the specimen in a
procedures, and other diagnostic 5-mL red-top tube.
procedures. For related laboratory ➤ Remove the needle, place a gauze
tests, refer to the Genitourinary over the puncture site and apply gen-
and Hepatobiliary System and tle pressure to stop bleeding.
Therapeutic/ Toxicology tables. Observe venipuncture site for bleed-
➤ Obtain a list of medications the ing or hematoma formation. Apply
nutritional supplements, and with adhesive bandage.
nutraceuticals. Note the last time ➤ Promptly transport the specimen to
and dose of medication taken. The the laboratory for processing and
requesting health care practitioner analysis.
the patient regularly uses these ➤ The results are recorded manually
products so that their effects can be or in a computerized system for re-
taken into consideration when call and postprocedure interpretation
reviewing results. by the appropriate health care practi-
tioner.
about pain related to the procedure. ➤ Nutritional considerations include the
Explain to the patient that there may avoidance of alcohol consumption.
be some discomfort during the ➤ A written report of the examination
venipuncture. will be sent to the requesting health
Antithrombin III 161
care practitioner, who will discuss concerns voiced by the patient or

the results with the patient. family.
➤ Reinforce information given by the ➤ Instruct the patient to be prepared
patient’s health care provider regard- to provide the pharmacist with a list
ing further testing, treatment, or of other medications he or she is
referral to another health care already taking in the event that the
provider. Explain to the patient the requesting health care practitioner
importance of following the medica- prescribes a medication.
tion regimen and instructions regard-
ing drug interactions. ➤ Depending on the results of this
procedure, additional testing may be
➤ Instruct the patient receiving performed to evaluate or monitor
haloperidol to immediately report progression of the disease process
any unusual symptoms (e.g., arrhyth- and determine the need for a change
mias, blurred vision, dry eyes, repet- in therapy. Evaluate test results in
itive uncontrolled movements) to his relation to the patient’s symptoms
or her health care practitioner. and other tests performed.
Instruct the patient receiving lithium
to immediately report any unusual
symptoms (e.g., anorexia, nausea, Related laboratory tests:
vomiting, diarrhea, dizziness, drowsi-
ness, dysarthria, tremor, muscle ➤ Related laboratory tests include albu-
twitching, visual disturbances) to his min, blood urea nitrogen, calcium,
or her health care practitioner. creatinine, glucose, magnesium,
Answer any questions or address any potassium, and sodium.
ANTITHROMBIN III
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Heparin cofactor assay, AT-III.

SPECIMEN: Plasma (1 mL) collected in a blue-top (sodium citrate) tube.
REFERENCE VALUE: (Method: Radioimmunodiffusion)

Units Units 10)
Immunologic assay 21–30 mg/dL 210–300 mg/L
Units Units 0.01)
Functional assay 85–115% of standard 0.85–1.15
• Drugs that may decrease AT-III levels

DESCRIPTION & RATIONALE: Anti- include asparaginase, estrogens, gesto-
thrombin III (AT-III) can inhibit dene, heparin, and oral contraceptives.
thrombin and factors IX, X, XI, and • Placement of the tourniquet for longer
XII. It is a heparin cofactor, interact- than 1 minute can result in venous sta-
ing with heparin and thrombin. AT- sis and changes in the concentration of
III acts to increase the rate at which the plasma proteins to be measured.
thrombin is neutralized or inhibited, Platelet activation may also occur
and it decreases the total quantity of under these conditions, resulting in
thrombin inhibited. Patients with low erroneous measurements.
levels show some level of resistance to
heparin therapy. ■
INDICATIONS: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Investigate tendency for thrombosis

Pretest:
RESULT ➤ Inform the patient that the test is
used to assist in the diagnosis of
Increased in: coagulation disorders.
• Acute hepatitis ➤ Obtain a history of the patient’s com-
• Inflammation allergens (especially allergies or sen-
• Menstruation appropriate health care practitioner
• Obstructive jaundice accordingly.
• Renal transplantation hematopoietic system and results
of previously performed laboratory
• Vitamin K deficiency tests, surgical procedures, and other
Decreased in: laboratory tests, refer to the Hema-
• Carcinoma topoietic System table.
• Chronic liver failure ➤ Obtain a list of medications the
• Cirrhosis nutritional supplements, and nutra-
• Congenital deficiency practitioner and laboratory should be
• Disseminated intravascular coagulation these products so that their effects
• Liver transplantation or partial hepate- can be taken into consideration
ctomy
• Nephrotic syndrome patient. Inform the patient that spec-
• Pulmonary embolism 5 to 10 minutes. Address concerns
CRITICAL VALUES: N/A Explain to the patient that there may
INTERFERING FACTORS: venipuncture.
• Drugs that may increase AT-III levels ➤ There are no food, fluid, or medica-
include anabolic steroids, gemfibrozil, tion restrictions unless by medical
and warfarin. direction.
Antithrombin III 163
Intratest: over the puncture site and apply gen-

➤ If the patient has a history of severe Observe venipuncture site for bleed-
allergic reaction to latex, care should ing or hematoma formation. Apply
be taken to avoid the use of equip- paper tape over gauze or replace
ment containing latex. with adhesive bandage.
➤ Instruct the patient to cooperate fully ➤ Promptly transport the specimen to
and to follow directions. Direct the the laboratory for processing and
patient to breathe normally and to analysis. The CLSI recommendation
avoid unnecessary movement. for processed and unprocessed sam-
➤ Observe standard precautions, and ples stored in unopened tubes is that
follow the general guidelines in testing should be completed within
Appendix A. Positively identify the 1 to 4 hours of collection.
patient, and label the appropriate ➤ The results are recorded manually
tubes with the corresponding patient or in a computerized system for
demographics, date, and time of col- recall and postprocedure interpreta-
lection. Perform a venipuncture; col- tion by the appropriate health care
lect the specimen in a 5-mL blue-top practitioner.
tube. Important note: Two different
concentrations of sodium citrate pre- Post-test:
servative are currently added to blue-
top tubes for coagulation studies: ➤ A written report of the examination
3.2% and 3.8%. The Clinical and will be sent to the requesting health
Laboratory Standards Institute/CLSI care practitioner, who will discuss
(formerly the National Committee for the results with the patient.
Clinical Laboratory Standards/ ➤ Reinforce information given by the
NCCLS) guideline for sodium citrate patient’s health care provider regard-
is 3.2%. Laboratories establish refer- ing further testing, treatment, or
ence ranges for coagulation testing referral to another health care
based on numerous factors, includ- provider. Answer any questions or
ing sodium citrate concentration, test address any concerns voiced by the
equipment, and test reagents. It is patient or family.
important to ask the laboratory
which concentration it recommends,
because each concentration will have
its own specific reference range.
When multiple specimens are drawn,
the blue-top tube should be collected
after sterile (i.e., blood culture) and
red-top tubes. When coagulation
testing is the only work to be done,
an extra red-top tube should be col-
lected before the blue-top tube to Related laboratory tests:
avoid contaminating the specimen ➤ Related laboratory tests include acti-
with tissue thromboplastin. vated partial thromboplastin time,
➤ Remove the needle, place a gauze protein C, protein S, and vitamin K.
1-ANTITRYPSIN AND 1-ANTITRYPSIN

PHENOTYPING
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: 1-antitrypsin: A1AT, 1-AT, AAT; 1-antitrypsin

phenotyping: A1AT phenotype, 1-AT phenotype, AAT phenotype, Pi phe-
notype.
SPECIMEN: Serum (1 mL) for 1-antitrypsin (1-AT) and serum (2 mL) for
1-AT phenotyping collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Rate nephelometry for 1-AT, isoelectric

focusing/high-resolution electrophoresis for 1-AT phenotyping)
1-Antitrypsin

0–1 mo 124–348 mg/dL 1.24–3.48 g/L
2–6 mo 111–297 mg/dL 1.11–2.97 g/L
7 mo–2 y 95–251 mg/dL 0.95–2.51 g/L
3 y–19 y 110–279 mg/dL 1.10–2.79 g/L
Adult 126–226 mg/dL 1.26–2.26 g/L
1-Antitrypsin Phenotyping directed against proteolytic enzymes,

There are three major protease such as trypsin, elastin, and plasmin,
inhibitor phenotypes: released by alveolar macrophages and
MM—Normal bacteria. In the absence of 1-AT,
SS—Intermediate; heterozygous functional tissue is destroyed by prote-
ZZ—Markedly abnormal; olytic enzymes and replaced with
homozygous excessive connective tissue. Emphy-
The total level of measurable 1-AT sema develops at an earlier age in 1-
varies with genotype. The effects of 1- AT–deficient emphysema patients
AT deficiency depend on the patient’s than in other emphysema patients.
personal habits, but are most severe in 1-AT deficiency is passed on as an
patients who smoke tobacco.
autosomal recessive trait. Inherited
deficiencies are associated early in life
with development of lung and liver
DESCRIPTION & RATIONALE: 1-AT disorders. In the pediatric population,
is the main glycoprotein produced by the ZZ phenotype usually presents as
the liver. Its inhibitory function is liver disease, cholestasis, and cirrhosis.
1-Antitrypsin and 1-Antitrypsin Phenotyping 165
Decreased in:
Greater than 80% of ZZ-deficient
individuals ultimately develop chronic • COPD
lung or liver disease. It is important • Homozygous 1-AT–deficient patients
to identify inherited deficiencies early • Liver disease (severe)
in life. Typically, 1-AT–deficient
• Liver cirrhosis (child)
patients have circulating levels less
than 50 mg/dL. Patients who have 1- • Malnutrition
AT values less than 140 mg/dL should • Nephrotic syndrome
be phenotyped.
Elevated levels are found in normal CRITICAL VALUES: N/A
individuals when an inflammatory
process, such as rheumatoid arthritis, INTERFERING FACTORS:
bacterial infection, neoplasm, or vas- • 1-AT is an acute-phase reactant pro-
culitis, is present. Decreased levels are tein, and any inflammatory process ele-
found in affected patients with vates levels. If a serum C-reactive
chronic obstructive pulmonary disease protein is performed simultaneously
and is positive, the patient should be
(COPD) and in children with cirrho-
retested for 1-AT in 10 to 14 days.
sis of the liver. Decreased 1-AT levels
also may be elevated into the normal • Rheumatoid factor causes false-positive
range in heterozygous 1-AT–defi- elevations.
cient patients during concurrent • Drugs that may increase serum 1-AT
infection, pregnancy, estrogen ther- levels include aminocaproic acid, estro-
apy, steroid therapy, cancer, and gen therapy, oral contraceptives (high-
postoperative periods. Homozygous dose preparations), oxymetholone,
1-AT–deficient patients do not show streptokinase, tamoxifen, and typhoid
such an elevation. ■ vaccine.
INDICATIONS:
• Assist in establishing a diagnosis of Nursing Implications and
COPD Procedure ● ● ● ● ● ● ● ● ● ● ●
• Assist in establishing a diagnosis of liver

disease Pretest:
• Detect hereditary absence or deficiency ➤ Inform the patient that the test is
of 1-AT used to identify chronic obstructive
pulmonary disease and liver disease
RESULT associated with 1-antitrypsin defi-
ciency.
• Acute and chronic inflammatory con- allergens (especially allergies or sen-
ditions sitivities to latex), and inform the
• Carcinomas appropriate health care practitioner
accordingly.
• Estrogen therapy
• Postoperative recovery hepatobiliary and respiratory system
• Pregnancy and results of previously performed
laboratory tests, surgical proce-
• Steroid therapy dures, and other diagnostic pro-
• Stress (extreme physical) cedures. For related laboratory tests,
refer to the Hepatobiliary and Respi- the laboratory for processing and
ratory System tables. analysis.
➤ Obtain a list of the medications ➤ The results are recorded manually
the patient is taking, including or in a computerized system for
herbs, nutritional supplements, and recall and postprocedure interpreta-
nutraceuticals. Oral contraceptives tion by the appropriate health care
should be withheld 24 hours before practitioner.
the specimen is collected, although
this restriction should first be con- Post-test:
firmed with the person ordering the
test. The requesting health care prac- ➤ Instruct the patient to resume usual
titioner and laboratory should be medication as directed by the health
advised if the patient regularly uses care practitioner.
these products so that their effects ➤ Nutritional considerations: Malnutri-
can be taken into consideration tion is commonly seen in 1-
when reviewing results. AT–deficient patients with severe
➤ Review the procedure with the respiratory disease for many rea-
patient. Inform the patient that spec- sons, including fatigue, lack of
imen collection takes approximately appetite, and gastrointestinal dis-
5 to 10 minutes. Address concerns tress. Research has estimated that
about pain related to the procedure. the daily caloric intake required for
Explain to the patient that there may respiration in patients with COPD is
be some discomfort during the 10 times higher than that required of
venipuncture. normal individuals. Inadequate nutri-
tion can result in hypophosphatemia,
especially in the respirator-dependent
patient. During periods of starvation,
direction.
phosphorus leaves the intracellular
space and moves outside the tissue,
Intratest: resulting in dangerously decreased
phosphorus levels. Adequate intake
➤ If the patient has a history of severe of vitamins A and C is important to
allergic reaction to latex, care should prevent pulmonary infection and to
be taken to avoid the use of equip- decrease the extent of lung tissue
ment containing latex. damage. The importance of following
➤ Instruct the patient to cooperate fully the prescribed diet should be
and to follow directions. Direct the stressed to the patient and caregiver.
patient to breathe normally and to ➤ Nutritional considerations: Water bal-
avoid unnecessary movement. ance must be closely monitored in
➤ Observe standard precautions, and 1-AT–deficient patients with COPD.
follow the general guidelines in Fluid retention can lead to pulmonary
Appendix A. Positively identify the edema.
patient, and label the appropriate ➤ Educate the patient with abnormal
tubes with the corresponding patient findings in preventive measures for
demographics, date, and time of col- protection of the lungs (e.g., avoid
lection. Perform a venipuncture; col- contact with persons who have res-
lect the specimen in a 5-mL red- or piratory or other infections; avoid the
tiger-top tube. use of tobacco; avoid areas having
➤ Remove the needle, place a gauze highly polluted air; and avoid work
over the puncture site and apply gen- environments with hazards such as
tle pressure to stop bleeding. fumes, dust, and other respiratory
Observe venipuncture site for bleed- pollutants).
ing or hematoma formation. Apply ➤ Instruct the affected patient in deep
paper tape over gauze or replace breathing and pursed-lip breathing
with adhesive bandage. to enhance breathing patterns as
➤ Promptly transport the specimen to appropriate. Inform the patient of
Apolipoprotein A 167
smoking cessation programs, as patient’s health care provider regard-

appropriate. ing further testing, treatment, or
➤ A written report of the examination referral to another health care
will be sent to the requesting health provider. Inform the patient of the
care practitioner, who will discuss importance of medical follow-up, and
the results with the patient. suggest ongoing support resources
to assist the patient in coping with
➤ Recognize anxiety related to test chronic illness and possible early
results, and be supportive of fear of death. Answer any questions or
shortened life expectancy. Discuss address any concerns voiced by the
the implications of abnormal test patient or family.
Provide teaching and information ➤ Depending on the results of this pro-
regarding the clinical implications of cedure, additional testing may be
the test results, as appropriate. performed to evaluate or monitor
Because decreased 1-AT can be an progression of the disease process
inherited disorder, it may be appro- and determine the need for a change
priate to recommend resources for in therapy. Evaluate test results in
genetic counseling if levels less than relation to the patient’s symptoms
140 mg/dL are reported. It may also and other tests performed.
be appropriate to inform the patient
that 1-AT phenotype testing can Related laboratory tests:
be performed on family members ➤ Related laboratory tests include
to determine the homozygous or angiotensin-converting enzyme,
heterozygous nature of the defi- anion gap, arterial/alveolar oxygen
ciency. ratio, blood gases, electrolytes,
➤ Reinforce information given by the osmolality, and phosphorus.
APOLIPOPROTEIN A
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Apo A.
REFERENCE VALUE: (Method: Immunonephelometry)

Sex/Age Units Units 0.01)
Male
Newborn 41–93 mg/dL 0.41–0.93 g/L
6 mo–4 y 67–163 mg/dL 0.67–1.63 g/L
Adult 81–166 mg/dL 0.81–1.66 g/L
Female
Newborn 38–106 mg/dL 0.38–1.06 g/L
6 mo–4 y 60–148 mg/dL 0.60–1.48 g/L
Adult 80–214 mg/dL 0.80–2.14 g/L
• Familial deficiencies of related enzymes

DESCRIPTION & RATIONALE: Apoli- and lipoproteins
poprotein A (Apo A), the major com-
• Hepatocellular disorders
ponent of high-density lipoprotein
(HDL), is synthesized in the liver and • Hypertriglyceridemia
intestines. Apolipoproteins assist in • Nephrotic syndrome
the regulation of lipid metabolism by
• Premature coronary heart disease
activating and inhibiting enzymes
required for this process. Apo A-I acti- • Smoking
vates the enzyme lecithin-cholesterol
acyltransferase (LCAT), whereas Apo CRITICAL VALUES: N/A
A-II inhibits LCAT. The apolipopro-
teins also help keep lipids in solution
as they circulate in the blood and Apo A levels include anticonvulsants,
direct the lipids toward the correct beclobrate, bezafibrate, ciprofibrate,
target organs and tissues in the body. estrogens, furosemide, lovastatin,
It is believed that Apo A measure- pravastatin, prednisolone, simvastatin,
ments may be more important than and ethanol (abuse).
HDL cholesterol measurements as a • Drugs that may decrease Apo A levels
predictor of coronary artery disease include androgens, -blockers, diuret-
(CAD). There is an inverse relation- ics, and probucol.
ship between Apo A levels and risk for
developing CAD. Because of difficul-
ties with method standardization, the procedure to be canceled or repeated.
above-listed reference ranges should
be used as a rough guide in assessing
abnormal conditions. Values for Nursing Implications and
African Americans are 5 to 10 mg/dL Procedure ● ● ● ● ● ● ● ● ● ● ●
higher than values for whites. ■

Pretest:
• Evaluation for risk of CAD used to assess and monitor risk for
coronary artery disease.
RESULT ➤ Obtain a history of the patient’s com-
Increased in: allergens (especially allergies or sen-
• Familial hyper--lipoproteinemia sitivities to latex), and inform the
• Weight reduction accordingly.
Decreased in: ➤ Obtain a history of the patient’s car-
diovascular system and results of
• Abetalipoproteinemia previously performed laboratory
• Cholestasis tests, surgical procedures, and other
• Chronic renal failure laboratory tests, refer to the Cardio-
vascular System table.
• Diabetes (uncontrolled)
➤ Obtain a list of medications the
• Diet high in carbohydrates or polyun- patient is taking, including herbs,
saturated fats nutritional supplements, and nutra-
Apolipoprotein A 169
ceuticals. The requesting health care the laboratory for processing and
practitioner and laboratory should be analysis.
➤ Review the procedure with the practitioner.
Explain to the patient that there may ➤ Instruct the patient to resume usual
be some discomfort during the diet as directed by the health care
venipuncture. practitioner.
➤ The patient should abstain from food ➤ Nutritional considerations: Decrea-
for 6 to 12 hours before specimen sed Apo A levels may be associated
collection. with CAD. Nutritional therapy is rec-
➤ There are no fluid or medication ommended for individuals identified
restrictions unless by medical direc- to be at high risk for developing
tion. CAD. Overweight patients should
be encouraged to achieve a normal
Intratest: weight. The American Heart Associ-
ation Step 1 and Step 2 diets may
➤ Ensure that the patient has complied be helpful in achieving a goal of
with dietary, medication, or activity reducing total cholesterol and triglyc-
restrictions and pretesting prepara- eride levels. The Step 1 diet empha-
tions; assure that food has been sizes a reduction in foods high in
restricted for at least 6 to 12 hours saturated fats and cholesterol. Red
prior to the procedure. meats, eggs, and dairy products
➤ If the patient has a history of severe are the major sources of saturated
allergic reaction to latex, care should fats and cholesterol. If triglycerides
be taken to avoid the use of equip- are also elevated, the patient
ment containing latex. should be advised to eliminate or
reduce alcohol and simple carbo-
➤ Instruct the patient to cooperate fully hydrates from the diet. The Step
and to follow directions. Direct the 2 diet recommends stricter reduc-
patient to breathe normally and to tions.
➤ Observe standard precautions, and will be sent to the requesting health
follow the general guidelines in care practitioner, who will discuss
Appendix A. Positively identify the the results with the patient.
tubes with the corresponding patient ➤ Recognize anxiety related to test
demographics, date, and time of col- results, and be supportive of fear
lection. Perform a venipuncture; of shortened life expectancy.
collect the specimen in a 5-mL red- Discuss the implications of abnormal
or tiger-top tube. test results on the patient’s lifestyle.
Provide teaching and informa-
➤ Remove the needle, place a gauze tion regarding the clinical implica-
over the puncture site and apply gen- tions of the test results, as appropri-
tle pressure to stop bleeding. ate. Educate the patient regard-
Observe venipuncture site for bleeding access to counseling services.
ing or hematoma formation. Apply Provide contact information, if desi-
paper tape over gauze or replace red, for the American Heart Associ-
with adhesive bandage. ation (http://www.americanheart.
➤ Promptly transport the specimen to org).
➤ Reinforce information given by the Related laboratory tests:

ing further testing, treatment, or ➤ Related laboratory tests include
referral to another health care antiarrhythmic drugs, apolipoprotein
provider. Answer any questions or B, aspartate aminotransferase, atrial
address any concerns voiced by the natriuretic peptide, B-type natriuretic
patient or family. peptide, blood gases, C-reactive
protein, calcium and ionized calcium,
➤ Depending on the results of this pro- cholesterol (total, HDL, and LDL),
cedure, additional testing may be creatine kinase and isoenzymes,
performed to evaluate or monitor pro- glucose, glycated hemoglobin, homo-
gression of the disease process and cysteine, ketones, lactate dehydroge-
determine the need for a change in nase and isoenzymes, lipoprotein
therapy. Evaluate test results in rela- electrophoresis, magnesium, myo-
tion to the patient’s symptoms and globin, potassium, triglycerides, and
other tests performed. troponin.
APOLIPOPROTEIN B
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Apo B.
REFERENCE VALUE: (Method: Immunonephelometry)
Newborn–5 y 11–31 mg/dL 0.11–0.31 g/L
5–17 y
Male 47–139 mg/dL 0.47–1.39 g/L
Female 41–96 mg/dL 0.41–0.96 g/L
Adult
Male 46–174 mg/dL 0.46–1.74 g/L
Female 46–142 mg/dL 0.46–1.42 g/L
DESCRIPTION & RATIONALE: tion of lipid metabolism by activating

Apolipoprotein B (Apo B), the major and inhibiting enzymes required for
component of the low-density this process. The apolipoproteins also
lipoproteins (chylomicrons, LDL, and help keep lipids in solution as they cir-
very-low-density lipoprotein), is syn- culate in the blood and direct the
thesized in the liver and intestines. lipids toward the correct target organs
Apolipoproteins assist in the regula- and tissues in the body. ■
Apolipoprotein B 171
INDICATIONS: CRITICAL VALUES: N/A

• Evaluation for risk of coronary artery
disease (CAD) INTERFERING FACTORS:
• Drugs that may increase Apo B levels
RESULT include amiodarone, androgens, -
blockers, catecholamines, cyclosporine,
Increased in: diuretics, ethanol (abuse), etretinate,
• Anorexia nervosa glucogenic corticosteroids, oral contra-
ceptives, and phenobarbital.
• Cushing’s syndrome
• Diabetes • Drugs that may decrease Apo B levels
include beclobrate, captopril, chole-
• Dysglobulinemia styramine, fibrates, ketanserin, lovas-
• Emotional stress tatin, niacin, nifedipine, pravastatin,
prazosin, probucol, and simvastatin.
• Hepatic disease
• Hepatic obstruction before the procedure may cause the
• Hyperlipoproteinemias procedure to be canceled or repeated.
• Hypothyroidism
• Infantile hypercalcemia Nursing Implications and
• Nephrotic syndrome Procedure ● ● ● ● ● ● ● ● ● ● ●
• Porphyria Pretest:
• Pregnancy ➤ Inform the patient that the test is
• Premature CAD used to assess and monitor risk for
• Renal failure ➤ Obtain a history of the patient’s com-
• Werner’s syndrome plaints, including a list of known
Decreased in:
• Acute stress (burns, illness) accordingly.
• Chronic anemias ➤ Obtain a history of the patient’s car-
diovascular system and results of
• Chronic pulmonary disease previously performed laboratory
• Familial deficiencies of related enzymes tests, surgical procedures, and
other diagnostic procedures. For
and lipoproteins
• Hyperthyroidism Cardiovascular System table.
• Inflammatory joint disease ➤ Obtain a list of medications the
• Intestinal malabsorption nutritional supplements, and nutra-
• -Lipoprotein deficiency (Tangier practitioner and laboratory should be
disease) advised if the patient regularly uses
• Malnutrition
• Myeloma when reviewing results.
• Reye’s syndrome ➤ Review the procedure with the
• Weight reduction imen collection takes approximately

Explain to the patient that there may ➤ Instruct the patient to resume usual
be some discomfort during the diet as directed by the health care
➤ The patient should abstain from food ➤ Nutritional considerations: Increased
for 6 to 12 hours before specimen Apo B levels may be associated with
collection. CAD. Nutritional therapy is recom-
mended for individuals identified
➤ There are no fluid or medication
to be at high risk for developing
restrictions unless by medical direc-
CAD. Overweight patients should
tion.
be encouraged to achieve a normal
weight. The American Heart Associa-
Intratest: tion Step 1 and Step 2 diets may be
helpful in achieving a goal of reduc-
➤ Ensure that the patient has complied ing total cholesterol and triglyceride
with dietary, medication, or activity levels. The Step 1 diet emphasizes a
restrictions and pretesting prepara- reduction in foods high in saturated
tions; assure that food has been fats and cholesterol. Red meats,
restricted for at least 6 to 12 hours eggs, and dairy products are the
prior to the procedure. major sources of saturated fats and
➤ If the patient has a history of severe cholesterol. If triglycerides are also
allergic reaction to latex, care should elevated, the patient should be
be taken to avoid the use of equip- advised to eliminate or reduce alco-
ment containing latex. hol and simple carbohydrates from
the diet. The Step 2 diet recom-
➤ Instruct the patient to cooperate fully mends stricter reductions.
patient to breathe normally and to ➤ A written report of the examination
avoid unnecessary movement. will be sent to the requesting health
➤ Observe standard precautions, and the results with the patient.
Appendix A. Positively identify the ➤ Recognize anxiety related to test
patient, and label the appropriate results, and be supportive of fear of
tubes with the corresponding patient shortened life expectancy. Discuss
demographics, date, and time of col- the implications of abnormal test
lection. Perform a venipuncture; col- results on the patient’s lifestyle.
lect the specimen in a 5-mL red- or Provide teaching and information
tiger-top tube. regarding the clinical implications of
the test results, as appropriate. Edu-
➤ Remove the needle, place a gauze cate the patient regarding access
over the puncture site and apply gen- to counseling services. Provide con-
tle pressure to stop bleeding. tact information, if desired, for the
Observe venipuncture site for bleed- American Heart Association (http://
ing or hematoma formation. Apply www.americanheart.org).
➤ Promptly transport the specimen to ing further testing, treatment, or
the laboratory for processing and referral to another health care pro-
analysis. vider. Answer any questions or
➤ The results are recorded manually address any concerns voiced by the
or in a computerized system for patient or family.
recall and postprocedure interpreta- ➤ Depending on the results of this pro-
tion by the appropriate health care cedure, additional testing may be
practitioner. performed to evaluate or monitor
Arthrogram 173
progression of the disease process natriuretic peptide, B-type natriuretic

and determine the need for a change peptide, blood gases, C-reactive
in therapy. Evaluate test results in protein, calcium and ionized calcium,
relation to the patient’s symptoms cholesterol (total, HDL, and LDL),
and other tests performed. creatine kinase and isoenzymes,
glucose, glycated hemoglobin, homo-
Related laboratory tests: cysteine, ketones, lactate dehydroge-
nase and isoenzymes, lipoprotein
➤ Related laboratory tests include anti- electrophoresis, magnesium, myo-
arrhythmic drugs, apolipoprotein A, globin, potassium, triglycerides, and
aspartate aminotransferase, atrial troponin.
ARTHROGRAM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Joint study.

AREA OF APPLICATION: Shoulder, elbow, wrist, hip, knee, ankle, temporo-
mandibular joint.
CONTRAST: Iodinated or gadolinium.
INDICATIONS:
DESCRIPTION & RATIONALE: An • Evaluate pain, swelling, or dysfunction
arthrogram evaluates the cartilage, lig- of a joint
aments, and bony structures that
• Monitor disease progression
compose a joint. After local anesthesia
is administered to the area of interest,
a fluoroscopically guided small-gauge RESULT
needle is inserted into the joint space. Normal Findings:
Fluid in the joint space is aspirated • Normal bursae, menisci, ligaments,
and sent to the laboratory for analysis. and articular cartilage of the joint (note:
Contrast medium is inserted into the the cartilaginous surfaces and menisci
joint space to outline the soft tissue should be smooth, without evidence of
structures and the contour of the erosion, tears, or disintegration)
joint. After brief exercise of the joint,
Abnormal Findings:
radiographs or magnetic resonance
images (MRIs) are obtained. Arthro- • Arthritis
grams are used primarily for assess- • Cysts
ment of persistent, unexplained joint • Diseases of the cartilage (chondroma-
discomfort. ■ lacia)
• Injury to the ligaments • Patients who are very obese, who may
• Joint derangement
ment
• Meniscal tears or laceration
• Muscle tears which may produce poor visualization
of the area to be examined
• Osteochondral fractures
• Osteochondritis dissecans Other considerations:
• Synovial tumor • Consultation with a physician should
• Synovitis tion safety concerns regarding younger
patients or patients who are lactating.
INTERFERING FACTORS • Risks associated with radiographic over-
exposure can result from frequent x-ray
This procedure is procedures. Personnel in the room with
contraindicated for: the patient should wear a protective
• Patients who are pregnant or suspected lead apron, stand behind a shield, or
of being pregnant, unless the potential leave the area while the examination is
benefits of the procedure far outweigh being done. Personnel working in the
the risks to the fetus and mother. area where the examination is being
done should wear badges that reveal
• Patients with bleeding disorders, active their level of exposure to radiation.
arthritis, or joint infections.
• Patients with allergies to shellfish
medium used may cause a life- Procedure ● ● ● ● ● ● ● ● ● ● ●
threatening allergic reaction. Patients

with a known hypersensitivity to the Pretest:
medium may benefit from premedica- ➤ Inform the patient that the procedure
tion with corticosteroids or the use of a assesses the joint being examined.
nonionic contrast medium. ➤ Obtain a history of the patient’s com-
plaints or symptoms, including a list
Factors that may of known allergens, especially aller-
impair clear imaging: gies or sensitivities to latex, iodine,
seafood, contrast medium, and dyes.
• Inability of the patient to cooperate
or remain still during the procedure ➤ Obtain a history of results of previ-
because of age, significant pain, or men- ously performed diagnostic proce-
tal status laboratory tests. For related diagnos-
• Metallic objects within the examina- tic tests, refer to the Musculoskele-
tion field (e.g., jewelry, earrings, dental tal System table.
amalgams), which may inhibit organ ➤ Record the date of the last menstrual
visualization and can produce unclear period and determine the possibil-
images ity of pregnancy in perimenopausal
women.
• Improper adjustment of the radi- ➤ Obtain a list of the medications the
ographic equipment to accommodate patient is taking.
obese or thin patients, which can cause ➤ Explain to the patient that some pain
overexposure or underexposure and a may be experienced during the test,
poor-quality study and there may be moments of dis-
Arthrogram 175
comfort. Explain the purpose of the ➤ X-rays or MRIs are taken of the joint.
test and how the procedure is per- ➤ The patient is instructed to inhale
formed. Inform the patient that the deeply and hold his or her breath
procedure is performed in the radiol- while the x-ray film is taken, and then
ogy department, usually by a physi- to exhale after the film is taken.
cian and support staff, and takes
approximately 30 to 60 minutes.
Post-test:
issues, as well as concern for mod- ➤ Inform the patient that further exam-
esty, is important in providing psy- inations may be needed to evaluate
chological support before, during, disease progression and to deter-
and after the procedure. mine the need for a change in ther-
➤ There are no food, fluid, or medica- apy.
tion restrictions. ➤ Answer any questions or concerns
➤ Make sure a written and informed voiced by the patient or family.
consent has been signed prior to the
➤ Assess the joint for swelling after the
procedure and before administering
test. Apply ice as needed.
any medications.
➤ Instruct the patient to use a mild
Intratest: analgesic (aspirin, acetaminophen),
as ordered, if there is discomfort.
➤ Observe standard precautions and
follow the general guidelines in ➤ Advise the patient to avoid strenu-
Appendix A. ous activity until approved by the
physician.
and to follow directions. Instruct the ➤ Instruct the patient to notify the
patient to remain still throughout the health care provider if he or she
procedure because movement pro- experiences fever or increased pain,
duces unreliable results. drainage, warmth, edema, or swell-
ing of the joint.
➤ Have the patient void before the pro-
cedure begins. ➤ Inform the patient that noises from
➤ Patients are given a gown and robe the joint after the procedure are
to wear. Clothing and metallic common and should disappear 24 to
objects are removed from the joint to 48 hours after the procedure.
be examined. ➤ A written report of the examina-
➤ When x-rays are used, lead protection will be completed by a health
tion is placed over the gonads to pre- care practitioner specializing in this
vent their irradiation. branch of medicine. The report will
be sent to the requesting health care
➤ Place the patient on the table in a practitioner, who will discuss the
supine position. results with the patient.
➤ The skin surrounding the joint is
aseptically cleaned and anes-
thetized.
needed to evaluate or monitor pro-
➤ A small-gauge needle is inserted into gression of the disease process and
the joint space. determine the need for a change in
➤ Any fluid in the space is aspirated and therapy. Evaluate test results in rela-
sent to the laboratory for analysis. tion to the patient’s symptoms and
other tests performed.
➤ Contrast medium is inserted into
the joint space with fluoroscopic
guidance. Related diagnostic tests:
➤ The needle is removed, and the joint ➤ Related diagnostic tests include
is exercised to help distribute the bone scan and radiography of the
contrast medium. bone.
ARTHROSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
AREA OF APPLICATION: Joints.
CONTRAST: None.
• Evaluate meniscal, patellar, condylar,

DESCRIPTION & RATIONALE: Arth- extrasynovial, and synovial injuries or
roscopy provides direct visualization diseases of the knee
of a joint through the use of a fiberop-
tic endoscope. The arthroscope has a • Evaluate the extent of arthritis
light, fiberoptics, and lenses; it con- • Evaluate the presence of gout
nects to a monitor, and the images are
• Monitor effectiveness of therapy
recorded for future study and compar-
ison. This procedure is used for • Remove loose objects
inspection of joint structures, per-
formance of a biopsy, and surgical RESULT
repairs to the joint. Meniscus removal,
spur removal, and ligamentous repair Normal Findings:
are some of the surgical procedures • Normal muscle, ligament, cartilage,
that may be performed. This proce- synovial, and tendon structures of the
dure is most commonly performed to joint
diagnose athletic injuries and acute or
chronic joint disorders. Because Abnormal Findings:
arthroscopy allows direct visualization, • Arthritis
degenerative processes can be accu- • Chondromalacia
rately differentiated from injuries. A
• Cysts
local anesthetic allows the arthroscope
to be inserted through the skin with • Degenerative joint changes
minimal discomfort. This procedure • Ganglion or Baker’s cyst
may also be done under a spinal or
• Gout or pseudogout
general anesthetic, especially if surgery
is anticipated. ■ • Joint tumors
• Loose bodies
INDICATIONS:
• Detect torn ligament or tendon • Meniscal disease
• Osteoarthritis
• Evaluate joint pain and damaged carti-
lage • Osteochondritis
Arthroscopy 177
• Subluxation, fracture, or dislocation Procedure ● ● ● ● ● ● ● ● ● ● ●
• Synovitis
Pretest:
• Torn cartilage
➤ Inform the patient that the procedure
• Torn ligament assesses the joint to be examined.
• Torn rotator cuff ➤ Obtain a history of the patient’s com-
• Trapped synovium plaints or symptoms, including a list
of known allergens, especially aller-
gies or sensitivities to latex.
INTERFERING FACTORS
ously performed diagnostic proce-
This procedure is dures, surgical procedures, and
contraindicated for: laboratory tests. For related diagnos-
• Patients with bleeding disorders, active tic tests, refer to the Musculoskele-
arthritis, or cardiac conditions tal System table.
• Patients with joint infection or skin ➤ Record the date of the last menstrual
infection near proposed arthroscopic period and determine the possibility
site of pregnancy in perimenopausal
women.
• Patients who have had an arthrogram ➤ Obtain a list of the medications the
within the last 14 days patient is taking,
➤ Explain to the patient that some pain
Factors that may may be experienced during the test,
impair clear imaging: and there may be moments of dis-
• Inability of the patient to cooperate or comfort. Explain the purpose of the
remain still during the procedure test and how the procedure is per-
because of age, significant pain, or men- formed. Inform the patient that the
tal status procedure is performed in the radiol-
ogy department, usually by a physi-
• Improper adjustment of the radi- cian and support staff, and takes
ographic equipment to accommodate approximately 30 to 60 minutes.
obese or thin patients, which can cause ➤ Sensitivity to cultural and social
overexposure or underexposure and a issues, as well as concern for mod-
poor-quality study esty, is important in providing psy-
• Patients who are very obese, who may and after the procedure.
ment ➤ Instruct the patient to refrain from
food and fluids for 6 to 8 hours
• Incorrect positioning of the patient, before the test.
which may produce poor visualization ➤ Make sure a written and informed
of the area to be examined consent has been signed prior to the
• Fibrous ankylosis of the joint prevent- any medications.
ing effective use of the arthroscope
➤ Determine previous abnormalities in
• Joints with flexion of less than 50 laboratory test results, particularly
hematologic or coagulation tests.
Other considerations: ➤ Crutch walking should be taught
• Failure to follow dietary restrictions before the procedure if it is antici-
before the procedure may cause the pated postoperatively.
procedure to be canceled or repeated. ➤ The joint area and areas 5 to 6 inches
above and below the joint are shaved is applied to the joint to remove
and prepared for the procedure. remaining irrigation solution.
➤ The patient is given a preprocedure ➤ The incision sites are sutured, and a
sedative, as ordered. pressure dressing is applied.
➤ Gloves and gowns are worn through-
Intratest: out the procedure.
➤ Resuscitation equipment and patient
Post-test:
monitoring equipment must be avail-
able. ➤ Advise the patient to avoid strenu-
➤ Have the patient remove dentures, ous activity involving the joint until
contact lenses, eyeglasses, and jew- approved by the health care practi-
elry. Notify the physician if the tioner.
patient has crownwork that could ➤ Instruct the patient to resume nor-
affect the examination. Have the mal diet and medications, as
patient remove clothing and change directed by the health care practi-
into a gown for the procedure. tioner.
➤ The extremity is scrubbed, elevated, ➤ Instruct the patient to take an anal-
and wrapped with an elastic band- gesic for joint discomfort after the
age from the distal portion of the procedure; ice bags may be used to
extremity to the proximal portion to reduce postprocedure swelling.
drain as much blood from the limb as
possible. ➤ Monitor the patient’s circulation and
sensations in the joint area.
➤ A pneumatic tourniquet placed
around the proximal portion of the ➤ Emphasize that any fever as well as
limb is inflated, and the elastic band- excessive bleeding, difficulty breath-
age is removed. ing, incision site redness, swelling,
➤ As an alternative to a tourniquet, a and tenderness must be reported to
mixture of lidocaine with epinephrine the health care practitioner.
and sterile normal saline may be ➤ To reduce swelling, instruct the pa-
instilled into the joint to help reduce tient to elevate the joint when sitting
bleeding. and to avoid overbending of the joint.
➤ The joint is placed in a 45 angle, and ➤ Inform the patient to shower after 48
a local anesthetic is administered. hours but to avoid a tub bath until
➤ A small incision is made in the skin in after his or her appointment with the
the lateral or medial aspect of the health care practitioner.
joint. ➤ A written report of the examination
➤ The arthroscope is inserted into the will be completed by a health care
joint spaces. The joint is manipulated practitioner specializing in this
as it is visualized. Added puncture branch of medicine. The report will
sites may be needed to provide a full be sent to the requesting health care
view of the joint. practitioner, who will discuss the
➤ Biopsy or treatment can be perfor- results with the patient.
med at this time, and photographs ➤ Depending on the results of this pro-
should be taken for future reference. cedure, additional testing may be
➤ After inspection, specimens may be needed to evaluate or monitor pro-
obtained for cytologic and microbio- gression of the disease process and
logic study. All specimens are placed determine the need for a change in
in appropriate containers, labeled therapy. Evaluate test results in rela-
with the corresponding patient tion to the patient’s symptoms and
demographics, date and time of col- other tests performed.
lection, site location, and promptly
sent to the laboratory. Related diagnostic tests:
➤ The joint is irrigated, and the arthro- ➤ Related diagnostic tests include bone
scope is removed. Manual pressure scan and radiography of the bone.
Aspartate Aminotransferase 179
ASPARTATE AMINOTRANSFERASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYMS: Serum glutamic-oxaloacetic transaminase,

AST, SGOT.
REFERENCE VALUE: (Method: Spectrophotometry, enzymatic at 37C)
Conventional Measurement of AST in evaluation of

Age & SI Units myocardial infarction has been
Newborn 47–150 U/L replaced by more sensitive tests, such
10 d–23 m 9–80 U/L as creatine kinase–MB fraction (CK-
2–59 y MB) and troponin. ■
Male 15–40 U/L
Female 13–35 U/L INDICATIONS:
60–90 y • Assist in the diagnosis of disorders or
Male 19–48 U/L injuries involving the tissues where AST
Female 9–36 U/L is normally found
• Assist (formerly) in the diagnosis of
myocardial infarction (Note: AST rises
within 6 to 8 hours, peaks at 24 to 48
DESCRIPTION & RATIONALE: Aspar- hours, and declines to normal within 72
tate aminotransferase (AST) is an to 96 hours of a myocardial infarction)
enzyme that catalyzes the reversible
transfer of an amino group between • Compare serially with alanine amino-
transferase levels to track the course of
aspartate and -ketoglutaric acid.
hepatitis
It was formerly known as serum
glutamic-oxaloacetic transaminase • Monitor response to therapy with
(SGOT). AST exists in large amounts potentially hepatotoxic or nephrotoxic
drugs
in liver and myocardial cells and in
smaller but significant amounts in • Monitor response to treatment for vari-
skeletal muscle, kidneys, pancreas, ous disorders in which AST may be ele-
and the brain. Serum AST rises when vated, with tissue repair indicated by
declining levels
there is cellular damage to the tissues
where the enzyme is found. AST val- RESULT
ues greater than 500 U/L are usually
associated with hepatitis and other Significantly increased in (greater
hepatocellular diseases in an acute than five times normal levels):
phase. AST levels are very elevated at • Acute hepatitis
birth and decrease with age. Note: • Acute hepatocellular disease
• Acute pancreatitis fluconazole, fluoroquinolones, foscar-

• Shock net, gentamicin, indomethacin, inter-
feron, interleukin-2, levamisole,
Moderately increased in (three to
levodopa, lincomycin, low-molecular-
five times normal levels): weight heparin, methyldopa, mono-
amine oxidase inhibitors, naproxen,
• Biliary tract obstruction
nifedipine, nitrofurans, oral contracep-
• Cardiac arrhythmias tives, probenecid, procainamide, qui-
• Chronic hepatitis nine, ranitidine, retinol, ritodrine,
sulfonylureas, tetracyclines, tobramy-
• Congestive heart failure cin, and verapamil.
• Dermatomyositis • Hemolysis falsely increases AST values.
• Liver tumors
• Muscular dystrophy Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
Slightly increased in (two to three
times normal):
Pretest:
• Cerebrovascular accident
➤ Inform the patient that the test is pri-
• Cirrhosis, fatty liver marily used to assess liver function.
• Delirium tremens ➤ Obtain a history of the patient’s
• Hemolytic anemia allergens (especially allergies or sen-
• Pericarditis sitivities to latex), and inform the
• Pulmonary infarction accordingly.
➤ Obtain a history of the patient’s car-
CRITICAL VALUES: N/A diovascular and hepatobiliary sys-
INTERFERING FACTORS performed laboratory tests, surgical
• Drugs that may increase AST levels by procedures, and other diagnostic
causing cholestasis include amitripty- procedures. For related laboratory
line, anabolic steroids, androgens, tests, refer to the Cardiovascular and
Hepatobiliary System tables.
benzodiazepines, chlorothiazide, chlor-
propamide, dapsone, erythromycin, ➤ Obtain a list of medications the
estrogens, ethionamide, gold salts,
imipramine, mercaptopurine, nitrofu- ceuticals. The requesting health care
rans, oral contraceptives, penicillins, practitioner and laboratory should be
phenothiazines, progesterone, pro- advised if the patient regularly uses
poxyphene, sulfonamides, tamoxifen, these products so that their effects
and tolbutamide. can be taken into consideration when
reviewing results.
• Drugs that may increase AST levels by
causing hepatocellular damage include patient. Inform the patient that spec-
acetaminophen (toxic), acetylsalicylic imen collection takes approximately
acid, allopurinol, amiodarone, anabolic 5 to 10 minutes. Address concerns
steroids, anticonvulsants, asparaginase, about pain related to the procedure.
azithromycin, bromocriptine, captopril, Explain to the patient that there may
cephalosporins, chloramphenicol, clin- be some discomfort during the
damycin, clofibrate, danazol, enflurane, venipuncture.
ethambutol, ethionamide, fenofibrate, ➤ There are no food, fluid, or medica-
Aspartate Aminotransferase 181
tion restrictions unless by medical is different; a low-protein diet may be

direction. in order if the patient’s liver can no
longer process the end products of
Intratest: protein metabolism. A diet of soft
foods may be required if esophageal
➤ If the patient has a history of severe varices have developed. Ammonia
allergic reaction to latex, care should levels may be used to determine
be taken to avoid the use of equip- whether protein should be added to
ment containing latex. or reduced from the diet. Patients
➤ Instruct the patient to cooperate fully should be encouraged to eat simple
and to follow directions. Direct the carbohydrates and emulsified fats
patient to breathe normally and to (as in homogenized milk or eggs), as
avoid unnecessary movement. opposed to complex carbohydrates
➤ Observe standard precautions, and (e.g., starch, fiber, and glycogen [ani-
follow the general guidelines in mal carbohydrates]) and complex
Appendix A. Positively identify the fats, which would require additional
patient, and label the appropriate bile to emulsify them so that they
tubes with the corresponding patient can be used. The cirrhotic patient
demographics, date, and time of should be observed carefully for the
collection. Perform a venipuncture; development of ascites, in which
collect the specimen in a 5-mL red- case fluid and electrolyte balance
or tiger-top tube. requires strict attention.
➤ Remove the needle, place a gauze ➤ Nutrional considerations: Increased
over the puncture site and apply gen- AST levels may be associated with
tle pressure to stop bleeding. coronary artery disease (CAD).
Observe venipuncture site for bleed- Nutritional therapy is recommended
ing or hematoma formation. Apply for individuals identified to be at high
paper tape over gauze or replace risk for CAD. Overweight patients
with adhesive bandage. should be encouraged to achieve a
➤ Promptly transport the specimen to normal weight. The American Heart
the laboratory for processing and Association Step 1 and Step 2 diets
analysis. may be helpful in achieving a goal of
reducing total cholesterol and triglyc-
➤ The results are recorded manually or eride levels. The Step 1 diet empha-
in a computerized system for recall sizes a reduction in foods high in
and postprocedure interpretation by saturated fats and cholesterol. Red
the appropriate health care practi- meats, eggs, and dairy products are
tioner. the major sources of saturated fats
and cholesterol. If triglycerides are
Post-test: also elevated, the patient should be
advised to eliminate or reduce alco-
➤ Nutritional considerations: Increased hol and simple carbohydrates from
AST levels may be associated with the diet. The Step 2 diet recom-
liver disease. Dietary recommenda- mends stricter reductions.
tions may be indicated and vary
depending on the condition and its ➤ Instruct the patient to immediately
severity. Currently, there are no spe- report chest pain and changes in
cific medications that can be given to breathing pattern to the health care
cure hepatitis, but elimination of practitioner.
alcohol ingestion and a diet opti- ➤ A written report of the examination
mized for convalescence are com- will be sent to the requesting health
monly included in the treatment plan. care practitioner, who will discuss
A high-calorie, high-protein, moder- the results with the patient.
ate-fat diet with a high fluid intake is
often recommended for patients ➤ Reinforce information given by the
with hepatitis. Treatment of cirrhosis patient’s health care provider regard-
ing further testing, treatment, or re- ferase, albumin, alkaline phos-

ferral to another health care provider. phatase, ammonia, antimitochondrial
Answer any questions or address antibody, 1-antitrypsin/phenotyping,
any concerns voiced by the patient bilirubin, ethanol, ferritin, -glutamyl-
or family. transferase, hepatitis antigens and
➤ Depending on the results of this pro- antibodies, iron/total iron-binding
cedure, additional testing may be capacity, liver biopsy, protein, and
performed to evaluate or monitor pro- prothrombin time if liver disease is
gression of the disease process and suspected; and antiarrhythmic drugs,
determine the need for a change in apolipoprotein A, apolipoprotein B,
therapy. Evaluate test results in rela- atrial natriuretic peptide, B-type natri-
tion to the patient’s symptoms and uretic peptide, blood gases, C-reac-
other tests performed. tive protein, calcium/ionized calcium,
cholesterol (total, HDL, & LDL), crea-
Related laboratory tests: tine kinase, homocysteine, lactate
dehydrogenase, myoglobin, potas-
➤ Related laboratory tests include sium, triglycerides, and troponin if
acetaminophen, alanine aminotrans- myocardial infarction is suspected.
ATRIAL NATRIURETIC PEPTIDE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Atrial natriuretic hormone, atrial natriuretic factor,

ANF, ANH.
SPECIMEN: Plasma (1 mL) collected in a chilled, lavender-top tube.

Conventional Units SI Units (Conventional Units 1)

20–77 pg/mL 20–77 ng/L
DESCRIPTION & RATIONALE: Atrial increases. The release of this cardiac

natriuretic peptide or atrial natriuretic peptide is stimulated by increases in
factor (ANF) is a hormone secreted the stretch of the atrial wall caused by
from cells in the right atrium of the an increase in blood pressure or blood
heart when right atrial pressure volume. ANF receptors are also stim-
Atrial Natriuretic Peptide 183
ulated by elevated sodium levels. This Nursing Implications and

extremely potent hormone enhances Procedure ● ● ● ● ● ● ● ● ● ● ●
salt and water excretions by blocking

aldosterone and renin secretion. ANF Pretest:
inhibits angiotensin II and vaso- ➤ Inform the patient that the test is
pressin, resulting in vasodilation and a used to assess cardiac function.
decrease in blood volume and blood ➤ Obtain a history of the patient’s
pressure. ■ complaints, including a list of known
allergens, (especially allergies or
INDICATIONS: sensitivities to latex), and inform
• Assist in the confirmation of congestive the appropriate health care practi-
heart failure (CHF), as indicated by tioner accordingly. Be alert to signs
increased level and symptoms of altered cardiopul-
monary tissue perfusion related
• Identify asymptomatic cardiac volume to ventilation-perfusion imbalance,
overload, as indicated by increased level decreased cardiac output related to
altered muscle contractility, and fluid-
volume excess related to glomerular
RESULT filtration rate.
Increased in: ➤ Obtain a history of the patient’s
cardiovascular system and results of
• Asymptomatic cardiac volume overload
• CHF tests, surgical procedures, and other
• Elevated cardiac filling pressure laboratory tests, refer to the Cardio-
vascular System table.
• Paroxysmal atrial tachycardia
Decreased in: N/A patient is taking, including herbs,
CRITICAL VALUES: N/A practitioner and laboratory should be
INTERFERING FACTORS: these products so that their effects
• Drugs that may increase ANF levels can be taken into consideration when
include atenolol, candoxatril, captopril, reviewing results.
carteolol, dopamine, morphine, oral ➤ Note any recent procedures that may
contraceptives, vasopressin, and vera- interfere with test results.
pamil. ➤ Review the procedure with the
• Drugs that may decrease ANF levels patient. Inform the patient that spec-
include clonidine, prazosin, and ura-
pidil. about pain related to the procedure.
• Recent radioactive scans or radiation Explain to the patient that there may
within 1 week before the test can inter- be some discomfort during the
fere with test results when radioim- venipuncture.
munoassay is the test method. ➤ Instruct the patient to fast for 6 to 12
hours before the test and to avoid
• Failure to follow dietary and medica- taking medications that interfere
tion restrictions before the procedure with test results, as directed by the
may cause the procedure to be canceled health care practitioner. Note: Drugs
or repeated. such as -blocking agents, calcium
antagonists, cardiac glycosides, and

Post-test:
vasodilators can affect results.
➤ Prepare an ice slurry in a cup or plas- ➤ Instruct the patient to resume usual
tic bag to have ready for immediate diet and medication, as directed by
transport of the specimen to the lab- the health care practitioner.
oratory. Prechill the lavender-top tube ➤ Nutritional considerations: Increased
in the ice slurry. ANF may be associated with coro-
nary artery disease (CAD). Nutritional
Intratest: therapy is recommended for the
patient identified to be at high risk for
developing CAD. If overweight, the
with dietary, medication, or activity
patient should be encouraged to
restrictions and pretesting prepara-
achieve a normal weight. The Ameri-
tions; assure that food has been
can Heart Association Step 1 and
restricted for at least 6 to 12 hours
Step 2 diets may be helpful in achiev-
prior to the procedure.
ing a goal of lowering total choles-
➤ If the patient has a history of severe terol and triglyceride levels. The Step
allergic reaction to latex, care should 1 diet emphasizes a reduction in
be taken to avoid the use of equip- foods high in saturated fats and cho-
ment containing latex. lesterol. Red meats, eggs, and dairy
➤ Instruct the patient to cooperate fully products are the major sources of
and to follow directions. Direct the saturated fats and cholesterol. If
patient to breathe normally and to triglycerides also are elevated, the
avoid unnecessary movement. patient should be advised to elimi-
nate or reduce alcohol and simple
carbohydrates from the diet. The
Step 2 diet recommends stricter
reductions.
tubes with the corresponding patient ➤ Nutritional considerations: Over-
demographics, date, and time of col- weight patients with high blood pres-
lection. Perform a venipuncture; col- sure should be encouraged to
lect the specimen in a prechilled achieve a normal weight. Other
5-mL lavender-top tube. changeable risk factors warranting
➤ Remove the needle, place a gauze patient education include strategies
over the puncture site and apply gen- to safely decrease sodium intake,
tle pressure to stop bleeding. increase physical activity, decrease
Observe venipuncture site for bleed- alcohol consumption, eliminate
ing or hematoma formation. Apply tobacco use, and decrease choles-
paper tape over gauze or replace terol levels.
with adhesive bandage. ➤ A written report of the examination
➤ The sample should be placed in an will be sent to the requesting health
ice slurry immediately after collec- care practitioner, who will discuss
tion. Information on the specimen the results with the patient.
label can be protected from water in ➤ Recognize anxiety related to test
the ice slurry by first placing the results, and be supportive of fear of
specimen in a protective plastic bag. shortened life expectancy. Discuss
Promptly transport the specimen to the implications of abnormal test
the laboratory for processing and results on the patient’s lifestyle.
analysis. Provide teaching and information
➤ The results are recorded manually or regarding the clinical implications of
in a computerized system for recall the test results, as appropriate.
and postprocedure interpretation by Educate the patient regarding access
the appropriate health care practi- to counseling services. Provide con-
tioner. tact information, if desired, for the
Audiometry, Hearing Loss 185
American Heart Association (www. Related laboratory tests:

americanheart.org).
➤ Reinforce information given by the ➤ Related laboratory tests include
patient’s health care provider regard- aldosterone, antiarrhythmic drugs,
ing further testing, treatment, or antidiuretic hormone, apolipoprotein
referral to another health care A, apolipoprotein B, aspartate amino-
provider. Answer any questions or transpeptidase, B-type natriuretic
address any concerns voiced by the peptide, blood gases, C-reactive pro-
patient or family. tein, calcium/ionized calcium, choles-
➤ Depending on the results of this terol (total, HDL, & LDL), creatine
procedure, additional testing may be kinase and isoenzymes, glucose, gly-
performed to evaluate or monitor cated hemoglobin, homocysteine,
progression of the disease process ketones, lactate dehydrogenase and
and determine the need for a change isoenzymes, lipoprotein electro-
in therapy. Evaluate test results in phoresis, magnesium, myoglobin,
relation to the patient’s symptoms potassium, renin, triglycerides, and
and other tests performed. troponin.
AUDIOMETRY, HEARING LOSS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: N/A.
AREA OF APPLICATION: Ears.
CONTRAST: N/A.
DESCRIPTION & RATIONALE: Hearing bone conduction indicates a sensori-

loss audiometry involves the quantita- neural hearing loss. An elevated
tive testing for a hearing deficit using threshold of air conduction that is
an electronic instrument called an more than an elevated threshold of
audiometer that measures and records bone conduction indicates a compos-
thresholds of hearing by air conduc- ite of both types of hearing loss. A con-
tion and bone conduction tests. These ductive hearing loss is caused by an
results determine if hearing loss is abnormality in the external auditory
conductive, sensorineural, or a combi- canal or middle ear, and a sensori-
nation of both. An elevated air- neural hearing loss by an abnormality
conduction threshold with a normal in the inner ear or of the VIII (audi-
bone-conduction threshold indicates a tory) nerve. Sensorineural hearing loss
conductive hearing loss. An equally can be further differentiated clinically
elevated threshold for both air and by sensory (cochlear) or neural (VIII
nerve) lesions. Additional information threshold, or mixed, as evidenced by

for comparing and differentiating abnormal air and bone thresholds) and
if further radiologic, audiologic, or
between conductive and sensorineural
vestibular procedures are needed to
hearing loss can be obtained by identify the cause.
performing hearing loss tuning fork
tests. ■ • Evaluate communication disabilities
and plan for rehabilitation interven-
tions.
INDICATIONS:
• Determine the need for a type of hear- • Evaluate degree and extent of preoper-
ing aid and evaluate its effectiveness. ative and postoperative hearing loss fol-
lowing stapedectomy in patients with
• Determine the type and extent of hear-
otosclerosis.
ing loss (conductive, as evidenced by a
reduced air threshold and unchanged • Screen for hearing loss in infants and
bone threshold, or sensorineural, as evi- children and determine the need for a
denced by a reduced air and bone referral to an audiologist.
RESULT
ANSI 1996 scale Elevated Pure Tone Averages

Slight Loss 16–25 dB
Mild Loss 26–40 dB
Moderate Loss 41–55 dB
Moderately Severe Loss 56–70 dB
Severe Loss 71–90 dB
Profound Loss Greater than 91 dB
Normal Findings: INTERFERING FACTORS:

• Normal pure tone average of –10 to
15 dB. Factors that may impair the
Abnormal Findings: results of the examination:
• Causes of conductive hearing loss • Inability of the patient to cooperate or
Obstruction of external ear canal remain still during the procedure
because of age, significant pain, or men-
Otitis externa
tal status may interfere with the test
Otitis media results.
Otosclerosis
• Obstructions of the ear canal by ceru-
• Causes of sensorineural hearing loss
men or other material or object will
Congenital damage or affect decibel (dB) perception.
malformations of the inner ear
Ototoxic drugs • Noisy environment or extraneous
Serious infections movements can affect results.
Trauma to the inner ear • Tinnitus or other sensations can cause
Tumor abnormal responses.
Vascular disorders
• Improper earphone fit or audiometer
CRITICAL VALUES: N/A calibration can affect results.
Audiometry, Hearing Loss 187
• Failure to follow pretesting preparations Intratest:

procedure to be canceled or repeated. ➤ Ensure that the patient has complied
with pretesting preparations; assure
that the patient has avoided an envi-
Nursing Implications and ronment with extrememly loud
Procedure ● ● ● ● ● ● ● ● ● ● ●
noises for at least 16 hours prior to
the procedure.
➤ Inform the patient that the procedure patient to remain still during the pro-
detects hearing loss. cedure because movement pro-
➤ Obtain a history of the patient’s duces unreliable results.
complaints, including a list of known ➤ Perform otoscopy examination to
allergens. ensure that the external ear canal is
free from any obstruction (see
➤ Obtain a history of the patient’s monograph titled “Otoscopy”).
known or suspected hearing loss,
including type and cause; ear condi- ➤ Test for closure of the canal by the
tions with treatment regimens; ear pressure of the earphones by com-
surgery; and other tests and proce- pressing the tragus. Tendency for the
dures to assess and diagnose audi- canal to close (often the case in chil-
tory deficit. dren and elderly patients) can be cor-
rected by the careful insertion of a
➤ Obtain a history of results of previ- small stiff plastic tube into the ante-
ously performed laboratory tests, rior canal.
➤ Place the patient in a sitting posi-
nostic procedures.
tion in comfortable proximity to the
➤ Obtain a list of the medications the audiometer in a soundproof room.
patient is taking, including herbs, The ear not being tested is masked
nutritional supplements, and nutra- to prevent crossover of test tones,
ceuticals. The requesting health care and the earphones are positioned on
practitioner should be advised if the the head and over the ear canals.
patient regularly uses these products ➤ Start the test by providing a trial tone
so that their effects can be taken of 30 dB (ASHA 1978 Guidelines) to
into consideration when reviewing the ear for 1 to 2 seconds to famil-
results. iarize the patient with the sounds.
➤ Review the procedure with the Instruct the patient to press the but-
patient. Instruct the patient to avoid ton each time a tone is heard, no
an environment with extremely loud matter how loudly or faintly it is per-
noises for at least 16 hours prior to ceived. If no response is indicated,
the procedure. Address concerns the level is increased to 50 dB and
about pain related to the procedure. then raised in 10-dB increments until
Explain to the patient that no dis- a response is obtained or until the
comfort will be experienced during audiometer’s limit is reached for the
the test. Inform the patient that an test frequency. The test results are
audiologist, physician, or nurse per- plotted on a graph called an audio-
forms the test, in a quiet, darkened gram using symbols that indicate the
room, and that the test can take up ear tested and responses using ear-
20 minutes to evaluate both ears. phones (air conduction) or oscillator
(bone conduction).
tion restrictions unless by medical Air Conduction:
direction.
➤ Air conduction is tested first by start-
➤ Ensure that the external auditory ing at 1000 Hz and gradually decreas-
canal is clear of impacted cerumen. ing the intensity 10 dB at a time until
the patient no longer presses the ➤ The results are recorded manually or
button, indicating that the tone is no on a paper strip from the automated
longer heard. The intensity is then equipment for recall and postproce-
increased 5 dB at a time until the dure interpretation by the appropri-
tone is heard again. This is repeated ate health care practitioner.
until the same response is achieved
at a 50% response rate at the same Post-test:
hertz (Hz) level. The threshold is
derived from the lowest decibel level ➤ Instruct the patient to resume usual
at which the patient correctly identi- activity, as directed by the health
fies three out of six responses to a care practitioner.
tone at that hertz level. The test is ➤ A written report of the examination
continued for each ear, testing the will be completed by a health care
better ear first, with tones delivered practitioner specializing in this branch
at 1000 Hz, 2000 Hz, 4000 Hz, and of medicine. The report will be sent
8000 Hz, and then again at 1000 Hz, to the requesting health care practi-
500 Hz, and 250 Hz to determine tioner, who will discuss the results
a second threshold. Results are with the patient.
recorded on a graph called an audio- ➤ Recognize anxiety related to test
gram. Averaging the air conduction results, and be supportive of impair-
thresholds at the 500-Hz, 1000-Hz, ed activity related to hearing loss
and 2000-Hz levels reveals the or perceived loss of independence.
degree of hearing loss and is called Discuss the implications of abnormal
the pure tone average (PTA). test results on the patient’s lifestyle.
Bone Conduction:
➤ Bone conduction is then tested using the test results, as appropriate.
an oscillator placed on the mastoid ➤ Reinforce information given by the
process behind the ear(s) after patient’s health care provider regard-
removal of the earphones. The raised ing further testing, treatment, or
and lowered tones are delivered as in referral to another health care
air conduction using 250 Hz, 500 Hz, provider. As appropriate, instruct the
1000 Hz, 2000 Hz, and 4000 Hz to patient in the use, cleaning, and stor-
determine the thresholds. An analy- ing of a hearing aid. Answer any
sis of thresholds for air and bone con- questions or address any concerns
duction tones is done to determine voiced by the patient or family.
the type of hearing loss (conductive,
sensorineural, or mixed). ➤ Depending on the results of this pro-
➤ In children between 6 months and 2 performed to evaluate or monitor
years of age, minimal response levels progression of the disease process
can be determined by behavioral and determine the need for a change
responses to test tone. In the child 2 in therapy. Evaluate test results in
years of age and older, play audiome- relation to the patient’s symptoms
try that requires the child to perform and other tests performed.
a task or raise a hand in response to
a specific tone is performed. In chil- Related diagnostic tests:
dren 12 years of age and older, the
child is asked to follow directions in ➤ Related diagnostic tests include
identifying objects; response to evoked brain potential studies for
speech of specific intensities can be hearing loss, otoscopy, spondee
used to evaluate hearing loss that is speech reception threshold, and tun-
affected by speech frequencies. ing fork tests (Webber, Rinne).
Barium Enema 189
BARIUM ENEMA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Air-contrast barium enema, double-contrast

barium enema, lower GI series, BE.
AREA OF APPLICATION: Colon.

CONTRAST: Barium sulfate, air, iodine mixture.
cess, congenital anomaly, motility

DESCRIPTION & RATIONALE: This disorder, or structural change
radiologic examination of the colon,
distal small bowel, and occasionally • Evaluate unexplained weight loss,
the appendix follows instillation of anemia, or a change in bowel pattern
barium using a rectal tube inserted • Identify and locate benign or malig-
into the rectum or an existing ostomy. nant polyps or tumors
The patient must retain the barium
while a series of radiographs are RESULT
obtained. Visualization can be
improved by using air or barium as Normal Findings:
the contrast medium (double-contrast • Normal size, filling, shape, position,
study). A combination of x-ray and and motility of the colon
fluoroscopy techniques is used to • Normal filling of the appendix and ter-
complete the study. This test is espe- minal ileum
cially useful in the evaluation of
patients experiencing lower abdomi- Abnormal Findings:
nal pain, changes in bowel habits, or • Appendicitis
the passage of stools containing blood • Colorectal cancer
or mucus, and for visualizing polyps,
diverticula, and tumors. A barium • Congenital anomalies
enema may be therapeutic; it may • Crohn’s disease
reduce an obstruction caused by
• Diverticular disease
intussusception, or telescoping of the
intestine. Barium enema should be • Fistulas
performed before an upper gastroin- • Gastroenteritis
testinal study or barium swallow. ■
• Granulomatous colitis
INDICATIONS: • Hirschsprung’s disease
• Determine the cause of rectal bleeding,
blood, pus, or mucus in feces • Intussusception
• Evaluate suspected inflammatory pro- • Perforation of the colon
• Polyps overexposure or underexposure and a

poor-quality study
• Sarcoma
• Patients who are very obese, who
• Sigmoid torsion
may exceed the weight limit for the
• Sigmoid volvulus equipment
• Stenosis • Incorrect positioning of the patient,
which may produce poor visualization
• Tumors of the area to be examined
• Ulcerative colitis • Inability of the patient to cooperate or
INTERFERING FACTORS: because of age, significant pain, or men-
tal status
This procedure is
contraindicated for: • Spasm of the colon, which can mimic
• Patients with allergies to shellfish the radiographic signs of cancer (Note:
or iodinated dye, when iodinated the use of intravenous glucagon mini-
contrast medium is used. The contrast mizes spasm)
medium, when used, may cause a life- • Inability of the patient to tolerate intro-
threatening allergic reaction. Patients duction of or retention of barium, air,
with a known hypersensitivity to con- or both in the bowel
trast medium may benefit from pre-
medication with corticosteroids or the
use of nonionic contrast medium. Other considerations:
• Complications of the procedure may
• Patients who are pregnant or suspected include hemorrhage and cardiac arrhy-
of being pregnant, unless the potential thmias.
the risks to the fetus and mother. • The procedure may be terminated if
• Patients with intestinal obstruction, chest pain or severe cardiac arrhythmias
acute ulcerative colitis, acute divertic- occur.
ulitis, megacolon, or suspected rupture • Failure to follow dietary restrictions
of the colon. and other pretesting preparations may
Factors that may repeated.
• Gas or feces in the gastrointestinal tract • Consultation with a physician should
resulting from inadequate cleansing or occur before the procedure for radia-
failure to restrict food intake before the tion safety concerns regarding younger
study patients or patients who are lactating.
• Retained barium from a previous radi- • Risks associated with radiographic over-
ologic procedure exposure can result from frequent x-ray
• Metallic objects within the examina- the patient should wear a protective
tion field (e.g., jewelry, body rings), lead apron, stand behind a shield, or
which may inhibit organ visualization leave the area while the examination is
and can produce unclear images being done. Personnel working in the
• Improper adjustment of the radi- area where the examination is being
ographic equipment to accommodate done should wear badges that reveal
obese or thin patients, which can cause their level of exposure to radiation.
Barium Enema 191
and perform colostomy irrigation

Nursing Implications and before the study.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that a laxative and
cleansing enema may be needed
Pretest: the day before the procedure, with
cleansing enemas on the morning of
the procedure, depending on the
assesses the colon.
institution’s policy.
➤ Obtain a history of the patient’s com- ➤ Instruct the patient to remove jew-
plaints or symptoms, including a list elry (including watches), credit cards,
of known allergens, especially aller- and other metallic objects.
gies or sensitivities to latex, iodine,
Intratest:
ously performed diagnostic proce- ➤ Ensure that the patient has complied
dures, surgical procedures, and with dietary, and medication restric-
laboratory tests. For related diagnos- tions and pretesting preparations for
tic tests, refer to the Gastrointestinal at least 6 hours prior to the proce-
System table. dure. Ensure that the patient has
removed all external metallic objects
➤ Ensure that this procedure is per- prior to the procedure.
formed before an upper gastroin-
testinal study or barium swallow. ➤ Assess for completion of bowel
preparation according to the institu-
➤ Record the date of the last menstrual tion’s procedure.
period and determine the possibil-
ity of pregnancy in perimenopausal ➤ Have emergency equipment readily
women. available.
➤ Patients are given a gown, robe, and
foot coverings to wear and instructed
patient is taking.
to void prior to the procedure.
➤ Explain to the patient that some pain ➤ Observe standard precautions, and
may be experienced during the test, follow the general guidelines in
and there may be moments of dis- Appendix A.
comfort. Explain the purpose of the
test and how the procedure is per- ➤ Instruct the patient to cooperate fully
formed. Inform the patient that the and to follow directions. Instruct the
procedure is performed in a radiol- patient to remain still throughout the
ogy department, usually by a physi- procedure because movement pro-
cian and support staff, and takes duces unreliable results.
approximately 30 to 60 minutes. ➤ Place the patient in the supine posi-
➤ Sensitivity to cultural and social tion on an exam table.
issues, as well as concern for mod- ➤ An initial image is taken. The patient
esty, is important in providing psy- is helped to a side-lying position
chological support before, during, (Sims’ position). A rectal tube is
and after the procedure. inserted into the anus while an
attached balloon is inflated after it is
➤ Instruct the patient to eat a low-
situated against the anal sphincter.
residue diet for several days before
the procedure and to consume only ➤ Barium is instilled into the colon, and
clear liquids the evening before the then its movement through the
test. The patient should fast and colon is observed by fluoroscopy.
restrict fluids for 8 hours prior to the ➤ Images are taken at different angles
procedure. and positions to aid in the evaluation
➤ Instruct patients with a colostomy to of the patient’s problem.
follow the same dietary preparation, ➤ For patients with a colostomy, an
take laxatives the evening before, indwelling urinary catheter is inserted
into the stoma and barium is admin- ➤ Instruct the patient to take a mild
istered. laxative and increase fluid intake
(four 8-ounce glasses) to aid in elimi-
➤ The patient is returned to a position
nation of barium, unless contraindi-
of comfort, and is placed on a bed-
cated.
pan or helped to the bathroom to
expel the barium. ➤ Instruct the patient that stools will be
white or light in color for 2 to 3 days.
➤ After the expulsion of the barium, an If the patient is unable to eliminate
additional film is taken of the intes- the barium, or if stools do not return
tine. to normal color, the patient should
➤ If a double-contrast barium enema notify the physician.
has been ordered, air is then instilled ➤ Advise patients with a colostomy to
in the intestine and additional films administer tap water colostomy irri-
are taken. gation to aid in barium removal.
➤ The results are recorded manually, ➤ A written report of the examination
on film, or by automated equipment will be completed by a health care
in a computerized system for recall practitioner specializing in this branch
and postprocedure interpretation by of medicine. The report will be sent
the appropriate health care practi- to the requesting health care practi-
tioner. tioner, who will discuss the results
with the patient.
Post-test: ➤ Depending on the results of this pro-
➤ Instruct the patient to resume usual needed to evaluate or monitor pro-
diet, fluids, medications, or activity, gression of the disease process and
as directed by the health care practi- determine the need for a change in
tioner. therapy. Evaluate test results in rela-
➤ If iodine is used, monitor for reaction to the patient’s symptoms and
tion to iodinated contrast medium, other tests performed.
including rash, urticaria, tachycardia,
hyperpnea, hypertension, palpita- Related diagnostic tests:
tions, nausea, or vomiting. ➤ Related diagnostic tests include
➤ Carefully monitor the patient for colonoscopy, computed tomography
fatigue and fluid and electrolyte abdomen and magnetic resonance
imbalance. imaging abdomen.
BARIUM SWALLOW
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Esophagram, video swallow, esophagus x-ray,

swallowing function, esophagography.
AREA OF APPLICATION: Esophagus.

CONTRAST: Barium sulfate, water-soluble iodinated contrast.
Barium Swallow 193
Abnormal Findings:
DESCRIPTION & RATIONALE: This • Achalasia
radiologic examination of the esopha-
• Acute or chronic esophagitis
gus evaluates motion and anatomic
structures of the esophageal lumen by • Benign or malignant tumors
recording images of the lumen while • Chalasia
the patient swallows a barium solution
• Diverticula
of milkshake consistency and chalky
taste. The procedure uses fluoroscopic • Esophageal ulcers
and cineradiographic techniques. The • Esophageal varices
barium swallow is often performed as
part of an upper gastrointestinal series • Hiatal hernia
or cardiac series and is indicated for • Perforation of the esophagus
patients with a history of dysphagia • Strictures or polyps
and regurgitation. In patients with
esophageal reflux, the radiologist may INTERFERING FACTORS:
identify reflux of the barium from the
stomach back into the esophagus. This procedure is
Muscular abnormalities such as acha- contraindicated for:
lasia, as well as diffuse esophageal • Patients who are pregnant or suspected
spasm, can be easily detected with this of being pregnant, unless the potential
procedure. ■ benefits of the procedure far outweigh
the risks to the fetus and mother
INDICATIONS: • Patients with intestinal obstruction or
• Confirm the integrity of esophageal suspected esophageal rupture, unless
anastomoses in the postoperative water-soluble iodinated contrast med-
patient ium is used
• Detect esophageal reflux, tracheoe- • Patients with suspected tracheoe-
sophageal fistulas, and varices sophageal fistula, unless barium is used
• Determine the cause of dysphagia,
heartburn, or regurgitation Factors that may
• Determine the type and location of
foreign bodies within the pharynx and
esophagus
• Evaluate suspected esophageal motility study
disorders
• Evaluate suspected polyps, strictures, ologic procedure
Zenker’s diverticula, tumor, or inflam-
mation • Metallic objects within the examina-
tion field (e.g., jewelry, body rings),
RESULT which may inhibit organ visualization
and can produce unclear images
Normal Findings: • Improper adjustment of the radi-
• Normal peristalsis through the esopha- ographic equipment to accommodate
gus into the stomach with normal obese or thin patients, which can cause
size, filling, patency, and shape of the overexposure or underexposure and a
esophagus poor-quality study
• Patients who are very obese, who may ➤ Obtain a history of the patient’s com-
exceed the weight limit for the equip- plaints or symptoms, including a list
ment of known allergens, especially aller-
gies or sensitivities to latex, iodine,
• Incorrect positioning of the patient, seafood, contrast medium, and dyes.
which may produce poor visualization ➤ Obtain a history of results of
of the area to be examined previously performed diagnostic pro-
cedures, surgical procedures, and
• Inability of the patient to cooperate laboratory tests. For related diagnos-
or remain still during the procedure tic tests, refer to the Gastrointestinal
because of age, significant pain, or men- System table.
tal status ➤ Ensure that this procedure is per-
Other considerations: testinal study or video swallow.
• The procedure may be terminated if ➤ Record the date of the last menstrual
chest pain, or severe cardiac arrhyth- period and determine the possibility
mias occur. of pregnancy in perimenopausal
women.
and other pretesting preparations may ➤ Obtain a list of the medications the
patient is taking.
repeated. ➤ Explain to the patient that some pain
may be experienced during the test,
• A potential complication of a barium and there may be moments of dis-
swallow is barium-induced fecal comfort. Explain the purpose of the
impaction. test, how the procedure is per-
formed, and the need to swallow
• Ensure that the procedure is done after contrast medium. Inform the patient
cholangiography and barium enema. that the procedure is performed in a
radiology department, usually by a
• Consultation with a physician should physician and support staff, and takes
occur before the procedure for radia- approximately 15 to 30 minutes.
patients or patients who are lactating. issues, as well as concern for mod-
• Risks associated with radiographic over- esty, is important in providing psy-
exposure can result from frequent x-ray chological support before, during,
the patient should wear a protective ➤ Instruct the patient to fast and
lead apron, stand behind a shield, or restrict fluids for 8 hours prior to the
procedure.
being done. Personnel working in the ➤ Instruct the patient to remove
area where the examination is being jewelry or other metallic objects.
their level of exposure to radiation. Intratest:
Nursing Implications and tions and pretesting preparations for
at least 6 hours prior to the proce-
Procedure ● ● ● ● ● ● ● ● ● ● ●
dure. Ensure that the patient has
Pretest: prior to the procedure.
➤ Inform the patient that the procedure ➤ Have emergency equipment readily
assesses the esophagus. available.
Barium Swallow 195
➤ Patients are given a gown, robe, and as directed by the health care practi-
foot coverings to wear and instructed tioner.
to void prior to the procedure. ➤ If iodine is used, monitor for reac-
➤ Observe standard precautions, and tion to iodinated contrast medium,
follow the general guidelines in including rash, urticaria, tachycardia,
Appendix A. hyperpnea, hypertension, palpita-
tions, nausea, or vomiting.
and to follow directions. Instruct the ➤ Carefully monitor the patient for
patient to remain still throughout the fatigue and fluid and electrolyte
procedure because movement pro- imbalance.
duces unreliable results. ➤ Instruct the patient to take a mild
➤ Place the patient in the supine posi- laxative and increase fluid intake (four
tion on an exam table, or have the 8-ounce glasses) to aid in elimination
patient stand in front of an x-ray fluo- of barium, unless contraindicated.
roscopy screen. ➤ Instruct the patient that stools will be
white or light in color for 2 to 3 days.
➤ An initial image is taken, and the
If the patient is unable to eliminate
patient is asked to swallow a barium
the barium, or if stools do not return
solution with or without a straw.
to normal color, the patient should
➤ Images are taken at different angles notify the physician.
and positions to aid in the evaluation ➤ A written report of the examination
of patient’s problem. will be completed by a health care
➤ The patient may be asked to drink practitioner specializing in this branch
additional barium to complete the of medicine. The report will be sent
study. Swallowing the additional to the requesting health care practi-
barium evaluates the passage of tioner, who will discuss the results
barium from the esophagus into the with the patient.
stomach. ➤ Depending on the results of this pro-
➤ Return the patient to a comfortable cedure, additional testing may be
position; help the patient from the needed to evaluate or monitor pro-
x-ray table to a chair or stretcher. gression of the disease process and
determine the need for a change in
➤ The results are recorded manually, therapy. Evaluate test results in rela-
on film, or by automated equipment tion to the patient’s symptoms and
in a computerized system for recall other tests performed.
Related diagnostic tests:
tioner.
Post-test: chest x-ray, computed tomography
thoracic, endoscopy, magnetic reso-
➤ Instruct the patient to resume usual nance imaging chest, and thyroid
diet, fluids, medications, or activity, scan.
BILIRUBIN AND BILIRUBIN FRACTIONS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Conjugated/direct bilirubin, unconjugated/indirect

bilirubin, delta bilirubin, TBil.

(1 mL) collected in green-top (heparin) tube or in a heparinized microtainer
is also acceptable.
REFERENCE VALUE: (Method: Spectrophotometry) Total bilirubin levels in

infants should decrease to adult levels by day 10 as the development of the
hepatic circulatory system matures. Values in breast-fed infants may take
longer to reach normal adult levels. Values in premature infants may initially
be higher than in full-term infants and also take longer to decrease to normal
levels.

Bilirubin Units Units 17.1)
Total bilirubin
Newborn–1 d 1.4–8.7 mg/dL 24–149 mol/L
1–2 d 3.4–11.5 mg/dL 58–97 mol/L
3–5 d 1.5–12.0 mg/dL 26–205 mol/L
1 mo–adult 0.3–1.2 mg/dL 5–21 mol/L
Unconjugated bilirubin Less than 1.1 mg/dL Less than 19 mol/L
Conjugated bilirubin Less than 0.3 mg/dL Less than 5 mol/L
Delta bilirubin Less than 0.2 mg/dL Less than 3 mol/L
DESCRIPTION & RATIONALE: Biliru- to urobilin. Urobilin is then excreted

bin is a byproduct of heme catabolism in the feces. Increases in bilirubin lev-
from aged red blood cells. Bilirubin is els can result from prehepatic and/or
primarily produced in the liver, spleen, posthepatic conditions, making frac-
and bone marrow. Total bilirubin is tionation useful in determining the
the sum of unconjugated bilirubin, cause of the increase in total bilirubin
monoglucuronide and diglucuronide, levels. Delta bilirubin has a longer
conjugated bilirubin, and albumin- half-life than the other bilirubin frac-
bound delta bilirubin. Unconjugated tions and therefore remains elevated
bilirubin is carried to the liver by albu- during convalescence after the other
min, where it becomes conjugated. In fractions have decreased to normal lev-
the small intestine, conjugated biliru- els. When bilirubin concentration
bin converts to urobilinogen and then increases, the yellowish pigment
Bilirubin and Bilirubin Fractions 197
deposits in skin and sclera. This Cholestatic drug reactions

increase in yellow pigmentation is Cirrhosis
termed jaundice or icterus. ■ Hepatitis
Hepatocellular damage
INDICATIONS: Infectious mononucleosis
• Assist in the differential diagnosis of
obstructive jaundice • Posthepatic jaundice
Advanced tumors of the liver
• Assist in the evaluation of liver and bil-
iary disease Biliary obstruction
• Monitor the effects of drug reactions • Other conditions

on liver function Anorexia or starvation
• Monitor the effects of phototherapy on Premature or breastfed infants
jaundiced newborns Hypothyroidism
• Monitor jaundice in newborn patients Decreased in: N/A
RESULT
CRITICAL VALUES: Greater than 15
Increased in: mg/dL
• Prehepatic (hemolytic) jaundice Note and immediately report to the
Erythroblastosis fetalis health care practitioner any critically
Hematoma increased values and related symptoms.
Hemolytic anemias Sustained hyperbilirubinemia can
result in brain damage. Kernicterus refers
Pernicious anemia
to the deposition of bilirubin in the basal
Physiologic jaundice of the ganglia and brainstem nuclei. There is no
newborn exact level of bilirubin that puts infants at
The post–blood transfusion period, risk for developing kernicterus. Symptoms
when a number of units are of kernicterus in infants include lethargy,
rapidly infused or in the case of a poor feeding, upward deviation of the
delayed transfusion reaction eyes, and seizures. Intervention for infants
Red blood cell enzyme may include early frequent feedings to
abnormalities (i.e., glucose-6- stimulate gastrointestinal motility, pho-
phosphate dehydrogenase, totherapy, and exchange transfusion.
pyruvate kinase, spherocytosis)
• Hepatic jaundice—bilirubin conjuga- INTERFERING FACTORS:
tion failure • Drugs that may increase bilirubin levels
Crigler-Najjar syndrome by causing cholestasis include amitri-
• Hepatic jaundice—disturbance in ptyline, anabolic steroids, androgens,
bilirubin transport benzodiazepines, chlorothiazide, chlor-
propamide, dapsone, erythromycin,
Dubin-Johnson syndrome estrogens, ethionamide, gold salts,
(preconjugation transport failure)
imipramine, mercaptopurine, nitrofu-
Gilbert’s syndrome rans, oral contraceptives, penicillins,
(postconjugation transport failure) phenothiazines, progesterone, pro-
• Hepatic jaundice—liver damage or poxyphene, sulfonamides, tamoxifen,
necrosis and tolbutamide.
Alcoholism • Drugs that may increase bilirubin
Cholangitis levels by causing hepatocellular damage
Cholecystitis include acetaminophen (toxic), acetyl-
salicylic acid, allopurinol, amiodarone, results of previously performed labo-

anabolic steroids, anticonvulsants, ratory tests, surgical procedures,
asparaginase, azithromycin, bromocrip- and other diagnostic procedures. For
tine, captopril, cephalosporins, chlo- related laboratory tests, refer to the
Hepatobiliary System table.
ramphenicol, clindamycin, clofibrate,
danazol, enflurane, ethambutol, ethion- ➤ Obtain a list of the medications the
amide, fenofibrate, fluconazole, fluoro-
quinolones, foscarnet, gentamicin, ceuticals. The requesting health care
indomethacin, interferon, interleukin- practitioner and laboratory should be
2, levamisole, levodopa, lincomycin, advised if the patient regularly uses
low-molecular-weight heparin, methyl- these products so their effects can
dopa, monoamine oxidase inhibitors, be taken into consideration when
naproxen, nifedipine, nitrofurans, oral reviewing results.
contraceptives, probenecid, procaina- ➤ Review the procedure with the
mide, quinine, ranitidine, retinol, patient. Inform the patient that spec-
ritodrine, sulfonylureas, tetracyclines, imen collection takes approximately
tobramycin, and verapamil. 5 to 10 minutes. Address concerns
• Drugs that may increase bilirubin levels Explain to the patient that there may
by causing hemolysis include ampho- be some discomfort during the
tericin B, carbamazepine, carbutamide, venipuncture.
cephaloridine, cephalothin, chlorpro- ➤ Sensitivity to cultural and social
mazine, chlorpropamide, dinitrophe- issues, as well as concern for mod-
nol, ibuprofen, insulin, isoniazid, esty, is important in providing psy-
levodopa, mefenamic acid, melphalan, chological support before, during,
methotrexate, methyldopa, penicillins,
phenacetin, procainamide, quinidine, ➤ There are no food, fluid, or medica-
quinine, rifampin, stibophen, sulfon- tion restrictions unless by medical
direction.
amides, and tolbutamide.
• Bilirubin is light sensitive. Therefore, Intratest:
the collection container should be suit- ➤ If the patient has a history of severe
ably covered to protect the specimen allergic reaction to latex, care should
from light between the time of collec- be taken to avoid the use of equip-
tion and analysis. ment containing latex.
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to assess liver function. tubes with the corresponding patient
➤ Obtain a history of the patient’s com- demographics, date, and time of col-
plaints, including a list of known lection. Perform a venipuncture; col-
allergens (especially allergies or sen- lect the specimen in a 5-mL red- or
sitivities to latex), and inform the tiger-top tube.
appropriate health care practitioner ➤ Remove the needle and place a
accordingly. gauze over the puncture site and
➤ Obtain a history of the patient’s apply gentle pressure to stop bleed-
hepatobiliary system, as well as ing. Observe venipuncture site for
Bilirubin and Bilirubin Fractions 199
bleeding or hematoma formation. The cirrhotic patient should be care-

Apply paper tape over gauze or fully observed for the development
replace with adhesive bandage. of ascites, in which case, fluid and
➤ Protect the specimen from light and electrolyte balance requires strict
promptly transport the specimen to attention. The alcoholic patient
the laboratory for processing and should be encouraged to avoid alco-
analysis. hol and also to seek appropriate
counseling for substance abuse.
or in a computerized system for re- ➤ Intervention for hyperbilirubinemia in
call and postprocedure interpretation the neonatal patient may include
by the appropriate health care practi- early frequent feedings (to stimulate
tioner. gastrointestinal motility), photother-
apy, and exchange transfusion.
➤ Nutritional considerations: Increased care practitioner, who will discuss
bilirubin levels may be associated the results with the patient.
with liver disease. Dietary recom-
mendations may be indicated ➤ Reinforce information given by the
depending on the condition and patient’s health care provider regard-
severity of the condition. Currently, ing further testing, treatment, or
for example, there are no specific referral to another health care
medications that can be given to provider. Answer any questions or
cure hepatitis, but elimination of address any concerns voiced by the
alcohol ingestion and a diet opti- patient or family.
mized for convalescence are com- ➤ Depending on the results of this pro-
monly included in the treatment plan. cedure, additional testing may be
A high-calorie, high-protein, moder- performed to evaluate or monitor
ate-fat diet with a high fluid intake is progression of the disease process
often recommended for the patient and determine the need for a change
with hepatitis. Treatment of cirrhosis in therapy. Evaluate test results in
is different because a low-protein relation to the patient’s symptoms
diet may be in order if the patient’s and other tests performed.
liver has lost the ability to process
the end products of protein metabo- Related laboratory tests:
lism. A diet of soft foods may also be
required if esophageal varices have ➤ Related laboratory tests include
developed. Ammonia levels may be alanine aminotransferase, albumin,
used to determine whether protein alkaline phosphatase, ammonia,
should be added to or reduced from amylase, antimitochondrial antibody,
the diet. Patients should be encour- anti–smooth muscle antibody, 1-
aged to eat simple carbohydrates antitrypsin/phenotyping, aspartate
and emulsified fats (as in homoge- aminotransferase, cholesterol, coag-
nized milk or eggs), as opposed to ulation factor assays, complete
complex carbohydrates (e.g., starch, blood count, copper, -glutamyltrans-
fiber, and glycogen [animal carbohy- ferase, hepatitis serologies, infec-
drates]) and complex fats, which tious mononucleosis screen, lipase,
would require additional bile to emul- liver biopsy, protein, prothrombin
sify them so that they can be used. time, and urinalysis.
BIOPSY, BLADDER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Bladder tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal tissue or cells.
DESCRIPTION & RATIONALE: A urol- • This test is contraindicated in patients
ogist performs a biopsy of the bladder with an acute infection of the bladder,
during cystoscopic examination. The urethra, or prostate.
procedure is usually carried out under • This procedure is contraindi-
general anesthesia. After the bladder is cated in patients with bleeding
filled with saline for irrigation, the disorders.
bladder and urethra are examined by
direct and lighted visualization using a before the procedure may cause the
cystoscope. A sample of suspicious procedure to be canceled or repeated.
bladder tissue is then excised and
examined macroscopically and micro-
scopically to determine the presence Nursing Implications and
of cell morphology and tissue abnor- Procedure ● ● ● ● ● ● ● ● ● ● ●
malities. ■
Pretest:
• Assist in confirmation of malignant used to establish a histologic diagno-
lesions of the bladder or ureter, espe- sis of bladder disease.
cially if tumor is seen by radiological ➤ Obtain a history of the patient’s com-
examination plaints, including a list of known
• Assist in the evaluation of cases in
sitivities to latex or anesthetics), and
which symptoms such as hematuria inform the appropriate health care
persist after previous treatment (e.g., practitioner accordingly.
removal of polyps or kidney stones)
• Monitor existing recurrent benign itourinary and immune systems, any
lesions for malignant changes bleeding disorders, and results of
tests (especially bleeding time,
RESULT: Positive findings in neoplasm of complete blood count, partial throm-
the bladder or ureter. boplastin time, platelets, and pro-
thrombin time), surgical procedures,
CRITICAL VALUES: N/A and other diagnostic procedures. For
Biopsy, Bladder 201
related tests, refer to the Genitouri- consent has been signed prior to the
nary and Immune System tables. procedure and before administering
➤ Record the date of the last menstrual any medications.
of pregnancy in perimenopausal Intratest:
women. ➤ Ensure that the patient has complied
➤ Note any recent procedures that can with dietary restrictions; assure that
interfere with test results. food has been restricted for at least
6 to 8 hours prior to the procedure.
patient is taking, including antico- ➤ Ensure that anticoagulant therapy
agulant therapy, acetylsalicylic acid, has been withheld for the appropri-
herbs, nutritional supplements, and ate amount of days prior to the pro-
nutraceuticals, especially those cedure. Amount of days to withhold
known to affect coagulation. It is rec- medication is dependent on the type
ommended that use be discontinued of anticoagulant. Notify the health
14 days before dental or surgical pro- care practitioner if patient anticoagu-
cedures. The requesting health care lant therapy has not been withheld.
practitioner and laboratory should be ➤ Have emergency equipment readily
advised if the patient regularly uses available.
can be taken into consideration ➤ Have the patient void before the pro-
when reviewing results. cedure.
➤ Review the procedure with the ➤ Observe standard precautions, and
patient. Inform patients that they follow the general guidelines in
may experience back pain and burn- Appendix A. Positively identify the
ing or pressure in the genital area patient, and label the appropriate
after the procedure. Prophylactic collection containers with the corre-
antibiotics may be administered sponding patient demographics,
before the procedure in certain date and time of collection, and site
cases. Address concerns about pain location.
related to the procedure. Explain to ➤ Assist the patient to a comfortable
the patient that a general anesthesia position, and direct the patient to
will be administered prior to the breathe normally during the begin-
biopsy. Explain to the patient that no ning of the general anesthetic.
pain will be experienced during the ➤ Record baseline vital signs, and con-
biopsy. Inform the patient that the tinue to monitor throughout the pro-
biopsy is performed under sterile cedure. Protocols may vary from
conditions by a health care practi- facility to facility.
tioner specializing in this procedure.
The procedure usually takes about Cystoscopy:
30 to 45 minutes to complete.
➤ Sensitivity to cultural and social ➤ After administration of general anes-
issues, as well as concern for mod- thesia, place the patient in a litho-
esty, is important in providing psy- tomy position on the examination
chological support before, during, table (with the feet up in stirrups).
and after the procedure. Drape the patient’s legs. Clean the
external genitalia with a suitable anti-
➤ Explain that an intravenous (IV) line septic solution and drape the area
will be inserted to allow infusion of with sterile towels.
IV fluids, antibiotics, anesthetics, and
analgesics. ➤ Once the cystoscope is inserted, the
bladder is irrigated with saline. A
➤ Instruct the patient that nothing tissue sample is removed using a
should be taken by mouth for 6 to 8 cytology brush or biopsy forceps.
hours prior to a general anesthetic. Catheters may be used to obtain
➤ Make sure a written and informed samples from the ureter.
Open biopsy: ➤ Inform the patient that blood may be

seen in the urine after the first or
➤ After administration of general second postprocedural voiding.
anesthesia and surgical prep are
completed, an incision is made, sus- ➤ Instruct the patient to report any fur-
picious areas are located, and tissue ther changes in urinary pattern, vol-
samples are collected. ume, or appearance.
General: Open biopsy:

➤ Monitor the patient for complications ➤ Observe the biopsy site for bleeding,
related to the procedure (e.g., aller- inflammation, or hematoma forma-
gic reaction, anaphylaxis). tion.
➤ Place tissue samples in properly ➤ Instruct the patient in the care and
labeled specimen container contain- assessment of the site. Instruct
ing formalin solution, and promptly the patient to report any redness,
transport the specimen to the labo- edema, bleeding, or pain at the
ratory for processing and analysis. biopsy site. Instruct the patient to
➤ The results are recorded manually keep the site clean and change the
or in a computerized system for dressing as needed.
General:
practitioner. ➤ Assess for nausea, pain, and bladder
spasms. Administer antiemetic, anal-
Post-test: gesic, and antispasmodic medica-
tions as needed and as directed by
➤ Instruct the patient to resume preop- the health care practitioner.
erative diet, as directed by the health ➤ Administer antibiotic therapy if
care practitioner. Assess the patient’s ordered. Remind the patient of the
ability to swallow before allowing the importance of completing the entire
patient to attempt liquids or solid course of antibiotic therapy, even if
foods. signs and symptoms disappear
➤ Monitor vital signs and neurologic before completion of therapy.
status every 15 minutes for 1 hour,
then every 2 hours for 4 hours, and
then as ordered by the health care
practitioner specializing in this
practitioner. Monitor temperature
branch of medicine. The report will
every 4 hours for 24 hours. Compare
with baseline values. Notify the
practitioner, who will discuss the
health care practitioner if tempera-
results with the patient.
ture is elevated. Protocols may vary
from facility to facility. ➤ Recognize anxiety related to test
results. Discuss the implications of
➤ Monitor fluid intake and output for 24
abnormal test results on the patient’s
hours. Instruct the patient on intake
lifestyle. Provide teaching and infor-
and output recording and provide
mation regarding the clinical implica-
appropriate measuring containers.
tions of the test results, as
➤ Encourage fluid intake of 3000 mL in appropriate. Educate the patient
24 hours, unless contraindicated. regarding access to counseling serv-
➤ Observe for delayed allergic reac- ices.
tions, such as rash, urticaria, tachy- ➤ Reinforce information given by the
cardia, hyperpnea, hypertension, patient’s health care provider regard-
palpitations, nausea, or vomiting. ing further testing, treatment, or
➤ Instruct the patient to immediately referral to another health care
report pain, chills, or fever. Assess for provider. Answer any questions or
infection, hemorrhage, or perforation address any concerns voiced by the
of the bladder. patient or family.
Biopsy, Bone 203
➤ Instruct the patient in the use of any performed to evaluate or monitor

ordered medications. Explain the progression of the disease process
importance of adhering to the ther- and determine the need for a change
apy regimen. As appropriate, instruct in therapy. Evaluate test results in
the patient in significant side effects relation to the patient’s symptoms
and systemic reactions associated and other tests performed.
responding literature provided by a Related laboratory tests:
pharmacist. ➤ Related laboratory tests include rou-
➤ Depending on the results of this pro- tine urinalysis and urine bladder can-
cedure, additional testing may be cer test.
BIOPSY, BONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Bone tissue.
REFERENCE VALUE: (Method: Microscopic study of bone samples)
No abnormal tissue or cells.
RESULT
DESCRIPTION & RATIONALE: Biopsy
is the excision of a sample of tissue that Abnormal findings in:
can be analyzed microscopically to • Ewing’s sarcoma
determine cell morphology and the
presence of tissue abnormalities. This • Multiple myeloma
test is used to assist in confirming the • Osteoma
diagnosis of cancer when clinical symp-
toms or x-rays are suspicious. After sur- • Osteosarcoma
gical incision to reveal the affected area,
bone biopsy is obtained. An alternative CRITICAL VALUES: N/A
collection method is needle biopsy, in
which a plug of bone is removed using
a special serrated needle. ■ • This procedure is contraindi-
cated in patients with bleeding
INDICATIONS: disorders.
• Differentiation of a benign from a
malignant bone lesion
before the procedure may cause the pro-
• Radiographic evidence of a bone lesion cedure to be canceled or repeated.
to promote relaxation and reduce

Nursing Implications and discomfort prior to the percutaneous
Procedure ● ● ● ● ● ● ● ● ● ● ● biopsy; a general anesthesia will be
administered prior to the open
Pretest: biopsy. Explain to the patient that no
pain will be experienced during the
➤ Inform the patient that the test is test when general anesthesia is
used to establish a histologic diagno- used, but that any discomfort with a
sis of bone disease. needle biopsy will be minimized with
➤ Obtain a history of the patient’s com- local anesthetics and systemic anal-
plaints, including a list of known gesics. Inform the patient that the
allergens (especially allergies or sen- biopsy is performed under sterile
sitivities to latex or anesthetics), and conditions by a health care practi-
inform the appropriate health care tioner specializing in this procedure.
practitioner accordingly. The surgical procedure usually takes
about 30 minutes to complete, and
sutures may be necessary to close
the site. A needle biopsy usually
tems, any bleeding disorders, and
takes about 20 minutes to complete.
results of previously performed
laboratory tests (especially com- ➤ Sensitivity to cultural and social
plete bleeding time, complete blood issues, as well as concern for mod-
count, partial thromboplastin time, esty, is important in providing psy-
platelets, and prothrombin time), sur- chological support before, during,
gical procedures, and other diagnos- and after the procedure.
tic procedures. For related laboratory ➤ Explain that an intravenous (IV) line
tests, refer to the Immune and will be inserted to allow infusion of
Musculoskeletal System tables. IV fluids, anesthetics, analgesics, or
➤ Record the date of the last menstrual IV sedation.
Open biopsy:
women. ➤ Instruct the patient that nothing
➤ Note any recent procedures that can should be taken by mouth for 6 to 8
interfere with test results. hours prior to a general anesthetic.
➤ Obtain a list of the medications the Needle biopsy:
patient is taking, including anticoagu-
lant therapy, acetylsalicylic acid, ➤ Instruct the patient that nothing
herbs, nutritional supplements, and should be taken by mouth for at least
nutraceuticals, especially those 4 hours prior to the procedure to
known to affect coagulation. It is rec- reduce the risk of nausea and vomit-
ommended that use be discontinued ing.
14 days before dental or surgical pro-
General:
cedures. The requesting health care
practitioner and laboratory should be ➤ Make sure a written and informed
advised if the patient regularly uses consent has been signed prior to the
these products so that their effects procedure and before administering
can be taken into consideration any medications.
➤ Review the procedure with the Intratest:
patient. Inform the patient that it
may be necessary to shave the site ➤ Ensure that the patient has complied
before the procedure. Address con- with dietary restrictions; assure that
cerns about pain related to the pro- food has been restricted for at least
cedure. Explain that a sedative 4 to 8 hours depending on the anes-
and/or analgesia will be administered thetic chosen for the procedure.
Biopsy, Bone 205
➤ Ensure that anticoagulant therapy inserted to remove the specimen.

has been withheld for the appropri- Pressure is applied to the site for 3
ate amount of days prior to the pro- to 5 minutes, then a sterile pressure
cedure. Amount of days to withhold dressing is applied.
medication is dependent on the type
of anticoagulant. Notify the health General:
care practitioner if patient anticoagu- ➤ Monitor the patient for complications
lant therapy has not been withheld. related to the procedure (e.g., aller-
➤ Have emergency equipment readily gic reaction, anaphylaxis).
available.
➤ Place tissue samples in properly
➤ Have the patient void before the pro- labeled specimen container contain-
cedure. ing formalin solution, and promptly
➤ Observe standard precautions, and transport the specimen to the labo-
follow the general guidelines in ratory for processing and analysis.
patient, and label the appropriate col-
lection containers with the corre-
sponding patient demographics,
date and time of collection, and site
practitioner.
location.
➤ Assist the patient to the desired Post-test:
position depending on the test site
to be used, and direct the patient to ➤ Instruct the patient to resume preop-
breathe normally during the begin- erative diet, as directed by the health
ning of the general anesthetic. care practitioner. Assess the patient’s
Instruct the patient to cooperate fully ability to swallow before allowing the
and to follow directions. Direct the patient to attempt liquids or solid
patient to breathe normally and to foods.
avoid unnecessary movement during
➤ Monitor vital signs and neurologic
the local anesthetic and the proce-
dure.
➤ Record baseline vital signs, and con- then as ordered by the health care
tinue to monitor throughout the pro- practitioner. Monitor temperature
cedure. Protocols may vary from every 4 hours for 24 hours. Compare
facility to facility. with baseline values. Notify the
➤ After the administration of general or health care practitioner if tempera-
local anesthesia, shave and cleanse ture is elevated. Protocols may vary
the site with an antiseptic solution, from facility to facility.
and drape the area with sterile
towels.
Open biopsy: cardia, hyperpnea, hypertension,
palpitations, nausea, or vomiting.
➤ After administration of general
anesthesia and surgical prep are ➤ Observe the biopsy site for bleed-
completed, an incision is made, sus- ing, inflammation, or hematoma for-
picious area(s) are located, and tis- mation.
sue samples are collected. ➤ Instruct the patient in the care and
Needle biopsy: assessment of the site. Instruct the
patient to report any redness, edema,
➤ Instruct the patient to take slow bleeding, or pain at the biopsy site.
deep breaths when the local anes- Instruct the patient to immediately
thetic is injected. Protect the site report chills or fever. Instruct the
with sterile drapes. A small incision patient to keep the site clean and
is made and the biopsy needle is change the dressing as needed.
➤ Assess for nausea and pain. Adminis- questions or address any concerns
ter antiemetic and analgesic medica- voiced by the patient or family.
tions as needed and as directed by ➤ Instruct the patient in the use of any
the health care practitioner. ordered medications. Explain the
➤ Administer antibiotic therapy if importance of adhering to the ther-
ordered. Remind the patient of the apy regimen. As appropriate, instruct
importance of completing the entire the patient in significant side effects
course of antibiotic therapy, even if and systemic reactions associated
signs and symptoms disappear with the prescribed medication.
before completion of therapy. Encourage him or her to review cor-
➤ A written report of the examination responding literature provided by a
will be completed by a health care pharmacist.
practitioner specializing in this ➤ Depending on the results of this pro-
branch of medicine. The report will cedure, additional testing may be
be sent to the requesting health care performed to evaluate or monitor
practitioner, who will discuss the progression of the disease process
results with the patient. and determine the need for a change
➤ Recognize anxiety related to test in therapy. Evaluate test results in
results. Discuss the implications of relation to the patient’s symptoms
abnormal test results on the and other tests performed.
patient’s lifestyle. Provide teaching
and information regarding the clinical Related laboratory tests:
implications of the test results, as ➤ Related laboratory tests include alka-
appropriate. Educate the patient line phosphatase; bone marrow
regarding access to counseling serv- biopsy; calcium and urine calcium;
ices. complete blood count; cortisol;
➤ Reinforce information given by the immunofixation electrophoresis;
patient’s health care provider regard- immunoglobulins A, G, and M; 2-
ing further testing, treatment, or microglobulin; parathyroid hormone;
referral to another health care phosphorus; urine and serum pro-
provider. Inform the patient of a fol- tein electrophoresis; urine and
low-up appointment for removal of serum total protein; urinalysis; and
sutures, if indicated. Answer any vitamin D.
BIOPSY, BONE MARROW

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Bone marrow aspirate, bone core biopsy, marrow and peripheral
smears.
REFERENCE VALUE: (Method: Microscopic study of bone and bone marrow

samples, flow cytometry) Reference ranges are subject to many variables, and
therefore the laboratory should be consulted for their specific interpretation.
Some generalities may be commented on regarding findings as follows:
Biopsy, Bone Marrow 207
• Ratio of marrow fat to cellular ele- tion, presence of megakaryocytes, and

ments is related to age, with the absence of fibrosis or tumor cells.
amount of fat increasing with increas-
• The myeloid-to-erythrocyte ratio
ing age.
(M:E) is 2:1 to 4:1 in adults. It may be
• Normal cellularity, cellular distribu- slightly higher in children.
Differential Parameter Conventional Units

Erythrocyte precursors 18–32%
Myeloblasts 0–2%
Promyelocytes 2–6%
Myelocytes 9–17%
Metamyelocytes 7–25%
Bands 10–16%
Neutrophils 18–28%
Eosinophils and precursors 1–5%
Basophils and precursors 0–1%
Monocytes and precursors 1–5%
Lymphocytes 9–19%
Plasma cells 0–1%
with differential showing increased

DESCRIPTION & RATIONALE: This numbers of leukocyte precursors
test involves the removal of a small • Evaluate hepatomegaly or splenomegaly
sample of bone marrow by aspiration,
needle biopsy, or open surgical biopsy • Identify bone marrow hyperplasia or
hypoplasia
for a complete hematologic analysis.
The marrow is a suspension of blood, • Monitor effects of exposure to bone
fat, and developing blood cells, which marrow depressants
is evaluated for morphology and • Monitor bone marrow response to
examined for all stages of maturation; chemotherapy or radiation therapy
iron stores; and M:E. Sudan black B
and periodic acid–Schiff (PAS) stains RESULT
can be performed for microscopic
Increased reticulocytes:
examination to differentiate the types
of leukemia, although flow cytometry • Compensated red blood cell (RBC) loss
and cytogenetics have become more • Response to vitamin B12 therapy
commonly used techniques for this
purpose. ■ Decreased reticulocytes:
INDICATIONS: • Aplastic crisis of sickle cell anemia or

• Determine marrow differential (pro- hereditary spherocytosis
portion of the various types of cells
present in the marrow) and M:E Increased neutrophils (total):
• Evaluate abnormal results of complete • Acute myeloblastic leukemia

blood count or white blood cell count • Myeloid (chronic) leukemias
Decreased neutrophils (total): Increased M:E:

• Aplastic anemia • Bone marrow failure
• Leukemias (monocytic and lympho- • Infections
blastic)
• Leukemoid reactions
Increased lymphocytes:
• Myeloid leukemia
• Aplastic anemia
• Lymphatic leukemia Decreased M:E:
• Lymphomas • Anemias
• Lymphosarcoma • Hepatic disease
• Mononucleosis • Polycythemia vera
• Viral infections • Posthemorrhagic hematopoiesis
Increased plasma cells: Increased normoblasts:

• Cancer • Anemias
• Cirrhosis of the liver • Chronic blood loss
• Connective tissue disorders • Polycythemia vera
• Hypersensitivity reactions
Decreased normoblasts:
• Infections
• Aplastic anemia
• Macroglobulinemia
• Ulcerative colitis • Folic acid or vitamin B12 deficiency
• Hemolytic anemia
Increased megakaryocytes:
• Hemorrhage Increased eosinophils:
• Increasing age • Bone marrow cancer
• Infections • Lymphadenoma
• Megakaryocytic myelosis • Myeloid leukemia
• Myeloid leukemia
• Pneumonia
• Polycythemia vera INTERFERING FACTORS:
• Recent blood transfusions, iron ther-
• Thrombocytopenia
apy, or administration of cytotoxic
agents may alter test results.
Decreased megakaryocytes:
• Agranulocytosis • This procedure is contraindicated
in patients with known bleeding
• Cirrhosis of the liver disorders.
• Pernicious aplastic anemia
• Radiation therapy before the procedure may cause the
• Thrombocytopenic purpura procedure to be canceled or repeated.
Biopsy, Bone Marrow 209
cedure. Explain that a sedative

Nursing Implications and and/or analgesia will be administered
Procedure ● ● ● ● ● ● ● ● ● ● ● to promote relaxation and reduce
discomfort prior to the percutaneous
Pretest: biopsy; a general anesthesia will be
administered prior to the open
➤ Inform the patient that the test is biopsy. Explain to the patient that no
used to establish a histologic diagno- pain will be experienced during the
sis of bone marrow and immune sys- test when general anesthesia is
tem disease. used, but that any discomfort with a
➤ Obtain a history of the patient’s com- needle biopsy will be minimized with
plaints, including a list of known local anesthetics and systemic anal-
allergens (especially allergies or sen- gesics. Inform the patient that the
sitivities to latex or anesthetics), and biopsy is performed under sterile
inform the appropriate health care conditions by a health care practi-
practitioner accordingly. tioner specializing in this procedure.
The surgical procedure usually takes
about 30 minutes to complete, and
hematopoietic and immune sys-
sutures may be necessary to close
the site. A needle biopsy usually
takes about 20 minutes to complete.
ratory tests (especially bleeding
time, complete blood count, partial ➤ Sensitivity to cultural and social
thromboplastin time, platelets, and issues, as well as concern for mod-
prothrombin time), surgical proce- esty, is important in providing psy-
dures, and other diagnostic proce- chological support before, during,
dures. For related laboratory tests, and after the procedure.
refer to the Hematopoietic and ➤ Explain that an intravenous (IV) line
Immune System tables. may be inserted to allow infusion of
➤ Record the date of the last menstrual IV fluids, anesthetics, or sedatives.
period and determine the possibility ➤ Instruct the patient that nothing
of pregnancy in perimenopausal should be taken by mouth for at least
women. 4 hours prior to the procedure to
➤ Note any recent procedures that can reduce the risk of nausea and
interfere with test results. vomiting.
lant therapy, acetylsalicylic acid,
any medications.
nutraceuticals, especially those Intratest:
known to affect coagulation. It is rec-
ommended that use be discontinued ➤ Ensure that the patient has complied
14 days before dental or surgical pro- with dietary restrictions; assure that
cedures. The requesting health care food has been restricted for at least
practitioner and laboratory should be 4 to 8 hours depending on the anes-
advised if the patient regularly uses thetic chosen for the procedure.
these products so that their effects ➤ Ensure that anticoagulant therapy
can be taken into consideration has been withheld for the appropri-
when reviewing results. ate amount of days prior to the pro-
➤ Review the procedure with the cedure. Amount of days to withhold
patient. Inform the patient that it medication is dependent on the type
may be necessary to shave the site of anticoagulant. Notify the health
before the procedure. Address con- care practitioner if patient anticoagu-
cerns about pain related to the pro- lant therapy has not been withheld.
➤ Have emergency equipment readily injected. Protect the site with sterile
available. drapes.
➤ Have the patient void before the pro- ➤ Local anesthetic is introduced deeply
cedure. enough to include periosteum. A cut-
➤ Observe standard precautions, and ting biopsy needle is introduced
follow the general guidelines in through a small skin incision and
Appendix A. bored into the marrow cavity. A core
needle is introduced through the cut-
➤ Positively identify the patient, and ting needle, and a plug of marrow is
label the appropriate collection con- removed. The needles are with-
tainers with the corresponding drawn, and the specimen is placed in
patient demographics, date and time a preservative solution. Pressure is
of collection, and site location. applied to the site for 3 to 5 minutes,
➤ Assist the patient to the desired and then a pressure dressing is
position depending on the test site applied.
to be used. In young children, the
most frequently chosen site is the General:
proximal tibia. Vertebral bodies T10
through L4 are preferred in older chil-
dren. In adults, the sternum or iliac
gic reaction, anaphylaxis).
crests are the preferred sites. Place
the patient in the prone, sitting, or ➤ Place tissue samples in properly
side-lying position for the vertebral labeled specimen container contain-
bodies; the side-lying position for ing formalin solution, and promptly
iliac crest or tibial sites; or the supine transport the specimen to the labo-
position for the sternum. Instruct the ratory for processing and analysis.
patient to cooperate fully and to fol- ➤ The results are recorded manually
low directions. Direct the patient to or in a computerized system for
breathe normally and to avoid unnec- recall and postprocedure interpreta-
essary movement during the local tion by the appropriate health care
anesthetic and the procedure. practitioner
➤ Record baseline vital signs, and con-
tinue to monitor throughout the pro- Post-test:
cedure. Protocols may vary from
facility to facility. ➤ Instruct the patient to resume preop-
erative diet, as directed by the health
➤ After the administration of general or care practitioner.
local anesthesia, shave and cleanse
the site with an antiseptic solution, ➤ Monitor vital signs and neurologic
and drape the area with sterile tow- status every 15 minutes for 1 hour,
els. then every 2 hours for 4 hours, and
Needle aspiration: practitioner. Monitor temperature
every 4 hours for 24 hours. Compare
➤ The health care practitioner will anes-
thetize the site with procaine or lido-
caine, and then insert a needle with
stylet into the marrow. The stylet is
from facility to facility.
removed, a syringe attached, and a
0.5-mL aliquot of marrow withdrawn. ➤ Observe for delayed allergic reac-
The needle is removed, and pressure tions, such as rash, urticaria, tachy-
is applied to the site. The aspirate is cardia, hyperpnea, hypertension,
applied to slides, and, when dry, a fix- palpitations, nausea, or vomiting.
ative is applied. ➤ Observe the biopsy site for bleeding,
inflammation, or hematoma forma-
Needle biopsy: tion.
➤ Instruct the patient to take slow deep ➤ Instruct the patient in the care and
breaths when the local anesthetic is assessment of the site. Instruct
Biopsy, Breast 211
the patient to report any redness, patient’s health care provider regard-
edema, bleeding, or pain at the ing further testing, treatment, or
biopsy site. Instruct the patient to referral to another health care
immediately report chills or fever. provider. Inform the patient of a fol-
Instruct the patient to keep the site low-up appointment for removal of
clean and change the dressing as sutures, if indicated. Answer any
needed. questions or address any concerns
➤ Assess for nausea and pain. Adminis- voiced by the patient or family.
ter antiemetic and analgesic medica- ➤ Instruct the patient in the use of any
tions as needed and as directed by ordered medications. Explain the
the health care practitioner. importance of adhering to the ther-
➤ Administer antibiotic therapy if apy regimen. As appropriate, instruct
ordered. Remind the patient of the the patient in significant side effects
importance of completing the entire and systemic reactions associated
course of antibiotic therapy, even with the prescribed medication.
if signs and symptoms disappear Encourage him or her to review cor-
before completion of therapy. responding literature provided by a
pharmacist.
will be completed by a health care ➤ Depending on the results of this pro-
practitioner specializing in this branch cedure, additional testing may be
of medicine. The report will be sent performed to evaluate or monitor
to the requesting health care practi- progression of the disease process
tioner, who will discuss the results and determine the need for a change
with the patient. in therapy. Evaluate test results in
➤ Recognize anxiety related to test and other tests performed.
results. Discuss the implications
of abnormal test results on the
patient’s lifestyle. Provide teaching Related laboratory tests:
and information regarding the clinical ➤ Related laboratory tests include com-
implications of the test results, as plete blood count, leukocyte alkaline
appropriate. Educate the patient phosphatase, lymph node biopsy,
regarding access to counseling serv- serum immunofixation electrophore-
ices. sis, urine immunofixation elec-
➤ Reinforce information given by the trophoresis, and vitamin B12.
BIOPSY, BREAST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Breast tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination
of tissue) No abnormal cells or tissue.
any bleeding disorders, and results

DESCRIPTION & RATIONALE: Biopsy of previously performed laboratory
is the excision of a sample of tissue tests (especially bleeding time,
complete blood count, partial throm-
that can be analyzed microscopically boplastin time, platelets, and pro-
to determine cell morphology and the thrombin time), surgical procedures,
presence of tissue abnormalities. Fine and other diagnostic procedures. For
needle and open biopsies of the breast related laboratory tests, refer to the
have become more commonly ordered Immune and Reproductive System
tables.
in recent years as increasing emphasis
on early detection of breast cancer has period and determine the possibility
become stronger. Breast biopsies are of pregnancy in perimenopausal
used to assist in the identification and women.
prognosis of breast cancer. ■ ➤ Note any recent procedures that can
INDICATIONS: ➤ Obtain a list of the medications
• Evidence of breast lesion by palpation, the patient is taking, including anti-
mammography, or ultrasound coagulant therapy, acetylsalicylic
acid, herbs, nutritional supplements,
• Observable breast changes such as “peau
and nutraceuticals, especially those
d’orange” skin, scaly skin of the areola, known to affect coagulation. It is rec-
drainage from the nipple, or ulceration ommended that use be discontinued
of the skin 14 days before dental or surgical pro-
RESULT: Positive findings in carcinoma of practitioner and laboratory should be
the breast. advised if the patient regularly uses
CRITICAL VALUES: N/A can be taken into consideration when
reviewing results.
INTERFERING FACTORS: ➤ Review the procedure with the
• This procedure is contraindi- patient. Inform the patient that it may
cated in patients with bleeding be necessary to shave the site
disorders. before the procedure. Instruct that
• Failure to follow dietary restrictions prophylactic antibiotics may be
before the procedure may cause the pro- administered prior to the procedure.
cedure to be canceled or repeated. to the procedure. Explain that a seda-
tive and/or analgesia will be adminis-
Nursing Implications and tered to promote relaxation and
reduce discomfort prior to the percu-
Procedure ● ● ● ● ● ● ● ● ● ● ●
taneous biopsy; a general anesthesia
will be administered prior to the open
Pretest: biopsy. Explain to the patient that no
➤ Inform the patient that the test is pain will be experienced during the
used to establish a histologic diagno- test when general anesthesia is
sis of breast disease. used, but that any discomfort with a
needle biopsy will be minimized with
➤ Obtain a history of the patient’s com- local anesthetics and systemic anal-
plaints, including a list of known gesics. Inform the patient that the
allergens (especially allergies or sen- biopsy is performed under sterile
sitivities to latex or anesthetics), and conditions by a health care practi-
inform the appropriate health care tioner specializing in this procedure.
practitioner accordingly. The surgical procedure usually takes
➤ Obtain a history of the patient’s about 20 to 30 minutes to complete,
immune and reproductive systems, and sutures may be necessary to
Biopsy, Breast 213
close the site. A needle biopsy sponding patient demographics, date

usually takes about 15 minutes to and time of collection, and site loca-
complete. tion, especially left or right breast.
➤ Sensitivity to cultural and social ➤ Assist the patient to the desired
issues, as well as concern for mod- position depending on the test site
esty, is important in providing psy- to be used, and direct the patient
chological support before, during, to breathe normally during the
and after the procedure. beginning of the general anesthesic.
➤ Explain that an intravenous (IV) line Instruct the patient to cooperate
may be inserted to allow infusion of fully and to follow directions. Direct
IV fluids, anesthetics, analgesics, or the patient to breathe normally and
IV sedation. to avoid unnecessary movement
during the local anesthetic and the
Open biopsy: procedure.
➤ Instruct the patient that nothing ➤ Record baseline vital signs, and
should be taken by mouth for 6 to 8 continue to monitor throughout the
hours prior to a general anesthetic. procedure. Protocols may vary from
facility to facility.
Needle biopsy: ➤ After the administration of general or
➤ Instruct the patient that nothing local anesthesia, shave and cleanse
should be taken by mouth for at the site with an antiseptic solution,
least 4 hours prior to the procedure and drape the area with sterile
to reduce the risk of nausea and towels.
vomiting.
Open biopsy:
General: ➤ After administration of general
➤ Make sure a written and informed anesthesia and surgical prep are
consent has been signed prior to the completed, an incision is made, sus-
procedure and before administering picious area(s) are located, and tis-
any medications. sue samples are collected.
Intratest: Needle biopsy:

➤ Ensure that the patient has complied ➤ Direct the patient to take slow deep
with dietary restrictions; assure that breaths when the local anesthetic
food has been restricted for at least is injected. Protect the site with
4 to 8 hours depending on the anes- sterile drapes. Instruct the patient
thetic chosen for the procedure. to take a deep breath, exhale force-
fully, and hold the breath while the
➤ Ensure that anticoagulant therapy biopsy needle is inserted and rotated
has been withheld for the appropri- to obtain a core of breast tissue.
ate amount of days prior to the pro- Once the needle is removed, the
cedure. Amount of days to withhold patient may breathe. Pressure is
medication is dependent on the type applied to the site for 3 to 5 minutes,
of anticoagulant. Notify the health then a sterile pressure dressing is
care practitioner if patient anticoagu- applied.
lant therapy has not been withheld.
➤ Have emergency equipment readily General:
available. ➤ Monitor the patient for complications
➤ Have the patient void before the pro- related to the procedure (e.g., aller-
cedure. gic reaction, anaphylaxis).
➤ Observe standard precautions, and ➤ Place tissue samples in formalin
follow the general guidelines in solution. Label the specimen, indi-
Appendix A. Positively identify the cating site location, and promptly
patient and label the appropriate col- transport the specimen to the labo-
lection containers with the corre- ratory for processing and analysis.
➤ The results are recorded manually or of medicine. The report will be sent
in a computerized system for recall to the requesting health care practi-
and postprocedure interpretation by tioner, who will discuss the results
the appropriate health care practi- with the patient.
tioner ➤ Recognize anxiety related to test
Post-test:
➤ Instruct the patient to resume preop- patient’s lifestyle. Provide teaching
erative diet, as directed by the health and information regarding the clinical
care practitioner. Assess the patient’s implications of the test results, as
ability to swallow before allowing appropriate. Educate the patient
the patient to attempt liquids or solid regarding access to counseling serv-
foods. ices.
➤ Monitor vital signs and neurologic ➤ Reinforce information given by
status every 15 minutes for 1 hour, the patient’s health care provider
then every 2 hours for 4 hours, and regarding further testing, treatment,
then as ordered by the health care or referral to another health care
practitioner. Monitor temperature provider. Inform the patient of a fol-
every 4 hours for 24 hours. Compare low-up appointment for removal of
with baseline values. Notify the sutures, if indicated. Instruct and
health care practitioner if tempera- educate the patient how to perform
ture is elevated. Protocols may vary monthly breast self-examination
from facility to facility. and emphasize, as appropriate, the
➤ Observe for delayed allergic reac- importance of having a mammogram
tions, such as rash, urticaria, tachy- performed annually. Answer any
cardia, hyperpnea, hypertension, questions or address any concerns
palpitations, nausea, or vomiting. voiced by the patient or family.
➤ Observe the biopsy site for bleed- ➤ Instruct the patient in the use of any
ing, inflammation, or hematoma for- ordered medications. Explain the
mation. importance of adhering to the ther-
the patient in significant side effects
assessment of the site. Instruct
and systemic reactions associated
the patient to report any redness,
edema, bleeding, or pain at the
Encourage the patient to review cor-
biopsy site. Instruct the patient to
immediately report chills or fever.
pharmacist.
Instruct the patient to keep the site
clean and change the dressing as ➤ Depending on the results of this pro-
needed. cedure, additional testing may be
➤ Assess for nausea and pain. Adminis- performed to evaluate or monitor
ter antiemetic and analgesic medica- progression of the disease process
tions as needed and as directed by and determine the need for a change
the health care practitioner. in therapy. Evaluate test results in
➤ Administer antibiotic therapy if and other tests performed.
ordered. Remind the patient of the
importance of completing the entire
course of antibiotic therapy, even Related laboratory tests:
if signs and symptoms disappear ➤ Related laboratory tests include can-
before completion of therapy. cer antigen 15-3, carcinoembryonic
➤ A written report of the examination antigen, estrogen receptors, HER-
will be completed by a health care 2/neu oncoprotein, and progesterone
practitioner specializing in this branch receptors.
Biopsy, Cervical 215
BIOPSY, CERVICAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cone Biopsy, LEEP.
SPECIMEN: Cervical tissue.
REFERENCE VALUE: (Method: Microscopic examination of tissue cells) No

abnormal cells or tissue.
DESCRIPTION & RATIONALE: Biopsy in conjunction with the local anes-

is the excision of a sample of tissue thetic when this method is used. ■
that can be analyzed microscopically
to determine cell morphology and the INDICATIONS:
presence of tissue abnormalities. The • Follow-up to abnormal Papanicolaou
cervical biopsy is used to assist in con- (Pap) smear, Schiller’s test, or col-
firmation of cancer when screening poscopy
tests are positive. Cervical biopsy is
• Suspected cervical malignancy
obtained using an instrument that
punches into the tissue and retrieves a
tissue sample. Schiller’s test entails RESULT
applying an iodine solution to the
Positive findings in:
cervix. Normal cells pick up the iodine
• Carcinoma in situ
and stain brown. Abnormal cells do
not pick up any color. Punch biopsy • Cervical dysplasia
results may indicate the need for a • Cervical polyps
cone biopsy of the cervix. Cone biopsy
is where a wedge shape of tissue is CRITICAL VALUES: N/A
removed from the cervix by using a
loop electrosurgical excision proce- INTERFERING FACTORS:
dure (LEEP). The LEEP procedure • The test is contraindicated in
can be performed by placing the cases of acute pelvic inflamma-
patient under a general anesthestic; by tory disease or bleeding disorders.
a regional anesthesia, such as a spinal • This test should not be performed
or epidural; or by a cervical block, while the patient is menstruating.
where a local anesthetic is injected • Failure to follow dietary restrictions
into the cervix. The patient is given before the procedure may cause the
oral or intravenous (IV) pain medicine procedure to be canceled or repeated.
and reduce discomfort prior to the

Nursing Implications and percutaneous biopsy; a general
Procedure ● ● ● ● ● ● ● ● ● ● ● anesthesia will be administered prior
to the open biopsy. Explain to the
Pretest: patient that no pain will be experi-
enced during the test when general
➤ Inform the patient that the test is anesthesia is used, but that any dis-
used to establish a histologic diagno- comfort with a needle biopsy will be
sis of cervical disease. minimized with local anesthetics and
➤ Obtain a history of the patient’s com- systemic analgesics. Inform the
plaints, including a list of known patient that the biopsy is performed
allergens (especially allergies or sen- under sterile conditions by a health
sitivities to latex or anesthetics), and care practitioner specializing in this
inform the appropriate health care procedure. The surgical procedure
practitioner accordingly. usually takes about 20 to 30 minutes
to complete, and sutures may be
necessary to close the site.
immune and reproductive systems,
any bleeding disorders, and results ➤ Sensitivity to cultural and social
of previously performed laboratory issues, as well as concern for mod-
tests (especially bleeding time, esty, is important in providing psy-
complete blood count, partial throm- chological support before, during,
boplastin time, platelets, and pro- and after the procedure.
thrombin time), surgical procedures, ➤ Explain that an IV line may be
and other diagnostic procedures. For inserted to allow infusion of IV
related laboratory tests, refer to the fluids, anesthetics, analgesics, or
Immune and Reproductive System IV sedation.
tables.
➤ Record the date of the last menstrual LEEP as an outpatient
period and determine the possibil- procedure:
ity of pregnancy in perimenopausal
women. ➤ Instruct the patient that nothing
➤ Obtain a list of the medications should be taken by mouth for at least
the patient is taking, including anti- 6 to 8 hours prior to a general anes-
coagulant therapy, acetylsalicylic thetic.
and nutraceuticals, especially those LEEP in health care
known to affect coagulation. It is rec- practitioner’s office:
ommended that use be discontinued
14 days before dental or surgical pro- ➤ Instruct the patient that nothing
cedures. The requesting health care should be taken by mouth for at least
practitioner and laboratory should be 4 hours prior to the procedure
advised if the patient regularly uses to reduce the risk of nausea and
these products so that their effects vomiting.
when reviewing results. General:
➤ Review the procedure with the ➤ Make sure a written and informed
patient. Inform the patient that it consent has been signed prior to the
may be necessary to shave the site procedure and before administering
before the procedure. Instruct that any medications.
prophylactic antibiotics may be
administered prior to the procedure. Intratest:
to the procedure. Explain that a ➤ Ensure that the patient has complied
sedative and/or analgesia will be with dietary restrictions; assure that
administered to promote relaxation food has been restricted for at least
Biopsy, Cervical 217
4 to 8 hours depending on the anes- apart the vagina for inspection of the
thetic chosen for the procedure. cervix.
➤ Ensure that anticoagulant therapy ➤ The diseased tissue is removed
has been withheld for the appropri- along with a small amount of healthy
ate amount of days prior to the pro- tissue along the margins of the
cedure. Amount of days to withhold biopsy to ensure that no diseased
medication is dependent on the type tissue is left in the cervix after the
of anticoagulant. Notify health care procedure.
practitioner if patient anticoagulant
therapy has not been withheld. LEEP as an outpatient
➤ Have emergency equipment readily procedure:
available.
➤ After administration of general anes-
➤ Have the patient void before the thesia and surgical prep are com-
procedure. pleted, the procedure is carried out
➤ Observe standard precautions, and as noted above.
Appendix A. Positively identify the General:
patient and label the appropriate col- ➤ Monitor the patient for complications
lection containers with the corre- related to the procedure (e.g., aller-
sponding patient demographics, gic reaction, anaphylaxis).
location. ➤ Place tissue samples in properly
labeled specimen container con-
➤ Have the patient remove clothes taining formalin solution, and pro-
below the waist. Assist the patient mptly transport the specimen to the
into a lithotomy position on a gyne- laboratory for processing and analy-
cologic exam table (with feet in stir- sis.
rups). Drape the patient’s legs.
Instruct the patient to cooperate ➤ The results are recorded manually or
fully and to follow directions. Direct in a computerized system for recall
the patient to breathe normally and and postprocedure interpretation by
to avoid unnecessary movement the appropriate health care practi-
during the local or general anesthetic tioner.
and the procedure.
Post-test:
➤ Punch biopsy: A small round punch is
rotated into the skin to the desired ➤ Instruct the patient to resume preop-
depth. The cylinder of skin is pulled erative diet, as directed by the health
upward with forceps and separated care practitioner. Assess the patient’s
at its base with a scalpel or scissors. ability to swallow before allowing the
If needed, sutures are applied. A ster- patient to attempt liquids or solid
ile dressing is applied over the site. foods.
➤ Record baseline vital signs, and con- ➤ Monitor vital signs and neurologic
tinue to monitor throughout the pro- status every 15 minutes for 1 hour,
cedure. Protocols may vary from then every 2 hours for 4 hours, and
facility to facility. then as ordered by the health care
➤ After the administration of general or practitioner. Monitor temperature
local anesthesia, shave and cleanse every 4 hours for 24 hours. Compare
the site with an antiseptic solution, with baseline values. Notify the
and drape the area with sterile health care practitioner if tempera-
towels. ture is elevated. Protocols may vary
LEEP in the health care
practitioner’s office:
➤ A speculum is inserted into the cardia, hyperpnea, hypertension,
vagina and is opened to gently spread palpitations, nausea, or vomiting.
➤ Instruct the patient to expect a gray- Provide teaching and information

green vaginal discharge for several regarding the clinical implications of
days, some vaginal bleeding may the test results, as appropriate.
occur for up to 1 week but should Educate the patient regarding access
not be heavier than a normal men- to counseling services.
ses, some pelvic pain may occur. ➤ Reinforce information given by the
Instruct the patient to avoid strenu- patient’s health care provider regard-
ous activity for 8 to 24 hours, to ing further testing, treatment, or
avoid douching or intercourse for 2 referral to another health care
weeks or as instructed by the health provider. Answer any questions or
care practitioner, and to report address any concerns voiced by the
excessive bleeding, chills, fever or patient or family.
any other unusual findings to the
health care practitioner. ➤ Instruct the patient in the use of any
➤ Assess for nausea and pain. Adminis- importance of adhering to the ther-
ter antiemetic and analgesic medica- apy regimen. As appropriate, instruct
tions as needed and as directed by the patient in significant side effects
the health care practitioner. and systemic reactions associated
➤ Administer antibiotic therapy if with the prescribed medication.
ordered. Remind the patient of the Encourage her to review corre-
importance of completing the entire sponding literature provided by a
course of antibiotic therapy, even pharmacist.
if signs and symptoms disappear ➤ Depending on the results of this pro-
before completion of therapy. cedure, additional testing may be
➤ A written report of the examination performed to evaluate or monitor
will be completed by a health progression of the disease process
care practitioner specializing in this and determine the need for a change
branch of medicine. The report will in therapy. Evaluate test results in
be sent to the requesting health care relation to the patient’s symptoms
practitioner, who will discuss the and other tests performed.
➤ Recognize anxiety related to test Related laboratory tests:
results and offer support. Discuss
the implications of abnormal test ➤ A related laboratory test is the Pap
results on the patient’s lifestyle. smear.
BIOPSY, CHORIONIC VILLUS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Chorionic villus tissue.
REFERENCE VALUE: (Method: Tissue culture) Normal karyotype.

Biopsy, Chorionic Villus 219
DESCRIPTION & RATIONALE: This Nursing Implications and

test is used to detect fetal abnor- Procedure ● ● ● ● ● ● ● ● ● ● ●
malities caused by numerous genetic

Pretest:
disorders. The advantage over amnio-
centesis is that it can be performed as ➤ Inform the patient that the test is
used to establish a histologic diagno-
early as the 8th week of pregnancy,
sis of in-utero genetic disorders.
permitting earlier decisions regarding
termination of pregnancy. However, complaints, including a list of known
unlike amniocentesis, this test will not allergens (especially allergies or sen-
detect neural tube defects. ■ sitivities to latex or anesthetics), and
inform the appropriate health care
INDICATIONS: practitioner accordingly.
• Assist in the diagnosis of in utero meta- ➤ Obtain a history of the patient’s
bolic disorders such as cystic fibrosis or reproductive system, as well as
other errors of lipid, carbohydrate, or results of previously performed labo-
amino acid metabolism ratory tests, surgical procedures,
and other diagnostic procedures.
• Detect abnormalities in the fetus of Include any family history of genetic
women of advanced maternal age disorders such as cystic fibro-
sis, Duchenne’s muscular dystrophy,
• Determine fetal gender when the hemophilia, sickle cell anemia, Tay-
mother is a known carrier of a sex- Sachs disease, thalassemia, and tri-
linked abnormal gene that could be somy 21. Obtain maternal Rh type. If
transmitted to male offspring, such as Rh-negative, check for prior sensiti-
hemophilia or Duchenne’s muscular zation. For related laboratory tests,
dystrophy refer to the Reproductive System
table.
• Evaluate fetus in families with a history ➤ Record the date of the last menstrual
of genetic disorders, such as Down period and determine that the
syndrome, Tay-Sachs disease, chromo- pregnancy is in the first trimester
some or enzyme anomalies, or inher- between the 10th and 12th weeks.
ited hemoglobinopathies ➤ Obtain a history of intravenous drug
use, high-risk sexual activity, or occu-
RESULT pational exposure.
ABNORMAL KARYOTYPE: Numerous
genetic disorders. Generally, the lab- nutraceuticals. The requesting health
oratory provides detailed interpretive care practitioner and laboratory
information regarding the specific chro- should be advised if the patient reg-
mosome abnormality detected. ularly uses these products so that
their effects can be taken into con-
patient. Warn the patient that normal
INTERFERING FACTORS: results do not guarantee a normal
• The test is contraindicated in the fetus. Assure the patient that pre-
patient with a history of or in the cautions to avoid injury to the fetus
presence of incompetent cervix. will be taken by localizing the fetus
with ultrasound. Address concerns
• Failure to follow dietary restrictions about pain related to the procedure.
before the procedure may cause the Explain that, during the transabdomi-
procedure to be canceled or repeated. nal procedure, any discomfort with a
needle biopsy will be minimized with position on a gynecologic examina-

local anesthetics. Explain that, during tion table (with feet in stirrups).
the transvaginal procedure, some Drape the patient’s legs. Instruct the
cramping may be experienced as patient to cooperate fully and to fol-
the catheter is guided through the low directions. Direct the patient to
cervix. Encourage relaxation and breathe normally and to avoid unnec-
controlled breathing during the pro- essary movement during the local
cedure to aid in reducing any mild anesthetic and the procedure.
discomfort. Inform the patient that ➤ Record maternal and fetal baseline
specimen collection is performed by vital signs, and continue to moni-
health care provider specializing in tor throughout the procedure. Moni-
this procedure and usually takes tor for uterine contractions. Monitor
approximately 10 to 15 minutes to fetal vital signs using ultrasound.
complete. Protocols may vary from facility to
➤ Sensitivity to cultural and social facility.
issues, as well as concern for mod- ➤ After the administration of local
esty, is important in providing psy- anesthesia, shave and cleanse the
chological support before, during, site with an antiseptic solution, and
and after the procedure. drape the area with sterile towels.
tion restrictions unless by medical Transabdominal biopsy:
direction.
➤ Assess the position of the amniotic
➤ Have the patient drink a glass of fluid, fetus, and placenta using ultra-
water about 30 minutes prior to test- sound.
ing so that the bladder is full. This
elevates the uterus higher in the ➤ A needle is inserted through the
pelvis. The patient should not void abdomen into the uterus, avoiding
before the procedure. contact with the fetus. A syringe is
connected to the needle and the
➤ Make sure a written and informed specimen of chorionic villus cells is
consent has been signed prior to the withdrawn from the uteroplacental
procedure and before administering area. Pressure is applied to the site
any medications. for 3 to 5 minutes, then a sterile
pressure dressing is applied.
Intratest:
➤ Ensure that the patient has a full Transvaginal biopsy:
bladder before the procedure. ➤ Assess the position of the fetus and
➤ Have emergency equipment readily placenta using ultrasound.
available. ➤ A speculum is inserted into the
➤ Observe standard precautions, and vagina and is opened to gently
follow the general guidelines in spread apart the vagina for inspection
Appendix A. Positively identify the of the cervix. The cervix is cleansed
patient, and label the appropriate with a swab of antiseptic solution.
collection containers with the cor- ➤ A catheter is inserted through the
responding patient demographics, cervix into the uterus, avoiding con-
date and time of collection, and site tact with the fetus. A syringe is
location. connected to the catheter and the
➤ Have the patient remove clothes specimen of chorionic villus cells is
below the waist. Transabdominal: withdrawn from the uteroplacental
Assist the patient into a supine posi- area.
tion on the exam table with abdomen
exposed. Drape the patient’s legs, General:
leaving abdomen exposed. Transvagi- ➤ Monitor the patient for complications
nal: Assist the patient into a lithotomy related to the procedure (e.g., pre-
Biopsy, Chorionic Villus 221
mature labor, allergic reaction, ana- patient of the importance of com-

phylaxis). pleting the entire course of antibiotic
➤ Place tissue samples in formalin therapy, even if signs and symptoms
solution. Label the specimen, indi- disappear before completion of ther-
cating site location, and pro- apy.
mptly transport the specimen to the ➤ A written report of the examina-
laboratory for processing and analy- tion will be completed by a health
sis. care practitioner specializing in this
➤ The results are recorded manually branch of medicine. The report will
or in a computerized system for be sent to the requesting health care
recall and postprocedure interpreta- practitioner, who will discuss the
tion by the appropriate health care results with the patient.
practitioner. ➤ Recognize anxiety related to test
Post-test: of abnormal test results on the
➤ After the procedure, the patient is patient’s lifestyle. Provide teaching
placed in the left side-lying position, and information regarding the clinical
and both maternal and fetal vital implications of the test results, as
signs are monitored for at least 30 appropriate. Encourage family to
minutes. Protocols may vary from seek counseling if concerned with
facility to facility. pregnancy termination or to seek
genetic counseling if chromosomal
➤ Observe for delayed allergic reac- abnormality is determined. Decisions
tions, such as rash, urticaria, tachy- regarding elective abortion should
cardia, hyperpnea, hypertension, take place in the presence of both
palpitations, nausea, or vomiting. parents. Provide a nonjudgmental,
➤ Observe the biopsy site for bleed- nonthreatening atmosphere for a
ing, inflammation, or hematoma discussion during which risks of
formation. delivering a developmentally chal-
➤ Instruct the patient in the care and lenged infant are discussed with
assessment of the site. Instruct the options (termination of pregnancy or
patient to report any redness, adoption). It is also important to dis-
edema, bleeding, or pain at the cuss problems the mother and father
biopsy site. Instruct the patient to may experience (guilt, depression,
keep the site clean and change the anger) if fetal abnormalities are
dressing as needed. detected.
➤ Instruct the patient to expect mild ➤ Reinforce information given by the
cramping, leakage of small amount patient’s health care provider regard-
of amniotic fluid, and vaginal spotting ing further testing, treatment, or
for up to 2 days following the pro- referral to another health care
cedure. Instruct the patient to report provider. Answer any questions or
moderate to severe abdominal address any concerns voiced by the
pain or cramps, increased or pro- patient or family.
longed leaking of amniotic fluid ➤ Instruct the patient in the use of any
from vagina or abdominal needle ordered medications. Explain the
site, vaginal bleeding that is heavier importance of adhering to the ther-
than spotting, and either chills or apy regimen. As appropriate, instruct
fever. the patient in significant side effects
➤ Administer RhoGAM to maternal Rh- and systemic reactions associated
negative patients to prevent mater- with the prescribed medication.
nal Rh sensitization should the fetus Encourage her to review corre-
be Rh-positive. sponding literature provided by a
pharmacist.
➤ Administer mild analgesic and antibi-
otic therapy as ordered. Remind the ➤ Depending on the results of this pro-
cedure, additional testing may be Related laboratory tests:

progression of the disease process ➤ Related laboratory tests include
and determine the need for a change amniotic fluid analysis, chromosome
in therapy. Evaluate test results in analysis, -fetoprotein, hexosam-
relation to the patient’s symptoms inidase A and B, and lecithin/sphin-
and other tests performed. gomyelin ratio.
BIOPSY, INTESTINAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Intestinal tissue or cells.
of tissue) No abnormal tissue or cells.
RESULT
DESCRIPTION & RATIONALE: Intes-
tinal biopsy is the excision of a tissue Abnormal findings in:
sample from the small intestine for • Cancer
microscopic analysis to determine cell
• Celiac disease
morphology and the presence of tissue
abnormalities. This test assists in con- • Lactose deficiency
firming the diagnosis of cancer or • Parasitic infestation
intestinal disorders. Biopsy specimen
is usually obtained during endoscopic • Tropical sprue
examination. ■
INDICATIONS:
• Assist in the diagnosis of various intes- INTERFERING FACTORS:
tinal disorders, such as lactose and • Barium swallow within 48 hours
other enzyme deficiencies, celiac dis- of small intestine biopsy affects results.
ease, and parasitic infections • This procedure is contraindi-
• Confirm suspected intestinal malig- cated in patients with bleeding
nancy disorders and aortic arch aneurysm.
• Confirm suspicious findings during • Failure to follow dietary restrictions
endoscopic visualization of the intes- before the procedure may cause the
tinal wall procedure to be canceled or repeated.
Biopsy, Intestinal 223
dure and usually takes about 60 min-

Nursing Implications and utes to complete.
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to establish a histologic diagno-
sis of intestinal disease. ➤ Explain that an intravenous (IV) line
will be inserted to allow infusion of IV
fluids, anesthetics, and analgesics.
allergens (especially allergies or sen- ➤ Explain that a clear liquid diet is to
sitivities to latex or anesthetics), and be consumed 1 day prior to the pro-
inform the appropriate health care cedure. Then food and fluids are
practitioner accordingly. restricted for 6 to 8 hours before
the test.
➤ Obtain a history of the patient’s gas-
trointestinal and immune systems, ➤ Patients are given a gown, robe, and
any bleeding disorders, and results foot coverings to wear and instructed
of previously performed laboratory to void prior to the procedure.
tests (especially bleeding time, ➤ Instruct the patient to remove den-
complete blood count, partial throm- tures, jewelry (including watches),
boplastin time, platelets, and pro- hairpins, credit cards, and other
thrombin time), surgical procedures, metallic objects. Inform the health
and other diagnostic procedures. care practitioner if the patient has
For related laboratory tests, refer to any crowns or caps on the teeth.
the Gastrointestinal and Immune
System tables.
➤ Record the date of the last menstrual procedure and before administering
period and determine the possibil- any medications.
women. Intratest:
interfere with test results. ➤ Ensure that the patient has complied
with dietary restrictions; assure that
➤ Obtain a list of the medications food has been restricted for at least
the patient is taking, including anti- 6 to 8 hours prior to the procedure if
coagulant therapy, acetylsalicylic general anesthesia will be used.
and nutraceuticals, especially those ➤ Ensure that anticoagulant therapy
known to affect coagulation. It is rec- has been withheld for the appropri-
ommended that use be discontinued ate amount of days prior to the pro-
14 days before dental or surgical procedure. Amount of days to withhold
cedures. The requesting health care medication is dependent on the type
practitioner and laboratory should of anticoagulant. Notify the health
be advised if the patient regularly care practitioner if patient anticoagu-
uses these products so that their lant therapy has not been withheld.
effects can be taken into considera- ➤ Have emergency equipment readily
tion when reviewing results. available.
➤ Review the procedure with the ➤ Observe standard precautions and
patient. Address concerns about pain follow the general guidelines in
related to the procedure. Explain that Appendix A. Positively identify the
a sedative may be administered to patient, and label the appropriate
promote relaxation during the proce- collection containers with the cor-
dure. Inform the patient that the pro- responding patient demographics,
cedure is performed by a health care date and time of collection, and site
practitioner specializing in this proce- location.
➤ Assist the patient into a semireclin- practitioner. Assess the patient’s

ing position. Instruct the patient to ability to swallow before allowing the
cooperate fully and to follow direc- patient to attempt liquids or solid
tions. Direct the patient to breathe foods.
normally and to avoid unnecessary ➤ Monitor vital signs and neurologic
movement. status every 15 minutes for 1 hour,
➤ Record baseline vital signs, and con- then every 2 hours for 4 hours, and
tinue to monitor throughout the pro- then as ordered by the health care
cedure. Protocols may vary from practitioner. Monitor temperature
facility to facility. every 4 hours for 24 hours. Compare
Esophagogastroduodeno- health care practitioner if tempera-
scopy (EGD) biopsy: ture is elevated. Protocols may vary
➤ A local anesthetic is sprayed into the
throat. A protective tooth guard and ➤ Instruct the patient to report any
a bite block may be placed in the chest pain, upper abdominal pain,
mouth. pain on swallowing, difficulty breath-
➤ The flexible endoscope is passed ing, or expectoration of blood. Report
into and through the mouth, and the these to the health care practitioner
patient is asked to swallow. Once immediately.
the endoscope passes into the ➤ Observe for delayed allergic reac-
esophagus, assist the patient into tions, such as rash, urticaria, tachy-
the left lateral position. A suction cardia, hyperpnea, hypertension,
device is used to drain saliva. palpitations, nausea, or vomiting.
➤ The esophagus, stomach, and duo- ➤ Administer mild analgesic and antibi-
denum are visually examined as the otic therapy as ordered. Remind the
endoscope passes through each patient of the importance of complet-
section. A biopsy specimen can be ing the entire course of antibiotic
taken from any suspicious sites. therapy, even if signs and symptoms
➤ Tissue samples are obtained by disappear before completion of
inserting a cytology brush or biopsy therapy.
forceps through the endoscope. ➤ A written report of the examina-
➤ When the examination and tissue tion will be completed by a health
removal are complete, the endo- care practitioner specializing in this
scope and suction device are with- branch of medicine. The report will
drawn and the tooth guard and bite be sent to the requesting health care
block are removed. practitioner, who will discuss the
related to the procedure (e.g., aller- ➤ Recognize anxiety related to test
gic reaction, anaphylaxis). results. Discuss the implications
➤ Place tissue samples in formalin patient’s lifestyle. Provide teaching
solution. Label the specimen, indi- and information regarding the clinical
cating site location, and promptly implications of the test results, as
transport the specimen to the labo- appropriate. Educate the patient
ratory for processing and analysis. regarding access to counseling
➤ The results are recorded manually services.
practitioner.
Post-test: address any concerns voiced by the
➤ Instruct the patient to resume usual patient or family.
diet, as directed by the health care ➤ Instruct the patient in the use of any
Biopsy, Kidney 225
ordered medications. Explain the in therapy. Evaluate test results in

importance of adhering to the ther- relation to the patient’s symptoms
apy regimen. As appropriate, instruct and other tests performed.
with the prescribed medication. Related laboratory tests:
Encourage him or her to review cor- ➤ Related laboratory tests include albu-
responding literature provided by a min, calcium, D-xylose tolerance,
pharmacist. fecal analysis (occult blood), fecal fat,
➤ Depending on the results of this pro- folic acid, gliadin antibodies, iron/
cedure, additional testing may be total iron-binding capacity, lactose
performed to evaluate or monitor tolerance, ova and parasites, potas-
progression of the disease process sium, prothrombin time, sodium,
and determine the need for a change vitamin B12, and vitamin D.
BIOPSY, KIDNEY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Renal biopsy.

SPECIMEN: Kidney tissue or cells.
tissue) No abnormal cells or tissue.
• Assist in the diagnosis of the cause of

DESCRIPTION & RATIONALE: Kidney renal disease
or renal biopsy is the excision of a
• Determine extent of involvement in
tissue sample from the kidney for
systemic lupus erythematosus or other
microscopic analysis to determine cell immunologic disorders
morphology and the presence of tissue
abnormalities. This test assists in con- • Monitor progression of nephrotic syn-
firming a diagnosis of cancer found on drome
x-ray or ultrasound or to diagnose cer- • Monitor renal function after transplan-
tain inflammatory or immunologic tation
conditions. Biopsy specimen is usually
obtained either percutaneously or RESULT
after surgical incision. ■
• Acute and chronic poststreptococcal
INDICATIONS: glomerulonephritis
• Assist in confirming suspected renal
malignancy • Amyloidosis infiltration
• Cancer diagnostic procedures. For related

laboratory tests, refer to the Geni-
• Disseminated lupus erythematosus tourinary and Immune System
• Goodpasture’s syndrome tables.
• Immunologic rejection of transplanted period and determine the possibil-
kidney ity of pregnancy in perimenopausal
women.
• Nephrotic syndrome
• Pyelonephritis interfere with test results.
• Renal venous thrombosis ➤ Obtain a list of the medications
the patient is taking, including anti-
coagulant therapy, acetylsalicylic
CRITICAL VALUES: N/A acid, herbs, nutritional supplements,
and nutraceuticals, especially those
INTERFERING FACTORS: known to affect coagulation. It is rec-
• This procedure is contraindicated ommended that use be discontinued
in bleeding disorders, advanced 14 days before dental or surgical pro-
renal disease, uncontrolled hyperten- cedures. The requesting health care
sion, or solitary kidney (except trans- practitioner and laboratory should be
planted kidney). these products so that their effects
• Obesity and severe spinal deformity can can be taken into consideration
make percutaneous biopsy impossible. when reviewing results.
• Failure to follow dietary restrictions patient. Inform the patient that it
before the procedure may cause the may be necessary to shave the
procedure to be canceled or repeated. site before the procedure. Instruct
that prophylactic antibiotics may be
administered prior to the procedure.
Nursing Implications and to the procedure. Explain that a seda-
Procedure ● ● ● ● ● ● ● ● ● ● ● tive and/or analgesia will be adminis-
tered to promote relaxation and
Pretest: reduce discomfort prior to the percu-
taneous biopsy; a general anesthesia
➤ Inform the patient that the test is will be administered prior to the open
used to establish a histologic diagno- biopsy. Explain to the patient that no
sis of kidney disease. pain will be experienced during the
➤ Obtain a history of the patient’s com- test when general anesthesia is
plaints, including a list of known used, but that any discomfort with a
allergens (especially allergies or sen- needle biopsy will be minimized with
sitivities to latex or anesthetics), and local anesthetics and systemic anal-
inform the appropriate health care gesics. Inform the patient that the
practitioner accordingly. biopsy is performed under sterile
➤ Obtain a history of the patient’s conditions by a health care practi-
genitourinary and immune system, tioner specializing in this procedure.
any bleeding disorders, and results The surgical procedure usually takes
of previously performed laboratory about 60 minutes to complete, and
tests (especially bleeding time, com- sutures may be necessary to close
plete blood count, partial thrombo- the site. A needle biopsy usually
plastin time, platelets, prothrombin takes about 40 minutes to complete.
time, blood urea nitrogen, and creati- ➤ Sensitivity to cultural and social
nine), surgical procedures, and other issues, as well as concern for mod-
Biopsy, Kidney 227
esty, is important in providing psy- ➤ Assist the patient to the desired

chological support before, during, position depending on the test site
and after the procedure. to be used, and direct the patient to
➤ Explain that an intravenous (IV) line breathe normally during the begin-
will be inserted to allow infusion of ning of the general anesthesic.
IV fluids, anesthetics, analgesics, or Instruct the patient to cooperate fully
IV sedation. and to follow directions. Direct the
Open biopsy: avoid unnecessary movement.
➤ Instruct the patient that nothing
tinue to monitor throughout the pro-
should be taken by mouth for 6 to 8
hours prior to a general anesthetic.
Needle biopsy: ➤ After the administration of general or
➤ Instruct the patient that nothing the site with an antiseptic solution,
should be taken by mouth for at least and drape the area with sterile
4 hours prior to the procedure to towels.
reduce the risk of nausea and
vomiting. Open biopsy:
General: ➤ After administration of general
anesthesia and surgical prep are
➤ Make sure a written and informed completed, an incision is made,
consent has been signed prior to the suspicious area(s) are located, and
procedure and before administering tissue samples are collected.
any medications.
Needle biopsy:
Intratest: ➤ A sandbag may be placed under the
abdomen to aid in moving the kid-
➤ Ensure that the patient has complied neys to the desired position. Direct
with dietary restrictions; assure that the patient to take slow deep
food has been restricted for at least breaths when the local anesthetic is
4 to 8 hours depending on the anes- injected. Protect the site with sterile
thetic chosen for the procedure. drapes. Instruct the patient to take a
➤ Ensure that anticoagulant therapy deep breath, exhale forcefully, and
has been withheld for the appropri- hold the breath while the biopsy nee-
ate amount of days prior to the pro- dle is inserted and rotated to obtain
cedure. Amount of days to withhold a core of renal tissue. Once the nee-
medication is dependent on the type dle is removed, the patient may
of anticoagulant. Notify the health breathe. Pressure is applied to the
care practitioner if patient anticoagu- site for 5 to 20 minutes, then a ster-
lant therapy has not been withheld. ile pressure dressing is applied.
available. General:
➤ Have the patient void before the ➤ Monitor the patient for complications
procedure. related to the procedure (e.g., aller-
follow the general guidelines in ➤ Place tissue samples in formalin
Appendix A. Positively identify the solution. Label the specimen, indi-
patient, and label the appropriate col- cating site location, and promptly
lection containers with the corre- transport the specimen to the labo-
sponding patient demographics, date ratory for processing and analysis.
and time of collection, and site loca- ➤ The results are recorded manually or
tion, especially left or right kidney. in a computerized system for recall
and postprocedure interpretation by provide appropriate measuring con-

the appropriate health care practi- tainers.
tioner. ➤ Instruct the patient to report any
changes in urinary pattern or volume
Post-test: or any unusual appearance of the
urine. If urinary volume is less than
➤ Instruct the patient to resume pre- 200 mL in the first 8 hours, encour-
operative diet, as directed by the age the patient to increase fluid
health care practitioner. Assess the intake unless contraindicated by
patient’s ability to swallow before another medical condition.
allowing the patient to attempt liq-
uids or solid foods. ➤ Assess for nausea and pain.
Administer antiemetic and analgesic
➤ Monitor vital signs and neurologic medications as needed and as
status every 15 minutes for 1 hour, directed by the health care practi-
then every 2 hours for 4 hours, tioner.
and then as ordered by the health
care practitioner. Monitor tempera- ➤ Administer antibiotic therapy if
ture every 4 hours for 24 hours. ordered. Remind the patient of the
Compare with baseline values. importance of completing the entire
Notify the health care practitioner if course of antibiotic therapy, even if
temperature is elevated. Protocols signs and symptoms disappear
may vary from facility to facility. before completion of therapy.
➤ Observe for delayed allergic reac- ➤ A written report of the examination
tions, such as rash, urticaria, tachy- will be completed by a health care
cardia, hyperpnea, hypertension, practitioner specializing in this
palpitations, nausea, or vomiting. branch of medicine. The report will
be sent to the requesting health
➤ Observe the biopsy site for bleed- care practitioner, who will discuss
ing, inflammation, or hematoma the results with the patient.
formation.
➤ Instruct the patient in the care results. Discuss the implications
and assessment of the site. Instruct of abnormal test results on the
the patient to report any redness, patient’s lifestyle. Provide teaching
edema, bleeding, or pain at the and information regarding the clinical
biopsy site. Instruct the patient to implications of the test results, as
immediately report chills or fever. appropriate. Educate the patient
Instruct the patient to keep the site regarding access to counseling
clean and change the dressing as services.
needed. Instruct the patient to
immediately report symptoms such
as backache, flank pain, shoulder
pain, light-headedness, burning on
urination, hematuria, chills, or fever,
provider. Inform the patient of a
which may indicate the presence
follow-up appointment for removal of
of infection, hemorrhage, or inadver-
sutures, if indicated. Answer any
tent puncture of other internal
questions or address any concerns
organs. Observe the patient for
voiced by the patient or family.
other signs of distress, including
hypotension and tachycardia. ➤ Instruct the patient in the use of any
➤ Inform the patient that blood may be importance of adhering to the ther-
seen in the urine after the first or apy regimen. As appropriate, instruct
second postprocedural voiding. the patient in significant side effects
➤ Monitor fluid intake and output for and systemic reactions associated
24 hours. Instruct the patient on with the prescribed medication.
intake and output recording and Encourage him or her to review cor-
Biopsy, Liver 229
responding literature provided by a Related laboratory tests:

pharmacist.
➤ Related laboratory tests include albu-
➤ Depending on the results of this pro- min, aldosterone, anti–glomerular
cedure, additional testing may be basement membrane antibody, 2-
performed to evaluate or monitor microglobulin, creatinine, creatinine
progression of the disease process clearance, osmolality (blood and
and determine the need for a change urine), potassium (blood and urine),
in therapy. Evaluate test results in protein (blood and urine), renin,
relation to the patient’s symptoms sodium (blood and urine), urea nitro-
and other tests performed. gen, urinalysis, and urine cytology.
BIOPSY, LIVER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Liver tissue or cells.
persistently elevated liver enzymes,

DESCRIPTION & RATIONALE: Liver hepatomegaly, or jaundice
biopsy is the excision of a tissue sam-
ple from the liver for microscopic RESULT
analysis to determine cell morphology
and the presence of tissue abnormali- Positive findings in:
ties. This test is used to assist in • Benign tumor
confirming a diagnosis of cancer or • Cancer
certain disorders of the hepatic • Cholesterol ester storage disease
parenchyma. Biopsy specimen is usu-
ally obtained either percutaneously or • Cirrhosis
after surgical incision. ■ • Galactosemia
• Hemochromatosis
INDICATIONS: • Hepatic involvement with systemic
• Assist in confirming suspected hepatic lupus erythematosus, sarcoidosis, or
malignancy amyloidosis
• Assist in confirming suspected hepatic • Hepatitis
parenchymal disease
• Parasitic infestations (e.g., amebiasis,
• Assist in diagnosing the cause of malaria, visceral larva migrans)
• Reye’s syndrome ➤ Obtain a list of the medications

• Wilson’s disease coagulant therapy, acetylsalicylic
CRITICAL VALUES: N/A and nutraceuticals, especially those
INTERFERING FACTORS: 14 days before dental or surgical pro-
• This procedure is contraindicated cedures. The requesting health care
in patients with bleeding disor- practitioner and laboratory should be
ders, suspected vascular tumor of the advised if the patient regularly uses
liver, ascites that may obscure proper these products so that their effects
insertion site for needle biopsy, subdi- can be taken into consideration
aphragmatic or right hemothoracic when reviewing results.
infection, or biliary tract infection. ➤ Review the procedure with the
• Failure to follow dietary restrictions may be necessary to shave the site
before the procedure may cause the before the procedure. Instruct that
procedure to be canceled or repeated. prophylactic antibiotics may be
Nursing Implications and to the procedure. Explain that a
Procedure ● ● ● ● ● ● ● ● ● ● ●
sedative and/or analgesia will be
administered to promote relaxation
Pretest: percutaneous biopsy; a general
➤ Inform the patient that the test is anesthesia will be administered prior
used to establish a histologic diagno- to the open biopsy. Explain to the
sis of liver disease. patient that no pain will be experi-
➤ Obtain a history of the patient’s com- anesthesia is used, but that any dis-
plaints, especially fatigue and pain comfort with a needle biopsy will be
related to inflammation and swelling minimized with local anesthetics and
of the liver. Include a list of known systemic analgesics. Inform the
allergens, especially allergies or sen- patient that the biopsy is performed
sitivities to latex or anesthetics, and under sterile conditions by a health
inform the appropriate health care care practitioner specializing in this
practitioner accordingly. procedure. The surgical procedure
➤ Obtain a history of the patient’s usually takes about 90 minutes to
hepatobiliary and immune system, complete, and sutures may be nec-
any bleeding disorders, and results essary to close the site. A needle
of previously performed laboratory biopsy usually takes about 15 min-
tests (especially bleeding time, com- utes to complete.
plete blood count, partial thrombo- ➤ Sensitivity to cultural and social
plastin time, platelets, prothrombin issues, as well as concern for mod-
time, and liver function tests), surgi- esty, is important in providing psy-
cal procedures, and other diagnostic chological support before, during,
procedures. For related laboratory and after the procedure.
Immune System tables.
will be inserted to allow infusion of
➤ Record the date of the last menstrual IV fluids, anesthetics, analgesics, or
period and determine the possibil- IV sedation.
women. Open biopsy:
➤ Note any recent procedures that can ➤ Instruct the patient that noth-
interfere with test results. ing should be taken by mouth for 6
Biopsy, Liver 231
to 8 hours prior to a general anes- coughing or straining, as this may

thetic. increase intra-abdominal pressure.
Needle biopsy: tinue to monitor throughout the pro-
➤ Instruct the patient that nothing cedure. Protocols may vary from
should be taken by mouth for at least facility to facility.
4 hours prior to the procedure to ➤ After the administration of general or
reduce the risk of nausea and local anesthesia, shave and cleanse
vomiting. the site with an antiseptic solu-
tion, and drape the area with sterile
General: towels.
consent has been signed prior to the Open biopsy:
procedure and before administering ➤ After administration of general
any medications. anesthesia and surgical prep are
completed, an incision is made, sus-
Intratest: picious area(s) are located, and tis-
sue samples are collected.
with dietary restrictions; assure that Needle biopsy:
food has been restricted for at least
4 to 8 hours depending on the anes- ➤ Direct the patient to take slow deep
thetic chosen for the procedure. breaths when the local anesthetic is
injected. Protect the site with sterile
➤ Ensure that anticoagulant therapy drapes. Instruct the patient to take a
has been withheld for the appropri- deep breath, exhale forcefully, and
ate amount of days prior to the pro- hold the breath while the biopsy
cedure. Amount of days to withhold needle is inserted and rotated to
medication is dependent on the type obtain a core of liver tissue. Once
of anticoagulant. Notify the health the needle is removed, the patient
care practitioner if patient anticoagu- may breathe. Pressure is applied to
lant therapy has not been withheld. the site for 3 to 5 minutes, then a
➤ Have emergency equipment readily sterile pressure dressing is applied.
available.
General:
➤ Have the patient void before the
procedure. ➤ Monitor the patient for complications
➤ Observe standard precautions, and related to the procedure (e.g., aller-
follow the general guidelines in gic reaction, anaphylaxis).
Appendix A. Positively identify the ➤ Place tissue samples in formalin
patient, and label the appropriate col- solution. Label the specimen, indi-
lection containers with the corre- cating site location, and promptly
sponding patient demographics, transport the specimen to the labo-
date and time of collection, and site ratory for processing and analysis.
location. ➤ The results are recorded manually
➤ Assist the patient to the desired or in a computerized system for
position depending on the test site recall and postprocedure interpreta-
to be used and direct the patient tion by the appropriate health care
to breathe normally during the practitioner.
beginning of the general anesthesic.
Instruct the patient to cooperate fully Post-test:
patient to breathe normally and to ➤ Instruct the patient to resume pre-
avoid unnecessary movement during operative diet, as directed by the
the local anesthetic and the proce- health care practitioner. Assess the
dure. Instruct the patient to avoid patient’s ability to swallow before
allowing the patient to attempt liq- ➤ Recognize anxiety related to test

uids or solid foods. results. Discuss the implications of
➤ Monitor vital signs and neurologic abnormal test results on the patient’s
status every 15 minutes for 1 hour, lifestyle. Provide teaching and
then every 2 hours for 4 hours, and information regarding the clinical
then as ordered by the health care implications of the test results, as ap-
practitioner. Monitor temperature propriate. Educate the patient regard-
every 4 hours for 24 hours. Compare ing access to counseling services.
with baseline values. Notify the ➤ Reinforce information given by the
health care practitioner if tempera- patient’s health care provider regard-
ture is elevated. Protocols may vary ing further testing, treatment, or
from facility to facility. referral to another health care
➤ Observe for delayed allergic reac- provider. Inform the patient of a
tions, such as rash, urticaria, tachy- follow-up appointment for removal of
cardia, hyperpnea, hypertension, sutures, if indicated. Answer any
palpitations, nausea, or vomiting. questions or address any concerns
➤ Observe the biopsy site for bleed-
ing, inflammation, or hematoma ➤ Instruct the patient in the use of any
formation. ordered medications. Explain the
assessment of the site. Instruct the
patient to report any redness,
edema, bleeding, or pain at the
biopsy site. Instruct the patient to
immediately report chills or fever.
Instruct the patient to keep the site
pharmacist.
clean and change the dressing as
needed. Instruct the patient to ➤ Depending on the results of this pro-
immediately report any pleuritic pain, cedure, additional testing may be
persistent right shoulder pain, or performed to evaluate or monitor
abdominal pain. progression of the disease process
➤ Assess for nausea and pain. Adminis-
ter antiemetic and analgesic medica-
tions as needed and as directed by
the health care practitioner.
➤ Administer antibiotic therapy if
ordered. Remind the patient of the Related laboratory tests:
importance of completing the entire ➤ Related laboratory tests include ala-
course of antibiotic therapy, even if nine aminotransferase, albumin,
signs and symptoms disappear alkaline phosphatase, ammonia,
before completion of therapy. amylase, antimitochondrial antibody,
➤ A written report of the examination anti–smooth muscle antibody, 1-
will be completed by a health care antitrypsin/phenotyping, aspartate
practitioner specializing in this aminotransferase, bilirubin, bilirubin
branch of medicine. The report of the fractions, cholesterol, coagulation
examination will be sent to the factor assays, complete blood count,
requesting health care practitioner, copper, -glutamyltransferase, infec-
who will discuss the results with the tious mononucleosis screen, lipase,
patient. prothrombin time, and urinalysis.
Biopsy, Lung 233
BIOPSY, LUNG
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Transbronchial lung biopsy, open lung biopsy.

SPECIMEN: Lung tissue or cells.
tissue) No abnormal tissue or cells; no growth in culture.
RESULT
DESCRIPTION & RATIONALE: A
biopsy of the lung is performed to Abnormal findings in:
obtain lung tissue for examination of • Amyloidosis
pathologic features. The specimen can
• Cancer
be obtained transbronchially or by
open lung biopsy. In a transbronchial • Granulomas
biopsy, forceps pass through the bron- • Infections caused by Blastomyces, Histo-
choscope to obtain the specimen. In plasma, Legionella spp., and Pneumocys-
a transbronchial needle aspiration tis jiroveci (formerly carinii)
biopsy, a needle passes through a bron- • Sarcoidosis
choscope to obtain the specimen. In a
transcatheter bronchial brushing, a • Systemic lupus erythematosus
brush is inserted through the broncho- • Tuberculosis
scope. In an open lung biopsy, the
chest is opened and a small thoracic CRITICAL VALUES:
incision is made to remove tissue from
the chest wall. Lung biopsies are used • Shortness of breath, cyanosis, or rapid
pulse during the procedure must be
to differentiate between infection and
reported immediately.
other sources of disease indicated by
initial radiology studies, computed • Any postprocedural decrease in breath
tomography scans, or sputum analysis. sounds noted at the biopsy site should
Specimens are cultured to detect path- be reported immediately.
ogenic organisms or directly examined
for the presence of malignant cells. ■ INTERFERING FACTORS:
• Conditions such as vascular
INDICATIONS: anomalies of the lung, bleeding
• Assist in the diagnosis of lung cancer abnormalities, or pulmonary hyperten-
• Assist in the diagnosis of fibrosis and sion may increase the risk of bleeding.
degenerative or inflammatory diseases • Conditions such as bullae or cysts
of the lung and respiratory insufficiency
• Assist in the diagnosis of sarcoidosis increase the risk of pneumothorax.
• Failure to follow dietary restrictions may be necessary to shave the site

before the procedure may cause the before the procedure. Instruct that
procedure to be canceled or repeated. prophylactic antibiotics may be
to the procedure. Explain that a
Nursing Implications and sedative and/or analgesia will be
Procedure ● ● ● ● ● ● ● ● ● ● ● administered to promote relaxation
Pretest: transbronchial needle aspiration
biopsy; a general anesthesia will
➤ Inform the patient that the test is be administered prior to the open
used to establish a histologic diagno- biopsy. Explain to the patient that no
sis of lung disease. pain will be experienced during the
➤ Obtain a history of the patient’s com- test when general anesthesia is
plaints, including a list of known used, but that any discomfort with a
allergens (especially allergies or sen- needle biopsy will be minimized
sitivities to latex or anesthetics), and with local anesthetics and systemic
inform the appropriate health care analgesics. Atropine is usually given
practitioner accordingly. before bronchoscopy examinations
➤ Obtain a history of the patient’s to reduce bronchial secretions and
immune and respiratory systems, prevent vagally induced bradycar-
any bleeding disorders, and results dia. Meperidine (Demerol) or mor-
of previously performed laboratory phine may be given as a sedative.
tests, (especially bleeding time, Lidocaine is sprayed in the patient’s
complete blood count, partial throm- throat to reduce discomfort caused
boplastin time, platelets, and pro- by the presence of the tube. Inform
thrombin time), surgical procedures, the patient that the biopsy is per-
and other diagnostic procedures. For formed under sterile conditions by a
related laboratory tests, refer to the health care practitioner specializing
Immune and Respiratory System in this procedure. The surgical proce-
tables. dure usually takes about 30 minutes
to complete, and sutures may be
➤ Note any recent procedures that can necessary to close the site. A needle
interfere with test results. biopsy usually takes about 15 to 30
➤ Record the date of the last menstrual minutes to complete.
period and determine the possibil- ➤ Sensitivity to cultural and social
ity of pregnancy in perimenopausal issues, as well as concern for mod-
women. esty, is important in providing psy-
➤ Obtain a list of the medications the chological support before, during,
patient is taking, including anticoa- and after the procedure.
gulant therapy, acetylsalicylic acid, ➤ Explain that an intravenous (IV) line
herbs, nutritional supplements, and will be inserted to allow infusion of
nutraceuticals, especially those IV fluids, antibiotics, anesthetics, and
known to affect coagulation. It is rec- analgesics.
14 days before dental or surgical pro- ➤ Instruct the patient that nothing
cedures. The requesting health care should be taken by mouth for 6 to 8
practitioner and laboratory should be hours prior to a general anesthetic.
advised if the patient regularly uses ➤ Have the patient void before the pro-
these products so that their effects cedure.
can be taken into consideration ➤ Make sure a written and informed
when reviewing results. consent has been signed prior to the
➤ Review the procedure with the procedure and before administering
patient. Inform the patient that it any medications.
Biopsy, Lung 235
➤ After the administration of general or

Intratest:
➤ Ensure that the patient has comp- the site with an antiseptic solution,
lied with dietary restrictions; assure and drape the area with sterile
that food has been restricted for at towels.
least 6 to 8 hours prior to the proce-
dure. Open biopsy:
➤ Ensure that anticoagulant therapy ➤ The patient is prepared for thoraco-
has been withheld for the appropri- tomy under general anesthesia in the
ate amount of days prior to the pro- operating room. Tissue specimens
cedure. Amount of days to withhold are collected from suspicious sites.
medication is dependent on the type Place specimen from needle aspira-
of anticoagulant. Notify the health tion or brushing on clean glass micro-
care practitioner if patient anticoagu- scope slides. Place tissue or aspirate
lant therapy has not been withheld. specimens in appropriate sterile con-
tainer for culture or appropriate fixa-
➤ Have emergency equipment readily tive container for histologic studies.
available. Keep resuscitation equip-
ment on hand in the case of respira- ➤ Carefully observe the patient for any
tory impairment or laryngospasm signs of respiratory distress during
after the procedure. the procedure.
➤ Avoid using morphine sulfate in ➤ A chest tube is inserted after the pro-
those with asthma or other pul- cedure.
monary disease. This drug can fur-
ther exacerbate bronchospasms and
Needle biopsy:
respiratory impairment. ➤ Instruct the patient to take slow deep
breaths when the local anesthetic is
injected. Protect the site with sterile
drapes. Assist patient to a sitting
position with arms on a pillow over a
bed table. Instruct patient to avoid
collection containers with the corre-
coughing during the procedure. The
needle is inserted through the poste-
rior chest wall and into the intercostal
location, especially left or right lung.
space. The needle is rotated to obtain
➤ Have patient remove dentures, con- the sample and then withdrawn.
tact lenses, eyeglasses, and jewelry. Pressure is applied to the site with a
Notify the physician if the patient Vaseline gauze, and a pressure dress-
has permanent crowns on teeth. ing is applied over the Vaseline gauze.
Have the patient remove clothing
and change into a gown for the Bronchoscopy:
procedure. ➤ Provide mouth care to reduce oral
➤ Assist the patient to a comfortable bacterial flora.
position, and direct the patient to ➤ After administration of general anes-
breath normally during the beginning thesia, position the patient in a
of the general anesthesia. Instruct supine position with the neck hyper-
the patient to cooperate fully and to extended. If local anesthesia is used,
follow directions. Direct the patient the patient is seated while the
to breathe normally and to avoid tongue and oropharynx are sprayed
unnecessary movement during the and swabbed with anesthetic.
local anesthetic and the procedure. Provide an emesis basin for the
➤ Record baseline vital signs and con- increased saliva and encourage the
tinue to monitor throughout the pro- patient to spit out the saliva because
cedure. Protocols may vary from the gag reflex may be impaired.
facility to facility. When loss of sensation is adequate,
the patient is placed in a supine or treat throat discomfort with lozenges

side-lying position. The fiberoptic and warm gargles when the gag
scope can be introduced through the reflex returns.
nose, the mouth, an endotracheal ➤ Monitor vital signs and neurologic
tube, a tracheostomy tube, or a rigid status every 15 minutes for 1 hour,
bronchoscope. Most common inser- then every 2 hours for 4 hours, and
tion is through the nose. Patients then as ordered by the health care
with copious secretions or massive practitioner. Monitor temperature
hemoptysis, or in whom airway com- every 4 hours for 24 hours. Compare
plications are more likely, may be with baseline values. Notify the
intubated before the bronchoscopy. health care practitioner if tempera-
Additional local anesthetic is applied ture is elevated. Protocols may vary
through the scope as it approaches from facility to facility.
the vocal cords and the carina, elimi-
nating reflexes in these sensitive ➤ Emergency resuscitation equipment
areas. The fiberoptic approach allows should be readily available if the
visualization of airway segments vocal cords become spastic after
without having to move the patient’s intubation.
head through various positions. ➤ Observe for delayed allergic reac-
➤ After visual inspection of the lungs, tions, such as rash, urticaria, tachy-
tissue samples are collected from cardia, hyperpnea, hypertension,
suspicious sites by bronchial brush palpitations, nausea, or vomiting.
or biopsy forceps to be used for ➤ Observe the biopsy site for bleed-
cytologic and microbiologic studies. ing, inflammation, or hematoma for-
➤ After the procedure, the broncho- mation.
scope is removed. Patients who had ➤ Observe the patient for hemoptysis,
local anesthesia are placed in a semi- difficulty breathing, cough, air
Fowler’s position to recover. hunger, excessive coughing, pain, or
absent breath sounds over the
General:
affected area. Report to health care
➤ Monitor the patient for complications provider. Monitor chest tube patency
related to the procedure (e.g., aller- and drainage after a thoracotomy.
➤ Evaluate the patient for symptoms
➤ Place tissue samples in properly indicating the development of pneu-
labeled specimen containers contain- mothorax, such as dyspnea, tachyp-
ing formalin solution, and promptly nea, anxiety, decreased breathing
transport the specimen to the labora- sounds, or restlessness. A chest x-
tory for processing and analysis. ray may be ordered to check for the
➤ The results are recorded manually presence of this complication.
or in a computerized system for ➤ Evaluate the patient for symptoms of
recall and postprocedure interpreta- empyema, such as fever, tachycar-
tion by the appropriate health care dia, malaise, or elevated white blood
practitioner. cell count.
Post-test: ➤ Observe the patient’s sputum for
blood if a biopsy was taken, because
➤ Instruct the patient to resume preop- large amounts of blood may indi-
erative diet, as directed by the health cate the development of a problem;
care practitioner. Assess the patient’s a small amount of streaking is
ability to swallow before allowing the expected. Evaluate the patient for
patient to attempt liquids or solid signs of bleeding, such as tachycar-
foods. dia, hypotension, or restlessness.
➤ Inform the patient that he or she may ➤ Instruct the patient in the care and
experience some throat soreness assessment of the biopsy site.
and hoarseness. Instruct patient to Instruct the patient to report any red-
Biopsy, Lung 237
ness, edema, bleeding, or pain at the lozenges or gargle for throat discom-
biopsy site. Instruct the patient to fort. Inform the patient of smoking
keep the site clean and change the cessation programs as appropriate.
dressing as needed. Malnutrition is commonly seen in
➤ Instruct the patient to remain in a patients with severe respiratory dis-
semi-Fowler’s position after bron- ease for numerous reasons, includ-
choscopy or fine needle aspiration to ing fatigue, lack of appetite, and
maximize ventilation. Semi-Fowler’s gastrointestinal distress. Adequate
position is a semisitting position with intake of vitamins A and C are
the knees flexed and supported by also important to prevent pulmonary
pillows on the bed or examination infection and to decrease the extent
table. Instruct the patient to stay in of lung tissue damage. The impor-
bed lying on the affected side for at tance of following the prescribed diet
least 2 hours with a pillow or rolled should be stressed to the patient/
towel under the site to prevent caregiver. Educate the patient regard-
bleeding. The patient will also need ing access to counseling services, as
to remain on bed rest for 24 hours. appropriate. Answer any questions or
➤ Assess for nausea and pain. Adminis- patient or family.
tions as needed and as directed by ➤ Instruct the patient in the use of any
the health care practitioner. ordered medications. Explain the
➤ Administer antibiotic therapy if apy regimen. As appropriate, instruct
ordered. Remind the patient of the the patient in significant side effects
importance of completing the entire and systemic reactions associated
course of antibiotic therapy, even if with the prescribed medication.
signs and symptoms disappear Encourage him or her to review cor-
before completion of therapy. responding literature provided by a
➤ A written report of the examination pharmacist.
will be completed by a health care ➤ Depending on the results of this pro-
practitioner specializing in this cedure, additional testing may be
branch of medicine. The report will performed to evaluate or monitor
be sent to the requesting health care progression of the disease process
practitioner, who will discuss the and determine the need for a change
results with the patient. in therapy. Evaluate test results in
➤ Recognize anxiety related to test relation to the patient’s symptoms
results. Discuss the implications of and other tests performed.
abnormal test results on the
patient’s lifestyle. Provide teaching Related laboratory tests:
and information regarding the clinical ➤ Related laboratory tests include
implications of the test results, as arterial/alveolar oxygen ratio, anti–
appropriate. Educate the patient glomerular basement membrane
regarding access to counseling antibody, blood gases, chest x-ray,
services. complete blood count, computed
➤ Reinforce information given by the tomography of the thorax, magnetic
patient’s health care provider regard- resonance imaging of the chest, lung
ing further testing, treatment, or perfusion scan, culture, Gram/acid-
referral to another health care fast stain, cytology, and sputum
provider. Instruct the patient to use findings.
BIOPSY, LYMPH NODE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Lymph node tissue or cells.
• Evaluate persistent enlargement of one

DESCRIPTION & RATIONALE: Lymph or more lymph nodes for unknown
node biopsy is the excision of a tissue reasons
sample from one or more lymph
nodes for microscopic analysis to RESULT
determine cell morphology and the Abnormal findings in:
presence of tissue abnormalities. This • Chancroid
test assists in confirming a diagnosis of
• Fungal infection (e.g., cat scratch dis-
cancer, diagnosing disorders causing
ease)
systemic illness, or determining the
stage of metastatic cancer. A biopsy • Immunodeficiency
specimen is usually obtained either by • Infectious mononucleosis
needle biopsy or after surgical inci- • Lymph involvement of systemic dis-
sion. Biopsies are most commonly eases (e.g., systemic lupus erythemato-
performed on the following types of sus, sarcoidosis)
lymph nodes: cervical nodes, which
• Lymphangitis
drain the face and scalp; axillary
nodes, which drain the arms, breasts, • Lymphogranuloma venereum
and upper chest; and inguinal nodes, • Malignancy (e.g., lymphomas, leu-
which drain the legs, external geni- kemias)
talia, and lower abdominal wall. ■
• Metastatic disease
INDICATIONS: • Parasitic infestation (e.g., pneumoco-
• Assist in confirming suspected fungal niosis)
or parasitic infections of the lymphatics
• Assist in confirming suspected malig- CRITICAL VALUES: N/A
nant involvement of the lymphatics INTERFERING FACTORS:
• Determine the stage of metastatic • This procedure is contraindicated
cancer in patients with bleeding
disorders.
• Differentiate between benign and
malignant disorders that may cause • Failure to follow dietary restrictions
lymph node enlargement before the procedure may cause
Biopsy, Lymph Node 239
the procedure to be canceled or prophylactic antibiotics may be

repeated. administered prior to the procedure.
Nursing Implications and administered to promote relaxation
Procedure ● ● ● ● ● ● ● ● ● ● ● and reduce discomfort prior to the
percutaneous biopsy; a general
Pretest: anesthesia will be administered prior
to the open biopsy. Explain to the
➤ Inform the patient that the test is patient that no pain will be experi-
used to establish a histologic diagno- enced during the test when general
sis of lymph node disease. anesthesia is used, but that any dis-
➤ Obtain a history of the patient’s com- comfort with a needle biopsy will be
plaints, including a list of known minimized with local anesthetics and
allergens (especially allergies or sen- systemic analgesics. Inform the
sitivities to latex or anesthetics), and patient that the biopsy is performed
inform the appropriate health care under sterile conditions by a health
practitioner accordingly. care practitioner specializing in this
procedure. The surgical procedure
usually takes about 30 minutes to
complete, and sutures may be nec-
essary to close the site. A needle
biopsy usually takes about 15 min-
ratory tests (especially bleeding
utes to complete.
time, complete blood count, partial
thromboplastin time, platelets, and ➤ Sensitivity to cultural and social
prothrombin time), surgical proce- issues, as well as concern for mod-
dures, and other diagnostic proce- esty, is important in providing psy-
dures. For related laboratory tests, chological support before, during,
refer to the Immune and Muscu- and after the procedure.
loskeletal System tables. ➤ Explain that an intravenous (IV) line
➤ Record the date of the last menstrual will be inserted to allow infusion of
period and determine the possibil- IV fluids, anesthetics, analgesics, or
ity of pregnancy in perimenopausal IV sedation.
women.
➤ Note any recent procedures that can Open biopsy:
➤ Instruct the patient that noth-
➤ Obtain a list of the medications the ing should be taken by mouth for 6
patient is taking, including anticoa- to 8 hours prior to a general anes-
gulant therapy, acetylsalicylic acid, thetic.
nutraceuticals, especially those
known to affect coagulation. It is rec- Needle biopsy:
ommended that use be discontinued ➤ Instruct the patient that nothing
14 days before dental or surgical pro- should be taken by mouth for at
cedures. The requesting health care least 4 hours prior to the procedure
practitioner and laboratory should be to reduce the risk of nausea and
advised if the patient regularly uses vomiting.
when reviewing results. General:
➤ Review the procedure with the ➤ Make sure a written and informed
patient. Inform the patient that it consent has been signed prior to the
may be necessary to shave the site procedure and before administering
before the procedure. Instruct that any medications.
Intratest: Needle biopsy:

➤ Instruct the patient to take slow
deep breaths when the local anes-
thetic is injected. Protect the site
food has been restricted for at least
with sterile drapes. The node is
4 to 8 hours depending on the anes-
grasped with sterile gloved fingers,
thetic chosen for the procedure.
and a needle (with attached syringe)
➤ Ensure that anticoagulant therapy is inserted directly into the node. The
has been withheld for the appropri- node is aspirated to collect the spec-
ate amount of days prior to the pro- imen. Pressure is applied to the site
cedure. Amount of days to withhold for 3 to 5 minutes, then a sterile
medication is dependent on the type dressing is applied.
of anticoagulant. Notify the health
care practitioner if patient anticoagu- General:
lant therapy has not been withheld.
➤ Have emergency equipment readily ➤ Monitor the patient for complications
available. related to the procedure (e.g., aller-
cedure. ➤ Place tissue samples in formalin solu-
tion. Label the specimen, indicating
➤ Observe standard precautions, and site location, and promptly transport
follow the general guidelines in the specimen to the laboratory for
Appendix A. Positively identify the processing and analysis.
collection containers with the cor- ➤ The results are recorded manually
responding patient demographics, or in a computerized system for
date and time of collection, and site recall and postprocedure interpreta-
location. tion by the appropriate health care
practitioner.
➤ Assist the patient to the desired
position depending on the test site
to be used and direct the patient Post-test:
to breathe normally during the begin-
ning of the general anesthesic. ➤ Instruct the patient to resume preop-
Instruct the patient to cooperate fully erative diet, as directed by the health
and to follow directions. Direct the care practitioner. Assess the patient’s
patient to breathe normally and ability to swallow before allowing the
to avoid unnecessary movement patient to attempt liquids or solid
during the local anesthetic and the foods.
procedure. ➤ Monitor vital signs and neurologic
➤ Record baseline vital signs, and con- status every 15 minutes for 1 hour,
tinue to monitor throughout the pro- then every 2 hours for 4 hours, and
cedure. Protocols may vary from then as ordered by the health care
facility to facility. practitioner. Monitor temperature
➤ After the administration of general or every 4 hours for 24 hours. Compare
local anesthesia, shave and cleanse with baseline values. Notify the
the site with an antiseptic solution, health care practitioner if tempera-
and drape the area with sterile ture is elevated. Protocols may vary
towels. from facility to facility.
Open biopsy: tions, such as rash, urticaria, tachy-
➤ After administration of general cardia, hyperpnea, hypertension,
anesthesia and surgical prep are palpitations, nausea, or vomiting.
completed, an incision is made, sus- ➤ Observe the biopsy site for bleed-
picious area(s) are located.and tissue ing, inflammation, or hematoma
samples are collected. formation.
Biopsy, Muscle 241
➤ Instruct the patient in the care ing further testing, treatment, or

and assessment of the site. Instruct referral to another health care
the patient to report any redness, provider. Inform the patient of a
edema, bleeding, or pain at the follow-up appointment for removal of
biopsy site. Instruct the patient to sutures, if indicated. Answer any
immediately report chills or fever. questions or address any concerns
Instruct the patient to keep the site voiced by the patient or family.
clean and change the dressing as ➤ Instruct the patient in the use of any
needed. ordered medications. Explain the
➤ Assess for nausea and pain. importance of adhering to the ther-
Administer antiemetic and analgesic apy regimen. As appropriate, instruct
medications as needed and as the patient in significant side effects
directed by the health care practi- and systemic reactions associated
tioner. with the prescribed medication.
➤ Administer antibiotic therapy if responding literature provided by a
ordered. Remind the patient of the pharmacist.
importance of completing the entire
course of antibiotic therapy, even if ➤ Depending on the results of this pro-
signs and symptoms disappear cedure, additional testing may be
before completion of therapy. performed to evaluate or monitor
➤ A written report of the examination and determine the need for a change
will be completed by a health care in therapy. Evaluate test results in
practitioner specializing in this relation to the patient’s symptoms
branch of medicine. The report will and other tests performed.
practitioner, who will discuss the Related laboratory tests:
➤ Related laboratory tests include CD4/
➤ Recognize anxiety related to test CD8 enumeration; cerebrospinal
results. Discuss the implications fluid analysis; Chlamydia serology;
of abnormal test results on the complete blood count; culture for
patient’s lifestyle. Provide teaching bacteria/fungus; cytomegalovirus
and information regarding the clinical serology; Gram stain; HIV-1/HIV-
implications of the test results, as 2 serology; immunofixation elec-
appropriate. Educate the patient trophoresis; immunoglobulins A, G,
regarding access to counseling and M; infectious mononucleosis
services. screen; rheumatoid factor; total pro-
➤ Reinforce information given by the tein; total protein electrophoresis;
patient’s health care provider regard- and toxoplasmosis serology.
BIOPSY, MUSCLE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Muscle tissue or cells.

of tissue) No abnormal tissue or cells.
DESCRIPTION & RATIONALE: Muscle • If electromyography is performed
biopsy is the excision of a muscle tis- before muscle biopsy, residual inflam-
sue sample for microscopic analysis to mation may lead to false-positive biopsy
determine cell morphology and the results.
presence of tissue abnormalities. This • This procedure is contraindi-
test is used to confirm a diagnosis of cated in patients with bleeding
neuropathy or myopathy and to diag- disorders.
nose parasitic infestation. A biopsy • Failure to follow dietary restrictions
specimen is usually obtained from the before the procedure may cause the pro-
deltoid or gastrocnemius muscle after cedure to be canceled or repeated.
a surgical incision. ■
• Assist in confirming suspected fungal

infection or parasitic infestation of the Pretest:
muscle
• Assist in diagnosing the cause of neu- used to establish a histologic diagno-
ropathy or myopathy sis of musculoskeletal disease.
• Assist in the diagnosis of Duchenne’s plaints, including a list of known
muscular dystrophy allergens (especially allergies or sen-
sitivities to latex or anesthetics), and
RESULT practitioner accordingly.
Abnormal findings in: immune and musculoskeletal sys-
• Alcoholic myopathy tems, any bleeding disorders, and
• Amyotrophic lateral sclerosis ratory tests, (especially bleeding
time, complete blood count, partial
• Duchenne’s muscular dystrophy thromboplastin time, platelets, and
• Fungal infection prothrombin time), surgical proce-
dures, and other diagnostic proce-
• Myasthenia gravis dures. For related laboratory tests,
• Myotonia congenita loskeletal System tables.
• Parasitic infestation ➤ Record the date of the last menstrual
• Polymyalgia rheumatica of pregnancy in perimenopausal
women.
• Polymyositis ➤ Note any recent procedures that can
CRITICAL VALUES: N/A ➤ Obtain a list of the medications the
Biopsy, Muscle 243
patient is taking, including anticoa- ➤ Make sure a written and informed

gulant therapy, acetylsalicylic acid, consent has been signed prior to the
herbs, nutritional supplements, and procedure and before administering
nutraceuticals, especially those any medications.
ommended that use be discontinued Intratest:
cedures. The requesting health care ➤ Ensure that the patient has complied
practitioner and laboratory should be with dietary restrictions; assure that
advised if the patient regularly uses food has been restricted for at least
these products so that their effects 4 hours prior to the procedure.
can be taken into consideration ➤ Ensure that anticoagulant therapy
when reviewing results. has been withheld for the appropri-
➤ Review the procedure with the ate amount of days prior to the
patient. Inform the patient that it procedure. Amount of days to with-
may be necessary to shave the site hold medication is dependent on the
before the procedure. Instruct that type of anticoagulant. Notify the
prophylactic antibiotics may be health care practitioner if patient
administered prior to the procedure. anticoagulant therapy has not been
Address concerns about pain related withheld.
to the procedure. Explain that a ➤ Have emergency equipment readily
sedative and/or analgesia will be available.
administered to promote relaxation ➤ Have the patient void before the pro-
and reduce discomfort prior to the cedure.
anesthesia will be administered prior ➤ Observe standard precautions, and
to the open biopsy. Explain to the follow the general guidelines in
patient that no pain will be experi- Appendix A. Positively identify the
enced during the test when general patient, and label the appropriate
anesthesia is used, but that any dis- collection containers with the corre-
comfort with a needle biopsy will be sponding patient demographics,
minimized with local anesthetics and date and time of collection, and site
systemic analgesics. Inform the location.
patient that the biopsy is performed ➤ Assist the patient to a comfortable
under sterile conditions by a health position: a supine position (for del-
care practitioner specializing in this toid biopsy) or prone position (for
procedure. The surgical procedure gastrocnemius biopsy). Instruct the
usually takes about 20 minutes to patient to cooperate fully and to fol-
complete, and sutures may be nec- low directions. Direct the patient to
essary to close the site. A needle breathe normally and to avoid unnec-
biopsy usually takes about 15 min- essary movement during the local
utes to complete. anesthetic and the procedure.
➤ Sensitivity to cultural and social ➤ Record baseline vital signs, and con-
issues, as well as concern for mod- tinue to monitor throughout the pro-
esty, is important in providing psy- cedure. Protocols may vary from
chological support before, during, facility to facility.
and after the procedure. ➤ After the administration of general or
➤ Explain that an intravenous (IV) line local anesthesia, shave and cleanse
may be inserted to allow infusion of the site with an antiseptic solution,
IV fluids, anesthetics, or sedatives. and drape the area with sterile
towels.
➤ Instruct the patient that nothing
should be taken by mouth for at least Open biopsy:
4 hours prior to the procedure
to reduce the risk of nausea and ➤ Assess baseline neurologic status.
vomiting. Instruct the patient to take slow
deep breaths when the local anes- every 4 hours for 24 hours. Compare
thetic is injected. Protect the site with baseline values. Notify the
with sterile drapes. health care practitioner if tempera-
➤ After infiltration of the site with local ture is elevated. Protocols may vary
anesthetic, a small incision is made from facility to facility.
through the dermis, exposing the ➤ Observe for delayed allergic reac-
muscle. A small area of muscle is tions, such as rash, urticaria, tachy-
excised and removed with forceps. cardia, hyperpnea, hypertension,
The area is then closed with sutures palpitations, nausea, or vomiting.
or similar material, and a sterile ➤ Observe the biopsy site for bleed-
dressing is applied. ing, inflammation, or hematoma
formation.
Needle biopsy:
➤ Instruct the patient to take slow assessment of the site. Instruct the
deep breaths when the local anes- patient to report any redness,
thetic is injected. Protect the site edema, bleeding, or pain at the
with sterile drapes. biopsy site. Instruct the patient to
➤ After infiltration of the site with local immediately report chills or fever.
anesthetic, a cutting biopsy needle is Instruct the patient to keep the site
introduced through a small skin clean and change the dressing as
incision and bored into the muscle. needed.
A core needle is introduced through ➤ Assess for nausea and pain. Adminis-
the cutting needle, and a plug of ter antiemetic and analgesic medica-
muscle is removed. The needles are tions as needed and as directed by
withdrawn, and the specimen is the health care practitioner.
placed in a preservative solution.
Pressure is applied to the site for 3 ➤ Administer antibiotic therapy if
to 5 minutes, and then a pressure ordered. Remind the patient of the
dressing is applied. importance of completing the entire
course of antibiotic therapy, even if
General: signs and symptoms disappear
related to the procedure (e.g., aller- ➤ A written report of the examination
gic reaction, anaphylaxis). will be completed by a health care
practitioner specializing in this branch
of medicine. The report will be sent
labeled specimen container contain-
to the requesting health care practi-
ing formalin solution, and promptly
tioner, who will discuss the results
transport the specimen to the labo-
with the patient. .
ratory for processing and analysis.
➤ The results are recorded manually ➤ Recognize anxiety related to test
or in a computerized systemfor results. Discuss the implications of
recall and postprocedure interpreta- abnormal test results on the
tion by the appropriate health care patient’s lifestyle. Provide teaching
practitioner. and information regarding the clinical
Post-test: appropriate. Educate the patient
regarding access to counseling
➤ Instruct the patient to resume preop- services.
erative diet, as directed by the health ➤ Reinforce information given by the
care practitioner. patient’s health care provider regard-
➤ Monitor vital signs and neurologic ing further testing, treatment, or
status every 15 minutes for 1 hour, referral to another health care
then every 2 hours for 4 hours, and provider. Inform the patient of a fol-
then as ordered by the health care low-up appointment for removal of
practitioner. Monitor temperature sutures, if indicated. Answer any
Biopsy, Prostate 245
questions or address any concerns progression of the disease process

voiced by the patient or family. and determine the need for a change
➤ Instruct the patient in the use of any in therapy. Evaluate test results in
ordered medications. Explain the relation to the patient’s symptoms
importance of adhering to the ther- and other tests performed.
and systemic reactions associated Related laboratory tests:
with the prescribed medication. ➤ Related laboratory tests include
Encourage him or her to review cor- acetylcholine receptor antibody,
responding literature provided by a aldolase, antinuclear antibodies,
pharmacist. antithyroglobulin antibodies, creatine
➤ Depending on the results of this pro- kinase and isoenzymes, Jo-1 anti-
cedure, additional testing may be body, myoglobin, and rheumatoid
performed to evaluate or monitor factor.
BIOPSY, PROSTATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Prostate tissue.
REFERENCE VALUE: (Method: Microscopic examination of tissue cells) No
abnormal cells or tissue.
DESCRIPTION & RATIONALE: Biopsy • This procedure is contraindi-
of the prostate gland is performed to cated in patients with bleeding
identify cancerous cells, especially if disorders.
serum prostate-specific antigen is • Failure to follow dietary restrictions
increased. ■ before the procedure may cause the
INDICATIONS: • The various sampling approaches
• Evaluate prostatic hypertrophy of have individual drawbacks that
unknown etiology should be considered: transurethral
• Investigate suspected cancer of the sampling does not always ensure that
prostate malignant cells will be included in the
specimen, whereas transrectal sampling
RESULT: Positive findings in prostate carries the risk of perforating the rec-
cancer. tum and creating a channel through
which malignant cells can seed normal
CRITICAL VALUES: N/A tissue.
anesthesia will be administered prior

Nursing Implications and to the open biopsy. Explain to the
Procedure ● ● ● ● ● ● ● ● ● ● ● patient that no pain will be experi-
Pretest: anesthesia is used, but that any dis-
comfort with a needle biopsy will be
➤ Inform the patient that the test is minimized with local anesthetics and
used to establish a histologic diagno- systemic analgesics. Inform the
sis of prostate disease. patient that the biopsy is performed
➤ Obtain a history of the patient’s com- under sterile conditions by a health
plaints, including a list of known care practitioner specializing in this
allergens (especially allergies or sen- procedure. The surgical procedure
sitivities to latex or anesthetics), and usually takes about 30 minutes to
inform the appropriate health care complete, and sutures may be nec-
practitioner accordingly. essary to close the site. A needle
biopsy usually takes about 20 min-
➤ Obtain a history of the patient’s gen- utes to complete.
itourinary and immune systems, any
bleeding disorders, and results of ➤ Sensitivity to cultural and social
previously performed laboratory issues, as well as concern for mod-
tests (especially bleeding time, esty, is important in providing psy-
complete blood count, partial throm- chological support before, during,
boplastin time, platelets, and pro- and after the procedure.
thrombin time), surgical procedures, ➤ Explain that an intravenous (IV) line
and other diagnostic procedures. For will be inserted to allow infusion of
related laboratory tests, refer to the IV fluids, antibiotics, anesthetics, and
Genitourinary and Immune System analgesics.
tables.
➤ Ensure that anticoagulant therapy
➤ Note any recent procedures that can has been withheld for the appropri-
interfere with test results. ate amount of days prior to the pro-
➤ Obtain a list of the medications cedure. Amount of days to withhold
the patient is taking, including anti- medication is dependent on the type
coagulant therapy, acetylsalicylic of anticoagulant. Notify the health
acid, herbs, nutritional supplements, care practitioner if patient anticoagu-
and nutraceuticals, especially those lant therapy has not been withheld.
known to affect coagulation. It is rec- ➤ Instruct the patient that nothing
ommended that use be discontinued should be taken by mouth for 6 to 8
14 days before dental or surgical pro- hours prior to a general anesthetic.
practitioner and laboratory should be ➤ Make sure a written and informed
advised if the patient regularly uses consent has been signed prior to the
these products so that their effects procedure and before administering
can be taken into consideration any medications.
Intratest:
patient. Inform the patient that it ➤ Ensure that the patient has complied
may be necessary to shave the site with dietary restrictions; assure that
before the procedure. Instruct that food has been restricted for at least
prophylactic antibiotics may be 6 to 8 hours prior to the procedure.
administered prior to the procedure. ➤ Have emergency equipment readily
Address concerns about pain related available.
sedative and/or analgesia will be ➤ Have the patient void before the
administered to promote relaxation procedure. Administer enemas if
and reduce discomfort prior to the ordered.
percutaneous biopsy; a general ➤ Observe standard precautions, and
Biopsy, Prostate 247
follow the general guidelines in ➤ Apply digital pressure to the biopsy

Appendix A. Positively identify the site. If there is no bleeding after the
patient, and label the appropriate col- perineal approach, place a sterile
lection containers with the corre- dressing on the biopsy site.
sponding patient demographics, ➤ Place tissue samples in properly
date and time of collection, and site labeled specimen containers contain-
location. ing formalin solution, and promptly
➤ Assist the patient to a comfortable transport the specimen to the labora-
position, and direct the patient to tory for processing and analysis.
breath normally during the beginning ➤ The results are recorded manually
of the general anesthesia.. or in a computerized system for
➤ Cleanse the biopsy site with an anti- recall and postprocedure interpreta-
septic solution, and drape the area tion by the appropriate health care
with sterile towels. practitioner.
tinue to monitor throughout the pro- Post-test:
cedure. Protocols may vary from ➤ Instruct the patient to resume preop-
facility to facility. erative diet, as directed by the health
Transurethral approach: care practitioner. Assess the patient’s
ability to swallow before allowing the
➤ After administration of general anes- patient to attempt liquids or solid
thesia, position the patient on a uro- foods.
logic exam table with the feet in
stirrups. The endoscope is inserted ➤ Monitor vital signs and neurologic
into the urethra. The tissue is excised status every 15 minutes for 1 hour,
with a cutting loop and is placed in then every 2 hours for 4 hours, and
formalin solution. then as ordered by the health care
Transrectal approach: every 4 hours for 24 hours. Compare
➤ After administration of general anes-
thesia, position the patient in the
Sims’ position. A rectal examination
is performed to locate suspicious
nodules. A biopsy needle guide is ➤ Monitor fluid intake and output for 24
placed at the biopsy site, and the bio- hours. Instruct the patient on intake
psy needle is inserted through the and output recording and provide
needle guide. The cells are aspirated, appropriate measuring containers.
the needle is withdrawn, and the ➤ Encourage fluid intake of 3000 mL,
sample is placed in formalin solution. unless contraindicated.
Perineal approach: ➤ Observe for delayed allergic reac-
➤ After administration of general anes- cardia, hyperpnea, hypertension,
thesia, position the patient in the palpitations, nausea, or vomiting.
lithotomy position. Clean the per-
ineum with an antiseptic solution, ➤ Observe the perineal approach
and protect the biopsy site with ster- biopsy site for bleeding, inflam-
ile drapes. A small incision is made mation, or hematoma formation.
and the sample is removed by needle Instruct the patient to keep the site
biopsy or biopsy punch and placed in clean and change the dressing as
formalin solution. needed.
➤ Instruct the patient to immediately
General: report pain, chills, of fever. Assess
➤ Monitor the patient for complications for infection, hemorrhage, or perfora-
related to the procedure (e.g., aller- tion of the urethra or rectum.
gic reaction, anaphylaxis). ➤ Inform the patient that blood may be
seen in the urine after the first or ing further testing, treatment, or
second post procedural voiding. referral to another health care
➤ Instruct the patient to report any fur- provider. Counsel the patient, as
ther changes in urinary pattern, vol- appropriate, that sexual dysfunc-
ume, or appearance. tion related to altered body func-
tion, drugs, or radiation may occur.
➤ Assess for nausea, pain, and bladder Educate the patient regarding access
spasms. Administer antiemetic, anal- to counseling services, as appropri-
gesic, and antispasmodic medica- ate. Answer any questions or
tions as needed and as directed by address any concerns voiced by the
the health care practitioner. patient or family.
➤ Administer antibiotic therapy if ➤ Instruct the patient in the use of any
ordered. Remind the patient of the ordered medications. Explain the
importance of completing the entire importance of adhering to the ther-
course of antibiotic therapy, even if apy regimen. As appropriate, instruct
signs and symptoms disappear the patient in significant side effects
before completion of therapy. and systemic reactions associated
➤ A written report of the examination with the prescribed medication.
will be completed by a health care Encourage him to review corre-
practitioner specializing in this branch sponding literature provided by a
of medicine. The report will be sent pharmacist.
with the patient.
results. Discuss the implications of and determine the need for a change
abnormal test results on the in therapy. Evaluate test results in
patient’s lifestyle. Provide teaching relation to the patient’s symptoms
and information regarding the clinical and other tests performed.
appropriate. Educate the patient
regarding access to counseling Related laboratory tests:
services. ➤ Related laboratory tests include
➤ Reinforce information given by the prostate-specific antigen and prosta-
patient’s health care provider regard- tic acid phosphatase.
BIOPSY, SKIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Skin tissue or cells.
Biopsy, Skin 249

DESCRIPTION & RATIONALE: Skin before the procedure may cause the
biopsy is the excision of a tissue sam- procedure to be canceled or repeated.
ple from suspicious skin lesions. The
microscopic analysis can determine
cell morphology and the presence of Nursing Implications and
tissue abnormalities. This test assists Procedure ● ● ● ● ● ● ● ● ● ● ●
in confirming the diagnosis of malig-

Pretest:
nant or benign skin lesions. A skin
biopsy can be obtained by any of these ➤ Inform the patient that the test is
four ways: curettage, shaving, exci- used to establish a histologic diagno-
sis of skin disease.
sion, or punch. ■
INDICATIONS: allergens (especially allergies or sen-
• Assist in the diagnosis of keratoses, sitivities to latex or anesthetics), and
warts, moles, keloids, fibromas, cysts, inform the appropriate health care
or inflamed lesions practitioner accordingly.
• Assist in the diagnosis of skin cancer ➤ Obtain a history of the patient’s
• Evaluate suspicious skin lesions tems, any bleeding disorders, and
results of previously performed
RESULT laboratory tests (especially bleed-
ing time, complete blood count, par-
Abnormal findings in: tial thromboplastin time, platelets,
• Basal cell carcinoma and prothrombin time), surgical pro-
cedures, and other diagnostic proce-
• Cysts dures. For related laboratory tests,
• Dermatitis refer to the Immune and Muscu-
• Dermatofibroma
• Keloids period and determine the possibility
• Malignant melanoma of pregnancy in perimenopausal
women.
• Neurofibroma ➤ Note any recent procedures that can
• Pemphigus interfere with test results.
• Pigmented nevi ➤ Obtain a list of the medications the
patient is taking, including anticoa-
• Seborrheic keratosis gulant therapy, acetylsalicylic acid,
• Skin involvement in systemic lupus nutraceuticals, especially those
erythematosus, discoid lupus erythe- known to affect coagulation. It is rec-
matosus, and scleroderma ommended that use be discontinued
• Squamous cell carcinoma 14 days before dental or surgical pro-
• Warts practitioner and laboratory should be
CRITICAL VALUES: N/A these products so that their effects
INTERFERING FACTORS: when reviewing results.
• This procedure is contraindi- ➤ Review the procedure with the
cated in patients with bleeding patient. Inform the patient that it
disorders. may be necessary to shave the site
before the procedure. Instruct that ➤ Have emergency equipment readily

prophylactic antibiotics may be available.
administered prior to the procedure. ➤ Have the patient void before the
Address concerns about pain related procedure.
sedative and/or analgesia will be ➤ Observe standard precautions, and
administered to promote relaxation follow the general guidelines in
and reduce discomfort prior to the Appendix A. Positively identify the
punch biopsy; a general anesthesia patient, and label the appropriate col-
will be administered prior to the lection containers with the corre-
open biopsy. Explain to the patient sponding patient demographics,
that no pain will be experienced dur- date and time of collection, and site
ing the test when general anesthesia location.
is used, but that any discomfort with ➤ Assist the patient to the desired
a punch biopsy will be minimized position depending on the test
with local anesthetics and systemic site to be used, and direct the
analgesics. Inform the patient that patient to breathe normally during
the biopsy is performed under sterile the local anesthetic and the proce-
conditions by a health care practi- dure. Instruct the patient to cooper-
tioner specializing in this procedure. ate fully and to follow directions and
The surgical procedure usually takes to avoid unnecessary movement.
about 30 minutes to complete, and ➤ Record baseline vital signs, and con-
sutures may be necessary to close tinue to monitor throughout the pro-
the site. A punch biopsy usually cedure. Protocols may vary from
takes about 20 minutes to complete. facility to facility.
➤ Sensitivity to cultural and social ➤ After the administration of general or
issues, as well as concern for mod- local anesthesia, shave and cleanse
esty, is important in providing psy- the site with an antiseptic solution,
chological support before, during, and drape the area with sterile
and after the procedure. towels.
➤ Explain that an intravenous (IV) line ➤ Curettage: The skin is scraped with a
may be inserted to allow infusion of curette to obtain specimen.
IV fluids, anesthetics, or sedatives,
depending on the type of biopsy. ➤ Shaving or excision: A scalpel is used
to remove a portion of the lesion that
protrudes above the epidermis. If the
lesion is to be excised, the incision is
direction.
made as wide and as deep as
➤ Make sure a written and informed needed to ensure that the entire
consent has been signed prior to the lesion is removed. Bleeding is con-
procedure and before administering trolled with external pressure to the
any medications. site. Large wounds are closed with
sutures. An adhesive bandage is
Intratest: applied when excision is complete.
➤ Ensure that the patient has complied ➤ Punch biopsy: A small, round punch
with dietary restrictions, if ordered about 4 to 6 mm in diameter is
by the health care practitioner. rotated into the skin to the desired
➤ Ensure that anticoagulant therapy depth. The cylinder of skin is pulled
has been withheld for the appropri- upward with forceps and separated
ate amount of days prior to the pro- at its base with a scalpel or scissors.
cedure. Amount of days to withhold If needed, sutures are applied. A ster-
medication is dependent on the type ile dressing is applied over the site.
of anticoagulant. Notify the health ➤ Monitor the patient for complications
care practitioner if patient anticoagu- related to the procedure (e.g., aller-
lant therapy has not been withheld. gic reaction, anaphylaxis).
Biopsy, Skin 251
➤ Place tissue samples in properly signs and symptoms disappear

labeled specimen container contain- before completion of therapy.
ing formalin solution, and promptly
➤ A written report of the examina-
care practitioner specializing in this
➤ The results are recorded manually branch of medicine. The report will
or in a computerized system for be sent to the requesting health care
recall and postprocedure interpreta- practitioner, who will discuss the
tion by the appropriate health care results with the patient.
practitioner.
Post-test: of abnormal test results on the
➤ Instruct the patient to resume preop- patient’s lifestyle. Provide teaching
erative diet, as directed by the health and information regarding the clinical
care practitioner. Assess the patient’s implications of the test results, as
ability to swallow before allowing the appropriate. Educate the patient
patient to attempt liquids or solid regarding access to counseling
foods. services.
➤ Monitor vital signs and neurologic ➤ Reinforce information given by

status every 15 minutes for 1 hour, the patient’s health care provider
then every 2 hours for 4 hours, and regarding further testing, treatment,
then as ordered by the health care or referral to another health care
practitioner. Monitor temperature provider. Inform the patient of a fol-
every 4 hours for 24 hours. Compare low-up appointment for the removal
with baseline values. Notify the of sutures, if indicated. Answer any
health care practitioner if tempera- questions or address any concerns
ture is elevated. Protocols may vary voiced by the patient or family.
from facility to facility. ➤ Instruct the patient in the use of any
➤ Observe for delayed allergic reac- ordered medications. Explain the
tions, such as rash, urticaria, tachy- importance of adhering to the ther-
cardia, hyperpnea, hypertension, apy regimen. As appropriate, instruct
palpitations, nausea, or vomiting. the patient in significant side effects
➤ Observe the biopsy site for bleed- with the prescribed medication.
ing, inflammation, or hematoma Encourage him or her to review cor-
formation. responding literature provided by a
➤ Instruct the patient in the care and pharmacist.
assessment of the site. Instruct the ➤ Depending on the results of this pro-
patient to report any redness, cedure, additional testing may be
edema, bleeding, or pain at the performed to evaluate or monitor
biopsy site. Instruct the patient to progression of the disease process
immediately report chills or fever. and determine the need for a change
Instruct the patient to keep the site in therapy. Evaluate test results in
clean and change the dressing as relation to the patient’s symptoms
needed. and other tests performed.
➤ Assess for nausea and pain. Adminis-
tions as needed and as directed by Related laboratory tests:
the health care practitioner. ➤ Related laboratory tests include aller-
➤ Administer antibiotic therapy if gen-specific immunoglobulin E (IgE),
ordered. Remind the patient of the antinuclear antibody, eosinophil
importance of completing the entire count, erythrocyte sedimentation
course of antibiotic therapy, even if rate, IgE, and skin culture.
BIOPSY, THYROID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Thyroid gland tissue or cells.

DESCRIPTION & RATIONALE: Thyroid
biopsy is the excision of a tissue sam- INTERFERING FACTORS:
ple for microscopic analysis to deter- • This procedure is contraindi-
mine cell morphology and the cated in patients with bleeding
presence of tissue abnormalities. This disorders.
test assists in confirming a diagnosis of • Failure to follow dietary restrictions
cancer or determining the cause of before the procedure may cause the
persistent thyroid symptoms. A biopsy procedure to be canceled or repeated.
specimen can be obtained by needle
aspiration or by surgical excision. ■
• Assist in the diagnosis of thyroid cancer

or benign cysts or tumors Pretest:
• Determine the cause of inflammatory ➤ Inform the patient that the test is
thyroid disease used to establish a histologic diagno-
sis of thyroid disease.
• Determine the cause of hyperthy-
roidism ➤ Obtain a history of the patient’s com-
• Evaluate enlargement of the thyroid allergens, especially allergies or sen-
gland sitivities to latex or anesthetics and
RESULT practitioner accordingly.
Positive findings in: endocrine and immune systems, any
• Benign thyroid cyst bleeding disorders, and results of
• Granulomatous thyroiditis tests (especially bleeding time,
• Hashimoto’s thyroiditis boplastin time, platelets, and pro-
• Nontoxic nodular goiter thrombin time), surgical procedures,
and other diagnostic procedures. For
• Thyroid cancer related laboratory tests, refer to the
Biopsy, Thyroid 253
Endocrine and Immune system chological support before, during and

tables. after the procedure.
➤ Record the date of the last menstrual ➤ Explain that an IV line may be inserted
period and determine possibility to allow infusion of IV fluids, anes-
of pregnancy in perimenopausal thetics, analgesics, or IV sedation.
women.
Open biopsy:
interfere with test results. ➤ Instruct the patient that nothing
should be taken by mouth for 6 to 8
patient is taking. Include herbs, nutri-
tional supplements, and nutraceuti-
Needle biopsy:
cals, including anticoagulant therapy,
acetylsalicylic acid, herbs, and nutra- ➤ Instruct the patient that nothing
ceuticals known to affect coagula- should be taken by mouth for at least
tion. It is recommended that use be 4 hours prior to the procedure to re-
discontinued 14 days before dental duce the risk of nausea and vomiting.
or surgical procedures. The request- ➤ Have the patient void before the
ing health care practitioner and labo- procedure.
ratory should be advised if the
patient regularly uses these products General:
so that their effects can be taken ➤ Make sure a written and informed
nto consideration when reviewing consent has been signed prior to the
results. procedure and before administering
➤ Review the procedure with the any medications.
may be necessary to shave the site Intratest:
before the procedure. Instruct that
prophylactic antibiotics may be ➤ Ensure that the patient has complied
administered prior to the procedure. with dietary restrictions; assure food
Address concerns about pain related has been restricted for at least 4 to 8
to the procedure. Explain that a hours depending on the anesthetic
sedative and/or analgesia will be chosen for the procedure.
administered to promote relaxation ➤ Ensure that anticoagulant therapy
and reduce discomfort prior to the has been withheld for the appropri-
percutaneous biopsy; a general ate amount of days prior to the pro-
anesthesia will be administered prior cedure. Amount of days to withhold
to the open biopsy. Explain to the medication is dependant on the type
patient that no pain will be experi- of anticoagulant. Notify health care
enced during the test when general practitioner if patient anticoagulant
anesthesia is used, but that any dis- therapy has not been withheld.
minimized with local anesthetics and ➤ Have emergency equipment readily
systemic analgesics. Inform the available.
patient that the biopsy is performed ➤ Observe standard precautions, and
under sterile conditions by a health follow the general guidelines in
care practitioner specializing in this Appendix A. Positively identify the
procedure., The surgical procedure patient and label the appropriate col-
usually takes about 30 minutes to lection containers with the correspon-
complete, and that sutures may be ding patient demographics, date and
necessary to close the site. A needle time of collection, and site location.
biopsy usually takes about 15 min- ➤ Assist the patient to the desired
utes to complete. position depending on the test
➤ Sensitivity to cultural and social site to be used and direct the patient
issues, as well as concern for mod- to breathe normally during the
esty, is important in providing psy- beginning of the general anesthesic.
Instruct the patient to cooperate fully Post-test:

patient to breathe normally and to ➤ Instruct the patient to resume pre-op
avoid unnecessary movement dur- diet, as directed by the health care
ing the local anesthetic and the practitioner. Assess the patient’s
procedure.. ability to swallow before allowing the
➤ Record baseline vital signs and con- patient to attempt liquids or solid
tinue to monitor throughout the pro- foods.
cedure. Protocols may vary from ➤ Monitor vital signs and neurologic
facility to facility. status every 15 minutes for 1 hour,
the site with an antiseptic solution,
every 4 hours for 24 hours. Notify
and drape the area with sterile
the health care practitioner if ele-
towels.
vated tempterature. Protocols may
vary from facility to facility.
Open biopsy:
➤ After administration of general tions, such as rash, urticaria, tachy-
anesthesia and surgical prep is com- cardia, hyperpnea, hypertension,
pleted, an incision is made, suspi- palpitations, nausea, or vomiting.
cious area(s) are located, and tissue ➤ Observe the biopsy site for bleed-
samples are collected. ing, inflammation, or hematoma
formation.
Needle biopsy: ➤ Instruct the patient in the care and
➤ Direct the patient to take slow deep assessment of the site. Instruct the
breaths when the local anesthetic patient to report any redness,
is injected. Protect the site with edema, bleeding, or pain at the
sterile drapes. Instruct the patient biopsy site. Instruct the patient to
to take a deep breath, exhale force- immediately report chills or fever.
fully, and hold the breath while the Instruct the patient to keep the site
biopsy needle is inserted and rotated clean and change the dressing as
to obtain a core of breast tissue. needed.
Once the needle is removed, the ➤ Assess for nausea and pain. Admini-
patient may breathe. Pressure is ster antiemetic and analgesic med-
applied to the site for 3 to 5 minutes, ications as needed and as directed
then a sterile pressure dressing is by the health care practitioner.
applied. ➤ Administer antibiotic therapy if
General: importance of completing the entire
➤ Monitor the patient for complications signs and symptoms disappear
related to the procedure (e.g., aller- before completion of therapy.
➤ Place tissue samples in properly will be completed by a health care
labelled specimen container contain- practitioner specializing in this branch
ing formalin solution, and promptly of medicine. The report will be sent
transport the specimen to the labo- to the requesting health care practi-
ratory for processing and analysis. tioner who will discuss the results
➤ The results are recorded manually with the patient.
or in a computerized system for ➤ Recognize anxiety related to test.
recall and postprocedure interpreta- Discuss the implications of the
tion by the appropriate healthcare abnormal test results on the patient’s
practitioner. lifestyle. Provide teaching and infor-
Bladder Cancer Markers, Urine 255
mation regarding the clinical impli- with the prescribed medication.

cations of the test results, as appro- Encourage them to review corre-
priate. Educate the patient regarding sponding literature provided by a
access to counseling services. pharmacist.
➤ Reinforce information given by the ➤ Depending on the results of this
patient’s health care provider regard- procedure, additional testing may be
ing further testing, treatment or performed to evaluate or monitor
provider. Inform the patient of a and determine the need for a change
follow-up appointment for removal of in therapy. Evaluate test results in
sutures, if indicated. Answer any relation to the patient’s symptoms
questions or address any concerns and other tests performed.
➤ Instruct the patient in the use of any Related laboratory tests
importance of adhering to the ther- ➤ Related laboratory tests include
apy regimen. As appropriate, instruct antithyroglobulin antibodies, thyroid-
the patient in significant side effects stimulating hormone, and free thy-
and systemic reactions associated roxine.
BLADDER CANCER MARKERS, URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: NMP22, Bard BTA.

SPECIMEN: Urine (5 mL), unpreserved random specimen collected in a
clean plastic collection container.
REFERENCE VALUE: (Method: Enzyme immunoassay for NMP22,

immunochromatographic for Bard BTA)
NMP22: Less than 10 units/mL Drug Administration. Compared to

Bard BTA: Negative cytologic studies, these assays are
believed to be more sensitive but less
specific for detecting transitional cell
DESCRIPTION & RATIONALE: Cys- carcinoma.
toscopy is still considered the gold
NMP22: Nuclear matrix proteins
standard for detection of bladder can-
(NMPs) are involved in the
cer, but other noninvasive tests are regulation and expression of
being developed, including several various genes. The NMP
urine assays approved by the Food and identified as NuMA is abundant
in bladder tumor cells. The dying itourinary and immune systems and
tumor cells release the soluble
NMP into the urine. This assay is
quantitative. related laboratory tests, refer to the
Bladder tumor antigen (BTA): A Genitourinary and Immune System
human complement factor tables.
H–related protein (hCFHrp) is
thought to be produced by
bladder tumor cells as protection
from the body’s natural immune ➤ Obtain a list of the medications the
response. The bladder tumor patient is taking, including herbs,
antigen is released from tumor nutritional supplements, and nutra-
cells into the urine. This assay is ceuticals. The requesting health care
qualitative. ■ practitioner and laboratory should be
these products so their effects can
INDICATIONS: be taken into consideration when
• Detection of bladder carcinoma reviewing results.
• Management of recurrent bladder ➤ Review the procedure with the
cancer patient. Address concerns about pain
the patient that there should be no
RESULT: Increased in bladder carcinoma. discomfort during the procedure.
Inform the patient that specimen col-
CRITICAL VALUES: N/A lection takes approximately 5 min-
utes, depending on the cooperation
and ability of the patient.
• NMP22: Any condition that results in ➤ Sensitivity to social and cultural
inflammation of the bladder or urinary issues, as well as concern for mod-
tract may cause falsely elevated values. esty, is important in providing psy-
• Bard BTA: Recent surgery, biopsy, or and after the procedure.
other trauma to the bladder or urinary ➤ There are no food, fluid, or medica-
tract may cause falsely elevated values. tion restrictions unless by medical
Active urinary tract infection, renal or direction.
bladder calculi, gross hemolysis, and
positive leukocyte dipstick may also Intratest:
cause false-positive results.
and to follow directions.
Nursing Implications and ➤ Observe standard precautions, and

Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: lection container with the correspon-
➤ Inform the patient that the test is ding patient demographics, date, and
used to diagnose bladder cancer. time of collection.
➤ Obtain a history of the patient’s com- ➤ Obtain urine specimen in a clean
plaints, including a list of known plastic collection container. Promptly
allergens, and inform the appropriate transport the specimen to the labo-
health care practitioner accordingly. ratory for processing and analysis.
➤ Obtain a history of the patient’s gen- ➤ The results are recorded manually
Bleeding Time 257
or in a computerized system for ➤ Reinforce information given by the

recall and postprocedure interpreta- patient’s health care provider regard-
tion by the appropriate health care ing further testing, treatment, or
practitioner. referral to another health care
Post-test: address any concerns voiced by the
patient or family.
will be sent to the requesting health ➤ Depending on the results of this pro-
care practitioner, who will discuss cedure, additional testing may be
the results with the patient. performed to evaluate or monitor
results, and be supportive of fear of
the implications of abnormal test
regarding the clinical implications of Related laboratory tests:
Educate the patient regarding access ➤ Related laboratory tests include blad-
to counseling services. der biopsy and urine cytology.
BLEEDING TIME
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Mielke bleeding time, Simplate bleeding time,

Template bleeding time, Surgicutt, Ivy bleeding time.
SPECIMEN: Whole blood.

REFERENCE VALUE: (Method: Timed observation of incision)
Template: 2.5 to 10 minutes

Ivy: 2 to 7 minutes DESCRIPTION & RATIONALE: Bleed-
There are slight differences in the ing time assesses platelet and capillary
disposable devices used to make the inci- function. ■
sion. Although the Mielke or Template
bleeding time is believed to offer greater INDICATIONS:
standardization to a fairly subjective pro- Many laboratories have discounted the
cedure, both methods are thought to be use of bleeding time testing in favor of
of equal sensitivity and reproducibility. PT, aPTT, platelet count or platelet func-
tion testing as appropriate. This change in on patients who must be restrained,

laboratory practice is based on the results have excessively cold or edematous
of studies that do not support its clinical arms, have a platelet count less than
value in either surgical or nonsurgical 50,000/mm3, have an infectious skin
applications. disease, or cannot have a blood pressure
cuff placed on the arm.
RESULT
This test does not predict excessive bleed-
ing during a surgical procedure.
Prolonged in: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Bernard-Soulier syndrome
Pretest:
• Fibrinogen disorders
• Glanzmann’s thrombasthenia ➤ Inform the patient that the test is
used to assess platelet function.
• Hereditary telangiectasia
• Liver disease plaints, including a list of known
• Macroglobulinemia allergens (especially allergies or sen-
• Some myeloproliferative disorders appropriate health care practitioner
• Renal disease accordingly.
• Thrombocytopenia ➤ Obtain a history of the patient’s
hematopoietic system, as well as
• von Willebrand’s disease results of previously performed labo-
Decreased in: N/A and other diagnostic procedures. For
CRITICAL VALUES: Hematopoietic System table.
Greater than 14 minutes ➤ The test should not be performed
Note and immediately report to the until a minimum of 10 days after the
health care practitioner any critically last dose of any medication contain-
increased values and related symptoms. ing acetylsalicylic acid.
INTERFERING FACTORS: ➤ Obtain a list of the medications the
• Drugs that may prolong bleeding time
include acetylsalicylic acid, aminocap- ceuticals. The requesting health care
roic acid, ampicillin, asparaginase, car- practitioner and laboratory should be
benicillin, cefoperazone, cilostazol, advised if the patient regularly uses
dextran, diltiazem, ethanol, flurbipro- these products so their effects can
fen, fluroxene, halothane, heparin, be taken into consideration when
ketorolac, mezlocillin, moxalactam, reviewing results.
nafcillin, naproxen, nifedipine, nons- ➤ Review the procedure with the
teroidal anti-inflammatory drugs, patient. Inform the patient that spec-
penicillin, piroxicam, plicamycin, pro- imen collection takes approximately
pranolol, streptokinase, sulindac, ticar- 2 to 15 minutes. Address concerns
cillin, tolmetin, urokinase, valproic about pain related to the procedure.
acid, and warfarin. Explain to the patient that there may
be some discomfort during the pro-
• Drugs that may decrease bleeding time cedure. Inform the patient that scar-
include desmopressin and erythropoi- ring, keloid formation, or infection
etin. may occur.
➤ There are no food or fluid restrictions
• The test should not be performed unless by medical direction.
Bleeding Time 259
dressing or butterfly bandage on the

Intratest:
site after the test.
➤ Instruct the patient to cooperate fully ➤ Inform the patient with a bleeding
and to follow directions. Direct the disorder of the importance of taking
patient to breathe normally and to precautions against bruising and
avoid unnecessary movement. bleeding. These precautions may
➤ Observe standard precautions, and include the use of soft-bristle tooth-
follow the general guidelines in brush, use of an electric razor, avoid-
Appendix A. Positively identify the ance of constipation, avoidance of
patient. Place a blood pressure cuff acetylsalicylic acid and similar prod-
on the arm above the elbow and ucts, and avoidance of intramuscular
inflate to 40 mm Hg. Cleanse the site injections.
with alcohol and wait until it is air-dry. ➤ A written report of the examination
Hold skin taut. Avoid superficial veins will be sent to the requesting health
and use bleeding time device to care practitioner, who will discuss
make a parallel incision about 3 mm the results with the patient.
deep into the muscular outside area
of the forearm distal to the antecu- ➤ Reinforce information given by the
bital fossa (in the direction of wrist to patient’s health care provider regard-
elbow). Start stopwatch immediately. ing further testing, treatment, or
At 30-second intervals, blot the inci- referral to another health care pro-
sion site, in a clockwise fashion, on vider. Answer any questions or
the edge of a piece of filter paper. address any concerns voiced by the
The test concludes when the bleed- patient or family.
ing stops or if bleeding continues ➤ Depending on the results of this
longer than 15 minutes. Bleeding procedure, additional testing may
time is determined by adding the be performed to evaluate or moni-
total number of blots on the filter tor progression of the disease pro-
paper (30 seconds or 0.5 minutes). cess and determine the need for a
➤ The results are recorded manually or change in therapy. Evaluate test
in a computerized system for recall results in relation to the patient’s
and postprocedure interpretation by symptoms and other tests per-
the appropriate health care practi- formed.
tioner.

➤ Observe the incision site for bleed- ➤ Related laboratory tests include clot
ing. It may be necessary to place a retraction and platelet count.
BLOOD GASES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Arterial blood gases (ABGs), venous blood gases,

capillary blood gases, cord blood gases.
SPECIMEN: Whole blood. Specimen volume and collection container may

vary with collection method. See Intratest section for specific collection
instructions. Specimen should be tightly capped and transported in an ice
slurry.
REFERENCE VALUE: (Method: Selective electrodes for pH, pCO2 and pO2)
Blood Gas Value (pH) Birth, Cord, Full Term Adult/Child

Arterial 7.11–7.36 7.35–7.45
Venous 7.25–7.45 7.32–7.43
Capillary 7.32–7.49 7.35–7.45
Scalp 7.25–7.40 N/A
SI units (conversion factor 1).

SI Units SI Units SI Units
(Conventional (Conventional (Conventional
pCO2 Arterial Units 0.133) Venous Units 0.133) Capillary Units 0.133)
Birth, cord, 32–66 mm Hg 4.3–8.8 kPa 27–49 mm Hg 3.6–6.5 kPa — —

full term
Adult/child 35–45 mm Hg 4.66–5.98 kPa 41–51 mm Hg 5.4–6.8 kPa 26–41 mm Hg 3.5–5.4 kPa
12/15/05
SI Units SI Units SI Units

8:35 PM
(Conventional (Conventional (Conversion

pO2 Arterial Units 0.133) Venous Units 0.133) Capillary Units 0.133)
Birth, cord, 8–24 mm Hg 1.1–3.2 kPa 17–41 mm Hg 2.3–5.4 kPa — —
full term
Adult/child 80–95 mm Hg 10.6–12.6 kPa 20–49 mm Hg 2.6–6.5 kPa 80–95 mm Hg 10.6–12.6 kPa
Page 261
261
Arterial Venous Capillary

SI Units mmol/L SI Units mmol/L SI Units mmol/L
(Conventional (Conventional (Conventional
HCO3 Units 1) Units 1) Units 1)
Birth, cord, 17–24 mEq/L 17–24 mEq/L N/A
full term
Adult/child 18–23 mEq/L 24–28 mEq/L 18–23 mEq/L
O2 Sat Arterial Venous Capillary

Birth, cord, 40–90% 40–70% —
full term
Adult/child 95–99% 70–75% 95–98%
Arterial Venous
SI Units mmol/L SI Units mmol/L
tCO2 (Conventional Units 1) (Conventional Units 1)
Birth, cord, 13–22 mEq/L 14–22 mEq/L
full term
Adult/child 22–29 mEq/L 25–30 mEq/L
BE Arterial SI Units mmol/L (Conventional Units 1)

Birth, cord, full term (10)–(2) mEq/L
Adult/child ( 2)–(3) mEq/L
DESCRIPTION & RATIONALE: Blood pH reflects the number of free hydro-

gas analysis is used to evaluate respira- gen ions (H) in the body. A pH less
tory function and provide a measure than 7.35 indicates acidosis. A pH
for determining acid-base balance. greater than 7.45 indicates alkalosis.
Respiratory, renal, and cardiovascular Changes in the ratio of free hydrogen
system functions are integrated in ions to bicarbonate will result in a
order to maintain normal acid-base compensatory response from the lungs
balance. Therefore, respiratory or or kidneys to restore proper acid-base
metabolic disorders may cause abnor- balance.
mal blood gas findings. The blood gas pCO2 is an important indicator of
measurements commonly reported are ventilation. The level of pCO2 is con-
pH, partial pressure of carbon dioxide trolled primarily by the lungs and is
in the blood (pCO2), partial pressure referred to as the respiratory com-
of oxygen in the blood (pO2), bicar- ponent of acid-base balance. The
bonate (HCO3–), O2 saturation, and main buffer system in the body is the
base excess (BE) or base deficit (BD). bicarbonate–carbonic acid system.
Blood Gases 263
Bicarbonate is an important alkaline factory to obtain the necessary infor-

ion that participates along with other mation regarding acid-base balance
anions such as hemoglobin, proteins, without subjecting the patient to an
and phosphates to neutralize acids. arterial puncture with its associated
For the body to maintain proper bal- risks.
ance, there must be a ratio of 20 parts As seen in the table of reference
bicarbonate to one part carbonic acid ranges, pO2 is lower in infants than in
(20:1). Carbonic acid level is indi- children and adults owing to the
rectly measured by pCO2. Bicar- respective level of maturation of the
bonate level is indirectly measured by lungs at birth. pO2 tends to trail off
the total carbon dioxide content after age 30 years, decreasing by
(tCO2). The carbonic acid level is not approximately 3 to 5 mm Hg per
measured directly, but can be esti- decade as the organs age and begin to
mated because it is 3% of the pCO2. lose elasticity. There is a formula that
Bicarbonate can also be calculated can be used to approximate the rela-
from these numbers once the carbonic tionship between age and pO2:
acid value has been obtained because
pO2 104 – (age 0.27)
of the 20:1 ratio. For example, if the
pCO2 was 40, the carbonic acid Like carbon dioxide, oxygen is car-
would be 1.2 (3% 40) and the ried in the body in a dissolved and
HCO3– would be 24 (20 1.2). The combined (oxyhemoglobin) form.
main acid in the acid-base system is Oxygen content is the sum of the dis-
carbonic acid. It is the metabolic or solved and combined oxygen. The
nonrespiratory component of the oxygen-carrying capacity of the blood
acid-base system and is controlled by indicates how much oxygen could be
the kidney. Bicarbonate levels can carried if all the hemoglobin were sat-
either be measured directly or esti- urated with oxygen. Percent oxygen
mated from the tCO2 in the blood. saturation is [oxyhemoglobin concen-
BE/BD reflects the amount of anions tration divided by (oxyhemoglobin
available in the blood to help buffer concentration+deoxyhemoglobin
changes in pH. A BD (negative BE) concentration)] times 100.
indicates metabolic acidosis, whereas Testing on specimens other than
positive BE indicates metabolic alka- arterial blood is often ordered when
losis. oxygen measurements are not needed
Extremes in acidosis are generally or when the information regarding
more life threatening than alkalosis. oxygen can be obtained by noninva-
Acidosis can develop either very sive techniques such as pulse oximetry.
quickly (e.g., cardiac arrest) or over a Capillary blood is satisfactory for
longer period of time (e.g., renal fail- most purposes for pH and pCO2; the
ure). Infants can develop acidosis use of capillary pO2 is limited to the
very quickly if they are not kept warm exclusion of hypoxia. Measurements
and given enough calories. Children involving oxygen are usually not use-
with diabetes tend to go into acidosis ful when performed on venous sam-
more quickly than do adults who have ples; arterial blood is required to
been dealing with the disease over a accurately measure pO2 and oxygen
longer period of time. In many cases a saturation. There is considerable evi-
venous or capillary specimen is satis- dence that prolonged exposure to high
levels of oxygen can result in injury, in the management of patients on ventila-

such as retinopathy of prematurity in tors or being weaned from ventilators.
Blood gas values are used to determine
infants or the drying of airways in any
acid-base status, the type of imbalance,
patient. Monitoring pO2 from blood and the degree of compensation as sum-
gases is especially appropriate under marized in the following section.
such circumstances. ■ Restoration of pH to near-normal values
is referred to as fully compensated bal-
ance. When pH values are moving in
INDICATIONS: This group of tests is used the same direction (i.e., increasing or
to assess conditions such as asthma, decreasing) as the pCO2 or HCO3–, the
chronic obstructive pulmonary disease imbalance is metabolic. When the pH
(COPD), embolism (e.g., fatty or other values are moving in the opposite
embolism) during coronary arterial direction from the pCO2 or HCO3–, the
bypass surgery, and hypoxia. It is also imbalance is caused by respiratory distur-
used to assist in the diagnosis of respira- bances. To remember this concept, the
tory failure, which is defined as a pO2 less following mnemonic can be useful:
than 50 mm Hg and pCO2 greater than MeTRO Metabolic Together, Respi-
50 mm Hg. Blood gases can be valuable ratory Opposite.
Acid-Base Disturbance pH pCO2 pO2 HCO3–

Respiratory Acidosis
Uncompensated Decreased Increased Normal Normal
Compensated Normal Increased Increased Increased
Respiratory Alkalosis
Uncompensated Increased Decreased Normal Normal
Compensated Normal Decreased Decreased Decreased
Metabolic (Nonrespiratory) Acidosis
Uncompensated Decreased Normal Decreased Decreased
Compensated Normal Decreased Decreased Decreased
Metabolic (Nonrespiratory) Alkalosis
Uncompensated Increased Normal Increased Increased
Compensated Normal Increased Increased Increased
RESULT: blood gas values may not always seem

• Acid-base imbalance is determined by straightforward.
evaluating pH, pCO2, and HCO3– val- • Respiratory conditions that interfere
ues. pH less than 7.35 reflects an acidic with normal breathing will cause CO2
state, whereas pH greater than 7.45 to be retained in the blood. This results
reflects alkalosis. pCO2 and HCO3– in an increase of circulating carbonic
determine whether the imbalance is acid and a corresponding decrease in
respiratory or nonrespiratory. Because a pH (respiratory acidosis). Acute res-
patient may have more than one imbal- piratory acidosis can occur in acute
ance and may also be in the process of pulmonary edema, severe respiratory
compensating, the interpretation of infections, bronchial obstruction,
Blood Gases 265
pneumothorax, hemothorax, open Anemia (severe)

chest wounds, opiate poisoning, Anorexia
respiratory depressant drug therapy, Anoxia
and inhalation of air with a high Asthma
CO2 content. Chronic respiratory aci-
Atelectasis
dosis can be seen in patients with
asthma, pulmonary fibrosis, emphy- Bronchitis
sema, bronchiectasis, and respiratory Bronchoconstriction
depressant drug therapy. Alternately, Carbon monoxide poisoning
respiratory conditions that increase the Cardiac disorders
breathing rate will cause CO2 to be Congenital heart defects
removed from the alveoli more rapidly Congestive heart failure
than it is being produced. This will
result in an alkaline pH. Acute respira- COPD
tory alkalosis may be seen in anxiety, Cystic fibrosis
hysteria, hyperventilation, and pul- Depression of respiratory center
monary embolus and with an increase Drugs depressing the respiratory
in artificial ventilation. Chronic respira- system
tory alkalosis may be seen in high fever, Electrolyte disturbances (severe)
administration of drugs (e.g., salicylate Emphysema
and sulfa) that stimulate the respiratory Fever
system, hepatic coma, hypoxia of high
altitude, and central nervous system Head injury
(CNS) lesions or injury that result in Hypercapnia
stimulation of the respiratory center. Hypothyroidism (severe)
Near drowning
• Metabolic (nonrespiratory) conditions
Pleural effusion
that cause the excessive formation or
decreased excretion of organic or inor- Pneumonia
ganic acids result in metabolic acidosis. Pneumothorax
Some of these conditions include inges- Poisoning
tion of salicylates, ethylene glycol, and Poliomyelitis
methanol, as well as uncontrolled dia- Pulmonary edema
betes, starvation, shock, renal disease, Pulmonary embolism
and biliary or pancreatic fistula.
Metabolic alkalosis results from condi- Pulmonary tuberculosis
tions that increase pH, as can be seen in Respiratory distress syndrome
excessive intake of antacids to treat gas- (adult and neonatal)
tritis or peptic ulcer, excessive adminis- Respiratory failure
tration of HCO3–, loss of stomach acid Sarcoidosis
caused by protracted vomiting, cystic Smoking
fibrosis, or potassium and chloride Tumor
deficiencies.
• A decreased pO2 that increases pCO2:
Respiratory Acidosis Decreased alveolar gas exchange:
cancer, compression or resection
• Decreased pH: of lung, respiratory distress
• Decreased O2 saturation: syndrome (newborns),
sarcoidosis
• Increased pCO2: Decreased ventilation or perfusion:
Acute intermittent porphyria asthma, bronchiectasis,
bronchitis, cancer, croup, cystic Metabolic Acidosis

fibrosis (mucoviscidosis),
emphysema, granulomata, • Decreased pH:
pneumonia, pulmonary infarction, • Decreased HCO3–:
shock
• Decrease base excess:
Hypoxemia: anesthesia, carbon
monoxide exposure, cardiac • Decreased tCO2:
disorders, high altitudes, near Decreased excretion of H:
drowning, presence of abnormal acquired (e.g., drugs,
hemoglobins hypercalcemia), Addison’s
Hypoventilation: cerebrovascular disease, diabetic ketoacidosis,
incident, drugs depressing Fanconi’s syndrome, inherited
the respiratory system, head (e.g., cystinosis, Wilson’s
injury disease), renal failure, renal
Right-to-left shunt: congenital heart tubular acidosis
disease, intrapulmonary Increased acid intake
venoarterial shunting Increased formation of acids:
diabetic ketoacidosis, high-
Compensation fat/low-carbohydrate diets
• Increased pO2: Increased loss of alkaline body
Hyperbaric oxygenation fluids: diarrhea, excess
potassium, fistula
Hyperventilation
Renal disease
• Increased base excess:
Increased HCO3– to bring pH to Compensation
(near) normal • Decreased pCO2:
Hyperventilation
Respiratory Alkalosis
• Increased pH: Metabolic Alkalosis
• Decreased pCO2: • Increased pH:
Anxiety • Increased HCO3–:
CNS lesions or injuries that cause
• Increased base excess:
stimulation of the respiratory
center • Increased tCO2:
Excessive artificial ventilation Alkali ingestion (excessive)
Fever Anoxia
Head injury Gastric suctioning
Hyperthermia Hypochloremic states
Hyperventilation Hypokalemic states
Hysteria Potassium depletion: Cushing’s
Salicylate intoxication disease, diarrhea, diuresis,
excessive vomiting, excessive
Compensation ingestion of licorice, inadequate
potassium intake, potassium-
• Decreased pO2: losing nephropathy, steroid
Rebreather mask administration
• Decreased base excess: Salicylate intoxication
Decreased HCO3– to bring pH to Shock
(near) normal Vomiting
Blood Gases 267
Compensation CRITICAL VALUES: Note and

immediately report to the health care
• Increased tCO2: practitioner any critically increased or
Hypoventilation decreased values and related symptoms.
Arterial Blood
Gas Parameter Less Than Greater Than
pH 7.20 7.60
HCO3– 10 mmol/L 40 mmol/L
pCO2 20 mm Hg 67 mm Hg
pO2 45 mm Hg
INTERFERING FACTORS: include althesin, barbiturates, granulo-

• Drugs that may cause an increase in cyte-macrophage colony-stimulating
HCO3– include acetylsalicylic acid (ini- factor, isoproterenol, and meperidine.
tially), antacids, carbenicillin, carbenox- • Samples for blood gases are obtained by
olone, ethacrynic acid, glycyrrhiza arterial puncture, which carries a risk of
(licorice), laxatives, mafenide, and sod- bleeding, especially in patients who
ium bicarbonate. have bleeding disorders or are taking
• Drugs that may cause a decrease in medications for a bleeding disorder.
HCO3– include acetazolamide, acetyl- • Recent blood transfusion may produce
salicylic acid (long term or high doses), misleading values.
citrates, dimethadione, ether, ethylene
glycol, fluorides, mercury compounds • Specimens with extremely elevated
(laxatives), methylenedioxyampheta- white blood cell counts will undergo
mine, paraldehyde, and xylitol. misleading decreases in pH resulting
from cellular metabolism, if transport
• Drugs that may cause an increase in to the laboratory is delayed.
pCO2 include acetylsalicylic acid,
aldosterone bicarbonate, carbenicillin, • Specimens collected soon after a
carbenoxolone, corticosteroids, dexam- change in inspired oxygen has occurred
ethasone, ethacrynic acid, laxatives will not accurately reflect the patient’s
(chronic abuse), and x-ray contrast oxygenation status.
agents. • Specimens collected within 20 to 30
• Drugs that may cause a decrease in minutes of respiratory passage suction-
pCO2 include acetazolamide, acetylsal- ing or other respiratory therapy will not
icylic acid, ethamivan, neuromuscular be accurate.
relaxants (secondary to postoperative • Excessive differences in actual body
hyperventilation), NSD 3004 (arterial temperature relative to normal body
long-acting carbonic anhydrase inhibi- temperature will not be reflected in the
tor), theophylline, tromethamine, and results. Temperature affects the amount
xylitol. of gas in solution. Blood gas analyzers
measure samples at 37 C (98.6 F);
• Drugs that may cause an increase
therefore, if the patient is hyperthermic
in pO2 include theophylline and
or hypothermic, it is important to
urokinase.
notify the laboratory of the patient’s
• Drugs that may cause a decrease in pO2 actual body temperature at the time the
specimen was collected. Fever will calculated values in a short period of

increase actual pO2 and pCO2 values; time. The cold temperature provided
therefore the uncorrected values meas- by the ice slurry will slow down but not
ured at 37 C will be falsely decreased. completely stop metabolic changes
Hypothermia decreases actual pO2 and occurring in the sample over time. Iced
pCO2 values; therefore the uncorrected specimens not analyzed within 60 min-
values measured at 37 C will be falsely utes of collection should be rejected for
increased. analysis.
• A falsely increased O2 saturation may
occur because of elevated levels of car-
bon monoxide in the blood. Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• O2 saturation is a calculated parameter
based on an assumption of 100% Pretest:
hemoglobin A. Values may be mislead-
ing when hemoglobin variants with ➤ Inform the patient that the test is
different oxygen dissociation curves are used to assess acid-base balance
present. Hemoglobin S will cause a and oxygenation level of the blood.
shift to the right, indicating decreased ➤ Obtain a history of the patient’s com-
oxygen binding. Fetal hemoglobin and plaints, including a list of known
methemoglobin will cause a shift to allergens (especially allergies or sen-
the left, indicating increased oxygen sitivities to latex and anesthetics),
and inform the appropriate health
binding. care practitioner accordingly.
• Excessive amounts of heparin in the ➤ Obtain a history of the patient’s res-
sample may falsely decrease pH, pCO2, piratory system and any bleeding dis-
and pO2. orders as well as results of previously
• Citrates should never be used as an procedures, and other diagnostic pro-
anticoagulant in evacuated collection cedures, especially bleeding time,
tubes for venous blood gas determina- clotting time, complete blood count,
tions because citrates will cause a partial thromboplastin time, platelets,
marked analytic decrease in pH. and prothrombin time. For other
• Air bubbles or blood clots in the speci- Cardiovascular, Genitourinary, and
men are cause for rejection. Air bubbles Respiratory System tables.
in the specimen can falsely elevate or ➤ Note any recent procedures that can
decrease the results depending on the interfere with test results.
patient’s blood gas status. If an evacu-
ated tube is used for venous blood gas
specimen collection, the tube must be lant therapy, acetylsalicylic acid,
removed from the needle before the herbs, and nutraceuticals known to
needle is withdrawn from the arm or affect coagulation. It is recom-
else the sample will be contaminated mended that use of these products
with room air. be discontinued 14 days before den-
tal or surgical procedures. The
• Specimens should be placed in ice requesting health care practitioner
slurry immediately after collection and laboratory should be advised if
because blood cells continue to carry the patient is regularly using these
out metabolic processes in the speci- products so their effects can be
men after it has been removed from the taken into consideration when
patient. These natural life processes can reviewing results.
affect pH, pO2, pCO2, and the other ➤ Record the patient’s temperature.
Blood Gases 269
➤ Indicate the type of oxygen, mode of ➤ There are no food, fluid, or medica-
oxygen delivery, and delivery rate as tion restrictions unless by medical
part of the test requisition process. direction.
Wait 30 minutes after a change in ➤ Prepare an ice slurry in a cup or plas-
type or mode of oxygen delivery or tic bag to have ready for immediate
rate for specimen collection. transport of the specimen to the lab-
oratory.
➤ If the sample is to be collected
by radial artery puncture, per-
form an Allen test before puncture to Intratest:
ensure that the patient has adequate ➤ If the patient has a history of severe
collateral circulation to the hand if allergic reaction to latex, care should
thrombosis of the radial artery occurs be taken to avoid the use of equip-
after arterial puncture. The modified ment containing latex.
Allen test is performed as follows:
extend the patient’s wrist over a ➤ Instruct the patient to cooperate fully
rolled towel. Ask the patient to make and to follow directions. Direct the
a fist with the hand extended over patient to breathe normally and to
the towel. Use the second and third avoid unnecessary movement.
fingers to locate the pulses of the ➤ Observe standard precautions and
ulnar and radial arteries on the pal- follow the general guidelines in
mar surface of the wrist. (The thumb Appendix A. Positively identify the
should not be used to locate these patient and label the appropriate
arteries because it has a pulse.) tubes with the corresponding patient
Compress both arteries and ask the demographics, date, and time of col-
patient to open and close the fist lection.
several times until the palm turns ➤ The results are recorded manually
pale. Release pressure on the ulnar or in a computerized system for
artery only. Color should return to the recall and post-procedure interpreta-
palm within 5 seconds if the ulnar tion by the appropriate health care
artery is functioning. This is a positive practitioner.
Allen test, and blood gases may be
drawn from the radial artery site. The Arterial
Allen test should then be performed
on the opposite hand. The hand to ➤ Perform an arterial puncture and col-
which color is restored fastest has lect the specimen in an air-free
better circulation and should be heparinized syringe. There is no
selected for specimen collection. demonstrable difference in results
between samples collected in plastic
syringes and samples collected in
patient and advise rest for 30 min-
glass syringes. It is very important
utes before specimen collection. Be
that no room air be introduced into
sure to explain to the patient that an
the collection container because the
arterial puncture may be painful. The
gases in the room and in the sample
site may be anesthetized with 1% to
will begin equilibrating immediately.
2% lidocaine before puncture.
The end of the syringe must be stop-
Assess if the patient has an allergy
pered immediately after the needle is
to local anesthetics, and inform the
withdrawn and removed. Apply a
pressure dressing over the puncture
➤ Inform the patient that specimen col- site. Samples should be mixed by
lection usually takes 10 to 15 min- gentle rolling of the syringe to ensure
utes. The person collecting the proper mixing of the heparin with the
specimen should be notified before- sample, which will prevent the for-
hand if the patient is receiving anti- mation of small clots leading to rejec-
coagulant therapy, or taking aspirin or tion of the sample. The tightly
other natural products that may pro- capped sample should be placed
long bleeding from the puncture site. in an ice slurry immediately after
collection. Information on the speci- the laboratory or respiratory therapy

men label can be protected from staff of the number of fleas used so
water in the ice slurry by first placing the fleas can be accounted for and
the specimen in a protective plastic removed before the sample is intro-
bag. Promptly transport the speci- duced into the blood gas analyzers.
men to the laboratory for processing Fleas left in the sample may damage
and analysis. the blood gas equipment if allowed
to enter the analyzer. Microtainer
Venous samples should be mixed by gentle
➤ Central venous blood is collected in a rolling of the capillary tube to ensure
heparinized syringe. proper mixing of the heparin with the
sample, which will prevent the for-
➤ Venous blood collected percuta- mation of small clots leading to
neously by venipuncture in a 5-mL rejection of the sample. Promptly
green-top (heparin) tube (for adult transport the specimen to the labo-
patients) or a heparinized microtainer ratory for processing and analysis.
(for pediatric patients). The vacuum
collection tube must be removed Cord blood
from the needle before the needle is
removed from the patient’s arm. ➤ The sample may be collected directly
Apply a pressure dressing over the from the cord, using a syringe. The
puncture site. Samples should be tightly capped sample should be
mixed by gentle rolling of the syringe placed in an ice slurry immediately
to ensure proper mixing of the after collection. Information on the
heparin with the sample, which will specimen label can be protected
prevent the formation of small clots from water in the ice slurry by first
leading to rejection of the sample. placing the specimen in a protective
The tightly capped sample should be plastic bag. Promptly transport the
placed in an ice slurry immediately specimen to the laboratory for pro-
after collection. Information on the cessing and analysis.
specimen label can be protected
from water in the ice slurry by first
Scalp sample
placing the specimen in a protective ➤ Samples for scalp pH may be col-
plastic bag. Promptly transport the lected anaerobically before delivery
specimen to the laboratory for pro- in special, scalp-sample collection
cessing and analysis. capillaries and transported immedi-
ately to the laboratory for analysis.
Capillary Some hospitals recommend that
➤ Perform a capillary puncture and col- fleas be added to the scalp tube
lect the specimen in two 250- before the ends are capped. See pre-
µL heparinized capillaries (scalp or ceding section on capillary collection
heel for neonatal patients) or a for discussion of fleas.
heparinized microtainer (for pediatric
patients). Observe standard precau- Post-test:
tions and follow the general guide-
lines in Appendix A. The capillary ➤ Pressure should be applied to the
tubes should be filled as much as puncture site for at least 5 minutes in
possible and capped on both ends. the unanticoagulated patient and for
Some hospitals recommend that at least 15 minutes in the case of a
metal “fleas” be added to the capil- patient receiving anticoagulant ther-
lary tube before the ends are apy. Observe puncture site for bleed-
capped. During transport, a magnet ing or hematoma formation. Apply
can be moved up and down the out- pressure bandage.
side of the capillary tube to facilitate ➤ Observe the patient for signs or
mixing and prevent the formation of symptoms of respiratory acido-
clots, which would cause rejection of sis, such as dyspnea, headache,
the sample. It is important to inform tachycardia, pallor, diaphoresis,
Blood Gases 271
apprehension, drowsiness, coma, cially in the respirator-dependent

hypertension, or disorientation. patient. During periods of starvation,
➤ Teach the patient breathing exer- phosphorus leaves the intracellular
cises to assist with the appropriate space and moves outside the tissue,
exchange of oxygen and carbon resulting in dangerously decreased
dioxide. phosphorus levels. Adequate intake
of vitamins A and C is also important
➤ Administer oxygen, if appropriate. to prevent pulmonary infection and to
➤ Teach the patient how to properly decrease the extent of lung tissue
use the incentive spirometer device damage. The importance of following
or mininebulizer, if ordered. the prescribed diet should be
stressed to the patient and/or
➤ Observe the patient for signs or
caregiver.
symptoms of respiratory alkalosis,
such as tachypnea, restlessness, agi- ➤ Water balance needs to be closely
tation, tetany, numbness, seizures, monitored in COPD patients. Fluid
muscle cramps, dizziness, or tingling retention can lead to pulmonary
fingertips. edema.
➤ Instruct the patient to breathe deeply ➤ A written report of the examination
and slowly; performing this type of will be sent to the requesting health
breathing exercise into a paper care practitioner, who will discuss
bag decreases hyperventilation and the results with the patient.
quickly helps the patient’s breathing ➤ Reinforce information given by the
return to normal. patient’s health care provider regard-
➤ Observe the patient for signs or ing further testing, treatment, or
symptoms of metabolic acidosis, referral to another health care
such as rapid breathing, flushed skin, provider. Answer any questions or
nausea, vomiting, dysrhythmias, address any concerns voiced by the
coma, hypotension, hyperventilation, patient or family.
and restlessness. ➤ Depending on the results of this pro-
➤ Observe the patient for signs or cedure, additional testing may be
symptoms of metabolic alkalo- performed to evaluate or monitor
sis, such as shallow breathing, progression of the disease process
weakness, dysrhythmias, tetany, and determine the need for a change
hypokalemia, hyperactive reflexes, in therapy. Evaluate test results in
and excessive vomiting. relation to the patient’s symptoms
➤ Nutritional considerations: Abnormal
blood gas values may be associated Related laboratory tests:
with diseases of the respiratory sys-
tem. Malnutrition is commonly seen ➤ Related laboratory tests include
in patients with severe respiratory anion gap, arterial/alveolar oxygen
disease for reasons including fatigue, ratio, chloride sweat, culture and
lack of appetite, and gastrointestinal smear for mycobacteria, electrolytes,
distress. Research has estimated Gram stain, osmolality, phosphorus,
that the daily caloric intake required pleural fluid analysis, lactic acid, lung
for respiration of patients with COPD biopsy, sputum bacterial culture, spu-
is 10 times higher than that of normal tum cytology, tuberculin skin tests,
individuals. Inadequate nutrition can and white blood cell count and cell
result in hypophosphatemia, espe- differential.
BLOOD GROUPS AND ANTIBODIES

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: ABO group and Rh typing, blood group

antibodies, type and screen, type and crossmatch.
SPECIMEN: Serum (2 mL) collected in a red-top tube or whole blood

(2 mL) collected in a lavender-top (EDTA) tube.
REFERENCE VALUE: (Method: FDA-licensed reagents with glass slides, glass

tubes, or automated systems) Compatibility (no clumping or hemolysis).
Rh Type Other Antibodies Other Antibodies That

(with any That React at 37 C React at Room
Blood Type ABO) or with Antiglobulin Temperature or Below
A Positive Kell Lewis
B Negative Duffy P
AB Kidd MN
O S Cold agglutinins
s
U
DESCRIPTION & RATIONALE: Blood blood (universal donor). Blood type is

typing is a series of tests that include genetically determined. After 6
the ABO and Rh blood-group system months of age, individuals develop
performed to detect surface antigens serum antibodies that react with A or
on red blood cells by an agglutination B antigen absent from their own red
test and compatibility tests to deter- blood cells. These are called anti-A
mine antibodies against these anti- and anti-B antibodies.
gens. The major antigens in the ABO In ABO blood typing, the patient’s
system are A and B, although AB and red blood cells mix with anti-A and
O are also common phenotypes. The anti-B sera, a process known as for-
patient with A antigens has type A ward grouping. The process then
blood; the patient with B antigens has reverses, and the patient’s serum mixes
type B blood. The patient with both A with type A and B cells in reverse
and B antigens has type AB blood grouping.
(universal recipient); the patient with Generally, only blood with the
neither A nor B antigens has type O same ABO and Rh group as the recip-
Blood Groups and Antibodies 273
ient is transfused because the anti-A negative mothers after sensitization by

pregnancy with an Rh-positive fetus
and anti-B antibodies are strong
agglutinins that cause a rapid, com- • Determine the need for a microdose of
plement-mediated destruction of immunosuppressive therapy (e.g., with
incompatible cells. ABO and Rh test- RhoGAM) during the first 12 weeks of
ing is also performed as a prenatal gestation or a standard dose after 12
screen in pregnant women to identify weeks’ gestation for complications such
as abortion, miscarriage, vaginal hem-
the risk of hemolytic disease of the
orrhage, ectopic pregnancy, or abdomi-
newborn. Although most of the anti- nal trauma
A and anti-B activity resides in the
immunoglobulin M (IgM) class of • Determine Rh blood type and perform
immunoglobulins, some activity rests antibody screen of prenatal patients on
with immunoglobulin G (IgG). Anti- initial visit to determine maternal Rh
type and to indicate whether maternal
A and anti-B antibodies of the IgG
red blood cells have been sensitized
class coat the red blood cells without by any antibodies known to cause
immediately affecting their viability hemolytic disease of the newborn, espe-
and can readily cross the placenta, cially anti-D antibody. Rh blood type,
resulting in hemolytic disease of the antibody screen, and antibody titration
newborn. Individuals with type O (if an antibody has been indentified)
blood frequently have more IgG anti- will be rechecked at 28 weeks’ gestation
A and anti-B; thus, ABO hemolytic and prior to injection of prophylactic
disease of the newborn will affect standard RhoGAM dose for Rh-
infants of type O mothers almost negative mothers. These tests will also
be repeated after delivery of an Rh-
exclusively (unless the newborn is also
positive fetus to an Rh-negative mother
type O). and prior to injection of prophylactic
Major antigens of the Rh system standard RhoGAM dose (if maternal
are D (or Rho), C, E, c, and e. Rh-negative blood has not been previ-
Individuals whose red blood cells pos- ously sensitized with Rh-positive cells
sess D antigen are called Rh-positive; resulting in a positive anti-D antibody
those who lack D antigen are called titer). A postpartum blood sample
Rh-negative, no matter what other Rh must be evaluated for fetal-maternal
antigens are present. Individuals who bleed on all Rh-negative mothers to
are Rh-negative produce anti-D anti- determine the need for additional doses
of Rh immune globulin. One in 300
bodies when exposed to Rh-positive
cases will demonstrate hemorrhage
cells by either transfusions or preg- greater than 15 mL of blood and
nancy. These anti-D antibodies cross require additional RhoGAM.
the placenta to the fetus and can cause
hemolytic disease of the newborn or • Identify donor ABO and Rh blood
type for stored blood
transfusion reactions if Rh-positive
blood is administered. ■ • Identify maternal and infant ABO and
Rh blood types to predict risk of
INDICATIONS: hemolytic disease of the newborn
• Determine ABO and Rh compatibility • Identify the patient’s ABO and Rh
of donor and recipient before trans- blood type, especially before a proce-
fusion (Type and Screen or Crossmatch) dure in which blood loss is a threat or
• Determine anti-D antibody titer of Rh- blood replacement may be needed
RESULT: • Cross-matching: compatibility between

• ABO system: A, B, AB, or O specific to donor and recipient
person
• Incompatibility indicated by clump-
• Rh system: positive or negative specific ing (agglutination) of red blood
to person cells
Alternative Transfusion Group

and Type of PACKED CELL
UNITS in Order of Preference
If Patient’s Own Group and
Group and Type Incidence (%) Type Not Available
O Positive 37.4 O Negative
O Negative 6.6 O Positive*
A Positive 35.7 A Negative, O Positive, O Negative
A Negative 6.3 O Negative, A Positive,* O Positive*
B Positive 8.5 B Negative, O Positive, O Negative
B Negative 1.5 O Negative, B Positive,* O Positive*
AB Positive 3.4 AB Negative, A Positive, B Positive,
A Negative, B Negative, O
Positive, O Negative
AB Negative 0.6 A Negative, B Negative, O Negative,
AB Positive,* A Positive,* B
Positive,* O Positive*
Rh Type
Rh Positive 85–90
Rh Negative 10–15
*If blood units of exact match to the patient’s group and type are not available, a switch
in ABO blood group is preferable to a change in Rh type. However, in extreme
circumstances, Rh-positive blood can be issued to an Rh-negative recipient. It is very
likely that the recipient will develop antibodies as the result of receiving Rh-positive red
blood cells. Rh antibodies are highly immunogenic, and, once developed, the recipient
can only receive Rh-negative blood for subsequent red blood cell transfusion.
CRITICAL VALUES: Note and im- Possible interventions in mildly febrile

mediately report to the health care practi- reactions would include slowing the rate
tioner any signs and symptoms associated of infusion, then verifying and comparing
with a blood transfusion reaction. patient identification, transfusion requisi-
Signs and symptoms of blood transfu- tion, and blood bag label. The patient
sion reaction range from mildly febrile to should be monitored closely for further
anaphylactic and may include chills, dys- development of signs and symptoms.
pnea, fever, headache, nausea, vomiting, Administration of epinephrine may be
palpitations and tachycardia, chest or ordered.
back pain, apprehension, flushing, hives, Possible interventions in a more severe
angioedema, diarrhea, hypotension, olig- transfusion reaction may include imme-
uria, hemoglobinuria, renal failure, sepsis, diate cessation of infusion, notification of
shock, and jaundice. Complications from the health care practitioner, keeping the
disseminated intravascular coagulation intravenous (IV) line open with saline or
(DIC) may also occur. lactated Ringer’s solution, collection of
Blood Groups and Antibodies 275
red- and lavender-top tubes for post- performed laboratory tests, surgical
transfusion workup, collection of urine, procedures, and other diagnostic
monitoring vital signs every 5 minutes, procedures. For related laboratory
ordering additional testing if DIC is sus- tests, refer to the Immune and
Hematopoietic System tables.
pected, maintaining patent airway and
blood pressure, and administering man- ➤ Note any recent procedures that
could interfere with test results.
nitol. See Appendix D for a more detailed
description of transfusion reactions and ➤ Obtain a list of the medications the
potential nursing inteventions. nutritional supplements, and nutra-
INTERFERING FACTORS: practitioner and laboratory should be
• Drugs including levodopa, methyl- advised if the patient regularly uses
dopa, methyldopate hydrochloride, these products so their effects can
and cephalexin may cause a false- be taken into consideration when
positive result in Rh typing and in anti- reviewing results.
body screens. ➤ Review the procedure with the
• Recent administration of blood, blood imen collection takes approximately
products, dextran, or IV contrast medi- 5 to 10 minutes. Address concerns
um causes cellular aggregation resem- about pain related to the procedure.
bling agglutination in ABO typing. Explain to the patient that there may
• Contrast material such as iodine, bar- venipuncture.
ium, and gadolinium may interfere
with testing. issues, as well as concern for mod-
• Abnormal proteins, cold agglutinins, esty, is important in providing psy-
and bacteremia may interfere with chological support before, during,
testing. and after the procedure.
• Testing does not detect every antibody tion restrictions unless by medical
and may miss the presence of a weak direction.
antibody. ➤ Make sure a written and informed
• History of bone marrow transplant, consent has been signed prior to any
cancer, or leukemia (may cause discrep- transfusion of ABO- and Rh-compati-
ble blood products.
ancy in ABO typing).
Intratest:
Nursing Implications and ➤ If the patient has a history of severe
Procedure ● ● ● ● ● ● ● ● ● ● ● allergic reaction to latex, care should
Pretest: ment containing latex.
➤ Inform the patient that the test is and to follow directions. Direct the
used to determine ABO blood group patient to breathe normally and to
and Rh type. avoid unnecessary movement.
➤ Obtain a history of the patient’s com- ➤ Observe standard precautions, and
plaints, including a list of known follow the general guidelines in
➤ Obtain a history of the patient’s lection. Perform a venipuncture; col-
immune and hematopoietic sys- lect the specimen in 5-mL red- and
tems, as well as results of previously lavender-top tubes.
➤ Although correct patient identifica- ➤ Inform patient of ABO blood and Rh

tion is important for test specimens, type, and advise the patient to
it is crucial when blood is collected record the information on a card or
for type and crossmatch. Therefore, other document normally carried.
additional requirements are neces- ➤ Inform women who are Rh-negative
sary, including the verification of two to inform the health care practitioner
unique identifiers that could include of their Rh-negative status if
any two unique patient demograph- they become pregnant or need a
ics such as name, social security transfusion.
number, hospital number, date, or
blood bank number on requisition ➤ A written report of the examination
and specimen labels; completing will be sent to the requesting health
and applying a wristband on the arm care practitioner, who will discuss
with the same information; and plac- the results with the patient.
ing labels with the same information ➤ Reinforce information given by
and blood bank number on blood the patient’s health care provider
sample tubes. regarding further testing, treatment,
➤ Remove the needle, and apply a or referral to another health care
pressure dressing over the puncture provider. Answer any questions or
site. address any concerns voiced by the
patient or family.
the laboratory for processing and ➤ Depending on the results of this pro-
analysis. cedure, additional testing may be
➤ The results are recorded manually or progression of the disease process
in a computerized system for recall and determine the need for a change
and postprocedure interpretation by in therapy. Evaluate test results in
the appropriate health care practi- relation to the patient’s symptoms
tioner. and other tests performed.

➤ Observe venipuncture site for bleed- ➤ Related laboratory tests include dir-
ing or hematoma formation. Apply ect and indirect antiglobulin, bilirubin,
paper tape or other adhesive to hold cold agglutinin, gram stain, haptoglo-
pressure bandage in place, or bin, immunoglobulin A, Kleihauer-
replace with a plastic bandage. Betke, and urinalysis.
BLOOD POOL IMAGING

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Cardiac blood pool scan, ejection fraction study,

gated cardiac scan, radionuclide ventriculogram, wall motion study, MUGA.

CONTRAST: Intravenous radioactive material.
Blood Pool Imaging 277
DESCRIPTION & RATIONALE: Multi- with a resting MUGA scan to obtain

gated blood pool imaging (MUGA; ejection fraction and assess regional
also known as cardiac blood pool scan) wall motion.
is used to diagnose cardiac abnormali- First-pass cardiac flow study is done
ties involving the left ventricle and to study heart chamber disorders,
myocardial wall abnormalities by including left-to-right and right-to-
imaging the blood within the cardiac left shunts, determine both right and
chamber rather than the myocardium. left ventricular ejection fractions, and
The ventricular blood pool can be assess blood flow through the great
imaged during the initial transit of a vessels. The study uses a jugular or
peripherally injected, intravenous antecubital vein injection of the
bolus of radionuclide (first-pass tech- radionuclide. ■
nique) or when the radionuclide
has reached equilibrium concentra- INDICATIONS:
tion. The patient’s electrocardiogram • Aid in the diagnosis of myocardial
(ECG) is synchronized to the gamma infarction
camera imager and computer and • Aid in the diagnosis of true or false ven-
thereby termed “gated.” For multi- tricular aneurysms
gated studies, technetium-99m (Tc- • Aid in the diagnosis of valvular heart
99m) pertechnetate is injected after an disease and determine the optimal time
injection of pyrophosphate, allowing for valve replacement surgery
the labeling of circulating red blood
• Detect left-to-right shunts and deter-
cells; Tc-99m sulfur colloid is used mine pulmonary-to-systemic blood
for first-pass studies. Studies detect flow ratios, especially in children
abnormalities in heart wall motion at
rest or with exercise, ejection fraction, • Determine cardiomyopathy
ventricular dilation, stroke volume, • Determine drug cardiotoxicity to stop
and cardiac output. The MUGA pro- therapy before development of conges-
cedure, performed with the heart in tive heart failure
motion, is used to obtain multiple • Determine ischemic coronary artery
images of the heart in contraction and disease
relaxation during an R-to-R cardiac
• Differentiate between chronic obstruc-
cycle. The resulting images can be tive pulmonary disease and left ventric-
displayed in a cinematic mode to ular failure
visualize cardiac function. Repetitive
data acquisitions are possible during • Evaluate ventricular size, function, and
wall motion after an acute episode or in
graded levels of exercise, usually a
chronic heart disease
bicycle ergometer or handgrip, to
assess ventricular functional response • Quantitate cardiac output by calculat-
to exercise. ing global or regional ejection fraction
After the administration of sublin-
RESULT
gual nitroglycerin, the MUGA scan
can evaluate the effectiveness of the Normal Findings:
drug on ventricular function. Heart • Normal wall motion, ejection fraction
shunt imaging is done in conjunction (55% to 65%), coronary blood flow,
ventricular size and function, and may exceed the weight limit for the
symmetry in contractions of the left equipment
ventricle
Abnormal Findings:
• Abnormal wall motion (akinesia or
dyskinesia) Other considerations:
• Cardiac hypertrophy • Conditions such as chest wall trauma,
cardiac trauma, angina that is difficult
• Cardiac ischemia
to control, significant cardiac arrhyth-
• Enlarged left ventricle mias, or a recent cardioversion proce-
• Infarcted areas are akinetic dure may affect test results.
• Ischemic areas are hypokinetic • Atrial fibrillation and extrasystoles

invalidate the procedure.
• Suboptimal cardiac stress or patient
INTERFERING FACTORS: exhaustion, preventing maximum heart
rate testing, will affect results when the
This procedure is procedure is done in conjunction with
contraindicated for: exercise testing.
• Testing is contraindicated in patients • Consultation with a physician should
with hypersensitivity to the radionu- occur before the procedure for radia-
clide and in pregnancy and lactation tion safety concerns regarding younger
unless the benefits of performing the patients or patients who are lactating.
test greatly outweigh the risks.
• Risks associated with radiographic
• Dipyridamole testing is not performed overexposure can result from frequent
in patients with anginal pain at rest or x-ray procedures. Personnel in the
in patients with severe atherosclerotic room with the patient should wear a
coronary vessels. protective lead apron, stand behind a
• Chemical stress with vasodilators shield, or leave the area while the exam-
should not be done to patients having ination is being done. Badges that
asthma; bronchospasm can occur. reveal the level of exposure to radiation
should be worn by persons working in
Factors that may the area where the examination is being
impair clear imaging: done.
because of age, significant pain, or Nursing Implications and
mental status Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
which may inhibit organ visualization ➤ Inform the patient that the test per-
and can produce unclear images mits assessment of the pumping
action of the heart.
• Improper adjustment of the radi-
ographic equipment to accommodate ➤ Obtain a history of the patient’s com-
plaints and symptoms, including a
obese or thin patients, which can cause list of known allergens.
overexposure or underexposure and
poor-quality study ➤ Obtain a history of results of previ-
• Patients who are very obese, who dures, surgical procedures, and
Blood Pool Imaging 279
laboratory tests. For related tests, ➤ Observe standard precautions, and

refer to the Cardiovascular System follow the general guidelines in
table. Appendix A.
➤ Obtain a list of the patient’s current ➤ Expose the chest and attach the ECG
medications. leads. Record baseline readings.
➤ Explain to the patient that some pain ➤ The radionuclide is administered
may be experienced during the test, intravenously, and, after 1 minute,
and there may be moments of dis- scanning is done to obtain views of
comfort. Explain the purpose of the the heart in the anterior, oblique, and
test and how the procedure is per- lateral views. Between 12 and 64
formed. Inform the patient that the images are obtained reflecting the
procedure is performed in a nuclear motion of heart over the entire car-
medicine department, usually by a diac cycle.
technologist and support staff, ➤ When the scan is done under
and takes approximately 30 to 60 exercise conditions, the patient is
minutes. assisted onto the treadmill or bicycle
➤ Sensitivity to cultural and social ergometer and is exercised to a cal-
issues, as well as concern for mod- culated 80% to 85% of the maxi-
esty, is important in providing psy- mum heart rate as determined by
chological support before, during, the protocol selected. Images are
and after the procedure. done at each exercise level and
begun immediately after injection of
the radionuclide.
of pregnancy in perimenopausal ➤ If nitroglycerin is given, a cardiologist
women. assessing the baseline MUGA scan
injects the medication and records
➤ Reassure the patient that radioactive another scan, and then repeats this
material poses no radioactive hazard procedure until blood pressure
and rarely produces side effects. reaches the desired level.
➤ Tell the patient to wear walking ➤ Patients who cannot exercise are
shoes for the treadmill or bicycle given dipyridamole before the radio-
exercise. Emphasize to the patient nuclide is injected.
the importance of reporting fatigue,
pain, or shortness of breath. ➤ Patient movement during the proce-
dure will affect the results and make
➤ Ask the patient to lie very still during interpretation difficult.
the procedure, as movement will
produce unclear images. ➤ The results are recorded manually on
film or in a computerized system for
➤ Restrict food for 4 hours, and med- recall and postprocedure interpreta-
ications for 24 hours before the test tion by the appropriate health care
as ordered by the physician. practitioner.
Intratest: Post-test:
➤ Ensure that the patient has complied ➤ Monitor ECG tracings and compare
with dietary preparations and other with baseline readings until stable.
pretesting restrictions. ➤ Observe the injection site for red-
➤ Ensure that emergency equipment ness, swelling, or hematoma.
is readily available during the ➤ Observe the patient for up to 60 min-
procedure. utes after the procedure for possible
➤ Have the patient remove all jewelry reaction to the radionuclide or com-
or other metallic objects, put on a plications from the procedure.
hospital gown, and then void. ➤ Advise the patient to drink fluids to
➤ The patient is placed at rest in the eliminate the radionuclide from the
supine position on the scanning body, unless otherwise contraindi-
table. cated.
➤ If a woman who is breast-feeding ➤ Inform the patient that abnormalities

must have a nuclear scan, she of the heart scan can indicate the
should not breast-feed the infant need for further studies, including
until the radionuclide has been elimi- cardiac catheterization and echocar-
nated. This could take as long as 3 diography.
days. She should be instructed to ➤ If possible, pregnant health care
express the milk and discard it dur- workers should avoid caring for a
ing the 3-day period to prevent ces- patient who has had a nuclear medi-
sation of milk production. cine procedure for the first 24 hours.
➤ Instruct the patient to wash hands ➤ Depending on the results of this pro-
with soap and water after each void- cedure, additional testing may be
ing for 24 hours. needed to evaluate and determine
➤ Instruct the patient to resume nor- the need for a change in therapy or
mal activity and diet, unless other- progression of the disease process.
wise indicated. Evaluate test results in relation to
the patient’s symptoms and other
➤ A written report of the examination tests performed.
practitioner who specializes in this Related diagnostic tests:
be sent to the requesting health care ➤ Related diagnostic tests include
practitioner, who will discuss the echocardiogram and myocardial per-
results with the patient. fusion scan.
BONE MINERAL DENSITOMETRY

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYMS: Ultrasound densitometry, DEXA, DXA, SXA,

QCT, RA.
Dual-energy x-ray absorptiometry (DEXA, DXA): Two x-rays of different
energy levels measure bone mineral density and predict risk of fracture.
Single-energy x-ray absorptiometry (SXA): A single-energy x-ray
measures bone density at peripheral sites.
Quantitative computed tomography (QCT): QCT is used to examine the
lumbar vertebrae. It measures trabecular and cortical bone density.
Results are compared to a known standard. This test is the most
expensive and involves the highest radiation dose of all techniques.
Radiographic absorptiometry (RA): A standard x-ray of the hand. Results
are compared to a known standard.
Ultrasound densitometry: Studies bone mineral content in peripheral
densitometry sites such as the heel or wrist. It is not as precise as x-ray
techniques, but less expensive than other techniques.
AREA OF APPLICATION: Lumbar spine, heel, hip, wrist, whole body.

CONTRAST: None.
Bone Mineral Densitometry 281
the hip, vertebrae, and distal forearm.

DESCRIPTION & RATIONALE: Bone Bone mineral loss is a disease of the entire
mineral density (BMD) can be meas- skeleton and not restricted to the areas
ured at any of several body sites, listed. The effect of the fractures has a
including the spine, hip, wrist, and wide range, from complete recovery to
heel. Machines to measure BMD chronic pain, disability, and possible
include computed tomography (CT), death.
radiographic absorptiometry, ultra- • Determine the mineral content of bone
sound, single-energy x-ray absorp- • Determine a possible cause of amenor-
tiometry (SXA), and most commonly, rhea
dual-energy x-ray absorptiometry • Establish a diagnosis of osteoporosis
(DEXA). The radiation exposure from
• Evaluate bone demineralization associ-
SXA and DEXA machines is approxi-
ated with chronic renal failure
mately one-tenth that of a standard
chest x-ray. • Evaluate bone demineralization associ-
ated with immobilization
The BMD values measured by the
various techniques cannot be directly • Monitor changes in BMD due to med-
compared. Therefore, they are stated ical problems or therapeutic interven-
tion
in terms of standard deviation (SD)
units. The patient’s T-score is the num- • Predict future fracture risk
ber of SD units above or below the
average BMD in young adults. A Z- RESULT
score is the number of SD units above • T-score estimates the actual fracture
or below the average value for a per- risk compared to young adults.
son of the same age as the measured • Normal bone mass is designated as a T-
patient. For most BMD readings, 1 score value not less than –1.
SD is equivalent to 10% to 12% of • Osteoporosis is defined as a BMD T-
the average young-normal BMD score value less than –2.5.
value. A T-score of –2.5 is therefore
• Low bone mass or osteopenia has T-
equivalent to a bone mineral loss of
scores from –1 to –2.5.
30% when compared to a young
adult. ■ • Fracture risk increases as BMD declines
from young-normal levels (low T-
scores).
INDICATIONS:
Osteoporosis is a condition characterized • Low Z-scores in older adults can be
by low BMD, which results in increased misleading because low BMD is very
risk of fracture. The National Osteoporo- common.
sis Foundation estimates that 4 to 6 mil- • Z-scores estimate fracture risk com-
lion postmenopausal women in the pared to others of the same age (versus
United States have osteoporosis, and an young-normal adults).
additional 13 to 17 million (30% to
50%) have low bone density at the hip. It INTERFERING FACTORS (OR FACTORS
is estimated that one of every two women ASSOCIATED WITH INCREASED RISK
will experience a fracture as a result of low OF OSTEOPOROSIS):
bone mineral content in her lifetime. The
measurement of BMD gives the best indi- This procedure is
cation of risk for a fracture. The lower the contraindicated for:
BMD, the greater the risk of fracture. • Patients who are pregnant or suspected
The most common fractures are those of of being pregnant, unless the potential
benefits of the procedure far outweigh in the area where the examination is
the risks to the fetus and mother. being done.
Factors that may

impair clear imaging: Nursing Implications and
• Inability of the patient to cooperate or Procedure ● ● ● ● ● ● ● ● ● ● ●

because of age, significant pain, or As a result of altered BMD,
mental status not the BMD testing process:
• Metallic objects within the examina- ➤ Vertebral fractures may cause com-
tion field (e.g., jewelry, earrings, and/or plications including back pain, height
dental amalgams), which may inhibit loss, and kyphosis.
organ visualization and can produce ➤ Limited activity may result including
unclear images difficulty bending and reaching.
➤ Patient may have poor self-esteem
resulting from the cosmetic effects
ographic equipment to accommodate of kyphosis.
➤ Potential restricted lung function
may result from fractures.
poor-quality study
➤ Fractures may alter abdominal
• Patients who are very obese, who anatomy, resulting in constipation,
may exceed the weight limit for the pain, distention, and diminished
equipment appetite.
➤ Potential for a restricted lifestyle may
result in depression and other psy-
which may produce poor visualization chological symptoms.
➤ Possible increased dependency on
family for basic care may occur.
Other considerations:
• The use of anticonvulsant drugs, cyto- Pretest:
toxic drugs, tamoxifen, glucocorticoid,
lithium, or heparin, as well as increased ➤ Obtain a history of the patient’s com-
alcohol intake, increased aluminum plaints and symptoms, including a
list of known allergens.
levels, excessive thyroxin, renal dialysis,
or smoking, may affect the test results ➤ Obtain a list of the patient’s current
by either increasing or decreasing the medications.
bone mineral content. ➤ Obtain a history of the patient’s bone
mineral status, as well as results of
• Consultation with a physician should previously performed diagnostic pro-
occur before the procedure for radia- cedures, surgical procedures, and
tion safety concerns regarding younger laboratory tests. For related tests,
patients or patients who are lactating. refer to the Musculoskeletal System
table.
➤ Explain the purpose of the test and
overexposure can result from frequent how the procedure is performed.
x-ray procedures. Personnel in the Inform the patient that the test usu-
room with the patient should wear a ally takes 15 minutes.
protective lead apron, stand behind a ➤ Make special note of age, previous
shield, or leave the area while the exam- fractures, thinness, smoking, family
ination is being done. Badges that history, fall risk, alcohol and coffee
reveal the level of exposure to radiation intake, age of menopause, and cal-
should be worn by persons working cium intake.
Bone Mineral Densitometry 283
➤ Record the date of the last menstrual calcium and vitamin D, weight-
period and determine the possibility bearing exercise, and avoidance of
of pregnancy in perimenopausal tobacco use and alcohol abuse.
women. ➤ Recognize anxiety related to test
➤ Sensitivity to cultural and social results, and be supportive of per-
issues, as well as concern for mod- ceived loss of independent function.
esty, is important in providing psy- Discuss the implications of abnormal
chological support before, during, test results on the patient’s lifestyle.
and after the procedure. Provide teaching and information
➤ There are no food, fluid, or medica- regarding the clinical implications of
tion restrictions unless by medical the test results, as appropriate.
direction. ➤ Reinforce information given by
the patient’s health care provider
Intratest: regarding further testing, treatment,
or referral to another health care
➤ Clothing is not usually removed provider. Answer any questions or
unless it contains metal or other address any concerns voiced by the
items that would interfere with the patient or family.
test.
➤ Patients may want to wear a gown
and robe, depending on the area to
be examined.
➤ Remove all metal objects from the be sent to the requesting health care
area to be examined. practitioner, who will discuss the
➤ Observe standard precautions, and results with the patient.
follow the general guidelines in ➤ Depending on the results of this pro-
Appendix A. cedure, additional testing may be
➤ Direct the patient to breathe nor- needed to evaluate or monitor pro-
mally and to avoid unnecessary gression of the disease process and
movement. determine the need for a change in
➤ The results are recorded manually on therapy. Evaluate test results in rela-
film or in a computerized system for tion to the patient’s symptoms, pre-
recall and postprocedure interpreta- vious BMD values, and other tests
tion by the appropriate health care performed.
practitioner.
Post-test:
➤ Related diagnostic tests include CT
➤ Post-test instructions should include of the spine or pelvis, and magnetic
instructions for adequate intake of resonance imaging of the pelvis.
BONE SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Bone imaging, radionuclide bone scan, bone

scintigraphy, whole-body bone scan.
AREA OF APPLICATION: Bone/skeleton.

CONTRAST & RATIONALE: Intravenous radioactive material (diphosphonate
compounds), usually combined with technetium-99m.
DESCRIPTION: This nuclear medicine even though x-rays have proved nega-
scan assists in diagnosing and deter- tive. A gamma camera detects the
mining the extent of primary and radiation emitted from the injected
metastatic bone disease and bone radioactive material. Whole-body or
trauma, and monitors the progression representative images of the skeletal
of degenerative disorders. Abnormali- system can be obtained. ■
ties are identified by scanning 1 to 3
hours after the intravenous injection INDICATIONS:
of a radionuclide such as technetium- • Aid in the diagnosis of benign tumors
99m methylene diphosphonate. Areas or cysts
of increased uptake and activity on the • Aid in the diagnosis of metabolic bone
bone scan represent abnormalities diseases
unless they occur in normal areas of • Aid in the diagnosis of osteomyelitis
increased activity, such as the sternum,
• Aid in the diagnosis of primary malig-
sacroiliac, clavicle, and scapular joints
nant bone tumors (e.g., osteogenic
in adults, and growth centers and cra- sarcoma, chondrosarcoma, Ewing’s sar-
nial sutures in children. The radionu- coma, metastatic malignant tumors)
clide mimics calcium physiologically
and therefore localizes in bone with • Aid in the detection of traumatic or
stress fractures
an intensity proportional to the degree
of metabolic activity. Gallium, mag- • Assess degenerative joint changes or
netic resonance imaging (MRI), or acute septic arthritis
white blood cell scanning can follow a • Assess suspected child abuse
bone scan to obtain a more sensitive
• Confirm temporomandibular joint
study if acute inflammatory condi- derangement
tions such as osteomyelitis or septic
arthritis are suspected. In addition, • Detect Legg-Calvé-Perthes disease
bone scan can detect fractures in • Determine the cause of unexplained
patients who continue to have pain, bone or joint pain
Bone Scan 285
• Evaluate the healing process following • Metallic objects within the examina-
fracture, especially if an underlying tion field (e.g., jewelry, earrings, and/or
bone disease is present dental amalgams), which may inhibit
organ visualization and can produce
• Evaluate prosthetic joints for infection,
unclear images.
loosening, dislocation, or breakage
• Evaluate tumor response to radiation or ographic equipment to accommodate
chemotherapy obese or thin patients, which can cause
• Identify appropriate site for bone overexposure or underexposure and
biopsy, lesion excision, or débridement poor-quality study.
RESULT exceed the weight limit for the equip-
ment.
Normal Findings:
• No abnormalities, as indicated by • Incorrect positioning of the patient,
homogeneous and symmetric distribu- which may produce poor visualization
tion of the radionuclide throughout all of the area to be examined.
skeletal structures • Retained barium from a previous radi-
ologic procedure may affect the image.
Abnormal Findings:
• A distended bladder may obscure pelvic
• Bone necrosis
detail.
• Degenerative arthritis
• Other nuclear scans done within the
• Fracture previous 24 to 48 hours may alter
• Legg-Calvé-Perthes disease image.
• Metastatic bone neoplasm Other considerations:
• Osteomyelitis • The existence of multiple myeloma or
• Paget’s disease thyroid cancer can result in a false-
negative scan for bone abnormalities.
• Primary metastatic bone tumors
• Improper injection of the radionuclide
• Renal osteodystrophy may allow the tracer to seep deep into
• Rheumatoid arthritis the muscle tissue, producing erroneous
hot spots.
INTERFERING FACTORS • Consultation with a physician should
This procedure is occur before the procedure for radia-
contraindicated for: tion safety concerns regarding younger
• Patients who are pregnant or suspected patients or patients who are lactating.
of being pregnant, unless the potential • Risks associated with radiologic overex-
benefits of the procedure far outweigh posure can result from frequent x-ray
the risks to the fetus and mother procedures. Personnel in the room with
Factors that may lead apron, stand behind a shield, or
impair clear imaging: leave the area while the examination is
• Inability of the patient to cooperate or being done. Badges that reveal the level
remain still during the procedure of exposure to radiation should be
because of age, significant pain, or worn by persons working in the area
mental status. where the examination is being done.
➤ Instruct the patient to lie very still

Nursing Implications and during the procedure because
Procedure ● ● ● ● ● ● ● ● ● ● ● movement will produce unclear
images.
Pretest: ➤ Sedate children who are unable to
➤ Inform the patient that the bone lie still.
scan can detect bone disease before
the disease can be detected with Intratest:
plain film x-rays.
➤ Obtain a history of the patient’s com- ➤ Ask patient to remove jewelry,
plaints and symptoms, including a including watches, and any other
list of known allergens. metallic objects.
➤ Obtain a history of results of ➤ Patients are given a gown, robe,
previously performed diagnostic pro- and foot coverings to wear and
cedures, surgical procedures, and instructed to void prior to the pro-
laboratory tests. For related tests, cedure.
refer to the Musculoskeletal System ➤ Observe standard precautions, and
table. follow the general guidelines in
➤ Obtain a list of the patient’s current Appendix A.
medications. ➤ Place the patient in a supine position
➤ Explain to the patient that some pain on a flat table with foam wedges to
may be experienced during the test, help maintain position and immobi-
and there may be moments of dis- lization. The radionuclide is adminis-
comfort. Explain the purpose of the tered intravenously, with images
test and how the procedure is taken every 3 seconds for the first
performed. Inform the patient that minute over the area to be exam-
the procedure is performed in a ined. This will evaluate the blood flow
nuclear medicine department, usu- to the area. A blood pool image is
ally by a technologist and support then obtained over the area to be
staff, and takes approximately 30 to examined (usually taking 2 to 3
60 minutes. minutes). A 2- to 3-hour delay is
➤ Sensitivity to cultural and social required between the injection and
issues, as well as concern for mod- the actual bone scan to improve
esty, is important in providing psy- tumor imaging.
chological support before, during, ➤ After the delay that allows the
and after the procedure. radionuclide to be taken up by the
➤ There are no food, fluid, or medica- bones, multiple images are obtained
tion restrictions unless by medical over the complete skeleton. A cam-
direction. era with a large field of view is used
➤ Record the date of the last menstrual to cover the whole area. Delayed
period and determine the possibility views may be taken up to 24 hours
of pregnancy in perimenopausal after the injection.
women. ➤ The results are recorded manually on
➤ Inform the patient that the technolo- film or in a computerized system for
gist will administer an intravenous recall and postprocedure interpreta-
injection of the radionuclide, and that tion by the appropriate health care
he or she will need to return 2 to 3 practitioner.
hours later for the scan. ➤ The patient may be imaged by
➤ After the injection, the patient should single-photon emission computed
be encouraged to increase fluid tomography (SPECT) techniques to
intake and continue normal physical further clarify areas of suspicious
activity. radionuclide localization.
Bronchoscopy 287
when discarding urine for 48 hours

Post-test:
after the procedure. Wash gloved
➤ Instruct the patient to resume usual hands with soap and water before
diet, medication, and activity as dir- removing gloves. Then wash ung-
ected by the health care practitioner. loved hands after the gloves are
➤ Unless contraindicated, advise removed.
patient to drink increased amounts ➤ Instruct the patient in the care and
of fluids for 24 to 48 hours to elimi- assessment of the injection site.
nate the radionuclide from the body. Observe for bleeding, hematoma for-
Tell the patient that radionuclide is mation, and inflammation.
eliminated from the body within 24
to 48 hours.
➤ If a woman who is breast-feeding care practitioner specializing in this
must have a nuclear scan, she branch of medicine. The report will
should not breast-feed the infant be sent to the requesting health care
until the radionuclide has been elimi- practitioner, who will discuss the
nated. This could take as long as 3 results with the patient.
days. She should be instructed to
express the milk and discard it dur- ➤ Depending on the results of this pro-
ing the 3-day period to prevent ces- cedure, additional testing may be
sation of milk production. needed to evaluate or monitor pro-
gression of the disease process and
➤ No other radionuclide tests should determine the need for a change in
be scheduled for 24 to 48 hours after therapy. Evaluate test results in rela-
this procedure. tion to the patient’s symptoms and
➤ Inform the patient to immediately other tests performed.
flush the toilet after each voiding
after the procedure and to meticu-
lously wash hands with soap and Related diagnostic tests:
water after each voiding for 48 hours ➤ Related diagnostic tests include
after the procedure. computed tomography of the spine
➤ Tell all caregivers to wear gloves or pelvis, and MRI of the pelvis.
BRONCHOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Flexible bronchoscopy.
AREA OF APPLICATION: Bronchial tree, larynx, trachea.
CONTRAST: None.
INDICATIONS:
DESCRIPTION & RATIONALE: This • Detect end-stage bronchogenic cancer
procedure provides direct visualiza-
• Detect lung infections and inflam-
tion of the larynx, trachea, and mation
bronchial tree by means of either a
rigid or a flexible bronchoscope. A • Determine etiology of persistent
cough, hemoptysis, hoarseness, unex-
fiberoptic bronchoscope with a light
plained chest x-ray abnormalities,
incorporated is guided into the tra- and/or abnormal cytologic findings in
cheobronchial tree. A local anesthetic sputum
may be used to allow the scope to be
• Determine extent of smoke-inhalation
inserted through the mouth or nose
or other traumatic injury
into the trachea and into the bronchi.
The patient must breathe during • Evaluate airway patency; aspirate deep
insertion and with the scope in place. or retained secretions
The purpose of the procedure is both • Evaluate endotracheal tube placement
diagnostic and therapeutic. or possible adverse sequelae to tube
The rigid bronchoscope allows placement
visualization of the larger airways, • Evaluate possible airway obstruction in
including the lobar, segmental, and patients with known or suspected sleep
subsegmental bronchi, while main- apnea
taining effective gas exchange. Rigid • Evaluate respiratory distress and
bronchoscopy is preferred when large tachypnea in an infant to rule out tra-
volumes of blood or secretions need to cheoesophageal fistula or other congen-
be aspirated, when foreign bodies are ital anomaly
to be removed, when large-sized • Identify bleeding sites and remove clots
biopsy specimens are to be obtained, within the tracheobronchial tree
and for most bronchoscopies in • Identify hemorrhagic and inflamma-
children. tory changes in Kaposi’s sarcoma
The flexible fiberoptic broncho-
• Intubate patients with cervical spine
scope has a smaller lumen that is injuries or massive upper airway edema
designed to allow for visualization of
all segments of the bronchial tree. The • Remove foreign body
accessory lumen of the bronchoscope • Treat lung cancer through instillation
is used for tissue biopsy, bronchial of chemotherapeutic agents, implanta-
washings, instillation of anesthetic tion of radioisotopes, or laser palliative
agents and medications, and to obtain therapy
specimens with brushes for cytologic
RESULT
examination. In general, fiberoptic
bronchoscopy is less traumatic to the Normal Findings:
surrounding tissues than the larger • Normal larynx, trachea, bronchi, bron-
rigid bronchoscopes. Fiberoptic bronchioles, and alveoli
choscopy is performed under local
Abnormal Findings:
anesthesia; patient tolerance is better
for fiberoptic bronchoscopy than for • Abscess
rigid bronchoscopy. ■ • Bronchial diverticulum
Bronchoscopy 289
• Bronchial stenosis organ visualization and can produce

unclear images
• Bronchogenic cancer
• Coccidioidomycosis, histoplasmosis, ographic equipment to accommodate
blastomycosis, phycomycosis obese or thin patients, which can cause
• Foreign bodies overexposure or underexposure and
poor-quality study
• Inflammation
• Interstitial pulmonary disease exceed the weight limit for the equip-
• Opportunistic lung infections (e.g., ment
pneumocystitis, nocardia, cytome- • Incorrect positioning of the patient,
galovirus) which may produce poor visualization
• Strictures of the area to be examined
• Tuberculosis Other considerations:

• Hypoxemic or hypercapnic states
• Tumors
require continuous oxygen adminis-
tration.
INTERFERING FACTORS
This procedure is before the procedure may cause the
contraindicated for: procedure to be canceled or repeated.
• Patients with bleeding disorders, espe-
cially those associated with uremia and
cytotoxic chemotherapy Nursing Implications and
• Patients with pulmonary hypertension Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients with cardiac conditions or dys- Pretest:

rhythmias
• Patients with disorders that limit exten- assesses the lungs and respiratory
sion of the neck system.
• Patients with severe obstructive tra- ➤ Obtain a history of the patient’s com-
cheal conditions plaints or symptoms, including a list
• Patients with or having the potential gies or sensitivities to latex and
for respiratory failure; introduction of anesthetics.
the bronchoscope alone may cause a 10 ➤ Obtain a history of the patient’s
to 20 mm Hg drop in PaO2 immune and respiratory systems,
any bleeding disorders, and results
Factors that may impair of previously performed laboratory
a complete examination: tests (especially bleeding time,
• Inability of the patient to cooperate or complete blood count, partial throm-
remain still during the procedure boplastin time, platelets, and pro-
because of age, significant pain, or thrombin time), surgical procedures,
mental status
• Metallic objects within the examina- Immune and Respiratory System
tion field (e.g., jewelry, earrings, and/or tables.
dental amalgams), which may inhibit ➤ Note any recent procedures that can
interfere with test results. Ensure ➤ Explain that an intravenous (IV) line
that this procedure is performed will be inserted to allow infusion of
before an upper gastrointestinal IV fluids, antibiotics, anesthetics, and
study or barium swallow. analgesics.
➤ Record the date of the last menstrual ➤ Instruct the patient that nothing
period and determine the possibility should be taken by mouth for 6 to 8
of pregnancy in perimenopausal hours prior to a general anesthetic.
women. ➤ Have the patient void before the pro-
➤ Obtain a list of the medications cedure.
the patient is taking, including ➤ Make sure a written and informed
anticoagulant therapy, acetylsalicylic consent has been signed prior to the
acid, herbs, nutritional supplements, procedure and before administering
and nutraceuticals, especially those any medications.
ommended that use be discontinued Intratest:
cedures. The requesting health care ➤ Ensure that the patient has complied
practitioner and laboratory should be with dietary restrictions; assure
advised if the patient regularly uses that food has been restricted for at
these products so that their effects least 6 to 8 hours prior to the proce-
can be taken into consideration dure. Ensure that the patient has
when reviewing results. removed (jewelry, dentures, all exter-
➤ Review the procedure with the nal metallic objects, etc.) prior to the
patient. Instruct that prophylactic procedure.
antibiotics may be administered prior ➤ Ensure that anticoagulant therapy
to the procedure. Address concerns has been withheld for the appropri-
about pain related to the procedure. ate amount of days prior to the pro-
Explain that a sedative and/or analge- cedure. Amount of days to withhold
sia may be administered to promote medication is dependent on the type
relaxation and reduce discomfort of anticoagulant. Notify the health
prior to the bronchoscopy. Explain care practitioner if patient anticoagu-
to the patient that some pain may lant therapy has not been withheld.
be experienced during the test, ➤ Have emergency equipment readily
and there may be moments of dis- available. Keep resuscitation equip-
comfort. Atropine is usually given ment on hand in the case of respira-
before bronchoscopy examinations tory impairment or laryngospasm
to reduce bronchial secretions and after the procedure.
prevent vagally induced bradycardia.
Meperidine (Demerol) or morphine ➤ Avoid using morphine sulfate in
may be given as a sedative. Lidocaine those with asthma or other pul-
is sprayed in the patient’s throat to monary disease. This drug can fur-
reduce discomfort caused by the ther exacerbate bronchospasms and
presence of the tube. Inform the respiratory impairment.
patient that the procedure is per- ➤ Observe standard precautions, and
formed in a GI lab or radiology depart- follow the general guidelines in
ment, under sterile conditions, by a Appendix A. Positively identify the
health care practitioner specializing in patient, and label the appropriate col-
this procedure. The procedure usually lection containers with the corre-
takes about 30 to 60 minutes to sponding patient demographics,
complete. date and time of collection, and site
➤ Sensitivity to cultural and social location, especially left or right lung.
issues, as well as concern for mod- ➤ Have patient remove dentures, con-
esty, is important in providing psy- tact lenses, eyeglasses, and jewelry.
chological support before, during, Notify the physician if the patient
and after the procedure. has permanent crowns on teeth.
Bronchoscopy 291
Have the patient remove clothing anesthetic. Provide an emesis basin

and change into a gown for the pro- for the increased saliva and encour-
cedure. age the patient to spit out the saliva
➤ Assist the patient to a comfortable because the gag reflex may be
position, and direct the patient to impaired. When loss of sensation is
breath normally during the beginning adequate, the patient is placed in a
of the general anesthesia. Instruct supine or side-lying position. The
the patient to cooperate fully and to fiberoptic scope can be introduced
follow directions. Direct the patient through the nose, the mouth, an
to breathe normally and to avoid endotracheal tube, a tracheostomy
unnecessary movement during the tube, or a rigid bronchoscope. Most
local anesthetic and the procedure. common insertion is through the
nose. Patients with copious secre-
➤ Record baseline vital signs and con- tions or massive hemoptysis, or in
tinue to monitor throughout the pro- whom airway complications are
cedure. Protocols may vary from more likely, may be intubated before
facility to facility. the bronchoscopy. Additional local
➤ After the administration of general or anesthetic is applied through the
local anesthesia, shave and cleanse scope as it approaches the vocal
the site with an antiseptic solution, cords and the carina, eliminating
and drape the area with sterile reflexes in these sensitive areas. The
towels. fiberoptic approach allows visualiza-
tion of airway segments without
Rigid bronchoscopy: having to move the patient’s head
through various positions.
➤ The patient is placed in the supine
position and a general anesthetic is ➤ After visual inspection of the lungs,
administered. The patient’s neck is tissue samples are collected from
hyperextended, and the lightly lubri- suspicious sites by bronchial brush
cated bronchoscope is inserted or biopsy forceps to be used for
orally and passed through the glottis. cytologic and microbiologic studies.
The patient’s head is turned or repo- ➤ After the procedure, the broncho-
sitioned to aid visualization of various scope is removed. Patients who had
segments. local anesthesia are placed in a semi-
➤ After inspection, the bronchial brush, Fowler’s position to recover.
suction catheter, biopsy forceps,
laser, and electrocautery devices are General:
introduced to obtain specimens for ➤ Monitor the patient for complications
cytologic or microbiologic study or related to the procedure (e.g., aller-
for therapeutic procedures. gic reaction, anaphylaxis).
➤ If a bronchial washing is performed, ➤ Place tissue samples in properly
small amounts of solution are labeled specimen containers contain-
instilled into the airways and ing formalin solution, and promptly
removed. transport the specimen to the labora-
➤ After the procedure, the broncho- tory for processing and analysis.
scope is removed and the patient is ➤ The results are recorded manually or
placed in a side-lying position with in a computerized system for recall
the head slightly elevated. and postprocedure interpretation by
Fiberoptic bronchoscopy: tioner.
➤ Provide mouth care to reduce oral
bacterial flora. Post-test:
➤ The patient is placed in a sitting posi- ➤ Instruct the patient to resume pre-
tion while the tongue and orophar- operative diet, as directed by the
ynx is sprayed or swabbed with local health care practitioner. Assess
the patient’s ability to swallow directed by the health care practi-

before allowing the patient to tioner.
attempt liquids or solid foods. ➤ Administer antibiotic therapy if
➤ Inform the patient that he or she may ordered. Remind the patient of the
experience some throat soreness importance of completing the entire
and hoarseness. Instruct patient to course of antibiotic therapy, even if
treat throat discomfort with lozenges signs and symptoms disappear
and warm gargles when the gag before completion of therapy.
reflex returns.
➤ Monitor vital signs and neurologic tion will be completed by a health
status every 15 minutes for 1 hour, care practitioner specializing in this
then every 2 hours for 4 hours, and branch of medicine. The report will
then as ordered by the health care be sent to the requesting health care
practitioner. Monitor temperature practitioner, who will discuss the
every 4 hours for 24 hours. Compare results with the patient.
health care practitioner if tempera- ➤ Recognize anxiety related to test
ture changes. Protocols may vary results. Discuss the implications of
from facility to facility. abnormal test results on the
➤ Emergency resuscitation equipment
and information regarding the clinical
should be readily available if the
vocal cords become spastic after
intubation.
regarding access to counseling
➤ Observe for delayed allergic reac- services.
cardia, hyperpnea, hypertension, ➤ Reinforce information given by
palpitations, nausea, or vomiting. the patient’s health care provider
regarding further testing, treatment,
➤ Observe the patient for hemoptysis,
difficulty breathing, cough, air
provider. Instruct the patient to use
hunger, excessive coughing, pain, or
lozenges or gargle for throat discom-
absent breathing sounds over the
fort. Inform the patient of smoking
affected area. Report to health care
cessation programs as appropriate.
provider.
Malnutrition is commonly seen in
➤ Evaluate the patient for symptoms patients with severe respiratory
indicating the development of pneu- disease for numerous reasons,
mothorax, such as dyspnea, tachyp- including fatigue, lack of appetite,
nea, anxiety, decreased breathing and gastrointestinal distress. Ade-
sounds, or restlessness. A chest x- quate intake of vitamins A and C
ray may be ordered to check for the is also important to prevent pul-
presence of this complication. monary infection and to decrease
➤ Evaluate the patient for symptoms of the extent of lung tissue damage.
empyema, such as fever, tachycar- The importance of following the pre-
dia, malaise, or elevated white blood scribed diet should be stressed to
cell count. the patient/caregiver. Educate the
➤ Observe the patient’s sputum for patient regarding access to coun-
blood if a biopsy was taken, because seling services, as appropriate.
large amounts of blood may indicate Answer any questions or address
the development of a problem; a any concerns voiced by the patient
small amount of streaking is or family.
expected. Evaluate the patient for ➤ Instruct the patient in the use of any
signs of bleeding such as tachycar- ordered medications. Explain the
dia, hypotension, or restlessness. importance of adhering to the ther-
➤ Assess for nausea and pain. apy regimen. As appropriate, instruct
Administer antiemetic and analgesic the patient in significant side effects
medications as needed and as and systemic reactions associated
B-Type Natriuretic Peptide and Pro-B-Type Natriuretic Peptide 293
with the prescribed medication. Related laboratory tests:

responding literature provided by a ➤ Related laboratory and diagnostic
pharmacist. tests include arterial/alveolar oxygen
➤ Depending on the results of this pro- ratio, anti–glomerular basement me-
cedure, additional testing may be mbrane antibody, blood gases, chest
needed to evaluate or monitor pro- x-ray, complete blood count, com-
gression of the disease process and puted tomography of the thorax, mag-
determine the need for a change in netic resonance imaging of the chest,
therapy. Evaluate test results in rela- lung scan, gram stain, culture and
tion to the patient’s symptoms and smear mycobacteria, culture sputum,
other tests performed. culture from gel cytology sputum.
B-TYPE NATRIURETIC PEPTIDE AND

PRO-B-TYPE NATRIURETIC PEPTIDE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: BNP and Pro-BNP.

SPECIMEN: Plasma (1 mL) collected in a plastic, lavender-top (EDTA)
tube.
REFERENCE VALUE: (Method: Immunochemiluminometric for BNP;

immuno(electro)chemiluminescence for Pro-BNP)
BNP Pro-BNP (N-Terminal)

Male Less than 100 pg/mL Less than or equal to 60 pg/mL
Female Less than 100 pg/mL 12–150 pg/mL
DESCRIPTION & RATIONALE: The first isolated in the brain of pigs, is a

peptides B-type natriuretic peptide neurohormone synthesized primarily
(BNP) and atrial natriuretic peptide in the ventricles of the human heart in
(ANP) assist in the regulation of fluid response to increases in ventricular
balance and blood pressure. BNP, Pro- pressure and volume. Circulating
BNP, and ANP are useful markers in levels of BNP and Pro-BNP increase
the diagnosis of congestive heart fail- in proportion to the severity of heart
ure. BNP or brain natriuretic peptide, failure. ■
INDICATIONS: tests, surgical procedures, and other

• Assist in determining the prognosis and diagnostic procedures. For related
laboratory tests, refer to the
therapy of patients with heart failure
Cardiovascular System table.
• Assist in the diagnosis of heart failure ➤ Obtain a list of the medications the
• Assist in differentiating heart failure patient is taking, including herbs,
from pulmonary disease nutritional supplements, and nutra-
• Screen for left ventricular dysfunction practitioner and laboratory should be
and therefore need for echocardiogra- advised if the patient regularly uses
phy for further assessment these products so that their effects
RESULT
Increased in: patient. Inform the patient that spec-
• Cardiac inflammation (myocarditis, imen collection takes approximately
cardiac allograft rejection)
• Cirrhosis Explain to the patient that there may
• Cushing’s syndrome venipuncture.
• Heart failure ➤ Sensitivity to social and cultural
• Kawasaki disease issues, as well as concern for mod-
• Left ventricular hypertrophy chological support before, during,
• Primary hyperaldosteronism tion restrictions unless by medical
• Primary pulmonary hypertension direction.
• Renal failure Intratest:

• Ventricular dysfunction ➤ If the patient has a history of severe
Decreased in: N/A
Procedure ● ● ● ● ● ● ● ● ● ● ●
primarily used to identify congestive tubes with the corresponding patient
heart failure. demographics, date, and time of col-
plaints, including a list of known lect the specimen in a 5-mL plastic,
allergens (especially allergies or sen- lavender-top tube.
sitivities to latex), and inform the ➤ Remove the needle, and apply a
appropriate health care practitioner pressure dressing over the puncture
accordingly. site.
➤ Obtain a history of the patient’s car- ➤ Promptly transport the specimen to
diovascular system and results of the laboratory for processing and
previously performed laboratory analysis.
CA 125 295
➤ The results are recorded manually or will be completed by a health care

in a computerized system for recall practitioner specializing in this
and postprocedure interpretation by branch of medicine. The report will
the appropriate health care practi- be sent to the requesting health care
tioner. practitioner, who will discuss the
Post-test: ➤ Reinforce information given by the
➤ Observe venipuncture site for bleed- patient’s health care provider regard-
ing or hematoma formation. Apply ing further testing, treatment, or
paper tape or other adhesive to referral to another health care
hold pressure bandage in place, or provider. Answer any questions or
replace with a plastic bandage. address any concerns voiced by the
patient or family.
➤ Treatment considerations for CHF:
Ensure that the patient (if not ➤ Depending on the results of this pro-
currently taking) is placed on cedure, additional testing may be
an angiotensin-converting enzyme performed to evaluate or monitor
inhibitor, β-blocker, and diuretic; and progression of the disease process
monitored with daily weights. and determine the need for a change
➤ Nutritional considerations: Instruct relation to the patient’s symptoms
patients to consume a variety of and other tests performed.
foods within the basic food groups,
eat foods high in potassium when
taking diuretics, eat a diet high in Related laboratory tests:
fiber (25 to 35 g/d), maintain a ➤ Related laboratory tests include
healthy weight, be physically active, aspartate aminotransferase, atrial
limit salt intake to 2000 mg/d, limit natriuretic factor, calcium and ionized
alcohol intake, and be a nonsmoker. calcium, C-reactive protein, creatine
➤ Nutritional considerations: Foods kinase and isoenzymes, glucose,
high in potassium include citrus homocysteine, lactate dehydroge-
fruits such as bananas, strawberries, nase and isoenzymes, magnesium,
oranges; cantaloupe; green leafy myoglobin, potassium, and tropinin.
vegetables such as spinach and bro- ➤ A Rapid BNP point-of-care immuno-
coli; dried fruits such as dates, assay may be performed, in which a
prunes, and raisins; legumes such as venous blood sample is collected,
peas and pinto beans; nuts and placed on a strip, and inserted into a
whole grains. device that measures BNP. Results
➤ A written report of the examination are completed in 10 to 15 minutes.
CA 125
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carbohydrate antigen 125, cancer antigen 125.

REFERENCE VALUE: (Method: Enzyme immunoassay)

Less than 35 U/mL Less than 35 kU/L
DESCRIPTION & RATIONALE: CA Nursing Implications and

125, a glycoprotein present in normal Procedure ● ● ● ● ● ● ● ● ● ● ●
endometrial tissue, appears in the

Pretest:
blood when natural endometrial pro-
tective barriers are destroyed, as occurs ➤ Inform the patient that the test is pri-
marily used in the serial monitoring
in cancer or endometriosis. Persist-
of ovarian cancers.
ently rising levels indicate a poor
prognosis, but absence of the tumor complaints, including a list of known
marker does not rule out tumor pres- allergens (especially allergies or sen-
ence. Levels may also rise in pancre- sitivities to latex), and inform the
atic, liver, colon, breast, and lung appropriate health care practitioner
accordingly.
cancers. It is not useful as a screening
test when used alone. ■
immune and reproductive systems,
as well as results of previously
INDICATIONS: performed laboratory tests, surgical
• Assist in the diagnosis of carcinoma of procedures, and other diagnostic
the cervix and endometrium procedures. For related laboratory
• Assist in the diagnosis of ovarian cancer Reproductive System tables.
• Monitor response to treatment of ovar- ➤ Obtain a list of the medications
ian cancer the patient is taking, including
RESULT nutraceuticals. The requesting health
Increased in: should be advised if the patient reg-
• Breast, colon, endometrial, liver, lung, their effects can be taken into con-
ovarian, and pancreatic cancer sideration when reviewing results.
• Endometriosis ➤ Review the procedure with the
• First-trimester pregnancy imen collection takes approximately
• Menses 5 to 10 minutes. Address concerns
• Ovarian abscess Explain to the patient that there may
• Pelvic inflammatory disease be some discomfort during the
venipuncture.
• Peritonitis
Decreased in: direction.
• Effective therapy or removal of the Intratest:
tumor
CRITICAL VALUES: N/A allergic reaction to latex, care should
INTERFERING FACTORS: N/A ment containing latex.
CA 15-3 297
➤ Instruct the patient to cooperate fully care practitioner, who will discuss
and to follow directions. Direct the the results with the patient.
patient to breathe normally and to ➤ Recognize anxiety related to test
avoid unnecessary movement. results, and be supportive of fear of
➤ Observe standard precautions, and shortened life expectancy. Discuss
follow the general guidelines in the implications of abnormal test
Appendix A. Positively identify the results on the patient’s lifestyle.
patient, and label the appropriate Provide teaching and information
tubes with the corresponding patient regarding the clinical implications of
demographics, date, and time of col- the test results, as appropriate.
lection. Perform a venipuncture; col- Educate the patient regarding access
lect the specimen in a 5-mL red-top to counseling services.
tube. ➤ Reinforce information given by the
➤ Remove the needle, and apply a patient’s health care provider regard-
pressure dressing over the puncture ing further testing, treatment, or
site. referral to another health care
➤ Promptly transport the specimen to provider. Inform the patient that
the laboratory for processing and serial specimens may be requested
analysis. at regular intervals. Answer any
➤ The results are recorded manually or voiced by the patient or family.
and postprocedure interpretation by ➤ Depending on the results of this pro-
the appropriate health care practi- cedure, additional testing may be
tioner. performed to evaluate or monitor
Post-test: in therapy. Evaluate test results in
➤ Observe venipuncture site for bleed- relation to the patient’s symptoms
ing or hematoma formation. Apply and other tests performed.
paper tape or other adhesive to hold
pressure bandage in place, or Related laboratory tests:
replace with a plastic bandage. ➤ Related laboratory tests include
➤ A written report of the examination breast biopsy, CA 15-3, CA 19-9, and
will be sent to the requesting health carcinoembryonic antigen (CEA).
CA 15-3
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carbohydrate antigen 15-3, cancer antigen 15-3.

REFERENCE VALUE: (Method: Microparticle immunoassay, MEIA)


DESCRIPTION & RATIONALE: CA Reproductive System tables.
15-3 monitors patients for recurrence ➤ Obtain a list of the medications the
of breast carcinoma. CA 27.29 (refer- patient is taking, including herbs,
ence range less than 38 U/mL), a nutritional supplements, and nutra-
ceuticals. Advise the requesting
more recently approved protein health care practitioner and labora-
marker, is replacing CA 15-3 in some tory if the patient regularly uses
reference laboratories. ■ these products so that their effects
INDICATIONS: Monitor recurrent carci-
noma of the breast ➤ Review the procedure with the
RESULT 5 to 10 minutes. Address concerns
Increased in: Recurrent carcinoma of Explain to the patient that there may
the breast be some discomfort during the
venipuncture.
Decreased in: Effective therapy or ➤ There are no food, fluid, or medica-
removal of the tumor tion restrictions unless by medical
direction.
CRITICAL VALUES: N/A Intratest:
INTERFERING FACTORS: N/A ➤ If the patient has a history of severe
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: avoid unnecessary movement.
➤ Inform the patient that the test is ➤ Observe standard precautions, and
used to monitor progression of ther- follow the general guidelines in
apy for various tumors. Appendix A. Positively identify the
allergens (especially allergies or sen- demographics, date, and time of col-
sitivities to latex), and inform the lection. Perform a venipuncture; col-
appropriate health care practitioner lect the specimen in a 5-mL red-top
accordingly. tube.
➤ Obtain a history of the patient’s ➤ Remove the needle, and apply a
immune and reproductive systems, pressure dressing over the puncture
as well as results of previously site.
CA 19-9 299
➤ The results are recorded manually or regarding the clinical implications of

in a computerized system for recall the test results, as appropriate.
and postprocedure interpretation by ➤ Reinforce information given by the
the appropriate health care practi- patient’s health care provider regard-
tioner. ing further testing, treatment, or
Post-test: provider. Inform the patient that
serial specimens may be requested
➤ Observe venipuncture site for bleed- at regular intervals. Answer any
ing or hematoma formation. Apply questions or address any concerns
paper tape or other adhesive to hold voiced by the patient or family.
pressure bandage in place, or ➤ Depending on the results of this pro-
replace with a plastic bandage. cedure, additional testing may be
will be sent to the requesting health progression of the disease process
care practitioner, who will discuss and determine the need for a change
the results with the patient. in therapy. Evaluate test results in
results and be supportive of per-
ceived loss of independence and Related laboratory tests:
fear of shortened life expectancy.
Discuss the implications of abnormal ➤ Related laboratory tests include
test results on the patient’s lifestyle. breast biopsy, CA 125, and carci-
Provide teaching and information noembryonic antigen.
CA 19-9
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carbohydrate antigen 19-9, cancer antigen 19-9.

REFERENCE VALUE: (Method: Immunoradiometric)

INDICATIONS:
DESCRIPTION & RATIONALE: CA • Monitor effectiveness of therapy
19–9 is used to monitor patients with • Monitor gastrointestinal, head and
various types of cancer. ■ neck, and gynecologic carcinomas
• Predict recurrence of cholangiocarci- ➤ Obtain a list of the medications

noma the patient is taking, including
• Predict recurrence of stomach, pancre- nutraceuticals. The requesting health
atic, colorectal, gallbladder, liver, and care practitioner and laboratory
urothelial carcinomas should be advised if the patient reg-
RESULT their effects can be taken into con-
Increased in:
• Gastrointestinal, head and neck, and patient. Inform the patient that spec-
gynecologic carcinomas imen collection takes approximately
• Recurrence of stomach, pancreatic, col-
orectal, gallbladder, liver, and urothelial Explain to the patient that there may
carcinomas be some discomfort during the
• Recurrence of cholangiocarcinoma venipuncture.
Decreased in: tion restrictions unless by medical
direction.
• Effective therapy or removal of the
tumor Intratest:
INTERFERING FACTORS: be taken to avoid the use of equip-
• Recent radioactive scans or radiation ment containing latex.
within 1 week before the test can inter- ➤ Instruct the patient to cooperate fully
fere with test results when radioim- and to follow directions. Direct the
munoassay is the test method. patient to breathe normally and to
used to monitor progression of ther- lect the specimen in a 5-mL red-top
apy for various tumors. tube.
➤ Obtain a history of the patient’s com- ➤ Remove the needle, and apply a
plaints, including a list of known pressure dressing over the puncture
allergens (especially allergies or sen- site.
accordingly.
analysis.
trointestinal and immune systems, ➤ The results are recorded manually or
as well as results of previously per- in a computerized system for recall
formed laboratory tests, surgical pro- and postprocedure interpretation by
cedures, and other diagnostic the appropriate health care practi-
procedures. For related laboratory tioner.
and Immune System tables. Post-test:
➤ Note any recent procedures that can ➤ Observe venipuncture site for bleed-
interfere with test results. ing or hematoma formation. Apply
Calcitonin and Calcitonin Stimulation Tests 301
paper tape or other adhesive to hold ing further testing, treatment, or

pressure bandage in place, or referral to another health care
replace with a plastic bandage. provider. Inform the patient that
➤ A written report of the examination serial specimens may be requested
will be sent to the requesting health at regular intervals. Answer any
care practitioner, who will discuss questions or address any concerns
the results with the patient. voiced by the patient or family.
➤ Recognize anxiety related to test ➤ Depending on the results of this pro-
results and be supportive of per- cedure, additional testing may be
ceived loss of independence and performed to evaluate or monitor
fear of shortened life expectancy. progression of the disease process
Discuss the implications of abnormal and determine the need for a change
test results on the patient’s lifestyle. in therapy. Evaluate test results in
Provide teaching and information relation to the patient’s symptoms
regarding the clinical implications of and other tests performed.
Educate the patient regarding access Related laboratory tests:
to counseling services. ➤ Related laboratory tests include
➤ Reinforce information given by the biopsy of suspect tissue, CA 125, CA
patient’s health care provider regard- 15-3, and carcinoembryonic antigen.
CALCITONIN AND CALCITONIN

STIMULATION TESTS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Thyrocalcitonin, hCT.

Medication Recommended
Procedure Administered Collection Times
Calcium and Calcium, 2 mg/kg IV 4 calcitonin levels—baseline
pentagastrin for 1 min, followed immediately before bolus;
stimulation by pentagastrin 0.5 and 1 min, 2 min, and 5
g/kg min postbolus
Pentagastrin Pentagastrin, 0.5 g/kg 4 calcitonin levels—baseline
stimulation IV push immediately before bolus;
and 1.5 min, 2 min, and 5
min postbolus
IV intravenous.
SI Units
Conventional Units (Conventional Units 1)
Calcitonin
Male Less than 19 pg/mL Less than 19 ng/L
Female Less than 14 pg/mL Less than 14 ng/L
Maximum Response
After Calcium and Pentagastrin Stimulation
After Pentagastrin Stimulation
• Screen family members of patients with

DESCRIPTION & RATIONALE: Calci- medullary thyroid carcinoma (20%
tonin, also called thyrocalcitonin, is have a familial pattern)
secreted by the parafollicular or C cells
of the thyroid gland in response to ele- RESULT
vated serum calcium levels. Calcitonin
Increased in:
antagonizes the effects of parathyroid
hormone and vitamin D so that cal- • Alcoholic cirrhosis
cium continues to be laid down in • Cancer of the breast, lung, and pan-
bone rather than reabsorbed into the creas
blood. Calcitonin also increases renal • Carcinoid syndrome
clearance of magnesium and inhibits
tubular reabsorption of phosphates. • C-cell hyperplasia
The net result is that calcitonin • Chronic renal failure
decreases the serum calcium level. The • Ectopic secretion (especially neuroen-
pentagastrin (Peptavlon) provocation docrine origins)
test and the calcium pentagastrin
provocation test are useful for diag- • Hypercalcemia (any cause)
nosing medullary thyroid cancer. ■ • Medullary thyroid cancer
• Pancreatitis
INDICATIONS:
• Assist in the diagnosis of hyperparathy- • Pernicious anemia
roidism
• Pregnancy (late)
• Assist in the diagnosis of medullary
• Pseudohypoparathyroidism
thyroid cancer
• Thyroiditis
• Evaluate altered serum calcium levels
• Zollinger-Ellison syndrome
• Monitor response to therapy for
medullary thyroid carcinoma
Decreased in: N/A
• Predict recurrence of medullary thyroid
carcinoma CRITICAL VALUES: N/A
Calcitonin and Calcitonin Stimulation Tests 303
INTERFERING FACTORS: imen collection takes approximately

• Drugs that may increase calcitonin lev- 5 to 10 minutes; a few extra minutes
are required to administer the stimu-
els include calcium, epinephrine, estro-
lation tests. Address concerns about
gens, glucagon, oral contraceptives, pain related to the procedure. Explain
pentagastrin, and sincalide. to the patient that there may be
• Recent radioactive scans or radiation some discomfort during the veni-
within 1 week before the test can inter- puncture.
fere with test results when radioim- ➤ The patient should fast for 10 to 12
munoassay is the test method. hours before specimen collection.
• Failure to follow dietary restrictions restrictions unless by medical
before the procedure may cause the direction.
procedure to be canceled or repeated. ➤ Prepare an ice slurry in a cup or plas-
tic bag to have ready for immediate
transport of the specimen to the lab-
Nursing Implications and oratory. Prechill the red-top tube in
Procedure ● ● ● ● ● ● ● ● ● ● ● the ice slurry.
Pretest: Intratest:
➤ Inform the patient that the test is ➤ Ensure that the patient has complied
used to detect C-cell hyperplasia of with dietary restrictions and pretest-
the the thyroid gland and to detect ing preparations; assure that food
and monitor tumors of the thyroid has been restricted for at least 10 to
gland. 12 hours prior to the procedure.
appropriate health care practitioner ➤ Instruct the patient to cooperate fully
accordingly. and to follow directions. Direct the
➤ Obtain a history of the patient’s avoid unnecessary movement.
endocrine, genitourinary, and mus-
culoskeletal systems, as well as ➤ Observe standard precautions, and
results of previously performed labo- follow the general guidelines in
ratory tests, surgical procedures, Appendix A. Positively identify the
and other diagnostic procedures. For patient, and label the appropriate
related laboratory tests, refer to the tubes with the corresponding patient
Endocrine, Genitourinary, and Mus- demographics, date, and time of col-
culoskeletal System tables. lection. Perform a venipuncture; col-
lect the specimen in a prechilled
➤ Note any recent procedures that can 5-mL red- or tiger-top tube.
➤ Remove the needle and apply a
➤ Obtain a list of medications the pressure dressing over the puncture
patient is taking, including herbs, site.
nutritional supplements, and nutra- ➤ The sample should be placed in an
ceuticals. The requesting health care ice slurry immediately after collec-
practitioner and laboratory should be tion. Information on the specimen
advised if the patient regularly uses label can be protected from water in
these products so that their effects the ice slurry by first placing the
can be taken into consideration specimen in a protective plastic bag.
when reviewing results. Promptly transport the specimen to
patient. Inform the patient that spec- analysis.
➤ The results are recorded manually or ing further testing, treatment, or

in a computerized system for recall referral to another health care
and postprocedure interpretation by provider. Answer any questions or
the appropriate health care practi- address any concerns voiced by the
tioner. patient or family.
Post-test: cedure, additional testing may be
➤ Observe venipuncture site for bleed-
pressure bandage in place, or
replace with a plastic bandage.
diet as directed by the health care Related laboratory tests:
practitioner.
adrenocorticotropic hormone, cal-
cium, carcinoembrionic antigen, cat-
echolamines, complete blood count,
magnesium, metanephrines, thyroid
➤ Reinforce information given by the biopsy, urine phosphorus, and vita-
patient’s health care provider regard- min D.
CALCIUM, BLOOD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Total calcium, Ca.

(1 mL) collected in green-top (heparin) tube is also acceptable.
Cord 8.2–11.2 mg/dL 2.05–2.80 mmol/L
0–10 d 7.6–10.4 mg/dL 1.90–2.60 mmol/L
11 d–2 y 9.0–11.0 mg/dL 2.25–2.75 mmol/L
3–12 y 8.8–10.8 mg/dL 2.20–2.70 mmol/L
13–18 y 8.4–10.2 mg/dL 2.10–2.55 mmol/L
Adult 8.2–10.2 mg/dL 2.05–2.55 mmol/L
Adult older 8.2–9.6 mg/dL 2.05–2.40 mmol/L
than 90 y
Calcium, Blood 305
DESCRIPTION & RATIONALE: Cal- Calcium values should be inter-

cium, the most abundant cation in the preted in conjunction with results of
body, participates in almost all of the other tests. Normal calcium with an
vital processes. Calcium concentration abnormal phosphorus value indicates
is largely regulated by the parathyroid impaired calcium absorption (possibly
glands and by the action of vitamin because of altered parathyroid hor-
D. Of the body’s calcium reserves, mone level or activity). Normal cal-
98% to 99% is stored in the teeth and cium with an elevated urea nitrogen
skeleton. Calcium values are higher in value indicates possible hyperparathy-
children because of growth and active roidism (primary or secondary).
bone formation. About 45% of the Normal calcium with decreased albu-
total amount of blood calcium circu- min value is an indication of hypercal-
lates as free ions that participate in cemia. The most common cause of
coagulation, neuromuscular conduc- hypocalcemia (low calcium levels) is
tion, intracellular regulation, glandu- hypoalbuminemia. The most com-
lar secretion, and control of skeletal mon causes of hypercalcemia (high
and cardiac muscle contractility. The calcium levels) are hyperparathy-
remaining calcium is bound to circu- roidism and cancer (with or without
lating proteins (40% bound mostly to bone metastases). ■
albumin) and anions (15% bound to
anions such as bicarbonate, citrate, INDICATIONS:
phosphate, and lactate) and plays • Detect parathyroid gland loss after thy-
no physiologic role. Calcium values roid or other neck surgery, as indicated
by decreased levels
can be adjusted up or down by
0.8 mg/dL for every 1 g/dL that albu- • Evaluate cardiac arrhythmias and coag-
min is greater than or less than 4 g/dL. ulation disorders to determine if altered
Calcium and phosphorus levels are serum calcium level is contributing to
inversely proportional. the problem
Fluid and electrolyte imbalances are • Evaluate the effects of various disorders
often seen in patients with serious ill- on calcium metabolism, especially dis-
ness or injury; in these clinical situa- eases involving bone
tions, the normal homeostatic balance • Monitor the effectiveness of therapy
of the body is altered. During surgery being administered to correct abnormal
or in the case of a critical illness, calcium levels, especially calcium defi-
bicarbonate, phosphate, and lactate ciencies
concentrations can change dramati- • Monitor the effects of renal failure and
cally. Therapeutic treatments may also various drugs on calcium levels
cause or contribute to electrolyte
imbalance. This is why total calcium RESULT
values can sometimes be misleading.
Abnormal calcium levels are used to Increased in:
indicate general malfunctions in • Acidosis
various body systems. Ionized calcium • Acromegaly
is used in more specific conditions
(see monograph titled “Calcium, • Addison’s disease
Ionized”). • Cancers (bone, Burkitt’s lymphoma,
Hodgkin’s lymphoma, leukemia, mye- • Long-term anticonvulsant therapy

loma, and metastases from other
• Malabsorption (celiac disease, tropical
organs)
sprue, pancreatic insufficiency)
• Dehydration • Massive blood transfusion
• Excessive intake (milk, antacids) • Neonatal prematurity
• Hyperparathyroidism • Osteomalacia (advanced)
• Idiopathic hypercalcemia of infancy • Renal tubular disease
• Lung disease (tuberculosis, histoplas- • Vitamin D deficiency (rickets)
mosis, coccidioidomycosis, berylliosis)
• Malignant disease without bone CRITICAL VALUES:
involvement (squamous cell carcinoma Less than 7 mg/dL
of the lung, kidney cancer) Greater than 12 mg/dL (some
patients can tolerate higher
• Milk-alkali syndrome (Burnett’s syn- concentrations)
drome) Note and immediately report to the
• Paget’s disease health care practitioner any critically
increased or decreased values and related
• Pheochromocytoma symptoms.
• Polycythemia vera Observe the patient for symptoms of
critically decreased or elevated calcium
• Renal transplant levels. Hypocalcemia is evidenced by con-
• Rhabdomyolysis vulsions, arrhythmias, changes in electro-
cardiogram (ECG) in the form of
• Sarcoidosis prolonged ST segment and Q-T interval,
facial spasms (positive Chvostek’s sign),
• Thyrotoxicosis
tetany, muscle cramps, numbness in
• Vitamin D toxicity extremities, tingling, and muscle twitch-
ing (positive Trousseau’s sign). Possible
Decreased in: interventions include seizure precautions,
• Acute pancreatitis increased frequency of ECG monitoring,
and administration of calcium or magne-
• Alcoholism sium.
• Alkalosis Severe hypercalcemia is manifested by
polyuria, constipation, changes in ECG
• Chronic renal failure (shortened ST segment), lethargy, muscle
• Cystinosis weakness, apathy, anorexia, headache,
and nausea and ultimately may result in
• Hepatic cirrhosis coma. Possible interventions include the
• Hyperphosphatemia administration of normal saline and
diuretics to speed up excretion or admin-
• Hypoalbuminemia istration of calcitonin or steroids to force
• Hypomagnesemia the circulating calcium into the cells.
• Hypoparathyroidism (congenital, idio-
pathic, surgical)
• Drugs that may increase calcium
• Inadequate nutrition
levels include anabolic steroids, some
• Leprosy antacids, calcitriol, calcium salts,
Calcium, Blood 307
danazol, diuretics (long-term), ergocal- increased or decreased calcium

ciferol, isotretinoin, lithium, oral levels.
contraceptives, parathyroid extract, ➤ Obtain a history of the patient’s com-
parathyroid hormone, prednisone, plaints, including a list of known
progesterone, tamoxifen, vitamin A, allergens (especially allergies or sen-
and vitamin D. sitivities to latex), and inform the
• Drugs that may decrease calcium levels accordingly.
include albuterol, alprostadil, amino- ➤ Obtain a history of the patient’s
glycosides, anticonvulsants, calcitonin, cardiovascular, gastrointestinal, geni-
diuretics (initially), gastrin, glucagon, tourinary, hematopoietic, hepatobil-
glucocorticoids, glucose, insulin, laxa- iary, and musculoskeletal systems,
tives (excessive use), magnesium salts, as well as results of previously
methicillin, phosphates, plicamycin, performed laboratory tests, surgi-
sodium sulfate (given intravenously), cal procedures, and other diagnostic
procedures. For related labora-
tetracycline (in pregnancy), trazodone,
tory tests, refer to the Cardiovascu-
and viomycin. lar, Gastrointestinal, Genitourinary,
• Calcium exhibits diurnal variation; Hematopoietic, Hepatobiliary, and
serial samples should be collected at the Musculoskeletal System tables.
same time of day for comparison. ➤ Note any recent procedures that can
• Venous hemostasis caused by pro-
longed use of a tourniquet during
venipuncture can falsely elevate cal- nutritional supplements, and nutra-
cium levels. ceuticals. The requesting health care
• Patients on ethylenediaminetetra-acetic practitioner and laboratory should be
acid (EDTA) therapy (chelation) may advised if the patient regularly uses
show falsely decreased calcium values. can be taken into consideration
• Hemolysis and icterus cause false-posi- when reviewing results.
tive results because of interference from ➤ Review the procedure with the
biologic pigments. patient. Inform the patient that spec-
• Specimens should never be collected 5 to 10 minutes. Address concerns
above an intravenous (IV) line because about pain related to the procedure.
of the potential for dilution when the Explain to the patient that there may
specimen and the IV solution combine be some discomfort during the
in the collection container, falsely venipuncture.
decreasing the result. There is also the ➤ Sensitivity to cultural and social
potential of contaminating the sample issues, as well as concern for mod-
with the substance of interest, if it is esty, is important in providing psy-
present in the IV solution, falsely chological support before, during,
increasing the result. and after the procedure.
Nursing Implications and direction.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest:
➤ Inform the patient that the test allergic reaction to latex, care should
is used to investigate various con- be taken to avoid the use of equip-
ditions indicated by abnormally ment containing latex.
➤ Instruct the patient to cooperate fully tion. Cooked vegetables yield more
and to follow directions. Direct the absorbable calcium than raw vegeta-
patient to breathe normally and to bles. Patients should be informed of
avoid unnecessary movement. the substances that can inhibit cal-
➤ Observe standard precautions, and cium absorption by irreversibly bind-
follow the general guidelines in ing to some of the calcium, making it
Appendix A. Positively identify the unavailable for absorption, such as
patient, and label the appropriate oxalates, which naturally occur in
tubes with the corresponding patient some vegetables and are found in
demographics, date, and time of col- tea; phytic acid, found in some cere-
lection. Perform a venipuncture; col- als; phosphoric acid, found in dark
lect the specimen in a 5-mL red- or cola; and insoluble dietary fiber (in
tiger-top tube. excessive amounts). Excessive pro-
tein intake can also negatively affect
➤ Remove the needle, and apply a calcium absorption, especially if it is
pressure dressing over the puncture combined with foods high in phos-
site. phorus and in the presence of a
➤ Promptly transport the specimen to reduced dietary calcium intake.
the laboratory for processing and ➤ A written report of the examination
analysis. will be sent to the requesting health
➤ The results are recorded manually or care practitioner, who will discuss
in a computerized system for recall the results with the patient.
the appropriate health care practi- patient’s health care provider regard-
tioner. ing further testing, treatment, or
➤ Observe venipuncture site for bleed- patient or family.
paper tape or other adhesive to hold ➤ Depending on the results of this pro-
pressure bandage in place, or cedure, additional testing may be
replace with a plastic bandage. performed to evaluate or monitor
➤ Nutritional considerations: Patients and determine the need for a change
with abnormal calcium values should in therapy. Evaluate test results in
be informed that daily intake of cal- relation to the patient’s symptoms
cium is important even though body and other tests performed.
stores in the bones can be called on
to supplement circulating levels. Related laboratory tests:
Dietary calcium can be obtained
from animal or plant sources. Milk ➤ Related laboratory tests include albu-
and milk products, sardines, clams, min, alkaline phosphatase, calci-
oysters, salmon, rhubarb, spinach, tonin, calcium (ionized and urine),
beet greens, broccoli, kale, tofu, electrolytes, kidney stone analysis,
legumes, and fortified orange juice magnesium (blood and urine),
are high in calcium. Milk and milk parathyroid hormone, phosphorus
products also contain vitamin D and (blood and urine), total protein, uri-
lactose, which assist calcium absorp- nalysis, and vitamin D.
Calcium, ionized 309
CALCIUM, IONIZED
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: free calcium, unbound calcium, Ca, Ca2.

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Specimen
should be transported tightly capped and remain unopened until testing.
Exposure of serum to room air changes the pH of the specimen due to the
release of carbon dioxide and can cause erroneous results.
REFERENCE VALUE: (Method: Ion-selective electrode)
Conventional Units Units 0.25)
Whole blood
Cord blood 5.20–5.84 mg/dL 1.30–1.46 mmol/L
Adult 4.60–5.08 mg/dL 1.12–1.32 mmol/L
Plasma
Adult 4.12–4.92 mg/dL 1.03–1.23 mmol/L
Serum
Cord blood 5.20–6.40 mg/dL 1.30–1.60 mmol/L
Adult 4.64–5.28 mg/dL 1.16–1.32 mmol/L
DESCRIPTION & RATIONALE: Cal- and by vitamin D. Compared to

cium is the most abundant cation in total calcium level, ionized calcium is
the body and participates in almost all a better measurement of calcium
vital body processes (see other calcium metabolism. Ionized calcium levels
monographs). Circulating calcium is are not influenced by protein concen-
found in the free or ionized form; trations, as seen in patients with
bound to organic anions such as lac- chronic renal failure, nephrotic syn-
tate, phosphate, or citrate; and bound drome, malabsorption, and multiple
to proteins such as albumin. Ionized myeloma. Levels are also not affected
calcium is the physiologically active in patients with metabolic acid-
form of circulating calcium. About base balance disturbances. Eleva-
half of the total amount of calcium tions in ionized calcium may be seen
circulates as free ions that participate when the total calcium is normal.
in blood coagulation, neuromuscular Measurement of ionized calcium
conduction, intracellular regulation, is useful to monitor patients undergo-
glandular secretion, and control of ing cardiothoracic surgery or organ
skeletal and cardiac muscle contractil- transplantation. It is also useful in
ity. Calcium levels are regulated the evaluation of patients in cardiac
largely by the parathyroid glands arrest. ■
INDICATIONS: • Trauma
• Detect ectopic parathyroid hor- • Vitamin D deficiency
mone–producing neoplasms
• Evaluate the effect of protein on cal- CRITICAL VALUES:
cium levels Less than 3.2 mg/dL
• Identify individuals with hypocalcemia Greater than 6.2 mg/dL
Note and immediately report to the
• Identify individuals with toxic levels of health care practitioner any critically
vitamin D increased or decreased values and related
• Investigate suspected hyperparathy- symptoms.
roidism Observe the patient for symptoms of
critically decreased or elevated calcium
• Monitor patients with renal failure or levels. Hypocalcemia is evidenced by con-
organ transplantation, in whom sec- vulsions, arrhythmias, changes in electro-
ondary hyperparathyroidism may be a cardiogram (ECG) in the form of
complication prolonged ST segment and Q-T interval,
• Monitor patients with sepsis or magne- facial spasms (positive Chvostek’s sign),
sium deficiency tetany, muscle cramps, numbness in
extremities, tingling, and muscle twitch-
ing (positive Trousseau’s sign). Possible
RESULT interventions include seizure precautions,
increased frequency of ECG monitor-
Increased in:
ing, and administration of calcium or
• Hyperparathyroidism magnesium.
• Parathyroid hormone–producing neo- Severe hypercalcemia is manifested by
plasms polyuria, constipation, changes in ECG
(shortened ST segment), lethargy, muscle
• Vitamin D toxicity weakness, apathy, anorexia, headache,
and nausea, and ultimately may result in
Decreased in: coma. Possible interventions include the
• Burns administration of normal saline and
diuretics to speed up excretion or admin-
• Hypoparathyroidism (primary)
istration of calcitonin or steroids to force
• Magnesium deficiency the circulating calcium into the cells.
• Multiple organ failure INTERFERING FACTORS:
• Pancreatitis • Drugs that may increase calcium levels
include antacids (some), calcitriol, and
• The post-dialysis period, as a result of lithium.
low-calcium dialysate administration
• Drugs that may decrease calcium levels
• The post-surgical period (i.e., major include calcitonin, citrates, foscarnet,
surgeries) and pamidronate (initially).
• The post-transfusion period, as a result • Calcium exhibits diurnal variation;
of the use of citrated preservative (cal- serial samples should be collected at the
cium chelator) same time of day for comparison.
• Premature infants with hypoproteine- • Venous hemostasis caused by pro-
mia and acidosis longed use of a tourniquet during
venipuncture can falsely elevate cal-
• Pseudohypoparathyroidism cium levels.
• Sepsis • Patients on ethylenediaminetetra-acetic
Calcium, ionized 311
acid (EDTA) therapy (chelation) may ➤ Review the procedure with the
show falsely decreased calcium values. patient. Inform the patient that spec-
• Specimens should never be collected 5 to 10 minutes. Address concerns
above an intravenous (IV) line because about pain related to the procedure.
of the potential for dilution when the Explain to the patient that there may
specimen and the IV solution combine be some discomfort during the
in the collection container, falsely venipuncture.
decreasing the result. There is also the ➤ Sensitivity to cultural and social
potential of contaminating the sample issues, as well as concern for mod-
with the substance of interest, if it is esty, is important in providing psy-
present in the IV solution, falsely chological support before, during,
increasing the result.
direction.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest: ➤ If the patient has a history of severe
➤ Inform the patient that the test is allergic reaction to latex, care should
used to investigate various con- be taken to avoid the use of equip-
ditions indicated by abnormally ment containing latex.
increased or decreased levels of ion- ➤ Instruct the patient to cooperate fully
ized calcium. and to follow directions. Direct the
➤ Obtain a history of the patient’s com- patient to breathe normally and to
plaints, including a list of known avoid unnecessary movement.
allergens (especially allergies or sen- ➤ Observe standard precautions, and
sitivities to latex), and inform the follow the general guidelines in
appropriate health care practitioner Appendix A. Positively identify the
accordingly. patient, and label the appropriate
cardiovascular, gastrointestinal, geni- demographics, date, and time of col-
tourinary, hematopoietic, hepatobil- lection. Perform a venipuncture and,
iary, and musculoskeletal systems, without using a tourniquet, collect
as well as results of previously the specimen in a 5-mL red- or tiger-
performed laboratory tests, surgical top tube. The specimen must be
procedures, and other diagnostic maintained in an anaerobic environ-
procedures. For related labora- ment.
tory tests, refer to the Cardiovas- ➤ Remove the needle, and apply a
cular, Gastrointestinal, Genitourinary, pressure dressing over the puncture
Hematopoietic, Hepatobiliary, and site.
Musculoskeletal System tables. ➤ The specimen should be stored
➤ Note any recent procedures that under anaerobic conditions after
could interfere with test results. collection to prevent the diffusion of
➤ Obtain a list of the medications the gas from the specimen. Falsely
patient is taking, including herbs, decreased values result from uncov-
nutritional supplements, and nutra- ered specimens. Promptly transport
ceuticals. The requesting health the specimen to the laboratory for
care practitioner and laboratory processing and analysis.
should be advised if the patient ➤ The results are recorded manually or
regularly uses these products so in a computerized system for recall
that their effects can be taken and postprocedure interpretation by
into consideration when reviewing the appropriate health care practi-
results. tioner.
tein intake can also negatively affect

Post-test:
calcium absorption, especially if it is
➤ Observe venipuncture site for bleed- combined with foods high in phos-
ing or hematoma formation. Apply phorus and in the presence of a
paper tape or other adhesive to hold reduced dietary calcium intake.
pressure bandage in place, or ➤ A written report of the examination
replace with a plastic bandage. will be sent to the requesting health
➤ Nutritional considerations: Patients care practitioner, who will discuss
with abnormal calcium values should the results with the patient.
be informed that daily intake of cal- ➤ Reinforce information given by the
cium is important even though body patient’s health care provider regard-
stores in the bones can be called on ing further testing, treatment, or
to supplement circulating levels. referral to another health care
Dietary calcium can be obtained provider. Answer any questions or
from animal or plant sources. Milk address any concerns voiced by the
and milk products, sardines, clams, patient or family.
oysters, salmon, rhubarb, spinach, ➤ Depending on the results of this pro-
beet greens, broccoli, kale, tofu, cedure, additional testing may be
legumes, and fortified orange juice performed to evaluate or monitor
are high in calcium. Milk and milk progression of the disease process
products also contain vitamin D and and determine the need for a change
lactose, which assist calcium absorp- in therapy. Evaluate test results in
tion. Cooked vegetables yield more relation to the patient’s symptoms
absorbable calcium than raw vegeta- and other tests performed.
bles. Patients should be informed of
the substances that can inhibit cal- Related laboratory tests:
cium absorption by irreversibly bind-
ing to some of the calcium, making ➤ Related laboratory tests include albu-
it unavailable for absorption, such min, alkaline phosphatase, calci-
as oxalates, which naturally occur tonin, calcium (blood and urine),
in some vegetables and are found in electrolytes, kidney stone panel,
tea; phytic acid, found in some cere- magnesium (blood and urine), para-
als; phosphoric acid, found in dark thyroid hormone, phosphorus (blood
cola; and insoluble dietary fiber (in and urine), total protein, urinalysis,
excessive amounts). Excessive pro- and vitamin D.
CALCIUM, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Urine (5 mL) from an unpreserved random or timed specimen
collected in a clean plastic collection container.

Calcium, Urine 313
Age Conventional Units* Units 0.025)*
Infant and child Up to 6 mg/kg per 24 h Up to 0.15 mmol/kg
per 24 h
Adult on average 100–300 mg/24 h 2.5–7.5 mmol/24 h
diet
*Values depend on diet. Average daily intake of calcium: 600–800 mg/24 h.
• Fanconi’s syndrome
DESCRIPTION & RATIONALE: Regu- • Glucocorticoid excess
lating electrolyte balance is a major
function of the kidneys. In normally • Hepatolenticular degeneration
functioning kidneys, urine levels • Hyperparathyroidism
increase when serum levels are high • Hyperthyroidism
and decrease when serum levels are
low to maintain homeostasis. Analyz- • Idiopathic hypercalciuria
ing urinary electrolyte levels can • Immobilization
provide important clues to the func- • Kidney stones
tioning of the kidneys and other
major organs. Tests for calcium in • Leukemia and lymphoma (some
instances)
urine usually involve timed urine col-
lections during a 12- or 24-hour • Myeloma
period. Measurement of random • Neoplasm of the breast or bladder
specimens may also be requested.
Urinary calcium excretion may also be • Osteitis deformans
expressed as calcium-to-creatinine • Osteolytic bone metastases (carcinoma,
ratio: In a healthy individual with sarcoma)
constant muscle mass, the ratio is less • Osteoporosis
than 0.14. ■
• Paget’s disease
INDICATIONS: • Renal tubular acidosis
• Assist in establishing the presence of
• Sarcoidosis
kidney stones
• Schistosomiasis
• Evaluate bone disease
• Thyrotoxicosis
• Evaluate dietary intake and absorption
• Vitamin D intoxication
• Evaluate renal loss
• Monitor patients on calcium replace- Decreased in:
ment • Hypocalcemia (other than renal dis-
ease)
RESULT
• Hypocalciuric hypercalcemia (familial,
Increased in:
nonfamilial)
• Acromegaly • Hypoparathyroidism
• Diabetes • Hypothyroidism
• Malabsorption (celiac disease, tropical assess bone resorption, renal stones,

sprue) and renal loss of calcium.
• Malignant bone neoplasm
• Nephrosis and acute nephritis allergens (especially allergies or sen-
• Osteoblastic metastases appropriate health care practitioner
• Osteomalacia accordingly.
• Pre-eclampsia endocrine, genitourinary, and mus-
• Pseudohypoparathyroidism culoskeletal systems and results of
• Renal osteodystrophy tests, surgical procedures, and other
• Rickets diagnostic procedures. For related
• Vitamin D deficiency Endocrine, Genitourinary, and Mus-
culoskeletal System tables.
CRITICAL VALUES: N/A ➤ Obtain a list of the medications the
INTERFERING FACTORS: nutritional supplements, and nutra-
• Drugs that can increase urine calcium practitioner and laboratory should be
levels include acetazolamide, ammo- advised if the patient regularly uses
nium chloride, asparaginase, calci- these products so that their effects
tonin, calcitriol, corticosteroids, can be taken into consideration
corticotropin, dexamethasone, diuret- when reviewing results.
ics (initially), ergocalciferol, ethacrynic ➤ Review the procedure with the
acid, mannitol (initially), meralluride, patient. Provide a nonmetallic urinal,
mercaptomerin, mersalyl, nandrolone, bedpan, or toilet-mounted collection
parathyroid extract, parathyroid hor- device. Address concerns about pain
mone, plicamycin, sodium sulfate, sul- related to the procedure. Explain to
fates, triamterene, viomycin, and the patient that there should be no
discomfort during the procedure.
vitamin D.
➤ Usually a 24-hour time frame for
• Drugs that can decrease urine calcium urine collection is ordered. Inform
levels include angiotensin, bicarbonate, the patient that all urine must be
calcitonin, citrates, diuretics (chronic), saved during that 24-hour period.
lithium, neomycin, oral contraceptives, Instruct the patient not to void
and spironolactone. directly into the laboratory collection
container. Instruct the patient to
• Failure to collect all the urine and store avoid defecating in the collection
the specimen properly during the 24- device and to keep toilet tissue out
hour test period invalidates the results. of the collection device to prevent
contamination of the specimen.
Place a sign in the bathroom to
Nursing Implications and remind the patient to save all urine.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Instruct the patient to void all urine
into the collection device and then to
Pretest: pour the urine into the laboratory col-
lection container. Alternatively, the
➤ Inform the patient that the test is specimen can be left in the collection
used to indicate sufficiency of dietary device for a health care staff mem-
calcium intake and rate of absorption. ber to add to the laboratory collec-
Urine calcium levels are also used to tion container.
Calcium, Urine 315
➤ Sensitivity to social and cultural collection period. If an indwelling uri-

issues, as well as concern for mod- nary catheter is in place, the
esty, is important in providing psy- drainage bag must be kept on ice.
chological support before, during, ➤ Begin the test between 6 and 8 a.m.,
and after the procedure. if possible. Collect first voiding and
➤ There are no fluid or medication discard. Record the time the speci-
restrictions unless by medical direc- men was discarded as the beginning
tion. of the timed collection period. The
➤ Instruct the patient to follow a nor- next morning, ask the patient to void
mal calcium diet for at least 4 days at the same time the collection was
before test. started, and add this last voiding to
the container.
Intratest: ➤ If an indwelling catheter is in place,
replace the tubing and container sys-
tem at the start of the collection
time. Keep the container system on
a normal calcium diet has been fol-
ice during the collection period or
lowed for at least 4 days prior to the
empty the urine into a larger con-
procedure.
tainer periodically during the collec-
➤ If the patient has a history of severe tion period; monitor to ensure
allergic reaction to latex, care should continued drainage, and conclude
be taken to avoid the use of equip- the test the next morning at the
ment containing latex. same hour the collection began.
➤ Instruct the patient to cooperate fully ➤ At the conclusion of the test, com-
and to follow directions. pare the quantity of urine with the
➤ Observe standard precautions, and urinary output record for the collec-
follow the general guidelines in tion; if the specimen contains less
Appendix A. Positively identify the than the recorded output, some
patient, and label the appropriate col- urine may have been discarded,
lection container with the correspon- invalidating the test.
ding patient demographics, date, and ➤ Include on the collection container’s
time of collection. label the amount of urine collected
and test start and stop times.
Random specimen (collect
Promptly transport the specimen to
in early morning): the laboratory for processing and
➤ Obtain urine specimen in a properly analysis.
labeled plastic collection container
and immediately transport urine. If General:
an indwelling catheter is in place, it
may be necessary to clamp off the
catheter for 15 to 30 minutes before
specimen collection. Cleanse speci-
men port with antiseptic swab, and
tioner.
then aspirate 5 mL of urine with a 21-
to 25-gauge needle and syringe.
Transfer urine to a plastic container. Post-test:
Timed specimen: ➤ Instruct the patient to resume usual
diet as directed by the health care
practitioner.
container, toilet-mounted collec-
tion device, and plastic bag (for ➤ Nutritional considerations: Increased
transport of the specimen con- urine calcium levels may be associ-
tainer). The specimen must be refrig- ated with kidney stones. Educate
erated or kept on ice throughout the the patient, if appropriate, as to the
importance of drinking a sufficient address any concerns voiced by the

amount of water when kidney patient or family.
stones are suspected. ➤ Depending on the results of this pro-
results. Discuss the implications of relation to the patient’s symptoms
abnormal test results on the and other tests performed.
and information regarding the clinical Related laboratory tests:
implications of the test results, as ➤ Related laboratory tests include
appropriate. calcium, kidney stone panel, mag-
➤ Reinforce information given by the nesium (blood and urine), parathy-
patient’s health care provider regard- roid hormone, phosphorus (blood
ing further testing, treatment, or and urine) potassium (blood and
referral to another health care urine), uric acid (blood and urine), uri-
provider. Answer any questions or nalysis, urine oxalate, and vitamin D.
CALCULUS, KIDNEY STONE PANEL

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Kidney stone analysis, nephrolithiasis analysis.

SPECIMEN: Kidney stones.
REFERENCE VALUE: (Method: Infrared spectrometry) None detected.
DESCRIPTION & RATIONALE: Renal The chemical nature of the stones is

calculi (kidney stones) are formed by confirmed qualitatively. ■
the crystallization of calcium oxalate
(most common), magnesium ammo- INDICATIONS: Identify substances pres-
ent in renal calculi
nium phosphate, calcium phosphate,
uric acid, and cystine. Formation of RESULT
stones may be due to reduced urine
flow and excessive amounts of the pre- Positive findings in:
viously mentioned insoluble sub- Presence of renal calculi
stances. The presence of stones is Negative findings in: N/A
confirmed by diagnostic visualization
or passing of the stones in the urine. CRITICAL VALUES: N/A
Calculus, Kidney Stone Panel 317
INTERFERING FACTORS: ➤ There are no food, fluid, or medica-

• Drugs and substances that may increase tion restrictions unless by medical
direction.
the formation of urine calculi include
probenecid and vitamin D.
Intratest:
• Adhesive tape should not be used to
attach stones to any transportation or and to follow directions.
collection container, because the
adhesive interferes with infrared spec- ➤ Observe standard precautions, and
trometry. Appendix A. Positively identify the
lection container with the correspon-
Nursing Implications and ding patient demographics, date, and
Procedure ● ● ● ● ● ● ● ● ● ● ●
time of collection.
➤ The patient presenting with symp-
Pretest: toms indicating the presence of kid-
➤ Inform the patient that the test is ney stones may be provided with a
used to identify the presence of kid- device to strain the urine. The patient
ney stones. should be informed to transfer any
particulate matter remaining in the
➤ Obtain a history of the patient’s com- strainer into the specimen collection
plaints, especially hematuria, recur- container provided. Stones removed
rent urinary tract infection, and by the health care practitioner should
abdominal pain. Also, obtain a list of be placed in the appropriate collec-
known allergens and inform the tion container.
accordingly. ➤ Promptly transport the specimen to
➤ Obtain a history of the patient’s gen- analysis.
itourinary system and results of
previously performed laboratory ➤ The results are recorded manually or
tests, surgical procedures, and in a computerized system for recall
other diagnostic procedures. For and postprocedure interpretation by
related laboratory tests, refer to the the appropriate health care practi-
Genitourinary System table. tioner.
the patient is taking, including Post-test:
herbs, nutritional supplements, and ➤ Inform the patient with kidney
nutraceuticals. The requesting health stones that the likelihood of recur-
care practitioner and laboratory rence is high. Educate the patient
should be advised if the patient reg- regarding risk factors that contribute
ularly uses these products so that to the likelihood of kidney stone for-
their effects can be taken into con- mation, including family history,
sideration when reviewing results. osteoporosis, urinary tract infec-
➤ Review the procedure with the tions, gout, magnesium deficiency,
patient. Address concerns about Crohn’s disease with prior resection,
pain related to the procedure. age, gender (males are two to three
Explain to the patient that there may times more likely to develop stones
be some discomfort during the pro- than females), and climate.
cedure. ➤ Dietary considerations: Nutritional
➤ Sensitivity to social and cultural therapy is indicated for individuals
issues, as well as concern for mod- identified as being at high risk for
esty, is important in providing psy- developing kidney stones. Educate
chological support before, during, the patient that diets rich in protein,
and after the procedure. salt, and oxalates increase the risk of
stone formation. Adequate fluid for 1 month after the stones have
intake should be encouraged. passed or been removed. Answer
➤ A written report of the examination any questions or address any con-
will be sent to the requesting health cerns voiced by the patient or family.
➤ Recognize anxiety related to test performed to evaluate or monitor
results. Discuss the implications of progression of the disease process
abnormal test results on the and determine the need for a change
patient’s lifestyle. Provide teaching in therapy. Evaluate test results in
and information regarding the clinical relation to the patient’s symptoms
implications of the test results, as and other tests performed.
appropriate.
patient’s health care provider regard- ➤ Related laboratory tests include cre-
ing further testing, treatment, or atinine clearance, urine calcium,
referral to another health care urine culture, urine magnesium,
provider. Follow-up testing of urine urine oxalate, urine phosphorus,
may be requested, but usually not urine uric acid, and urinalysis.
CAPSULE ENDOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Pill GI endoscopy .

AREA OF APPLICATION: Esophagus, stomach, upper duodenum,
and small bowel.
CONTRAST: None.
DESCRIPTION & RATIONALE: This second. The images are transmitted to

outpatient procedure involves ingest- a recording device, which saves all
ing a small (size of a large vitamin pill) images for review later by a health care
capsule that is wireless and contains a practitioner. This device is approxi-
small video camera that will pass nat- mately the size of a personal compact
urally through the digestive system disc player. The recording device is
while taking pictures of the intestine. worn on a belt around the patient’s
The capsule is 11 mm by 30 mm and waist, and the video images are trans-
contains a camera, light source, radio mited to aerials taped to the body and
transmitter, and battery. The patient stored on the device. After 8 hours,
swallows the capsule, and the camera the device is removed and returned
takes and transmits two images per to the health care practitioner for
Capsule Endoscopy 319
Abnormal Findings:
processing. Thousand of images are
downloaded onto a computer for • Achalasia
viewing by a health care practitioner • Acute and chronic gastric and duode-
specialist. The capsule is disposable nal ulcers
and will be excreted naturally in the • Crohn’s disease, infectious enteritis,
patient’s bowel movements. In the and celiac sprue
rare case that it will not be excreted
naturally, it will need to be removed • Diverticular disease
endoscopically or surgically. ■ • Duodenal cancer, diverticula, and
ulcers
INDICATIONS:
• Assist in differentiating between benign • Duodenitis
and neoplastic tumors • Esophageal or pyloric stenosis
• Detect gastric or duodenal ulcers • Esophageal varices
• Detect gastrointestinal tract (GI) • Esophagitis or strictures
inflammatory disease
• Gastric cancer, tumors, and ulcers
• Determine the presence and location
of GI bleeding, and vascular abnor- • Gastritis
malities
• Hiatal hernia
• Evaluate the extent of esophageal
• Mallory-Weiss syndrome
injury after ingestion of chemicals
• Evaluate stomach or duodenum after • Perforation of the esophagus, stomach,
surgical procedures or small bowel
• Evaluate suspected gastric obstruction • Polyps
• Identify Crohn’s disease, infectious • Small bowel tumors

enteritis, and celiac sprue • Strictures
• Identify source of chronic diarrhea • Tumors (benign or malignant)
• Investigate the cause of abdominal
pain, celiac syndrome, and other mal- CRITICAL VALUES: N/A
absorption syndromes
RESULT
This procedure is
Normal Findings: contraindicated for:
• Esophageal mucosa is normally yellow- • Patients who have had surgery involv-
pink. At about 9 inches from the inci- ing the stomach or duodenum, which
sor teeth, a pulsation indicates the can make locating the duodenal papilla
location of the aortic arch. The gastric difficult
mucosa is orange-red and contains
• Patients with a bleeding disorder
rugae. The proximal duodenum is red-
dish and contains a few longitudinal • Patients with unstable cardiopul-
folds, whereas the distal duodenum has monary status, blood coagulation
circular folds lined with villi. No defects, or cholangitis, unless the
abnormal structures or functions are patient received prophylactic antibiotic
observed in the esophagus, stomach, or therapy before the test (otherwise the
duodenum. examination must be rescheduled)
• Patients with unstable cardiopul- ➤ Obtain a list of the medications the

monary status, blood coagulation patient is taking.
defects, known aortic arch aneurysm, ➤ Explain the purpose of the test and
large esophageal Zenker’s diverticulum, how the procedure is performed.
recent GI surgery, esophageal varices, Inform the patient that the procedure
or known esophageal perforation is begun in a GI lab or health care
practitioner’s office, usually by a
Factors that may health care practitioner or support
impair clear imaging: staff, and that it takes approximately
30 to 60 minutes to begin the proce-
• Gas or feces in the gastrointestinal tract dure.
failure to restrict food intake before the issues, as well as concern for mod-
study esty, is important in providing psy-
• Retained barium from a previous radi- chological support before, during,
ologic procedure
➤ Instruct the patient to start a liquid
Other considerations: diet on the day before the procedure.
From 10 p.m. the evening before the
• The patient should not be near any procedure, the patient should not eat
electromangetic source, such as mag- or drink except for necessary med-
netic resonance imaging (MRI) or ama- ication with a sip of water.
teur (ham) radio equipment. ➤ Instruct the patient not to take any
• Undergoing an MRI during the proce- medication for 2 hours prior to the
dure may result in serious damage to procedure.
the patient’s intestestinal tract or ➤ Instruct the patient to abstain from
abdomen. The patient should contact smoking for 24 hours prior to the
his or her health care practitioner for procedure.
evaluation prior to any other proce- ➤ Instruct the patient to stop taking
dure. medications that have a coating
effect, such as Sucralfate and Pepto-
• Delayed capsule transit times may be a Bismol, 3 days before the procedure.
result of narcotic use, somatostatin use,
➤ Inform the patient that there is a
gastroparesis, or psychiatric illness. chance of intestinal obstruction asso-
ciated with the procedure.
Nursing Implications and ➤ Instruct the patient to take a stan-
dard bowel prep the night before the
Procedure ● ● ● ● ● ● ● ● ● ● ●
procedure.
Pretest: ➤ Instruct the patient to wear loose,
two-piece clothing on the day of
➤ Inform the patient that the procedure the procedure. This assists with the
assesses the gastrointestinal tract. placement of the sensors on the
➤ Obtain a history of the patient’s com- patient’s abdomen.
plaints or symptoms. ➤ Make sure a written and informed
➤ Obtain a history of results of previ- consent has been signed prior to the
ously performed diagnostic proce- procedure.
laboratory tests. For related diagnos- Intratest:
tic tests, refer to the Gastrointestinal ➤ Ensure that the patient has complied
System table. with dietary and medication restric-
➤ Ensure that this procedure is per- tions and pretesting preparations
formed before an upper GI series or for at least 8 hours prior to the
barium swallow. procedure.
Capsule Endoscopy 321
➤ Observe standard precautions, and after the test is ended, or as toler-

follow the general guidelines in ated after the examination, as
Appendix A. directed by the health care practi-
➤ Obtain accurate height, weight, and tioner.
abdominal girth measurements prior ➤ Instruct the patient to remove the
to beginning the examination. recorder and return it to the health
➤ Instruct the patient to cooperate fully care practitioner.
and to follow directions. ➤ Patients are asked to verify the elim-
➤ Ask the patient to ingest the capsule ination of the capsule, but not to
with a full glass of water. The water retrieve the capsule.
may have Simethicone in it to reduce ➤ Inform the patient that the capsule is
gastric and bile bubbles. a single-use device that does not
➤ After ingesting the capsule, the harbor any environmental hazards.
patient should not eat or drink for at ➤ Emphasize that any abdominal pain,
least 2 hours. After 4 hours, the fever, nausea, vomiting, or difficulty
patient may have a light snack. breathing must be immediately
➤ After ingesting the capsule and until reported to the health care practi-
it is excreted, the patient should not tioner.
be near any source of powerful elec- ➤ A written report of the examination
tromagnetic fields, such as MRI or will be completed by a health care
amateur (ham) radio equipment. practitioner specializing in this
➤ The procedure lasts approximately 8 branch of medicine. The report will
hours. be sent to the requesting health care
➤ Instruct the patient not to disconnect results with the patient.
the equipment or remove the belt at
any time during the test. ➤ Depending on the results of this pro-
➤ If the data recorder stops function- needed to evaluate or monitor pro-
ing, instruct the patient to record the gression of the disease process and
time and the nature of any event determine the need for a change in
such as eating or drinking. therapy. Evaluate test results in rela-
➤ Instruct the patient to keep a timed tion to the patient’s symptoms and
diary for the day detailing the food other tests performed.
and liquids ingested and symptoms
during the recording period. Related diagnostic tests:
➤ Instruct the patient to avoid any
strenuous physical activity, bending, ➤ Related diagnostic tests include
or stooping during the test. computed tomography of the abdo-
men; esophagogastroduodenoscopy
Post-test: (upper GI series); kidney, ureter, and
bladder study; magnetic resonance
➤ Instruct the patient to resume nor- imaging of the abdomen, and ultra-
mal activity, medication, and diet sound of the abdomen.
CARBON DIOXIDE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: CO2 combining power, CO2, tCO2.

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube, plasma
(1 mL) collected in a green-top (lithium or sodium heparin) tube; or whole
blood (1 mL) collected in a green-top (lithium or sodium heparin) tube or
heparinized syringe.
REFERENCE VALUE: (Method: Colorimetry, enzyme assay, or pCO2

electrode)

Carbon Dioxide Units Units 1)
Plasma or serum (venous)
Infant–2 y 13–29 mmol/L 13–29 mmol/L
2 y and older 23–29 mmol/L 23–29 mmol/L
Whole blood (venous)
Infant–2 y 18–28 mmol/L 18–28 mmol/L
2 y and older 22–26 mmol/L 22–26 mmol/L
DESCRIPTION & RATIONALE: Serum CO2 provides the basis for the prin-
or plasma carbon dioxide (CO2) cipal buffering system of the extracel-
measurement is usually done as part of lular fluid system, which is the
an electrolyte panel. Total CO2 bicarbonate–carbonic acid buffer sys-
(tCO2) is an important component of tem. CO2 circulates in the body either
the body’s buffering capability, and bound to protein or physically dis-
measurements are used mainly in the solved. Constituents in the blood that
evaluation of acid-base balance. It is contribute to tCO2 levels are bicar-
important to understand the differ- bonate, carbamino compounds, and
ences between tCO2 (CO2 content) carbonic acid (carbonic acid includes
and CO2 gas (pCO2). Total CO2 undissociated carbonic acid and dis-
reflects the majority of CO2 in the solved CO2). Bicarbonate is the sec-
body, mainly in the form of bicarbon- ond largest group of anions in the
ate (HCO3–); is present as a base; and extracellular fluid (chloride being the
is regulated by the kidneys. CO2 gas largest group of extracellular anions).
contributes little to the tCO2 level, is tCO2 levels closely reflect bicarbonate
acidic, and is regulated by the lungs. (HCO3–) levels in the blood, because
(See monograph titled “Blood Gases” 90% to 95% of CO2 circulates as
for more information.) HCO3–. ■
Carbon Dioxide 323
INDICATIONS: • Diabetic ketoacidosis

• Evaluate decreased venous CO2 in the • Diarrhea (severe)
case of compensated metabolic acidosis
• High fever
• Evaluate increased venous CO2 in
the case of compensated metabolic • Metabolic acidosis
alkalosis
• Respiratory alkalosis
• Monitor decreased venous CO2 as a
result of compensated respiratory • Salicylate intoxication
alkalosis • Starvation
• Monitor increased venous CO2 as a
result of compensation for respiratory
acidosis secondary to significant respi-
CRITICAL VALUES:
ratory system infection or cancer; Less than 15 mmol/L
decreased respiratory rate Greater than 40 mmol/L
Observe the patient for signs and
RESULT symptoms of excessive or insufficient
CO2 levels, and report these findings to
Increased in: the health care practitioner. If the patient
• Acute intermittent porphyria has been vomiting for several days and is
breathing shallowly, or if the patient has
• Airway obstruction had gastric suctioning and is breathing
• Asthmatic shock shallowly, this may indicate elevated CO2
levels. Decreased CO2 levels are evi-
• Brain tumor denced by deep, vigorous breathing and
• Bronchitis (chronic) flushed skin.
• Cardiac disorders INTERFERING FACTORS:

• Depression of respiratory center • Drugs that may cause an increase in
tCO2 levels include acetylsalicylic acid,
• Electrolyte disturbance (severe) aldosterone, bicarbonate, carbenicillin,
• Emphysema carbenoxolone, corticosteroids, dexam-
ethasone, ethacrinic acid, laxatives
• Hypothyroidism (chronic abuse), and x-ray contrast
• Hypoventilation agents.
• Metabolic alkalosis • Drugs that may cause a decrease in
tCO2 levels include acetazolamide,
• Myopathy acetylsalicylic acid (initially), amiloride,
• Pneumonia ammonium chloride, fluorides, met-
formin, methicillin, nitrofurantoin,
• Poliomyelitis NSD 3004 (long-acting carbonic anhy-
• Respiratory acidosis drase inhibitor), paraldehyde, tetracy-
cline, triamterene, and xylitol.
• Tuberculosis (pulmonary)
• Prompt and proper specimen process-
Decreased in: ing, storage, and analysis are important
to achieve accurate results. The speci-
• Acute renal failure men should be stored under anaerobic
conditions after collection to prevent
• Anxiety
the diffusion of CO2 gas from the spec-
• Dehydration imen. Falsely decreased values result
from uncovered specimens. It is esti- Intratest:

mated that CO2 diffuses from the sam-
ple at the rate of 6 mmol/h. ➤ If the patient has a history of severe
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
used to assess the effect of total car- Appendix A. Positively identify the
bon dioxide levels on respiratory and patient, and label the appropriate
metabolic acid-base balance. tubes with the corresponding patient
plaints, including a list of known lection. Perform a venipuncture; col-
allergens (especially allergies or sen- lect the specimen in a 5-mL red- or
sitivities to latex), and inform the tiger-, or green-top tube.
appropriate health care practitioner ➤ Remove the needle, and apply a
accordingly. pressure dressing over the puncture
site.
genitourinary and respiratory sys- ➤ Promptly transport the specimen to
tems, as well as results of previously the laboratory for processing and
performed laboratory tests, surgical analysis.
procedures, and other diagnostic ➤ The results are recorded manually or
procedures. For related laboratory in a computerized system for recall
tests, refer to the Cardiovascular, and postprocedure interpretation by
Genitourinary, and Respiratory Sys- the appropriate health care practi-
tem tables. tioner.
➤ Note any recent procedures that can Post-test:
➤ Obtain a list of the medications the ➤ Observe venipuncture site for bleed-
patient is taking, including herbs, ing or hematoma formation. Apply
nutritional supplements, and nutra- paper tape or other adhesive to hold
ceuticals. The requesting health care pressure bandage in place, or
practitioner and laboratory should be replace with a plastic bandage.
advised if the patient regularly uses ➤ Nutritional considerations: Abnormal
these products so that their effects CO2 values may be associated with
can be taken into consideration diseases of the respiratory system.
when reviewing results. Malnutrition is commonly seen in
patients with severe respiratory dis-
➤ Review the procedure with the ease for reasons including fatigue,
patient. Inform the patient that spec- lack of appetite, and gastrointestinal
imen collection takes approximately distress. Research has estimated
5 to 10 minutes. Address concerns that the daily caloric intake required
about pain related to the procedure. for respiration of patients with
Explain to the patient that there may chronic obstructive pulmonary dis-
be some discomfort during the ease is 10 times higher than that of
venipuncture. normal individuals. Adequate intake
➤ There are no food, fluid, or medica- of vitamins A and C is also important
tion restrictions unless by medical to prevent pulmonary infection and
direction. to decrease the extent of lung tissue
Carboxyhemoglobin 325
damage. The importance of following ➤ Depending on the results of this pro-

the prescribed diet should be cedure, additional testing may be
stressed to the patient and/or care- performed to evaluate or monitor
giver. progression of the disease process
will be sent to the requesting health in therapy. Evaluate test results in
care practitioner, who will discuss relation to the patient’s symptoms
the results with the patient. and other tests performed.
patient’s health care provider regard- Related laboratory tests:
referral to another health care ➤ Related laboratory tests include
provider. Answer any questions or anion gap, arterial/alveolar oxygen
address any concerns voiced by the ratio, blood gases, electrolytes,
patient or family. ketones, and salicylate.
CARBOXYHEMOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Carbon monoxide, CO, COHb, COH.

SPECIMEN: Whole blood (1 mL) collected in a green-top (heparin) or
lavender-top (EDTA) tube, depending on laboratory requirement. Specimen
should be transported tightly capped (anaerobic) and in an ice slurry if blood
gases are to be performed simultaneously. Carboxyhemoglobin is stable at
room temperature.
REFERENCE VALUE: (Method: Spectrophotometry, co-oximetry)
% Saturation of the exhaust of automobiles, coal and

Hemoglobin gas burning, and tobacco smoke.
Newborns 10–12% Endogenous CO is produced as a
Nonsmokers Up to 2% result of red blood cell catabolism.
Smokers Up to 12% CO levels are elevated in newborns as
a result of the combined effects of
high hemoglobin turnover and the
inefficiency of the infant’s respiratory
DESCRIPTION & RATIONALE: Exoge- system. CO binds tightly to hemoglo-
nous carbon monoxide (CO) is a col- bin with an affinity 250 times greater
orless, odorless, tasteless byproduct of than oxygen, competitively and dra-
incomplete combustion derived from matically reducing the oxygen-carry-
ing capacity of hemoglobin. The INDICATIONS:

increased percentage of bound CO • Assist in the diagnosis of suspected CO
reflects the extent to which normal poisoning
transport of oxygen has been nega- • Evaluate the effect of smoking on the
tively affected. Overexposure causes patient
hypoxia, which results in headache,
• Evaluate exposure to fires and smoke
nausea, vomiting, vertigo, collapse, or
inhalation
convulsions. Toxic exposure causes
anoxia, increased levels of lactic acid,
and irreversible tissue damage, which RESULT
can result in coma or death. Acute
Increased in:
exposure may be evidenced by a
• CO poisoning
cherry red color to the lips, skin, and
nail beds; this observation may not be • Hemolytic disease
apparent in cases of chronic exposure.
A direct correlation has been impli- • Tobacco smoking
cated between carboxyhemoglobin
levels and symptoms of atherosclerotic Decreased in: N/A
disease, angina, and myocardial
infarction. ■ CRITICAL VALUES:
Percent of total
hemoglobin Symptoms
10%–20% Asymptomatic
10%–30% Disturbance of judgment, headache, dizziness
30%–40% Dizziness, muscle weakness, vision problems,
confusion, increased heart rate, increased
breathing rate
50%–60% Loss of consciousness
Greater than 60% Seizures, coma, death
Women and children may suffer more be collected before administration of oxy-
severe symptoms of carbon monoxide gen therapy.
poisoning at lower levels of carbon
monoxide than men because women and
children usually have lower red blood cell Nursing Implications and
counts. Procedure ● ● ● ● ● ● ● ● ● ● ●
A possible intervention in moderate

CO poisoning is the administration of Pretest:
supplemental oxygen given at atmos-
pheric pressure. In severe CO poisoning, used to evaluate the extent of car-
hyperbaric oxygen treatments may be bon monoxide poisoning and toxicity.
used.
INTERFERING FACTORS: Specimen should allergens (especially allergies or
Carboxyhemoglobin 327
sensitivities to latex), and inform the ➤ Observe standard precautions, and

appropriate health care practitioner follow the general guidelines in
accordingly. Appendix A. Positively identify the
➤ Obtain a history of the patient’s res-
piratory system and results of previ-
lection. Perform a venipuncture; col-
nostic procedures. For related labo-
lavender-top tube. The tightly capped
ratory tests, refer to the Respiratory
sample should be placed in an ice
System table.
slurry immediately after collection.
➤ Note any recent procedures that can Information on the specimen label
interfere with test results. can be protected from water in the
➤ Obtain a list of medications the ice slurry if the specimen is first
patient is taking, including herbs, placed in a protective plastic bag.
nutritional supplements, and nutra- ➤ Remove the needle, and apply a
ceuticals. The requesting health care pressure dressing over the puncture
practitioner and laboratory should be site.
advised if the patient regularly uses ➤ Promptly transport the specimen to
these products so that their effects the laboratory for processing and
can be taken into consideration analysis.
when reviewing results. ➤ The results are recorded manually or
➤ Review the procedure with the in a computerized system for recall
patient. Explain to the patient or fam- and postprocedure interpretation by
ily members that the cause of the the appropriate health care practi-
headache, vomiting, dizziness, con- tioner.
vulsions, or coma could be related to
CO exposure. Inform the patient that Post-test:
mately 5 to 10 minutes. Address
concerns about pain related to the
there may be some discomfort dur-
ing the venipuncture.
➤ If carboxyhemoglobin measurement will be sent to the requesting health
will be performed simultaneously care practitioner, who will discuss
with arterial blood gases, prepare the results with the patient.
an ice slurry in a cup or plastic bag
and have it on hand for immediate
results, and be supportive of im-
transport of the specimen to the
paired activity related to fear
laboratory.
of shortened life expectancy. Discuss
➤ There are no food, fluid, or medica- the implications of abnormal test
tion restrictions unless by medical results on the patient’s lifestyle.
direction. Provide teaching and information
Intratest: the test results, as appropriate.
➤ If the patient has a history of severe to counseling services. Educate the
allergic reaction to latex, care should patient regarding avoiding gas
be taken to avoid the use of equip- heaters and indoor cooking fires
ment containing latex. without adequate ventilation, and the
➤ Instruct the patient to cooperate fully need to have gas furnaces checked
and to follow directions. Direct the yearly for CO leakage. Inform the
patient to breathe normally and to patient of smoking cessation pro-
avoid unnecessary movement. grams, as appropriate.
➤ Reinforce information given by the progression of the disease process

patient’s health care provider regard- and determine the need for a change
ing further testing, treatment, or in therapy. Evaluate test results in
referral to another health care relation to the patient’s symptoms
provider. Answer any questions or and other tests performed.
patient or family. Related laboratory tests
➤ Depending on the results of this pro- ➤ Related laboratory tests include arte-
cedure, additional testing may be rial/alveolar oxygen ratio, blood
performed to evaluate or monitor gases, and complete blood count.
CARCINOEMBRYONIC ANTIGEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CEA.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Plasma (1 mL)
collected in lavender-top (EDTA) tube is also acceptable. Care must be
taken to use the same type of collection container if serial measurements
are to be taken.
REFERENCE VALUE: (Method: Enzyme immunoassay)
SI Units
Smoking Status Conventional Units (Conventional Units 1)
Smoker Less than 5.0 ng/mL Less than 5.0 g/L
Nonsmoker Less than 2.5 ng/mL Less than 2.5 g/L
DESCRIPTION & RATIONALE: Carci- cancer, it is useful for monitoring

noembryonic antigen (CEA) is a gly- response to antineoplastic therapy in
coprotein normally produced only breast and gastrointestinal cancer. ■
during early fetal life and rapid multi-
plication of epithelial cells, especially
INDICATIONS:
• Determine stage of colorectal cancer
those of the digestive system. CEA and test for recurrence
also appears in the blood of chronic
• Monitor response to treatment of
smokers. Although the test is not
breast and gastrointestinal cancers
diagnostic for any specific disease and
is not useful as a screening test for RESULT
Carcinoembryonic Antigen 329
Increased in: ➤ Review the procedure with the

• Benign tumors, including benign patient. Inform the patient that spec-
breast disease imen collection takes approximately
• Chronic tobacco smoking about pain related to the procedure.
• Colorectal, pulmonary, gastric, pancre- be some discomfort during the
atic, breast, head or neck, esophageal, venipuncture.
ovarian, or prostate cancer ➤ There are no food, fluid, or medica-
• Radiation therapy (transient) tion restrictions unless by medical
direction.
Decreased in: N/A
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that the test is Appendix A. Positively identify the
used to monitor the progress of vari- patient, and label the appropriate
ous types of cancer and evaluate the tubes with the corresponding patient
response to therapy. demographics, date, and time of col-
plaints, including a list of known lect the specimen in a 5-mL red- or
allergens (especially allergies or sen- lavender -top tube.
accordingly. site.
gastrointestinal, immune, and repro- the laboratory for processing and
ductive systems, as well as results analysis.
of previously performed laboratory ➤ The results are recorded manually or
tests, surgical procedures, and other in a computerized system for recall
diagnostic procedures. For related and postprocedure interpretation by
laboratory tests, refer to the Gas- the appropriate health care practi-
trointestinal, Immune, and Repro- tioner.
ductive System tables.
➤ Obtain a list of medications the Post-test:
nutritional supplements, and nutra- ➤ Observe venipuncture site for bleed-
ceuticals. The requesting health care ing or hematoma formation. Apply
practitioner and laboratory should be paper tape or other adhesive to hold
advised if the patient regularly uses pressure bandage in place, or
these products so that their effects replace with a plastic bandage.
can be taken into consideration ➤ A written report of the examination
when reviewing results. will be sent to the requesting health
➤ Determine if the patient smokes, care practitioner, who will discuss
because smokers may have false the results with the patient.
elevations. ➤ Recognize anxiety related to test
results, and be supportive of per- tinuing scheduled therapy or follow-

ceived loss of independence and up visits. Answer any questions or
fear of shortened life expectancy. address any concerns voiced by the
Discuss the implications of abnormal patient or family.
test results on the patient’s lifestyle. ➤ Depending on the results of this pro-
Provide teaching and information cedure, additional testing may be
regarding the clinical implications of performed to evaluate or monitor
the test results, as appropriate. progression of the disease process
Educate the patient regarding access and determine the need for a change
to counseling services. in therapy. Evaluate test results in
➤ Reinforce information given by the relation to the patient’s symptoms
patient’s health care provider regard- and other tests performed.
referral to another health care Related laboratory tests
provider. Inform the patient that the
test may be repeated periodically to ➤ Related laboratory tests include
monitor response to therapy. Instruct biopsy of suspicious tissue, CA
the patient in the importance of con- 15–3, CA 19–9, and CA 125.
CATECHOLAMINES, BLOOD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Epinephrine, norepinephrine, dopamine.

SPECIMEN: Plasma (2 mL) collected in green-top (heparin) tube.
REFERENCE VALUE: (Method: High-performance liquid chromatography)
Conventional Units SI Units

Epinephrine
Supine, 30 min 0–110 pg/mL 0–600 pmol/L
Standing, 30 min 0–140 pg/mL 0–764 pmol/L
Norepinephrine
Supine, 30 min 70–750 pg/mL 414–4432 pmol/L
Standing, 30 min 200–1700 pg/mL 1182–10,047 pmol/L
Dopamine
Supine or standing 0–30 pg/mL 0–196 pmol/L
Catecholamines, Blood 331
• Evaluate acute hypertensive episode

DESCRIPTION & RATIONALE: Cate-
• Evaluate hypertension of unknown
cholamines are produced by the chro-
origin
maffin tissue of the adrenal medulla.
They are also found in sympathetic • Screen for pheochromocytoma among
nerve endings and in the brain. The family members with an autosomal
major catecholamines are epineph- dominant inheritance pattern for
Lindau–von Hippel disease or multiple
rine, norepinephrine, and dopamine.
endocrine neoplasia
They prepare the body for the fight-
or-flight stress response, help regulate RESULT
metabolism, and are excreted from the
body by the kidneys. Catecholamine Increased in:
levels are affected by diurnal varia- • Diabetic acidosis (epinephrine and
tions, fluctuating in response to stress, norepinephrine)
postural changes, diet, smoking, • Ganglioblastoma (epinephrine, slight
drugs, and temperature changes. As a increase; norepinephrine, large increase)
result, blood measurement is not as
reliable as a 24-hour timed urine test. • Ganglioneuroma (all are increased;
norepinephrine, largest increase)
Results are most reliable when the
specimen is collected during a hyper- • Hypothyroidism (epinephrine and nor-
tensive episode. Catecholamines are epinephrine)
measured when there is high suspicion • Long-term manic-depressive disorders
of pheochromocytoma but urine (epinephrine and norepinephrine)
results are normal or borderline.
• Myocardial infarction (epinephrine and
Findings should be compared with the norepinephrine)
metabolites of epinephrine and norep-
inephrine, metanephrines and vanil- • Neuroblastoma (all are increased; nor-
lylmandelic acid, and with the epinephrine and dopamine, largest
increase)
product of dopamine metabolism,
homovanillic acid. Use of a clonidine • Pheochromocytoma (epinephrine, con-
suppression test with measurement tinuous or intermittent increase; norep-
of plasma catecholamines may be inephrine, slight increase)
requested. Failure to suppress produc- • Shock (epinephrine and norepineph-
tion of catecholamines after adminis- rine)
tration of clonidine supports the • Strenuous exercise (epinephrine and
diagnosis of pheochromocytoma. ■ norepinephrine)
INDICATIONS: Decreased in:

• Assist in the diagnosis of neurob- • Autonomic nervous system dysfunc-
lastoma, ganglioneuroma, or dysau- tion (norepinephrine)
tonomia
• Orthostatic hypotension (norepineph-
• Assist in the diagnosis of paragan- rine)
gliomas
• Parkinson’s disease (dopamine)
• Assist in the diagnosis of pheochromo-
cytoma CRITICAL VALUES: N/A

• Drugs that may increase catecholamine sitivities to latex), and inform the
levels include ajmaline, chlorpro-
accordingly.
mazine, cyclopropane, diazoxide, ether,
monoamine oxidase inhibitors, nitro- ➤ Obtain a history of the patient’s
glycerin, pentazocine, perphenazine, endocrine system, as well as results
phenothiazine, promethazine, and
theophylline. diagnostic procedures. For related
• Drugs that may decrease catecholamine laboratory tests, refer to the Endo-
levels include clonidine, metyrosine, crine System table.
and reserpine. ➤ Record the date of the last menstrual
period.
• Stress, hypoglycemia, smoking, and
drugs can produce elevated plasma cat- ➤ Obtain a list of the medications the
echolamines.
• Secretion of catecholamines exhibits ceuticals. The requesting health care
diurnal variation, with the lowest levels practitioner and laboratory should
occurring at night. be advised if the patient regularly
uses these products so that their
• Secretion of catecholamines varies dur- effects can be taken into considera-
ing the menstrual cycle, with higher tion when reviewing results.
levels excreted during the luteal phase ➤ Review the procedure with the
and lowest levels during ovulation. patient. Inform the patient that he
or she may be asked to keep warm
• Diets high in amines (e.g., bananas, and to rest for 45 to 60 minutes
avocados, beer, aged cheese, chocolate, before the test. Inform the patient
cocoa, coffee, fava beans, grains, tea, that multiple specimens may be
vanilla, walnuts, Chianti wine) can required. Inform the patient that
produce elevated plasma catecholamine specimen collection takes approxi-
levels, although this effect is more likely mately 5 to 10 minutes. Address
to be seen relative to certain urinary concerns about pain related to the
metabolites. procedure. Explain to the patient that
• Recent radioactive scans within 1 week ing the venipuncture.
of the test can interfere with test results. ➤ Sensitivity to social and cultural
• Failure to follow dietary restrictions issues, as well as concern for mod-
procedure to be canceled or repeated. and after the procedure.
➤ Inform the patient that a saline lock
may be inserted before the test
Nursing Implications and because the stress of repeated
Procedure ● ● ● ● ● ● ● ● ● ● ● venipunctures may increase cate-
cholamine levels.
Pretest: ➤ Instruct the patient to follow a nor-
➤ Inform the patient that the test is mal-sodium diet for 3 days before
used to diagnose catecholamine- testing, abstain from smoking
secreting tumors and in the investi- tobacco for 24 hours before testing,
gation of hypertension. and avoid consumption of foods high
in amines for 48 hours before testing.
plaints, including a list of known ➤ Instruct the patient to avoid self-
Catecholamines, Blood 333
prescribed medications for 2 weeks utes, and then obtain a second sam-
before testing (especially appetite ple as previously described.
suppressants and cold and allergy ➤ The sample should be placed in an
medications, such as nose drops, ice slurry immediately after collec-
cough suppressants, and bron- tion. Information on the specimen
chodilators). label can be protected from water in
➤ Instruct the patient to withhold the ice slurry if the specimen is first
prescribed medication (especially placed in a protective plastic bag.
methyldopa, epinephrine, levodopa, Promptly transport the specimen to
and methenamine mandelate) if the laboratory for processing and
directed by the health care practi- analysis.
tioner. ➤ The results are recorded manually or
➤ Instruct the patient to fast from food in a computerized system for recall
and fluids for 10 to 12 hours before and postprocedure interpretation by
the test. the appropriate health care practi-
tioner.
tic bag to have ready for immediate
transport of the specimen to the lab- Post-test:
oratory. Prechill the green-top tube in ➤ Observe venipuncture site for bleed-
the ice slurry. ing or hematoma formation. Apply
Intratest: pressure bandage in place, or
diet, fluids, medications or activity,
tions as well as other pretesting
as directed by the health care practi-
preparations; assure that food and
tioner.
fluids have been restricted for at
least 10 to 12 hours prior to the pro- ➤ Assess the patient for increased
cedure. pulse and blood pressure, hyper-
glycemia, shakiness, and palpitations
➤ If the patient has a history of severe associated with increased values.
be taken to avoid the use of equip- ➤ A written report of the examination
ment containing latex. will be sent to the requesting health
➤ Instruct the patient to cooperate fully the results with the patient.
avoid unnecessary movement. results. Discuss the implications of
➤ Observe standard precautions, and lifestyle. Provide teaching and
follow the general guidelines in information regarding the clinical
Appendix A. Positively identify the implications of the test results, as
patient, and label the appropriate appropriate. Educate the patient
tubes with the corresponding patient regarding access to counseling
demographics, position of the services.
patient, date, and time of collection.
➤ Reinforce information given by
Perform a venipuncture between 6
and 8 a.m.; collect the specimen in a
prechilled 5-mL green-top tube.
➤ Remove the needle, and apply a provider. Answer any questions or
pressure dressing over the puncture address any concerns voiced by the
site. patient or family.
➤ Ask the patient to stand for 10 min- ➤ Depending on the results of this pro-

and determine the need for a change calcitonin, urine catecholamines,
in therapy. Evaluate test results in urine homovanillic acid, urine met-
relation to the patient’s symptoms anephrines, and urine vanillylman-
and other tests performed. delic acid.
CATECHOLAMINES, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Epinephrine, norepinephrine, dopamine.

SPECIMEN: Urine (25 mL) from a timed specimen collected in a clean plas-
tic, amber collection container with 6N hydrochloric acid as a preservative.
REFERENCE VALUE: (Method: High-performance liquid chromatography)

Epinephrine
1–4 y 0–6.0 g/24 h 0–32.8 nmol/24 h
4 – 10 y 0–10.0 g/24 h 0–54.6 nmol/24 h
10–15 y 0.5–20 g/24 h 2.7–109 nmol/24 h
Adult 0–20 g/24 h 0–109 nmol/24 h
Norepinephrine
1–4 y 0–29 g/24 h 0–171 nmol/24 h
4–10 y 8–65 g/24 h 47–384 nmol/24 h
10 y–adult 15–80 g/24 h 89–473 nmol/24 h
Dopamine
1–4 y 10–260 g/24 h 65–1698 nmol/24 h
4 y–adult 65–400 g/24 h 424–2612 nmol/24 h
DESCRIPTION & RATIONALE: Cat- pathetic nerve endings and in the

echolamines are produced by the brain. The major catecholamines are
chromaffin tissue of the adrenal epinephrine, norepinephrine, and
medulla. They also are found in sym- dopamine. They prepare the body for
Catecholamines, Urine 335
the fight-or-flight stress response, help • Ganglioblastoma (epinephrine, slight

regulate metabolism, and are excreted increase; norepinephrine, large increase)
from the body by the kidneys. Levels • Ganglioneuroma (all are increased;
are affected by diurnal variations, fluc- norepinephrine, largest increase)
tuating in response to stress, postural • Hypothyroidism (epinephrine and nor-
changes, diet, smoking, drugs, and epinephrine)
temperature changes. As a result,
• Long-term manic-depressive disorders
blood measurement is not as reliable
(epinephrine and norepinephrine)
as a 24-hour timed urine test. For test
results to be valid, all of the previously • Myocardial infarction (epinephrine and
mentioned environmental variables norepinephrine)
must be controlled when the test is • Neuroblastoma (all are increased; nor-
performed. Elevated homovanillic epinephrine and dopamine, largest
acid levels rule out pheochromocy- increase)
toma because this tumor primarily • Pheochromocytoma (epinephrine, con-
secretes epinephrine. Elevated cate- tinuous or intermittent increase; norep-
cholamines without hypertension inephrine, slight increase)
suggest neuroblastoma or ganglioneu-
• Shock (epinephrine and norepineph-
roma. Findings should be compared rine)
with metanephrines and vanillylman-
delic acid, which are the metabolites • Strenuous exercise (epinephrine and
of epinephrine and norepinephrine. norepinephrine)
Findings should also be compared
Decreased in:
with homovanillic acid, which is the
• Autonomic nervous system dysfunc-
product of dopamine metabolism. ■ tion (norepinephrine)
INDICATIONS: • Orthostatic hypotension (norepineph-
• Assist in the diagnosis of neuroblas- rine)
toma, ganglioneuroma, or dysautono- • Parkinson’s disease (dopamine)
mia
• Assist in the diagnosis of pheochromo- CRITICAL VALUES: N/A
cytoma
• Evaluate acute hypertensive episode • Drugs that may increase urine
• Evaluate hypertension of unknown catecholamine levels include acetamin-
origin ophen, atenolol, dopamine (intra-
venous), isoproterenol, methyldopa,
• Screen for pheochromocytoma among niacin, nitroglycerin, prochlorperazine,
family members with an autosomal rauwolfia, reserpine, syrosingopine,
dominant inheritance pattern for and theophylline.
Lindau–von Hippel disease or multiple
endocrine neoplasia • Drugs that may decrease urine
catecholamine levels include brety-
RESULT lium tosylate, clonidine, decaborane,
guanethidine, guanfacine, methyldopa,
Increased in: ouabain, radiographic substances, and
reserpine.
• Diabetic acidosis (epinephrine and
norepinephrine) • Stress, hypoglycemia, smoking, and
drugs can produce elevated cate- practitioner and laboratory should be

cholamines. advised if the patient regularly uses
• Secretion of catecholamines exhibits can be taken into consideration
diurnal variation, with the lowest levels when reviewing results.
occurring at night. ➤ Review the procedure with the
• Secretion of catecholamines varies dur- patient. Provide a nonmetallic urinal,
bedpan, or toilet-mounted collection
ing the menstrual cycle, with higher device. Address concerns about pain
levels excreted during the luteal phase related to the procedure. Explain to
and lowest levels during ovulation. the patient that there should be no
• Diets high in amines (e.g., bananas, discomfort during the procedure.
avocados, beer, aged cheese, chocolate, ➤ Usually a 24-hour time frame for
cocoa, coffee, fava beans, grains, tea, urine collection is ordered. Inform
vanilla, walnuts, Chianti wine) can the patient that all urine over a 24-
hour period must be saved; if a pre-
produce elevated catecholamine levels. servative has been added to the
• Failure to collect all urine and store 24- container, instruct the patient not to
hour specimen properly will yield a discard the preservative. Instruct
falsely low result. the patient not to void directly into
the laboratory collection container.
• Failure to follow dietary restrictions Instruct the patient to avoid defecat-
before the procedure may cause the ing in the collection device and to
procedure to be canceled or repeated. keep toilet tissue out of the collec-
tion device to prevent contamination
of the specimen. Place a sign in the
bathroom as a reminder to save all
Nursing Implications and urine.
Procedure ● ● ● ● ● ● ● ● ● ● ●
into the collection device, then pour
Pretest: the urine into the laboratory collec-
tion container. Alternatively, the
➤ Inform the patient that the test is specimen can be left in the collection
used to diagnose pheochromocy- device for a health care staff mem-
toma and in the workup of neurob- ber to add to the laboratory collec-
lastoma. tion container.
accordingly.
➤ Obtain a history of the patient’s Instruct the patient to:
endocrine system and results of pre- ➤ Follow a normal-sodium diet for 3
viously performed laboratory tests, days before testing.
nostic procedures. For related labo- ➤ Avoid consumption of foods high in
ratory tests, refer to the Endocrine amines for 48 hours before testing.
System table. ➤ Avoid excessive stress and exercise
➤ Record the date of the last menstrual during the 24-hour collection period.
period. ➤ Abstain from smoking tobacco for 24
➤ Obtain a list of medications the hours before testing.
patient is taking, including herbs, ➤ Avoid self-prescribed medications for
nutritional supplements, and nutra- 2 weeks before testing (especially
ceuticals. The requesting health care appetite suppressants and cold and
Catecholamines, Urine 337
allergy medications, such as nose next morning, ask the patient to void
drops, cough suppressants, and at the same time the collection was
bronchodilators). started and add this last voiding to
➤ Withhold prescribed medication the container.
(especially methyldopa, epinephrine, ➤ If an indwelling catheter is in place,
levodopa, and methenamine mande- replace the tubing and container sys-
late) if directed by the health care tem at the start of the collection
practitioner. time. Keep the container system
➤ Fast from food and fluids for 10 to 12 on ice during the collection period
hours before the test. or empty the urine into a larger
container periodically during the col-
Intratest: lection period; monitor to ensure
continued drainage, and conclude
➤ Ensure that the patient has complied the test the next morning at the
with dietary, medication, and activity same hour the collection was begun.
restrictions and with pretesting
➤ At the conclusion of the test, com-
preparations: assure that food and
pare the quantity of urine with the
fluids have been restricted for at
urinary output record for the collec-
least 10 to 12 hours prior to the pro-
tion; if the specimen contains less
cedure, and that excessive exercise
and stress have been avoided prior
some urine may have been dis-
to the procedure. Instruct the patient
carded, invalidating the test.
to continue to avoid excessive exer-
cise and stress during the 24-hour ➤ Include on the collection container’s
collection of urine. label the amount of urine, test start
and stop times, and ingestion of any
foods or medications that can affect
test results.
ment containing latex. ➤ Promptly transport the specimen to
➤ Instruct the patient to cooperate fully the laboratory for processing and
and to follow directions. analysis.
➤ Observe standard precautions, and ➤ The results are recorded manually or

follow the general guidelines in in a computerized system for recall
Appendix A. Positively identify the and postprocedure interpretation by
patient, and label the appropriate col- the appropriate health care practi-
lection container with the correspon- tioner.
ding patient demographics, date, and
time of collection.
Post-test:
➤ Obtain a clean 3-L urine specimen as directed by the health care practi-
container, toilet-mounted collection tioner.
of the specimen container). The ➤ A written report of the examination
specimen must be refrigerated or will be sent to the requesting health
kept on ice throughout the collection care practitioner, who will discuss
period. If an indwelling urinary the results with the patient.
catheter is in place, the drainage bag ➤ Recognize anxiety related to test
must be kept on ice. results. Discuss the implications
➤ Begin the test between 6 and 8 a.m., of abnormal test results on the
if possible. Collect first voiding and patient’s lifestyle. Provide teaching
discard. Record the time the speci- and information regarding the clinical
men was discarded as the beginning implications of the test results, as
of the timed collection period. The appropriate.
➤ Reinforce information given by the and determine the need for a change
patient’s health care provider regard- in therapy. Evaluate test results in
ing further testing, treatment, or relation to the patient’s symptoms
referral to another health care and other tests performed.
address any concerns voiced by the Related laboratory tests:
patient or family.
➤ Depending on the results of this pro- calcitonin, plasma catecholamines,
cedure, additional testing may be urine homovanillic acid, urine met-
performed to evaluate or monitor anephrines, and urine vanillylman-
progression of the disease process delic acid.
CD4/CD8 ENUMERATION
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: T-cell profile.

SPECIMEN: Whole blood (1 mL) collected in green-top (heparin) tube.
REFERENCE VALUE: (Method: Flow cytometry)
Total lymphocytes 1500–4000/mm3

CD3 876–1900/mm3
CD4 450–1400/mm3
CD8 190–725/mm3
CD20 64–475/mm3
CD4/CD8 ratio 1.0–3.5
DESCRIPTION & RATIONALE: Enu- depressed CD4 count is an excellent

meration of lymphocytes, identifica- predictor of imminent opportunistic
tion of cell lineage, and identification infection. ■
of cellular stage of development are
used to diagnose and classify malig- INDICATIONS:
nant myeloproliferative diseases and • Assist in the diagnosis of acquired
to plan treatment. T-cell enumeration immunodeficiency syndrome (AIDS)
is also useful in the evaluation and and plan treatment
management of immunodeficiency • Evaluate malignant myeloproliferative
and autoimmune disease. A severely diseases and plan treatment
CD4/CD8 Enumeration 339
• Evaluate thymus-dependent or cellular ➤ Obtain a history of the patient’s

immunocompetence hematopoietic and immune systems
and results of previously performed
RESULT laboratory tests, surgical procedures,
Increased in: Hematopoietic and Immune System
• Malignant myeloproliferative diseases tables.
(e.g., acute and chronic lymphocytic ➤ Note any recent procedures that can
leukemia, lymphoma) interfere with test results.
Decreased in: patient is taking, including herbs,
• AIDS nutritional supplements, and nutra-
• Aplastic anemia practitioner and laboratory should be
• Hodgkin’s disease advised if the patient regularly uses
can be taken into consideration when
CRITICAL VALUES: N/A reviewing results.
• Drugs that may increase T-cell count direction.
include interferon-.
• Drugs that may decrease T-cell count Intratest:
include chlorpromazine and pred-
nisone. allergic reaction to latex, care should
• Specimens should be stored at room be taken to avoid the use of equip-
temperature. ment containing latex.
• Recent radioactive scans or radiation and to follow directions. Direct the
can decrease T-cell counts. patient to breathe normally and to
• Values may be abnormal in patients
with severe recurrent illness or after ➤ Observe standard precautions, and
recent surgery requiring general anes- follow the general guidelines in
thesia.
Nursing Implications and collection. Perform a venipuncture;
Procedure ● ● ● ● ● ● ● ● ● ● ● collect the specimen in a 5-mL
green-top tube.
Pretest: ➤ Remove the needle, and apply a
➤ Inform the patient that the test is pressure dressing over the puncture
primarily used to monitor disease site.
progression and effectiveness of ➤ Promptly transport the specimen to
retroviral therapy. the laboratory for processing and
➤ Obtain a history of the patient’s com- analysis.
plaints, including a list of known ➤ The results are recorded manually or
allergens (especially allergies or sen- in a computerized system for recall
sitivities to latex), and inform the and postprocedure interpretation by
appropriate health care practitioner the appropriate health care practi-
accordingly. tioner.

Post-test:
Educate the patient as to the risk
➤ Observe venipuncture site for bleed- of infection related to immunosup-
ing or hematoma formation. Apply pressed inflammatory response and
paper tape or other adhesive to fatigue related to decreased energy
hold pressure bandage in place, or production. Educate the patient
replace with a plastic bandage. regarding access to counseling
services.
➤ Nutritional considerations: As appro-
priate, stress the importance of ➤ Reinforce information given by
good nutrition and suggest that the the patient’s health care provider
patient meet with a nutritional spe- regarding further testing, treatment,
cialist. Stress the importance of fol- or referral to another health care
lowing the care plan for medications provider. Answer any questions or
and follow-up visits. Inform the address any concerns voiced by the
patient that subsequent requests for patient or family.
follow-up blood work at regular inter-
vals should be anticipated.
results, and be supportive of im- and other tests performed.
paired activity related to perceived
loss of independence and fear of Related laboratory tests:
the implications of abnormal test ➤ Related laboratory tests include
results on the patient’s lifestyle. bone marrow, complete blood count,
Provide teaching and information HIV-1/HIV-2 antibodies, and 2-
regarding the clinical implications of microglobulin.
CEREBROSPINAL FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CSF analysis.

SPECIMEN: CSF (1 to 3 mL) collected in three or four separate plastic coni-
cal tubes. Tube 1 is used for chemistry and serology testing, tube 2 is used
for microbiology, tube 3 is used for cell count, and tube 4 is used for miscel-
laneous testing.
REFERENCE VALUE: (Method: Macroscopic evaluation of appearance; spec-
trophotometry for glucose, lactic acid, and protein; radioimmunoassay for
myelin basic protein; nephelometry for immunoglobulin G [IgG]; elec-
trophoresis for oligoclonal banding; Gram stain, India ink preparation, and
culture for microbiology; microscopic examination of fluid for cell count;
flocculation for Venereal Disease Research Laboratory [VDRL])
Cerebrospinal Fluid Analysis 341
Lumbar Puncture Conventional Units SI Units

Color and appearance Crystal clear
(Conventional Units 10)
Protein 15–45 mg/dL 150–450 mg/L
Glucose
Infant or child 60–80 mg/dL 3.3–4.4 mmol/L
Adult 40–70 mg/dL 2.2–3.9 mmol/L
Lactic acid
Neonate 10–60 mg/dL 1.1–6.7 mmol/L
3–10 d 10–40 mg/dL 1.1–4.4 mmol/L
Adult Less than 25.2 mg/dL Less than 2.8 mmol/L
Myelin basic protein Less than 2.5 ng/mL Less than 2.5 g/L
Oligoclonal bands Absent
IgG Less than 3.4 mg/dL Less than 34 mg/L
Gram stain Negative
India ink Negative
Culture No growth
RBC count 0 0
WBC count
Less than 1 y 0–30/mL 0–30 106/L
1–4 y 0–20/mL 0–20 106/L
5–12 y 0–10/mL 0–10 106/L
Adult 0–5/mL 0–5 106/L
WBC Differential Adult Children Adult Children
Lymphocytes 40%–80% 5%–13% 0.4–0.8 0.55–0.35
Monocytes 15%–45% 50%–90% 0.15–0.45 0.50–0.90
Neutrophils 0%–6% 0%–8% 0–0.6 0–0.8
VDRL Nonreactive
Cytology No abnormal
cells seen
RBC red blood cell; VDRL Venereal Disease Research Laboratory; WBC white
blood cell.
DESCRIPTION & RATIONALE: Cere- and neurosecretion. CSF analysis

brospinal fluid (CSF) circulates in the helps determine the presence and
subarachnoid space and has a twofold cause of bleeding and assists in diag-
function: to protect the brain and nosing cancer, infections, and degen-
spinal cord from injury and to trans- erative and autoimmune diseases of
port products of cellular metabolism the brain and spinal cord. Specimens
for analysis are most frequently • Myelin basic protein: trauma, stroke,
obtained by lumbar puncture and tumor, multiple sclerosis, subacute scle-
rosing panencephalitis
sometimes by ventricular or cisternal
puncture. Lumbar puncture can also • IgG and oligoclonal banding: multiple
have therapeutic uses, including injec- sclerosis, CNS syphilis, and subacute
tion of drugs and anesthesia. ■ sclerosing panencephalitis
• Gram stain: meningitis due to
INDICATIONS: Streptococcus pneumoniae, Haemophilus
• Assist in the diagnosis and differentia- influenzae, Neisseria meningitidis, Cryp-
tion of subarachnoid or intracranial tococcus neoformans
hemorrhage
• India ink preparation: meningitis due
• Assist in the diagnosis and differentia- to C. neoformans
tion of viral or bacterial meningitis or
encephalitis • Culture: encephalitis or meningitis due
to herpes simplex virus, S. pneumoniae,
• Assist in the diagnosis of diseases such H. influenzae, N. meningitidis, C. neo-
as multiple sclerosis, autoimmune dis- formans
orders, or degenerative brain disease
• RBC count: hemorrhage
• Assist in the diagnosis of neurosyphilis
and chronic central nervous system • White blood cell (WBC) count:
(CNS) infections General increase—injection of
• Detect obstruction of CSF circulation contrast media or anticancer
due to hemorrhage, tumor, or edema drugs in subarachnoid space;
CSF infarct; metastatic tumor in
• Establish the presence of any condition contact with CSF; reaction to
decreasing the flow of oxygen to the repeated lumbar puncture
brain Elevated WBC count with a
• Monitor for metastases of cancer into predominance of neutrophils
indicative of bacterial meningitis
the CNS
Elevated WBC count with a
• Monitor severe brain injuries predominance of lymphocytes
indicative of viral, tubercular,
RESULT parasitic, or fungal meningitis;
multiple sclerosis
Increases in:
Elevated WBC count with a
• Color and appearance: bloody—hem- predominance of monocytes
orrhage; xanthochromic—old hemor- indicative of chronic bacterial
rhage, red blood cell (RBC) breakdown, meningitis, amebic meningitis,
methemoglobin, bilirubin (greater than multiple sclerosis, toxoplasmosis
6 mg/dL), increased protein (greater Increased plasma cells indicative of
than 150 mg/dL), melanin (meningeal acute viral infections, multiple
melanosarcoma), carotene (systemic sclerosis, sarcoidosis, syphilitic
carotenemia); hazy—meningitis; pink meningoencephalitis, subacute
to dark yellow—aspiration of epidural sclerosing panencephalitis,
fat; turbid—cells, microorganisms, pro- tubercular meningitis, parasitic
tein, fat, or contrast medium infections, Guillain-Barré
syndrome
• Protein: meningitis, encephalitis
Presence of eosinophils indicative
• Lactic acid: bacterial, tubercular, fungal of parasitic and fungal infections,
meningitis acute polyneuritis, idiopathic
hypereosinophilic syndrome, • Drugs that may increase CSF glucose

reaction to drugs or a shunt levels include cefotaxime and dexam-
in CSF ethasone.
• VDRL: syphilis • RBC count may be falsely elevated
with a traumatic spinal tap.
• Cytology: malignant cells within 1 week before the test can inter-
Decreases in:
• Glucose: bacterial and tubercular
meningitis
CRITICAL VALUES: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Positive Gram stain, India ink prepara-

tion, or culture Pretest:
• Presence of malignant cells or blasts ➤ Inform the patient that the test is
primarily used to assist in the differ-
• Elevated white blood cell count ential diagnosis of infection or hem-
• Glucose greater than 37 mg/dL orrhaging in the brain. It is also
used in the evaluation of other con-
Note and immediately report to the ditions with significant neuromuscu-
health care practitioner any positive or lar affects.
critically increased results and related ➤ Obtain a history of the patient’s
symptoms. complaints, including a list of known
INTERFERING FACTORS: sitivities to latex or anesthetics), and
This procedure is practitioner accordingly.
contraindicated for: ➤ Obtain a history of the patient’s
• This procedure is contraindicated tems and results of previously per-
if infection is present at the nee- formed laboratory tests, surgical
dle insertion site. procedures, and other diagnostic
• It may also be contraindicated in
patients with degenerative joint Musculoskeletal System tables.
disease or coagulation defects and in
patients who are uncooperative during ➤ Note any recent procedures that can
the procedure.
• Use with extreme caution in patient is taking. Include herbs, nutri-
patients with increased intracra- tional supplements, and nutraceuti-
nial pressure because overly rapid cals. The requesting health care
removal of CSF can result in herniation. practitioner and laboratory should be
Other considerations: these products so that their effects
• Drugs that may decrease CSF protein
levels include cefotaxime and dexam-
ethasone. ➤ Review the procedure with the
patient. Inform the patient that the
• Interferon- may increase myelin basic position required may be awkward,
protein levels. but that someone will assist during
the procedure. Stress the impor- tubes with the corresponding patient
tance of remaining still and breathing demographics, date, and time of col-
normally throughout the procedure. lection. Collect the specimen in four
Inform the patient that specimen col- plastic conical tubes.
lection takes approximately 20 min- ➤ Record baseline vital signs.
utes. Address concerns about pain
related to the procedure. Inform the ➤ To perform a lumbar puncture,
patient that a stinging sensation may position the patient in the knee-
be felt when the local anesthetic is chest position at the side of the bed.
injected. Tell the patient to report any Provide pillows to support the spine
pain or other sensations that may or for the patient to grasp. The sitting
require repositioning the spinal nee- position is an alternative. In this posi-
dle. Explain to the patient that there tion, the patient must bend the neck
may be some discomfort during the and chest to the knees.
procedure. Tell the patient the proce- ➤ Prepare the site—usually between
dure will be performed by a health L3 and L4, or between L4 and L5—
care practitioner. with povidone-iodine and drape the
area.
issues, as well as concern for mod- ➤ A local anesthetic is injected. Using
esty, is important in providing psy- sterile technique, the health care
chological support before, during, practitioner inserts the spinal needle
and after the procedure. through the spinous processes of
the vertebrae and into the subarach-
noid space. The stylet is removed. If
the needle is properly placed, CSF
direction.
drips from the needle.
➤ Attach the stopcock and manometer,
and measure initial pressure. Normal
pressure for an adult in the lateral
any medications.
recumbent position is 90 to 180 mm
H2O; normal pressure for a child age
Intratest: 8 years or younger is 10 to 100 mm
➤ If the patient has a history of severe H2O. These values depend on the
allergic reaction to latex, care should body position and are different in a
be taken to avoid the use of equip- horizontal or sitting position.
ment containing latex. ➤ CSF pressure may be elevated if the
➤ Ensure that anticoagulant therapy patient is anxious, holding his or her
has been withheld for the appropri- breath, or tensing muscles. It may
ate amount of days prior to the pro- also be elevated if the patient’s
cedure. Amount of days to withhold knees are flexed too firmly against
medication is dependant on the type the abdomen. CSF pressure may
of anticoagulant. Notify health care be significantly elevated in patients
practitioner if patient anticoagulant with intracranial tumors. If the
therapy has not been withheld. initial pressure is elevated, the health
care practitioner may perform Queck-
➤ Have emergency equipment readily enstedt’s test. To perform this test,
available. pressure is applied to the jugular vein
➤ Instruct the patient to cooperate fully for about 10 seconds. CSF pressure
and to follow directions. Direct the usually rises rapidly in response to
patient to breathe normally and to the occlusion, and then returns to
avoid unnecessary movement. the pretest level within 10 seconds
➤ Observe standard precautions, and after the pressure is released. Slug-
follow the general guidelines in gish response may indicate CSF
Appendix A. Positively identify the obstruction.
patient, and label the appropriate ➤ Obtain four vials of spinal fluid in
separate tubes (1 to 3 mL in each), Changing position is acceptable as

and label them numerically (1-4 or 5) long as the body remains horizontal.
in the order they were filled. ➤ A written report of the examination
➤ A final pressure reading is taken, and will be sent to the requesting health
the needle is removed. Clean the care practitioner, who will discuss
puncture site with an antiseptic solu- the results with the patient.
tion, and apply a small bandage. ➤ Recognize anxiety related to test
➤ Promptly transport the specimen to results. Discuss the implications
the laboratory for processing and of abnormal test results on the
analysis. patient’s lifestyle. Provide teaching
➤ The results are recorded manually or and information regarding the clinical
in a computerized system for recall implications of the test results, as
and postprocedure interpretation by appropriate.
the appropriate health care practi- ➤ Reinforce information given by
tioner. the patient’s health care provider
➤ Observe puncture site for bleeding, address any concerns voiced by the
CSF leakage, or hematoma forma- patient or family.
tion. Apply paper tape or other ➤ Instruct the patient in the use of any
adhesive to hold pressure bandage ordered medications. Explain the
in place, or replace with a plastic importance of adhering to the ther-
bandage. apy regimen. As appropriate, instruct
➤ Monitor vital signs and neurologic the patient in significant side effects
status and for headache every 15 and systemic reactions associated
minutes for 1 hour, then every 2 with the prescribed medication.
hours for 4 hours, and then as Encourage him or her to review cor-
ordered by the health care practi- responding literature provided by a
tioner. Monitor temperature every 4 pharmacist.
hours for 24 hours. Compare with ➤ Depending on the results of this pro-
baseline values. Notify the health cedure, additional testing may be
care practitioner if temperature is performed to evaluate or monitor
elevated. Protocols may vary from progression of the disease process
facility to facility. and determine the need for a change
➤ If permitted, administer fluids to in therapy. Evaluate test results in
replace lost CSF and help prevent or relation to the patient’s symptoms
relieve headache—a side effect of and other tests performed.
lumbar puncture.
➤ Position the patient flat in the supine
position with head of bed at not ➤ Related laboratory tests include
more than a 30 elevation, following complete blood count, culture for
the health care provider’s instruc- appropriate organisms, Gram stain,
tions. Maintain position for 8 hours. and syphilis serology.
CERULOPLASMIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Copper oxidase, Cp.

REFERENCE VALUE: (Method: Nephelometry)
SI Units
Age Conventional Units (Conventional Units 10)
Newborn–3 mo 5–18 mg/dL 50–180 mg/L
6–12 mo 33–43 mg/dL 330–430 mg/L
1–3 y 26–55 mg/dL 260–550 mg/L
4–5 y 27–56 mg/dL 270–560 mg/L
6–7 y 24–48 mg/dL 240–480 mg/L
Greater than 7 y 20–54 mg/dL 200–540 mg/L
Increased in:
DESCRIPTION & RATIONALE: Cerulo- • Acute infections
plasmin is an 2-globulin produced
• Biliary cirrhosis
by the liver that binds copper for
transport in the blood after it is • Cancer of the bone, lung, stomach
absorbed from the gastrointestinal sys-
• Copper intoxication
tem. Decreased production of this
globulin causes copper to be deposited • Hodgkin’s disease
in body tissues such as the brain, liver, • Leukemia
corneas, and kidneys. ■
• Pregnancy (last trimester)
INDICATIONS:
• Assist in the diagnosis of Menkes • Rheumatoid arthritis
(kinky hair) disease • Tissue necrosis
• Assist in the diagnosis of Wilson’s dis-
ease Decreased in:
• Determine genetic predisposition to • Menkes disease
Wilson’s disease • Nutritional deficiency of copper
• Monitor patient response to total par-
• Wilson’s disease
enteral nutrition (hyperalimentation)
RESULT CRITICAL VALUES: N/A
Ceruloplasmin 347
INTERFERING FACTORS: be taken to avoid the use of equip-

• Drugs that may increase ceruloplasmin ment containing latex.
levels include anticonvulsants, nore- ➤ Instruct the patient to cooperate fully
thindrone, oral contraceptives, and and to follow directions. Direct the
tamoxifen. patient to breathe normally and to
• Drugs that may decrease ceruloplasmin ➤ Observe standard precautions, and
levels include asparaginase and lev- follow the general guidelines in
onorgestrel (Norplant). Appendix A. Positively identify the
• Excessive therapeutic intake of zinc patient, and label the appropriate
may interfere with intestinal absorption demographics, date, and time of col-
of copper. lection. Perform a venipuncture; col-
tiger-top tube.
Nursing Implications and ➤ Remove the needle, and apply a
Procedure ● ● ● ● ● ● ● ● ● ● ● pressure dressing over the puncture
site.
Pretest: ➤ Promptly transport the specimen to
analysis.
used in the evaluation of copper
intoxication and liver disease, espe- ➤ The results are recorded manually or
cially Wilson’s disease. in a computerized system for recall
➤ Obtain a history of the patient’s com- the appropriate health care practi-
plaints, including a list of known tioner.
sitivities to latex), and inform the Post-test:
accordingly. ➤ Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s paper tape or other adhesive to
hepatobiliary system and results of hold pressure bandage in place, or
previously performed laboratory replace with a plastic bandage.
diagnostic procedures. For related ➤ Nutritional considerations: Instruct
laboratory tests, refer to the Hepa- the patient with copper deficiency to
tobiliary System table. increase intake of foods rich in cop-
per, as appropriate. Organ meats,
➤ Obtain a list of medications the shellfish, nuts, and legumes are
patient is taking, including herbs, good sources of dietary copper. High
nutritional supplements, and nutra- intake of zinc, iron, calcium, and
ceuticals. The requesting health care manganese interferes with copper
practitioner and laboratory should be absorption. Copper deficiency does
advised if the patient regularly uses not normally occur in adults; how-
these products so that their effects ever, patients receiving long-term
can be taken into consideration total parenteral nutrition should be
when reviewing results. evaluated if signs and symptoms
➤ There are no food, fluid, or medica- of copper deficiency appear, such
tion restrictions unless by medical as jaundice or eye color changes.
direction. Kayser-Fleischer rings (green-gold
rings) in the cornea and a liver biopsy
specimen showing more than 250
Intratest: g of copper per gram confirms
➤ If the patient has a history of severe Wilson’s disease.
allergic reaction to latex, care should ➤ A written report of the examination
will be sent to the requesting health cedure, additional testing may be

care practitioner, who will discuss performed to evaluate or monitor
the results with the patient. progression of the disease process
➤ Reinforce information given by and determine the need for a change
the patient’s health care provider in therapy. Evaluate test results in
regarding further testing, treatment, relation to the patient’s symptoms
or referral to another health care and other tests performed.
patient or family. ➤ Related laboratory tests include cop-
➤ Depending on the results of this proper, liver biopsy, and zinc.
CHEST X-RAY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Chest radiography, CXR.

AREA OF APPLICATION: Lungs.
CONTRAST: None.
DESCRIPTION & RATIONALE: Chest tions, can be done at the bedside and
radiography, commonly called chest include only the anteroposterior pro-
x-ray, is one of the most frequently jection. Films may be taken with the
performed radiologic diagnostic stud- patient supine or in a lateral decubitus
ies. This study yields information position, if the presence of free pleural
about the pulmonary, cardiac, and fluid is in question. Other projections
skeletal systems. X-rays penetrate air that can be obtained are the obliques,
easily; areas filled with air appear dark lateral decubitus, and lordotic; in gen-
or black on x-ray film. Bones appear eral, the part being studied is placed
near-white on the film because x-rays next to the film. Films may be taken
cannot penetrate them to reach the on full inspiration and on full expira-
film. Organs and tissues appear as tion to detect a pneumothorax. Rib
shades of gray because they absorb detail films may be taken to delineate
more x-ray than air but less than bone. rib pathology, useful when chest
A routine chest x-ray includes a pos- radiographs suggest fractures or
teroanterior view, in which x-rays are metastatic lesions. Fluoroscopic stud-
passing from the posterior to the ante- ies of the chest can also be done to
rior, and a lateral view. Portable x-rays, evaluate movement of the chest and
done in more acute or critical situa- diaphragm during breathing and
Chest X-Ray 349
coughing. In the beginning of the dis- • Foreign bodies lodged in the pul-
ease process of tuberculosis, asthma, monary system
and chronic obstructive pulmonary • Fractures of the sternum, ribs, and
disease, the results of the chest x-ray spine
may not correlate with the clinical sta-
• Lung pathology, including tumors
tus of the patient and may even be
normal. ■ • Malposition of tubes or wires
• Mediastinal tumor and pathology
INDICATIONS:
• Aid in the diagnosis of diaphrag- • Pericardial effusion
matic hernia, lung tumors, intravenous
devices, and metastasis. • Pericarditis
• Evaluate known or suspected pul- • Pleural effusion

monary disorders, chest trauma, car- • Pneumonia
diovascular disorders, and skeletal
disorders • Pneumothorax
• Evaluate placement and position of an • Pulmonary bases, fibrosis, infiltrates

endotracheal tube, tracheostomy tube, • Tuberculosis
nasogastric feeding tube, pacemaker
wires, central venous catheters, Swan- • Vascular abnormalities
Ganz catheters, chest tubes, and intra-
aortic balloon pump CRITICAL VALUES: N/A
• Evaluate positive PPD or Mantoux INTERFERING FACTORS:
tests.
• Monitor resolution, progression, or This procedure is
maintenance of disease
• Monitor effectiveness of the treatment of being pregnant, unless the potential
regimen benefits of the procedure far outweigh
RESULT
Factors that may impair the
Normal Findings: results of the examination:
• Normal lung fields, cardiac size, medi-
astinal structures, thoracic spine, ribs,
and diaphragm
Abnormal Findings:
• Atelectasis • Improper adjustment of the radi-
• Bronchitis obese or thin patients, which can cause
• Curvature of the spinal column (scolio- overexposure or underexposure and a
sis) poor-quality study
• Enlarged heart • Patients who are very obese, who may

• Enlarged lymph nodes ment
• Flattened diaphragm • Incorrect positioning of the patient,
which may produce poor visualization ➤ Obtain a list of the medications the
of the area to be examined patient is taking.
• Inability of the patient to cooperate or patient. Explain to the patient that no
remain still during the procedure pain will be experienced during the
because of age, significant pain, or test, but there may be moments
mental status of discomfort. Inform the patient
that the procedure is performed in
Other considerations: the radiology department or at the
• The procedure may be terminated if bedside, by a registered radiologic
techologist, and takes approximately
chest pain or severe cardiac arrhythmias
5 to 15 minutes to complete.
occur.
• Consultation with a physician should issues, as well as concern for mod-
occur before the procedure for radia- esty, is important in providing psy-
tion safety concerns regarding younger chological support before, during,
patients or patients who are lactating. and after the procedure.
• Risks associated with radiographic tion restrictions unless by medical
overexposure can result from frequent direction.
x-ray procedures. Personnel in the ➤ Instruct the patient to remove den-
room with the patient should wear a tures, jewelry (including watches),
protective lead apron, stand behind a hairpins, credit cards, and other
shield, or leave the area while the exam- metallic objects.
ination is being done. Personnel work-
ing in the area where the examination Intratest:
that reveal their level of exposure to ➤ Ensure that the patient has removed
jewelry, dentures, all external metal-
radiation.
lic objects, wires, and the like prior to
the procedure.
Nursing Implications and and foot coverings to wear and
Procedure ● ● ● ● ● ● ● ● ● ● ● instructed to void prior to the
procedure.
➤ Inform the patient that the procedure follow the general guidelines in
assesses cardiopulmonary status. Appendix A.
➤ Obtain a history of the patient’s ➤ Instruct the patient to cooperate fully
symptoms and complaints, including and to follow directions. Instruct the
a list of known allergens. patient to remain still throughout the
➤ Obtain a history of results of duces unreliable results.
tests, surgical procedures, and ➤ Place the patient in the standing
other diagnostic procedures. For position in front of the x-ray film or
related diagnostic tests, refer to the detector.
Cardiovascular and Respiratory Sys- ➤ Have the patient place hands on
tem table. hips, extend neck, and position
➤ Record the date of the last menstrual shoulders forward.
period and determine the possibility ➤ Position the chest with the left side
of pregnancy in perimenopausal against the film holder for a lateral
women. view.
Chlamydia Group Antibody 351
➤ For portable examinations, elevate of abnormal test results on the

the head of the bed to the high patient’s lifestyle. Provide teaching
Fowler’s position. and information regarding the clinical
➤ Ask the patient to inhale deeply and implications of the test results, as
hold his or her breath while the x-ray appropriate.
images are taken, and then to exhale ➤ Reinforce information given by
after the images are taken. the patient’s health care provider
➤ The results are recorded on a sheet regarding further testing, treatment,
of x-ray film or electronically, in a or referral to another health care
computerized system, for recall and provider. Answer any questions or
postprocedure interpretation by the address any concerns voiced by the
appropriate health care practitioner. patient or family.
performed to evaluate and deter-
➤ A written report of the examina- mine the need for a change in ther-
tion will be completed by a health apy or progression of the disease
care practitioner specializing in this process. Evaluate test results in rela-
branch of medicine. The report will tion to the patient’s symptoms and
be sent to the requesting health care other tests performed.
results with the patient. Related diagnostic tests:
➤ Recognize anxiety related to test ➤ Related diagnostic tests include com-
results and be supportive of impaired puted tomography of the thorax, elec-
activity related to respiratory capac- trocardiogram, lung perfusion scan,
ity and perceived loss of physical magnetic resonance imaging of the
activity. Discuss the implications chest, and pulmonary function.
CHLAMYDIA GROUP ANTIBODY

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
REFERENCE VALUE: (Method: Indirect fluorescent antibody, polymerase
chain reaction) Negative or less than fourfold increase in titer.
DESCRIPTION & RATIONALE: Chla- by Chlamydia trachomatis. These

mydia, one of the most common sex- gram-negative bacteria are called obli-
ually transmitted infections, is caused gate cell parasites because they require

living cells for growth. There are
three serotypes of C. trachomatis: One • Chlamydial infection
group causes lymphogranuloma • Infantile pneumonia
venereum, with symptoms of the first • Infertility
phase of the disease appearing 2 to 6
• Lymphogranuloma venereum
weeks after infection; another causes a
genital tract infection different from • Ophthalmia neonatorum
lymphogranuloma venereum, in • Pelvic inflammatory disease
which symptoms in men appear 7 to
28 days after intercourse (women are • Urethritis
generally asymptomatic); and the
third causes the ocular disease tra-
choma (incubation period, 7 to 10 INTERFERING FACTORS: N/A
days). Chlamydia psittaci is the cause
of psittacosis in birds and humans. It
is increasing in prevalence as a Nursing Implications and
pathogen responsible for other signifi- Procedure ● ● ● ● ● ● ● ● ● ● ●
cant diseases of the respiratory system.

The incubation period for C. psittaci Pretest:
infections in humans is 7 to 15 days, ➤ Inform the patient that the test is
which is followed by chills, fever, and used to assist in the diagnosis of
a persistent nonproductive cough. chlamydia infection.
Chlamydia is difficult to culture ➤ Obtain a history of the patient’s com-
and grow, so antibody testing has plaints, including a list of known
become the technology of choice. The allergens (especially allergies or sen-
antigen used in many screening kits is appropriate health care practitioner
not species specific and can confirm accordingly.
only the presence of Chlamydia ➤ Obtain a history of the patient’s
spp. Newer technology using DNA immune and reproductive systems,
probes can identify the species. Assays as well as results of previously per-
that can specifically identify C. tra- formed laboratory tests, surgical
procedures, and other diagnostic
chomatis require special collection and procedures. For related laboratory
transport kits. They also have specific tests, refer to the Immune and
collection instructions, and the speci- Reproductive System tables.
mens are collected on swabs. The ➤ Obtain a list of medications the
laboratory performing this testing patient is taking, including herbs,
should be consulted before specimen nutritional supplements, and nutra-
collection. ■ practitioner and laboratory should be
INDICATIONS: these products so that their effects
• Establish Chlamydia as the cause of can be taken into consideration
atypical pneumonia
• Establish the presence of chlamydial patient. Inform the patient that spec-
infection imen collection takes approximately
RESULT about pain related to the procedure.
Chlamydia Group Antibody 353
Explain to the patient that there may ➤ Recognize anxiety related to test
be some discomfort during the results, and be supportive. Discuss
venipuncture. the implications of abnormal test
➤ Inform the patient that several tests results on the patient’s lifestyle.
may be necessary to confirm diagno- Provide teaching and information
sis. Any individual positive result regarding the clinical implications of
should be repeated in 7 to 10 days to the test results, as appropriate.
monitor a change in titer. Emphasize the need to return to
have a convalescent blood sample
➤ There are no food, fluid, or medica- taken in 7 to 14 days. Educate the
tion restrictions unless by medical patient regarding access to counsel-
direction. ing services.
➤ Social and cultural considerations:
Intratest: Counsel the patient, as appropriate,
➤ If the patient has a history of severe as to the risk of sexual transmission
allergic reaction to latex, care should and educate the patient regarding
be taken to avoid the use of equip- proper prophylaxis. Reinforce the
ment containing latex. importance of strict adherence to
the treatment regimen.
and to follow directions. Direct the ➤ Social and cultural considerations:
patient to breathe normally and to Inform the patient with positive C.
avoid unnecessary movement. trachomatis that findings must be
reported to a local health depart-
➤ Observe standard precautions, and ment official, who will question the
follow the general guidelines in patient regarding his or her sexual
Appendix A. Positively identify the partners.
Offer support, as appropriate, to
patients who may be the victim of
rape or sexual assault. Educate the
top tube.
ing services. Provide a nonjudgmen-
➤ Remove the needle, and apply a tal, nonthreatening atmosphere for a
pressure dressing over the puncture discussion during which you explain
site. the risks of sexually transmitted dis-
➤ Promptly transport the specimen to eases. It is also important to discuss
the laboratory for processing and emotions the patient may experi-
analysis. ence (guilt, depression, anger) as a
victim of rape or sexual assault.
or in a computerized system for ➤ Provide emotional support if the
recall and postprocedure interpreta- patient is pregnant and if results are
tion by the appropriate health care positive. Inform the patient that
practitioner. Chlamydia infection during preg-
nancy places the newborn at risk for
Post-test: pneumonia and conjunctivitis.
paper tape or other adhesive to hold referral to another health care
pressure bandage in place, or provider. Answer any questions or
➤ A written report of the examination patient or family.
will be sent to the requesting health ➤ Depending on the results of this pro-
care practitioner, who will discuss cedure, additional testing may be
the results with the patient. performed to evaluate or monitor
progression of the disease process Related laboratory tests:

in therapy. Evaluate test results in ➤ Related laboratory tests include
relation to the patient’s symptoms cultures bacterial (and genital), and
and other tests performed. syphilis serology.
CHLORIDE, BLOOD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cl–.
SI Units
Premature 95–110 mEq/L 95–110 mmol/L
0–1 mo 98–113 mEq/L 98–113 mmol/L
2 mo–adult 97–107 mEq/L 97–107mmol/L
DESCRIPTION & RATIONALE: Chlo- of enzymes. The chloride content of

ride is the most abundant anion in the venous blood is slightly higher than
extracellular fluid. Its most important that of arterial blood because chloride
function is in the maintenance of ions enter red blood cells in response
acid-base balance, in which it com- to absorption of carbon dioxide into
petes with bicarbonate for sodium. the cell. As carbon dioxide enters the
Chloride levels generally increase and blood cell, bicarbonate leaves and
decrease proportional to sodium levels chloride is absorbed in exchange to
and inversely proportional to bicar- maintain electrical neutrality within
bonate levels. Chloride also partici- the cell.
pates with sodium in the maintenance Chloride is provided by dietary
of water balance and aids in the regu- intake, mostly in the form of sodium
lation of osmotic pressure. Chloride chloride. It is absorbed by the gas-
contributes to gastric acid (hydrochlo- trointestinal system, filtered out by
ric acid) for digestion and activation the glomeruli, and reabsorbed by the
Chloride Blood 355
renal tubules. Excess chloride is high risk because their renal response
excreted in the urine. Serum values to change in pH is slower, resulting in
normally remain fairly stable. A slight a more rapid development of elec-
decrease may be detectable after meals trolyte imbalance. ■
because chloride is used to produce
hydrochloric acid as part of the diges- INDICATIONS:
tive process. Measurement of chloride • Assist in confirming a diagnosis of dis-
levels is not as essential as measure- orders associated with abnormal chlo-
ride values, as seen in acid-base and
ment of other electrolytes such as
fluid imbalances
sodium or potassium. Chloride is usu-
ally included in standard electrolyte • Differentiate between types of acidosis
panels to detect the presence of (hyperchloremic versus anion gap)
unmeasured anions via calculation of • Monitor effectiveness of drug therapy
the anion gap. Chloride levels are usu- to increase or decrease serum chloride
ally not interpreted apart from levels
sodium, potassium, carbon dioxide,
and anion gap. RESULT
The patient’s clinical picture needs
Increased in:
to be considered in the evaluation of
electrolytes. Fluid and electrolyte • Acute renal failure
imbalances are often seen in patients • Cushing’s disease
with serious illness or injury because • Dehydration
in these cases the clinical situation has
affected the normal homeostatic bal- • Diabetes insipidus
ance of the body. It is also possible • Excessive infusion of normal saline
that therapeutic treatments being • Head trauma with hypothalamic stim-
administered are causing or contribut- ulation or damage
ing to the electrolyte imbalance.
• Hyperparathyroidism (primary)
Children and adults are at high risk
for fluid and electrolyte imbalances • Metabolic acidosis (associated with
when chloride levels are depleted. prolonged diarrhea)
Children are considered to be at high • Renal tubular acidosis
risk during chloride imbalance
• Respiratory alkalosis (e.g., hyperventi-
because a positive serum chloride bal- lation)
ance is important for expansion of the
extracellular fluid compartment. • Salicylate intoxication
Anemia, the result of decreased hemo- Decreased in:
globin levels, is a frequent issue for
• Addison’s disease
elderly patients. Because hemoglobin
participates in a major buffer system • Burns
in the body, depleted hemoglobin lev- • Congestive heart failure
els affect the efficiency of chloride ion • Cushing’s syndrome
exchange for bicarbonate in red blood
cells, which in turn affects acid-base • Diabetic ketoacidosis
balance. Elderly patients are also at • Excessive sweating
• Gastrointestinal loss from vomiting • Drugs that may cause a decrease

(severe), diarrhea, nasogastric suction, in chloride levels include aldos-
or fistula terone, bicarbonate, corticosteroids,
corticotropin, cortisone, diuretics,
• Metabolic alkalosis
ethacrynic acid, furosemide, hydro-
• Overhydration flumethiazide, laxatives (if chronic
• Respiratory acidosis (chronic) abuse occurs), mannitol, meralluride,
mersalyl, methyclothiazide, metola-
• Salt-losing nephritis zone, and triamterene. Many of these
• Syndrome of inappropriate antidiuretic drugs can cause a diuretic action
hormone secretion that inhibits the tubular reabsorption
of chloride. Note: Triamterene has
• Water intoxication nephrotoxic and azotemic effects, and
when organ damage has occurred,
CRITICAL VALUES: increased serum chloride levels result.
Less than 80 mEq/L Potassium chloride (found in salt sub-
Greater than 115 mEq/L stitutes) can lower blood chloride levels
Note and immediately report to the and raise urine chloride levels.
health care practitioner any critically • Elevated triglyceride or protein levels
increased or decreased values and related may cause a volume-displacement error
symptoms. Observe the patient for symp- in the specimen, reflecting falsely
toms of critically decreased or elevated decreased chloride values when chlo-
chloride levels. Proper interpretation of ride measurement methods employing
chloride values must be made within the predilution specimens are used (e.g.,
context of other electrolyte values and indirect ion-selective electrode, flame
requires clinical knowledge of the patient. photometry).
The following may be seen in
hypochloremia: twitching or tremors, • Specimens should never be collected
which may indicate excitability of the above an intravenous (IV) line because
nervous system; slow and shallow breath- of the potential for dilution when the
ing; and decreased blood pressure as a specimen and the IV solution combine
result of fluid loss. Possible interventions in the collection container, falsely
relate to treatment of the underlying decreasing the result. There is also the
cause. potential of contaminating the sample
Signs and symptoms associated with with the normal saline, contained in the
hyperchloremia are weakness, lethargy, IV solution, falsely increasing the result.
and deep, rapid breathing. Proper inter-
ventions include treatments that correct
the underlying cause. Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Drugs that may cause an increase in Pretest:
chloride levels include acetazolamide,
acetylsalicylic acid, ammonium chlo- used to evaluate electrolytes, acid-
ride, androgens, bromide, chloroth- base balance, and hydration level.
iazide, cholestyramine, cyclosporine,
estrogens, guanethidine, hydrochloro- complaints, including a list of known
thiazide, lithium, methyldopa, nons- allergens (especially allergies or sen-
teroidal anti-inflammatory drugs, sitivities to latex), and inform the
oxyphenbutazone, phenylbutazone, appropriate health care practitioner
and triamterene. accordingly.
Chloride Blood 357
➤ Obtain a history of the patient’s patient, and label the appropriate

cardiovascular, endocrine, gastroin- tubes with the corresponding patient
testinal, genitourinary, and respira- demographics, date, and time of col-
tory systems, as well as results of lection. Perform a venipuncture; col-
previously performed laboratory lect the specimen in a 5-mL red- or
tests, surgical procedures, and tiger-top tube.
other diagnostic procedures. For ➤ Remove the needle, and apply a
related laboratory tests, refer to the pressure dressing over the puncture
Cardiovascular, Endocrine, Gas- site.
trointestinal, Genitourinary, and Res-
piratory System tables.
➤ Specimens should not be collected analysis.
during hemodialysis.
➤ Obtain a list of medications the in a computerized system for recall
patient is taking, including herbs, and postprocedure interpretation by
nutritional supplements, and nutra- the appropriate health care practi-
ceuticals. The requesting health care tioner.
advised if the patient regularly uses Post-test:
can be taken into consideration ➤ Observe venipuncture site for bleed-
when reviewing results. ing or hematoma formation. Apply
➤ Review the procedure with the paper tape or other adhesive to hold
patient. Inform the patient that spec- pressure bandage in place, or
imen collection takes approximately replace with a plastic bandage.
5 to 10 minutes. Address concerns ➤ Observe the patient on saline IV fluid
about pain related to the procedure. replacement therapy for signs of
Explain to the patient that there may overhydration, especially in cases in
be some discomfort during the which there is a history of cardiac or
venipuncture. renal disease. Signs of overhydration
➤ Sensitivity to social and cultural include constant, irritable cough;
issues, as well as concern for mod- chest rales; dyspnea; or engorge-
esty, is important in providing psy- ment of neck and hand veins.
chological support before, during, ➤ Evaluate the patient for signs and
and after the procedure. symptoms of dehydration. Check
➤ There are no food, fluid, or medica- the patient’s skin turgor, mucous
tion restrictions unless by medical membrane moisture, and ability to
direction. produce tears. Dehydration is a sig-
nificant and common finding in geri-
Intratest: atric and other patients in whom
renal function has deteriorated.
➤ If the patient has a history of severe ➤ Monitor daily weights as well as
allergic reaction to latex, care should intake and output to determine
be taken to avoid the use of equip- whether fluid retention is occurring
ment containing latex. because of sodium and chloride
➤ Instruct the patient to cooperate excess. Patients at risk for or with a
fully and to follow directions. Direct history of fluid imbalance are also at
the patient to breathe normally and risk for electrolyte imbalance.
to avoid unnecessary movement. ➤ Nutritional considerations: Careful
Instruct the patient not to clench and observation of the patient on IV fluid
unclench fist immediately before or replacement therapy is important. A
during specimen collection. patient receiving a continuous 5%
➤ Observe standard precautions, and dextrose solution (D5W) may not be
follow the general guidelines in taking in an adequate amount of
Appendix A. Positively identify the chloride to meet the body’s needs.
The patient, if allowed, should be ➤ A written report of the examination

encouraged to drink fluids such as will be sent to the requesting health
broths, tomato juice, or colas and to care practitioner, who will discuss
eat foods such as meats, seafood, or the results with the patient.
eggs, which contain sodium and ➤ Reinforce information given by the
chloride. The use of table salt may patient’s health care provider regard-
also be appropriate. ing further testing, treatment, or
➤ Nutritional considerations: Instruct referral to another health care
patients with elevated chloride levels provider. Answer any questions or
to avoid eating or drinking anything address any concerns voiced by the
containing sodium chloride salt. The patient or family.
patient or caregiver should also be ➤ Depending on the results of this pro-
encouraged to read food labels to cedure, additional testing may be
determine which products are suit- performed to evaluate or monitor
able for a low-sodium diet. progression of the disease process
➤ Nutritional considerations: Instruct in therapy. Evaluate test results in
patients with low chloride levels that relation to the patient’s symptoms
a decrease in iron absorption may and other tests performed.
occur as a result of less chloride
available to form gastric acid, which Related laboratory tests:
is essential for iron absorption.
In prolonged periods of chloride ➤ Related laboratory tests include
deficit, iron-deficiency anemia could anion gap, carbon dioxide, osmolal-
develop. ity, potassium, and sodium.
CHLORIDE, SWEAT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Sweat test, pilocarpine iontophoresis sweat

test, sweat chloride.
SPECIMEN: Sweat (0.1 mL minimum) collected by pilocarpine

iontophoresis.
REFERENCE VALUE: (Method: Ion-specific electrode or titration)
SI Units
Normal 5–40 mEq/L 5–40 mmol/L
Intermediate 40–60 mEq/L 40–60 mmol/L
Chloride, Sweat 359
• Screen for suspected CF in children

DESCRIPTION & RATIONALE: Cystic with recurring respiratory infections
fibrosis (CF) is a genetic disease that
• Screen for suspected CF in infants with
affects normal functioning of the
failure to thrive and infants who pass
exocrine glands, causing them to meconium late
excrete large amounts of electrolytes.
Patients with CF have sweat elec- • Screen for suspected CF in individuals
trolyte levels two to five times normal. with malabsorption syndrome
Sweat test values, with family history
and signs and symptoms, are required RESULT
to establish a diagnosis of CF. CF is
Increased in:
transmitted as an autosomal recessive
trait and is characterized by abnormal
exocrine secretions within the lungs, • Alcoholic pancreatitis
pancreas, small intestine, bile ducts,
• CF
and skin. Clinical presentation may
include chronic problems of the gas- • Chronic pulmonary infections
trointestinal and/or respiratory sys- • Congenital adrenal hyperplasia
tem. Testing of stool samples for
decreased trypsin activity has been • Diabetes insipidus
used as a screen for CF in infants and • Familial cholestasis
children, but this is a much less reli-
able method than the sweat test. • Familial hypoparathyroidism
The sweat test is a noninvasive • Fucosidosis
study done to assist in the diagnosis of
CF when considered with other test • Glucose-6-phosphate dehydrogenase
deficiency
results and physical assessments. This
test is usually performed on children, • Hypothyroidism
although adults may also be tested; it
• Mucopolysaccharidosis
is not usually ordered on adults
because results can be highly variable • Nephrogenic diabetes insipidus
and should be interpreted with cau- • Renal failure
tion. Sweat for specimen collection is
induced by a small electrical current Decreased in:
carrying the drug pilocarpine. The test
• Edema
measures the concentration of chlo-
ride produced by the sweat glands of • Hypoaldosteronism
the skin. A high concentration of • Hypoproteinemia
chloride in the specimen indicates the
presence of CF. The sweat test is used • Sodium depletion
less commonly to measure the con-
centration of sodium ions for the CRITICAL VALUES:
same purpose. ■ 20 years or younger: Greater than
60 mmol/L considered diagnostic
INDICATIONS: of CF
• Assist in the diagnosis of CF Older than 20 years: Greater than
• Screen for CF in individuals with a 70 mmol/L considered diagnostic
family history of the disease of CF

health care practitioner any critically Nursing Implications and
increased values and related symptoms. Procedure ● ● ● ● ● ● ● ● ● ● ●
Values should be interpreted with consid-

eration of family history and clinical signs Pretest:
and symptoms. ➤ Inform the patient that the test is
The validity of the test result is affected used to assist in the diagnosis of
tremendously by proper specimen collec- cystic fibrosis.
tion and handling. Before proceeding ➤ Obtain a history of the patient’s com-
with appropriate patient education and plaints, including a list of known
counseling, it is important to perform allergens (especially allergies or sen-
duplicate testing on patients whose sitivities to latex), and inform the
results are in the diagnostic or intermedi- appropriate health care practitioner
accordingly.
ate ranges. A negative test should be
repeated if test results do not support the ➤ Obtain a history of the patient’s
endocrine and respiratory systems,
clinical picture. especially failure to thrive or CF in
other family members, as well as
INTERFERING FACTORS: ratory tests, surgical procedures,
• An inadequate amount of sweat may and other diagnostic procedures. For
produce inaccurate results. Sweat Endocrine and Respiratory System
testing in infants less than 1 month tables.
old is not recommended because ➤ Obtain a list of medications the
they are often incapable of produc- patient is taking, including herbs,
ing an adequate amount of sweat nutritional supplements, and nutra-
sample. ceuticals. The requesting health care
• This test should not be performed advised if the patient regularly uses
on patients with skin disorders these products so that their effects
(e.g., rash, erythema, eczema). can be taken into consideration
• Improper cleaning of the skin or
improper application of gauze pad or patient and caregiver. Encourage the
filter paper for collection affects test caregiver to stay with and support
results. the child during the test. The ion-
tophoresis and specimen collection
• Hot environmental temperatures may usually takes approximately 75 to 90
reduce the sodium chloride concentra- minutes. Address concerns about
tion in sweat; cool environmental tem- pain related to the procedure. Inform
peratures may reduce the amount of the patient and caregiver there is no
sweat collected. pain associated with the test, but a
stinging sensation may be experi-
• If the specimen container that stores enced when the low electrical cur-
the gauze or filter paper is handled rent is applied at the site.
without gloves, the test results may ➤ Sensitivity to social and cultural
show a false increase in the final weight issues, as well as concern for mod-
of the collection container. esty, is important in providing psy-
• Screening for CF can be performed and after the procedure.
using a silver nitrate test paper, and a ➤ There are no food, fluid, or medica-
positive test can be validated by pilo- tion restrictions unless by medical
carpine iontophoresis. direction.
Chloride, Sweat 361
➤ After 1 hour, the paraffin covering is

Intratest:
removed, and disks are placed in a
➤ Instruct the patient to cooperate fully preweighed container with a for-
and to follow directions. ceps. The container is sealed and
sent immediately to the laboratory
for weighing and analysis of chloride
content. At least 100 mg of sweat is
required for accurate results.
lection container with the correspon- ➤ Terminate the test if the patient com-
ding patient demographics, date, and plains of burning at the electrode
time of collection. site. Reposition the electrode before
the test is resumed.
➤ The patient is placed in a
position that will allow expo- ➤ Promptly transport the specimen to
sure of the site on the forearm or the laboratory for processing and
thigh. To ensure collection of an ade- analysis. Do not directly handle the
quate amount of sweat in a small preweighed specimen container or
infant, two sites (right forearm and filter paper.
right thigh) can be used. The patient ➤ The results are recorded manually or
should be covered to prevent cool in a computerized system for recall
environmental temperatures from and postprocedure interpretation by
affecting sweat production. The site the appropriate health care practi-
selected for iontophoresis should tioner.
never be the chest or left side
because of the risk of cardiac arrest
from the electrical current.
Post-test:
➤ The site is washed with distilled ➤ Observe the site for unusual color,
water and dried. A positive electrode sensation, or discomfort.
is attached to the site on the right ➤ Inform the patient and caregiver that
forearm or right thigh and covered redness at the site fades in 2 to 3
with a pad that is saturated with pilo- hours.
carpine, a drug that stimulates
sweating. A negative electrode is
covered with a pad that is saturated
as directed by the health care practi-
with bicarbonate solution. Ionto-
tioner.
phoresis is achieved by supplying a
low (4 to 5 mA) electrical current via ➤ Nutritional considerations: If appro-
the electrode for 12 to 15 minutes. priate, instruct the patient and
Battery-powered equipment is pre- caregiver that nutrition may be
ferred over an electrical outlet to sup- altered because of impaired diges-
ply the current. tive processes associated with CF.
Increased viscosity of exocrine
➤ The electrodes are removed, reveal-
gland secretion may lead to poor
ing a red area at the site, and the site
absorption of digestive enzymes and
is washed with distilled water and
fat-soluble vitamins, necessitating
dried to remove any possible con-
supplementary oral intake of diges-
taminants on the skin.
tive enzymes with each meal and
➤ Preweighed disks made of filter vitamin (A, D, E, and K) supplemen-
paper are placed on the site with a tation. Malnutrition also is seen com-
forceps; to prevent evaporation of monly in patients with chronic,
sweat collected at the site, the disks severe respiratory disease for many
are covered with paraffin or plastic reasons, including fatigue, lack of
and sealed at the edges. The disks appetite, and gastrointestinal dis-
are left in place for about 1 hour. tress. Research has estimated that
Distract the child with books or the daily caloric intake for respiration
games to allay fears. in patients with chronic obstructive
pulmonary disease is 10 times Educate the patient regarding access

higher than normal individuals. to counseling services. Help the
Inadequate nutrition can result in patient and caregiver to cope with
hypophosphatemia, especially in a long-term implications. Recognize
respirator-dependent patient. During that anticipatory anxiety and grief
periods of starvation, phosphorus related to potential lifestyle changes
leaves the intracellular space and may be expressed when someone is
moves outside the tissue, resulting faced with a chronic disorder. Provide
in dangerously decreased phospho- information regarding genetic coun-
rus levels. To prevent pulmonary seling and possible screening of
infection and decrease the extent of other family members if appropri-
lung tissue damage, adequate intake ate. Provide contact information,
of vitamins A and C is also important. if desired, for the Cystic Fibrosis
Excessive loss of sodium chloride Foundation (http://www.cff.org).
through the sweat glands of a ➤ Reinforce information given by the
patient with CF may necessitate patient’s health care provider regard-
increased salt intake, especially in ing further testing, treatment, or
environments where increased referral to another health care
sweating is induced. The importance provider. Explain that a positive
of following the prescribed diet sweat test alone is not diagnostic of
should be stressed to the patient CF; repetition of borderline and posi-
and caregiver. tive tests is generally recommended.
➤ If appropriate, instruct the patient Answer any questions or address
and caregiver that ineffective airway any concerns voiced by the patient
clearance related to excessive pro- or family.
duction of mucus and decreased cil-
iary action may result.
results, and be supportive of im- and other tests performed.
paired activity related to perceived
loss of independence and fear of Related laboratory tests:
the implications of abnormal test ➤ Related laboratory tests include
results on the patient’s lifestyle. 1-antitrypsin/phenotype, amylase,
Provide teaching and information anion gap, electrolytes, fecal analy-
regarding the clinical implications of sis, fecal fat, osmolality, and phos-
the test results, as appropriate. phorus.
Cholangiography, Percutaneous Transhepatic 363
CHOLANGIOGRAPHY, PERCUTANEOUS
TRANSHEPATIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Percutaneous cholecystogram, PTC, PTHC.

AREA OF APPLICATION: Biliary system.
CONTRAST: Radiopaque iodine-based contrast medium.
INDICATIONS:
DESCRIPTION & RATIONALE: Percu- • Aid in the diagnosis of obstruction
taneous transhepatic cholangiography caused by gallstones, benign strictures,
(PTC) is a test used to the visualize malignant tumors, congenital cysts,
the biliary system in order to evaluate and anatomic variations
persistent upper abdominal pain after • Determine the cause, extent, and loca-
cholecystectomy and to determine the tion of mechanical obstruction
presence and cause of obstructive
• Determine the cause of upper abdomi-
jaundice. The liver is punctured with
nal pain after cholecystectomy
a thin needle under fluoroscopic guid-
ance, and contrast medium is injected • Distinguish between obstructive and
as the needle is slowly withdrawn. nonobstructive jaundice
This test visualizes the biliary ducts
without depending on the gallblad- RESULT
der’s concentrating ability. The intra-
hepatic and extrahepatic biliary Normal Findings:
ducts, and occasionally the gallblad- • Biliary ducts are normal in diameter,
der, can be visualized to determine with no evidence of dilation, filling
defects, duct narrowing, or extravasa-
possible obstruction. In obstruction
tion.
of the extrahepatic ducts, a catheter
can be placed in the duct to allow • Contrast medium fills the ducts and
external drainage of bile. Endoscopic flows freely.
retrograde cholangiopancreatography • Gallbladder appears normal in size and
(ERCP) and PTC are the only meth- shape.
ods available to view the biliary tree in
the presence of jaundice. ERCP poses Abnormal Findings:
less risk and is probably done more • Anatomic biliary or pancreatic duct
often. PTC is an invasive procedure variations
and has potential risks, including • Biliary sclerosis
bleeding, septicemia, bile peritonitis,
and extravasation of the contrast • Cholangiocarcinoma
medium. ■ • Cirrhosis
• Common bile duct cysts failure to restrict food intake before the
study
• Gallbladder carcinoma
• Gallstones • Retained barium from a previous radi-
ologic procedure
• Hepatitis
• Nonobstructive jaundice tion field (e.g., jewelry, body rings),
• Pancreatitis which may inhibit organ visualization
• Sclerosing cholangitis
• Tumors, strictures, inflammation, or ographic equipment to accommodate
gallstones of the common bile duct obese or thin patients, which can cause
CRITICAL VALUES: N/A poor-quality study
INTERFERING FACTORS: exceed the weight limit for the equip-
ment
This procedure is
contraindicated for: • Incorrect positioning of the patient,
• Patients with allergies to shellfish of the area to be examined
medium used may cause a life- • Inability of the patient to cooperate or
threatening allergic reaction. Patients remain still during the procedure
with a known hypersensitivity to the because of age, significant pain, or
medium may benefit from premedica- mental status
nonionic contrast medium. Other considerations:
• Patients who are pregnant or suspected • The procedure may be terminated if
of being pregnant, unless the potential chest pain or severe cardiac arrhythmias
benefits of the procedure far outweigh occur.
the risks to the fetus and mother. • Failure to follow dietary restrictions
• Patients with cholangitis. The and other pretesting preparations may
injection of the contrast medium cause the procedure to be canceled or
can increase biliary pressure, leading to repeated.
bacteremia, septicemia, and shock. • Peritonitis may occur as a result of bile
extravasation.
• Patients with postoperative wound sep-
sis, hypersensitivity to iodine, or acute • Consultation with a physician should
renal failure. occur before the procedure for radia-
• Patients with bleeding disorders,
patients or patients who are lactating.
massive ascites, or acute renal
failure. • Risks associated with radiographic over-
Factors that may the patient should wear a protective
impair clear imaging: lead apron, stand behind a shield, or
• Gas or feces in the gastrointestinal tract leave the area while the examination is
resulting from inadequate cleansing or being done. Personnel working in the
Cholangiography, Percutaneous Transhepatic 365
area where the examination is being ➤ Type and screen the patient’s blood
done should wear badges that reveal for possible transfusion.
their level of exposure to radiation. ➤ Patients receiving metformin (Glu-
Procedure ● ● ● ● ● ● ● ● ● ● ● after the test. Failure to do so may
Pretest: ➤ Instruct the patient to fast and
restrict fluids for 8 hours prior to the
procedure.
assesses the biliary ducts.
➤ Inform the patient that a laxative and
cleansing enema may be needed the
day before the procedure, with
allergens, especially allergies or sen-
cleansing enemas on the morning of
the procedure depending on the
contrast medium, and dyes.
institution’s policy.
laboratory tests. For related diagnos-
any medications.
tic tests, refer to the Gastrointestinal
and Hepatobiliary System tables.
Intratest:
➤ Ensure that this procedure is per-
formed before an esophagogastro- ➤ Ensure that the patient has complied
duodenoscopy (upper gastrointestinal with dietary and medication restric-
study) or barium swallow. tions and pretesting preparations for
➤ Record the date of the last menstrual at least 6 hours prior to the proce-
period and determine the possibility dure. Ensure that the patient has
of pregnancy in perimenopausal removed all external metallic objects
women. prior to the procedure.
➤ Obtain a list of the medications the ➤ Assess for completion of bowel
patient is taking. preparation according to the institu-
tion’s procedure.
patient. Explain to the patient that ➤ Instruct the patient to remove jew-
some pain may be experienced dur- elry (including watches), credit cards,
ing the test, and there may be and other metallic objects.
moments of discomfort. Explain the ➤ Obtain baseline vital signs.
purpose of the test and how the pro- ➤ Have emergency equipment readily
cedure is performed. Inform the available.
patient that there may be some
abdominal discomfort from the nee-
foot coverings to wear and instruc-
dle insertion; however, the area will
ted to void prior to the procedure.
have received prior anesthesia.
Inform the patient that the procedure ➤ Instruct the patient to cooperate fully
is performed in a radiology depart- and to follow directions. Instruct the
ment, usually by a health care practi- patient to remain still throughout the
tioner and support staff, and takes procedure because movement pro-
approximately 30 to 60 minutes. duces unreliable results.
➤ Sensitivity to cultural and social ➤ Observe standard precautions, and
issues, as well as concern for mod- follow the general guidelines in
esty, is important in providing psy- Appendix A.
chological support before, during, ➤ Place the patient in the supine posi-
and after the procedure. tion on an exam table.
➤ A kidney, ureter, and bladder (KUB) baseline values. Notify the health
or plain film is taken to ensure that care practitioner if temperature is
no barium or stool will obscure visu- elevated. Protocols may vary from
alization of the biliary system. facility to facility.
➤ An area over the abdominal wall is ➤ Monitor for reaction to iodinated con-
anesthetized, and the needle is trast medium, including rash,
inserted and advanced under fluoro- urticaria, tachycardia, hyperpnea,
scopic guidance. Contrast medium is hypertension, palpitations, nausea,
injected when placement is con- or vomiting.
firmed by the free flow of bile. ➤ Renal function should be assessed
➤ A specimen of bile may be sent to before metformin is restarted.
the laboratory for culture and cyto- ➤ Observe the puncture site for signs
logic analysis. of bleeding, hematoma formation,
➤ At the end of the procedure, the con- ecchymosis, or leakage of bile.
trast medium is aspirated from the Notify the health care practitioner if
biliary ducts, relieving pressure on any of these is present.
the dilated ducts. ➤ Advise the patient to watch for
➤ The results are recorded manually, symptoms of infection, such as pain,
on film, or by automated equipment, fever, increased pulse rate, and mus-
in a computerized system for recall cle aches.
and postprocedure interpretation by ➤ A written report of the examina-
the appropriate health care practi- tion will be completed by a health
tioner. care practitioner specializing in this
➤ If an obstruction is found during the branch of medicine. The report will
procedure, a catheter is inserted into be sent to the requesting health care
the bile duct to allow drainage of bile. practitioner, who will discuss the
➤ Maintain pressure over the needle
insertion site for several hours if ➤ Depending on the results of this pro-
bleeding is persistent. cedure, additional testing may be
➤ Establish a closed and sterile
drainage system if a catheter is left
in place.
therapy. Evaluate test results in rela-
tion to the patient’s symptoms and
Post-test: other tests performed.
diet, fluids, medications, or activity, Related diagnostic tests:
as directed by the health care practi- ➤ Related diagnostic tests include com-
tioner. puted tomography of the abdomen,
➤ Monitor vital signs and neurologic hepatobiliary scan, kidney, ureter,
status every 15 minutes for 1 hour, bladder (KUB) studies, and magnetic
then every 2 hours for 4 hours, and resonance imaging of the abdomen,
as ordered. Take temperature every 4 and ultrasound of the liver and biliary
hours for 24 hours. Compare with tract.
Cholangiography, Postoperative 367
CHOLANGIOGRAPHY,
POSTOPERATIVE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: T-tube cholangiography.

AREA OF APPLICATION: Gallbladder, bile ducts.
CONTRAST: Iodinated contrast medium.
Normal Findings:
DESCRIPTION & RATIONALE: After • Biliary ducts are normal in size.
cholecystectomy, a self-retaining, T-
• Contrast medium fills the ductal sys-
shaped tube may be inserted into the tem and flows freely.
common bile duct. Postoperative (T-
tube) cholangiography is a fluoro- Abnormal Findings:
scopic and radiographic examination • Appearance of channels of contrast
of the biliary tract that involves the medium outside of the biliary ducts,
injection of a contrast medium indicating a fistula
through the T-tube inserted during
• Filling defects, dilation, or shadows
surgery. This test may be performed at within the biliary ducts, indicating cal-
the time of surgery and 7 to 10 days culi or neoplasm
after cholecystectomy to assess the
patency of the common bile duct and CRITICAL VALUES: N/A
to detect any remaining calculi. T-
tube placement may also be done after INTERFERING FACTORS:
a liver transplant because biliary duct This procedure is
obstruction or anastomotic leakage is contraindicated for:
possible. This test should be per- • Patients who are pregnant or suspected
formed before any gastrointestinal of being pregnant, unless the potential
studies using barium and after any benefits of the procedure far outweigh
studies involving the measurement of the risks to the fetus and mother.
iodinated compounds. ■ • Patients with cholangitis. The
injection of the contrast medium
INDICATIONS: can increase biliary pressure, leading to
• Determine biliary duct patency before bacteremia, septicemia, and shock.
T-tube removal • Patients with postoperative
• Identify the cause, extent, and location wound sepsis, hypersensitivity to
of obstruction after surgery iodine, or acute renal failure.
RESULT or iodinated dye. The contrast
medium used may cause a life- • Consultation with a physician should

threatening allergic reaction. Patients occur before the procedure for radia-
with a known hypersensitivity to the tion safety concerns regarding younger
medium may benefit from premedica- patients or patients who are lactating.
• Risks associated with radiographic over-
Factors that may procedures. Personnel in the room with
impair clear imaging: the patient should wear a protective lead
• Gas or feces in the gastrointestinal tract apron, stand behind a shield, or leave
resulting from inadequate cleansing or the area while the examination is being
failure to restrict food intake before the done. Personnel working in the area
study where the examination is being done
should wear badges that reveal their
• Retained barium from a previous radi- level of exposure to radiation.
ologic procedure
tion field (e.g., jewelry, body rings), Nursing Implications and
which may inhibit organ visualization Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
ographic equipment to accommodate ➤ Inform the patient that the procedure
obese or thin patients, which can cause assesses the biliary ducts.
overexposure or underexposure and a ➤ Obtain a history of the patient’s
poor-quality study complaints, including a list of known
• Patients who are very obese, who sitivities to latex, iodine, seafood,
may exceed the weight limit for the contrast medium, and dyes.
equipment ➤ Obtain a history of results of previ-
• Incorrect positioning of the patient, ously performed diagnostic proce-
which may produce poor visualization dures, surgical procedures, and
of the area to be examined laboratory tests. For related diagnos-
• Inability of the patient to cooperate or and Hepatobiliary System tables.
because of age, significant pain, or formed before an esophagogastro-
mental status duodenoscopy (upper gastrointestinal
study) or barium swallow.
• The procedure may be terminated if
chest pain or severe cardiac arrhyth- of pregnancy in perimenopausal
mias occur. women.
• Air bubbles resembling calculi may be ➤ Obtain a list of the medications the
seen if there is inadvertent injection of patient is taking.
air. ➤ Review the procedure with the
• Peritonitis may occur as a result of bile patient. Explain to the patient that
extravasation. some pain may be experienced dur-
ing the test, and there may be
• Failure to follow dietary restrictions moments of discomfort. Explain the
and other pretesting preparations may purpose of the test and how the pro-
cause the procedure to be canceled or cedure is performed. Inform the
repeated. patient that the procedure is per-
Cholangiography, Postoperative 369
formed in a radiology department, ➤ The patient is placed on an examina-

usually by a health care practitioner tion table in the supine position.
and support staff, and takes approxi- ➤ The area around the T-tube is draped;
mately 30 to 60 minutes. the end of the T-tube is cleansed with
➤ Sensitivity to cultural and social 70% alcohol. If the T-tube site is
issues, as well as concern for mod- inflamed and painful, a local anes-
esty, is important in providing psy- thetic (e.g., lidocaine) may be
chological support before, during, injected around the site. A needle is
and after the procedure. inserted into the open end of the T-
➤ Instruct the patient to fast and tube, and the clamp is removed.
restrict fluids for 8 hours prior to the ➤ Contrast medium is injected, and flu-
procedure. oroscopy is performed to visualize
➤ Make sure a written and informed contrast medium moving through
consent has been signed prior to the the duct system.
procedure and before administering ➤ The patient may feel a bloating sen-
any medications. sation in the upper right quadrant as
the contrast medium is injected. The
Intratest: tube is clamped, and films are taken
of the right upper quadrant in multi-
➤ Ensure that the patient has complied ple positions. A delayed film may be
with dietary and medication restric- taken 15 minutes later to visualize
tions and pretesting preparations for passage of the contrast medium into
at least 6 hours prior to the proce- the duodenum.
dure. Ensure that the patient has ➤ For procedures done after surgery,
removed all external metallic objects the T-tube is removed if findings are
prior to the procedure. normal; a dry, sterile dressing is
➤ Assess for completion of bowel applied to the site.
preparation according to the institu- ➤ If retained calculi are identified, the T-
tion’s procedure. tube is left in place for 4 to 6 weeks
➤ Instruct the patient to remove jew- until the tract surrounding the T-tube
elry (including watches), credit cards, is healed to perform a percutaneous
and other metallic objects. removal.
➤ Have emergency equipment readily ➤ The results are recorded manually, on
available. film, or by automated equipment, in a
computerized system, for recall and
➤ Patients are given a gown, robe, and postprocedure interpretation by the
foot coverings to wear and instructed appropriate health care practitioner.
➤ Observe standard precautions, and Post-test:
➤ Monitor T-tube site and change ster-
Appendix A.
ile dressing, as ordered. Instruct the
➤ Instruct the patient to cooperate fully patient on the care of the site and
and to follow directions. Instruct the dressing changes.
patient to remain still throughout the ➤ Instruct the patient to resume usual
procedure because movement pro- diet, fluids, medications, or activity,
duces unreliable results. as directed by the health care practi-
➤ Clamp the T-tube 24 hours before tioner.
and during the procedure, if ordered, ➤ Monitor vital signs and neurologic
to help prevent air bubbles from status every 15 minutes for 1 hour,
entering the ducts. then every 2 hours for 4 hours, and
➤ An x-ray of the abdomen is obtained as ordered. Take temperature every 4
to determine if any residual contrast hours for 24 hours. Compare with
medium is present from previous baseline values. Notify the health
studies. care practitioner if temperature is
elevated. Protocols may vary from ➤ Depending on the results of this pro-
facility to facility. cedure, additional testing may be
➤ Monitor for reaction to iodinated needed to evaluate or monitor pro-
contrast medium, including rash, gression of the disease process and
urticaria, tachycardia, hyperpnea, determine the need for a change in
hypertension, palpitations, nausea, therapy. Evaluate test results in rela-
or vomiting. tion to the patient’s symptoms and
➤ Carefully monitor the patient for
fatigue and fluid and electrolyte
imbalance. Related diagnostic tests:
➤ A written report of the examination ➤ Related diagnostic tests include com-
will be completed by a health care puted tomography of the abdomen;
practitioner specializing in this hepatobiliary scan; kidney, ureter, and
branch of medicine. The report will bladder film; magnetic resonance
be sent to the requesting health care imaging of the abdomen, and ultra-
practitioner, who will discuss the sound of the liver and hepatobiliary
results with the patient. system.
CHOLANGIOPANCREATOGRAPHY,
ENDOSCOPIC RETROGRADE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: ERCP.
AREA OF APPLICATION: Gallbladder, bile ducts, pancreatic ducts.
DESCRIPTION & RATIONALE: Endo- allow direct visualization of the biliary

scopic retrograde cholangiopancre- and pancreatic ducts. ERCP is less
atography (ERCP) allows direct invasive and has less morbidity than
visualization of the pancreatic and bil- PTC. It is useful in the evaluation of
iary ducts with a flexible endoscope patients with jaundice, because the
and, after injection of contrast mate- ducts can be visualized even when the
rial, with x-rays. It allows the physi- patient’s bilirubin level is high. (In
cian to view the pancreatic, hepatic, contrast, oral cholecystography and
and common bile ducts and the intravenous cholangiography are not
ampulla of Vater. ERCP and percuta- able to visualize the biliary system
neous transhepatic cholangiography when the patient has high bilirubin
(PTC) are the only procedures that levels.) By endoscopy, the distal end of
Cholangiopancreatography, Endoscopic Retrograde 371
This procedure is
the common bile duct can be contraindicated for:
widened, and gallstones can be
removed and stents placed in nar- of being pregnant, unless the potential
rowed bile ducts to allow bile to be benefits of the procedure far outweigh
drained in jaundiced patients. During the risks to the fetus and mother.
endoscopy, specimens of suspicious
tissue can be taken for pathologic
review, and manometry pressure read- medium used may cause a life-
ings can be obtained from the bile and threatening allergic reaction. Patients
pancreatic ducts. ERCP is used in the with a known hypersensitivity to the
diagnosis and follow-up of pancreatic medium may benefit from premedica-
disease. ■ tion with corticosteroids or the use of
INDICATIONS:
• Assess jaundice of unknown cause to Factors that may
differentiate biliary tract obstruction impair clear imaging:
from liver disease • Gas or feces in the gastrointestinal tract
• Collect specimens for cytology resulting from inadequate cleansing or
• Identify obstruction caused by calculi, study
cysts, ducts, strictures, stenosis, and
anatomic abnormalities • Retained barium from a previous radi-
ologic procedure
• Retrieve calculi from the distal com-
mon bile duct and release strictures • Previous surgery involving the stomach
or duodenum, which can make locat-
• Perform therapeutic procedures, such ing the duodenal papilla difficult
as sphincterotomy and placement of
biliary drains • A patient with Zenker’s diverticulum
involving the esophagus, who may be
RESULT unable to undergo ERCP
• A patient with unstable cardiopul-
Normal Findings: monary status, blood coagulation
• Normal appearance of the duodenal defects, or cholangitis (test may have
papilla to be rescheduled unless the patient
• Patency of the pancreatic and common received antibiotic therapy before
bile ducts the test)
• A patient with known acute pancre-
Abnormal Findings: atitis
• Duodenal papilla tumors
• Pancreatic cancer ographic equipment to accommodate
• Pancreatic fibrosis
• Pancreatitis poor-quality study
• Sclerosing cholangitis • Patients who are very obese, who may
CRITICAL VALUES: N/A ment
INTERFERING FACTORS: • Incorrect positioning of the patient,
which may produce poor visualization tic tests, refer to the Gastrointestinal
of the area to be examined and Hepatobiliary System tables.
• Inability of the patient to cooperate or formed before an upper gastroin-
remain still during the procedure testinal study or barium swallow.
mental status period and determine the possibility
Other considerations: women.
• The procedure may be terminated if ➤ Obtain a list of the medications the
chest pain or severe cardiac arrhythmias patient is taking.
occur.
• Failure to follow dietary restrictions patient. Explain to the patient that
and other pretesting preparations may some pain may be experienced dur-
moments of discomfort. Explain the
repeated. purpose of the test and how the pro-
• Consultation with a physician should cedure is performed. Inform the
patient that the procedure is per-
formed in a GI lab or radiology
tion safety concerns regarding younger department, usually by a health care
patients or patients who are lactating. practitioner and support staff, and
takes approximately 30 to 60 min-
utes.
overexposure can result from frequent
x-ray procedures. Personnel in the ➤ Sensitivity to cultural and social
room with the patient should wear a issues, as well as concern for mod-
protective lead apron, stand behind a chological support before, during,
shield, or leave the area while the and after the procedure.
examination is being done. Personnel
➤ Instruct the patient to fast and
working in the area where the examina-
tion is being done should wear badges procedure.
that reveal their level of exposure to
radiation. ➤ Make sure a written and informed
any medications.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest: ➤ Ensure that the patient has complied
with dietary, and medication restric-
➤ Inform the patient that the procedure tions and pretesting preparations
assesses the biliary ducts. for at least 6 hours prior to the pro-
➤ Obtain a history of the patient’s com- cedure. Ensure that the patient has
plaints, including a list of known removed all external metallic objects
allergens, especially allergies or sen- prior to the procedure.
sitivities to latex, iodine, seafood, ➤ Assess for completion of bowel
contrast medium, and dyes. preparation according to the institu-
➤ Obtain a history of results of previ- tion’s procedure.
ously performed diagnostic proce- ➤ Instruct the patient to remove jew-
dures, surgical procedures, and elry, including watches, credit cards,
laboratory tests. For related diagnos- and other metallic objects.
Cholangiopancreatography, Endoscopic Retrograde 373
➤ Have emergency equipment readily ➤ Intravenous glucagon or anticholin-

available. ergics can be administered to mini-
➤ Patients are given a gown, robe, mize duodenal spasm and to
and foot coverings to wear and facilitate visualization of the ampulla
instructed to void prior to the proce- of Vater.
dure. ➤ ERCP manometry can be done at
➤ Observe standard precautions, and this time to measure the pressure in
follow the general guidelines in the bile duct, pancreatic duct, and
Appendix A. Positively identify the sphincter of Oddi at the papilla area
patient, and label the appropriate via the catheter as it is placed in the
containers with the corresponding area before the contrast medium is
patient demographics, date, and injected.
time of collection, if cytology sam- ➤ When the catheter is in place, con-
ples are collected. trast medium is injected into the
➤ Instruct the patient to cooperate fully pancreatic and biliary ducts via the
and to follow directions. Instruct the catheter, and fluoroscopic films are
patient to remain still throughout the taken. Biopsy specimens for cyto-
procedure because movement pro- logic analysis can be obtained during
duces unreliable results. the procedure.
➤ Insert an intravenous line for admin- ➤ Place specimens in appropriate con-
istration of drugs, as needed. tainers, label them properly, and
➤ Administer ordered sedation. promptly transport them to the labo-
ratory.
➤ An x-ray of the abdomen is obtained
to determine if any residual contrast ➤ The results are recorded manually,
medium is present from previous on film, or by automated equipment,
studies. in a computerized system, for recall
➤ The oropharynx is sprayed or
swabbed with a topical local anes-
tioner.
thetic.
➤ The patient is placed on an examina-
tion table in the left lateral position Post-test:
with the left arm behind the back and ➤ Instruct the patient to resume usual
right hand at the side with the neck diet, fluids, medications, or activity
slightly flexed. A protective guard is after 24 hours, or as directed by the
inserted into the mouth to cover the health care practitioner.
teeth. A bite block can also be
inserted to maintain adequate open- ➤ Do not allow the patient to eat or
ing of the mouth. drink until the gag reflex returns,
after which the patient is permitted
➤ The endoscope is passed through
to eat lightly for 12 to 24 hours.
the mouth with a dental suction
device in place to drain secretions. A ➤ Monitor vital signs and neurologic
side-viewing flexible fiberoptic endo- status every 15 minutes for 1 hour,
scope is passed into the duodenum, then every 2 hours for 4 hours, and
and a small cannula is inserted into as ordered. Take temperature every 4
the duodenal papilla (ampulla of hours for 24 hours. Compare with
Vater). baseline values. Notify the health
care practitioner if temperature is
➤ The patient is placed in the prone
elevated. Protocols may vary from
position. The duodenal papilla is visu-
alized and cannulated with a catheter.
Occasionally the patient can be ➤ Monitor for reaction to iodinated
turned slightly to the right side to aid contrast medium, including rash,
in visualization of the papilla. urticaria, tachycardia, hyperpnea,
hypertension, palpitations, nausea, or practitioner, who will discuss the

vomiting. results with the patient.
➤ Tell the patient to expect some ➤ Depending on the results of this pro-
throat soreness and possible hoarse- cedure, additional testing may be
ness. Advise the patient to use needed to evaluate or monitor pro-
warm gargles, lozenges, ice packs to gression of the disease process and
the neck, or cool fluids to alleviate determine the need for a change in
throat discomfort. therapy. Evaluate test results in rela-
➤ Inform the patient that any belching, tion to the patient’s symptoms and
bloating, or flatulence is the result of other tests performed.
air insufflation.
➤ Emphasize that any severe pain,
fever, difficulty breathing, or expecto- Related diagnostic tests:
ration of blood must be reported to ➤ Related diagnostic tests include com-
the physician immediately. puted tomography of the abdomen;
➤ A written report of the examination hepatobiliary scan; kidney, ureter, and
will be completed by a health care bladder film; magnetic resonance
practitioner specializing in this imaging of the abdomen, and ultra-
branch of medicine. The report will sound of the liver and hepatobiliary
be sent to the requesting health care system.
CHOLESTEROL, HDL AND LDL

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: 1-Lipoprotein cholesterol, high-density

cholesterol, HDLC, -lipoprotein cholesterol, low-density cholesterol,
LDLC.

Cholesterol, HDL and LDL 375
HDLC Conventional Units Units 0.0259)
Birth 6–56 mg/dL 0.16–1.45 mmol/L
Children and adults
Desirable Greater than 60 mg/dL Greater than 1.56 mmol/L
Acceptable 40–60 mg/dL 0.9–1.56 mmol/L
Low Less than 40 mg/dL Less than 0.9 mmol/L
Risk Units Conventional Factor 0.0259)
Optimal Less than 100 mg/dL Less than 2.59 mmol/L
Near optimal 100–129 mg/dL 2.59–3.34 mmol/L
Borderline high 130–159 mg/dL 2.67–4.11 mmol/L
High 160–189 mg/dL 4.14–4.90 mmol/L
Very high Greater than 190 mg/dL Greater than 4.92 mmol/L
DESCRIPTION & RATIONALE: High- risk of CAD). Levels of LDLC in

density lipoprotein cholesterol terms of risk for CAD are directly pro-
(HDLC) and low-density lipoprotein portional to risk and vary by age
cholesterol (LDLC) are the major group. The LDLC can be estimated
transport proteins for cholesterol in using the Friedewald formula:
the body. It is believed that HDLC LDLC(Total Cholesterol) –
may have protective properties in that (HDLC) – (VLDLC)
its role includes transporting choles-
Very-low-density lipoprotein choles-
terol from the arteries to the liver.
terol (VLDLC) is estimated by divid-
LDLC is the major transport protein
ing the triglycerides (conventional
for cholesterol to the arteries from the
units) by 5. Triglycerides in SI units
liver. LDLC can be calculated using
would be divided by 2.18 to estimate
total cholesterol, total triglycerides,
VLDLC. It is important to note that
and HDLC levels.
the formula is valid only if the triglyc-
HDLC levels less than 40 mg/dL in
erides are less than 400 mg/dL or 4.52
men and women represent a coronary
mmol/L. ■
risk factor. There is an inverse rela-
tionship between HDLC and risk of INDICATIONS:
coronary artery disease (CAD) (i.e., • Determine the risk of cardiovascular
lower HDLC levels represent a higher disease
• Evaluate the response to dietary and • Cushing’s syndrome

drug therapy for hypercholesterolemia • Diabetes
• Investigate hypercholesterolemia in • Diet high in cholesterol and satu-
light of family history of cardiovascular rated fat
disease
• Dysglobulinemias
RESULT • Hepatic disease
• Hepatic obstruction
LDLC Recommended Levels • Hyperlipoproteinemia types IIA and
IIB
HDLC increased in: • Hypothyroidism
• Alcoholism
• Porphyria
• Chronic hepatitis
• Pregnancy
• Exercise
• Premature CAD
• Familial hyper--lipoproteinemia
• Syndrome X (metabolic syndrome)
HDLC decreased in: • Tendon and tuberous xanthomas
• Abetalipoproteinemia
LDLC decreased in:
• Cholestasis • Acute stress (severe burns, illness)
• Chronic renal failure • Chronic anemias
• Fish eye disease • Chronic pulmonary disease
• Genetic predisposition or enzyme/ • Genetic predisposition or enzyme/
cofactor deficiency cofactor deficiency
• Hepatocellular disorders • Hyperthyroidism
• Hypertriglyceridemia • Hypolipoproteinemia and abetal-
ipoproteinemia
• Inflammatory joint disease
• Obesity
• Myeloma
• Premature CAD
• Reye’s syndrome
• Sedentary lifestyle
• Severe hepatocellular destruction or
• Smoking disease
• Tangier disease • Tangier disease
• Syndrome X (metabolic syndrome) CRITICAL VALUES: N/A
• Uncontrolled diabetes
• Drugs that may increase HDLC levels
LDLC increased in: include albuterol, anticonvulsants,
• Anorexia nervosa cholestyramine, cimetidine, clofibrate
and other fibric acid derivatives,
• Chronic renal failure
estrogens, ethanol (moderate use),
• Corneal arcus lovastatin, niacin, oral contraceptives,
Cholesterol, HDL and LDL 377
pindolol, pravastatin, prazosin, and ➤ Obtain a history of the patient’s com-

simvastatin. plaints, including a list of known
• Drugs that may decrease HDLC levels sitivities to latex), and inform the
include acebutolol, atenolol, danazol, appropriate health care practitioner
diuretics, etretinate, interferon, isotre- accordingly.
tinoin, linseed oil, metoprolol, ➤ Obtain a history of the patient’s car-
neomycin, nonselective -adrenergic diovascular system and results of
blocking agents, probucol, proges- previously performed laboratory
terone, steroids, and thiazides. tests, surgical procedures, and other
diagnostic procedures. The presence
• Drugs that may increase LDLC levels of other risk factors, such as family
include androgens, catecholamines, history of heart disease, smoking,
chenodiol, cyclosporine, danazol, obesity, diet, lack of physical activity,
diuretics, etretinate, glucogenic corti- hypertension, diabetes, previous
costeroids, and progestins. myocardial infarction, and previous
vascular disease, should be investi-
• Drugs that may decrease LDLC levels gated. For related laboratory tests,
include aminosalicylic acid, cholestyra- refer to the Cardiovascular System
mine, colestipol, estrogens, fibric table.
acid derivatives, interferon, lovastatin, ➤ Obtain a list of medications the
neomycin, niacin, pravastatin, pra- patient is taking, including herbs,
zosin, probucol, simvastatin, terazosin, nutritional supplements, and nutra-
and thyroxine. ceuticals. The requesting health care
• Some of the drugs used to lower total advised if the patient regularly uses
cholesterol and LDLC or increase these products so that their effects
HDLC may cause liver damage. can be taken into consideration
• Grossly elevated triglyceride levels ➤ Review the procedure with the
invalidate the Friedewald formula for patient. Inform the patient that spec-
mathematical estimation of LDLC; if imen collection takes approximately
the triglyceride level is greater than 5 to 10 minutes. Address concerns
400 mg/dL, the formula should not about pain related to the procedure.
be used. Explain to the patient that there may
• Fasting before specimen collection is venipuncture.
highly recommended. Ideally, the ➤ Instruct the patient to fast for 12
patient should be on a stable diet for 3 hours before specimen collection.
weeks and fast for 12 hours before spec- ➤ Confirm with the requesting health
imen collection. care practitioner that the patient
should withhold medications known
• Failure to follow dietary restrictions to influence test results, and instruct
before the procedure may cause the the patient accordingly.
procedure to be canceled or repeated. ➤ There are no fluid restrictions unless
by medical direction.
Nursing Implications and Intratest:

Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: with dietary and medication restric-
tions as well as other pretesting
➤ Inform the patient that the test is preparations; assure that food has
used to assess and monitor risk for been restricted for at least 12 hours
coronary artery disease. prior to the procedure.
➤ If the patient has a history of severe eggs, and dairy products are the
allergic reaction to latex, care should major sources of saturated fats and
be taken to avoid the use of equip- cholesterol. If triglycerides also are
ment containing latex. elevated, the patient should be
➤ Instruct the patient to cooperate fully advised to eliminate or reduce alco-
and to follow directions. Direct the hol and simple carbohydrates from
patient to breathe normally and to the diet. The Step 2 diet recom-
avoid unnecessary movement. mends stricter reductions.
➤ Observe standard precautions, and ➤ Social and cultural considerations:
follow the general guidelines in Numerous studies point to the
Appendix A. Positively identify the prevalence of excess body weight in
patient, and label the appropriate American children and adolescents.
tubes with the corresponding patient Experts estimate that obesity is
demographics, date, and time of col- present in 25% of the population
lection. Perform a venipuncture; col- ages 6 to 11 years. The medical,
lect the specimen in a 5-mL red- or social, and emotional consequences
tiger-top tube. of excess body weight are signifi-
➤ Remove the needle and apply a pres- cant. Special attention should be
sure dressing over the puncture site. given to instructing the child and
caregiver regarding health risks and
➤ Promptly transport the specimen to weight-control education.
analysis. ➤ A written report of the examination
➤ The results are recorded manually or will be sent to the requesting health
in a computerized system for recall care practitioner, who will discuss
and postprocedure interpretation by the results with the patient.
the appropriate health care practi- ➤ Recognize anxiety related to test
tioner. results, and be supportive of fear of
Post-test: the implications of abnormal test
to counseling services. Provide con-
➤ Instruct the patient to resume usual tact information, if desired, for the
diet, fluids, and medications, as American Heart Association (http://
directed by the health care practi- www.americanheart.org).
tioner.
➤ Nutritional considerations: De-
creased HDLC level and increased
LDLC level may be associated with
ferral to another health care provider.
CAD. Nutritional therapy is recom-
mended for the patient identified to
be at high risk for developing CAD. If
or family.
overweight, the patient should be
encouraged to achieve a normal ➤ Depending on the results of this pro-
weight. The American Heart Associa- cedure, additional testing may be
tion Step 1 and Step 2 diets may be performed to evaluate or monitor
helpful in achieving a goal of lower- progression of the disease process
ing total cholesterol and triglyceride and determine the need for a change
levels. The Step 1 diet emphasizes a in therapy. Evaluate test results in
reduction in foods high in saturated relation to the patient’s symptoms
fats and cholesterol. Red meats, and other tests performed.
Cholesterol, Total 379
C-reactive protein, creatine kinase

and isoenzymes, glucose, glycated
➤ Related laboratory tests include hemoglobin, homocysteine, ketones,
antiarrhythmic drugs, apolipoprotein lactate dehydrogenase and isoen-
A, apolipoprotein B, aspartate amino- zymes, lipoprotein electrophoresis,
transferase, atrial natriuretic peptide, magnesium, myoglobin, potassium,
blood gases, B-type natriuretic total cholesterol, triglycerides, and
peptide, calcium (blood and ionized), troponin.
CHOLESTEROL, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable. It is important
to use the same tube type when serial specimen collections are anticipated
for consistency in testing.
Serum
SI Units
Risk Conventional Units (Conventional Units 0.0259)
Desirable Less than 200 mg/dL Less than 5.18 mmol/L
Borderline 200–239 mg/dL 5.18–6.19 mmol/L
High Greater than 240 mg/dL Greater than 6.22 mmol/L
Plasma values may be 10% lower than serum values.
DESCRIPTION & RATIONALE: Choles- androgens. Cholesterol is obtained

terol is a lipid needed to form cell from the diet (exogenous cholesterol)
membranes and a component of the and also synthesized in the body
materials that render the skin water- (endogenous cholesterol). Although
proof. It also helps form bile salts, most body cells can form some
adrenal corticosteroids, estrogen, and cholesterol, it is produced mainly by
the liver and intestinal mucosa. RESULT

Cholesterol is an integral component
in cell membrane maintenance and Increased in:
hormone production. Very low cho- • Acute intermittent porphyria
lesterol values, as are sometimes seen • Alcoholism
in critically ill patients, can be as life-
• Anorexia nervosa
threatening as very high levels.
According to the National Choles- • Cholestasis
terol Education Program, maintaining • Chronic renal failure
cholesterol levels less than 200 mg/dL
significantly reduces the risk of coro- • Diabetes (with poor control)
nary heart disease; no age and gender • Diets high in cholesterol and fats
stratification is presented as part of its • Familial hyperlipoproteinemia
recommendation. Numerous studies
have been done, and there are incon- • Glomerulonephritis
sistencies among the studies as to tar- • Glycogen storage disease (von Gierke
get “normals” segregated by age and disease)
gender. Beyond the total cholesterol
• Gout
and high-density lipoprotein choles-
terol (HDLC) values, other important • Hypothyroidism (primary)
risk factors must be considered. Many • Ischemic heart disease
myocardial infarctions occur even in
patients whose cholesterol levels are
considered to be within acceptable • Obesity
limits or who are in a moderate-risk • Pancreatic and prostatic malignancy
category. The combination of risk fac-
tors and lipid values helps identify • Pregnancy
individuals at risk so that appropriate • Syndrome X (metabolic syndrome)
interventions can be taken. If the cho-
• Werner’s syndrome
lesterol level is greater than 200
mg/dL, repeat testing after a 12- to Decreased in:
24-hour fast is recommended. ■ • Burns
• Chronic myelocytic leukemia
INDICATIONS:
• Assist in determining risk of cardiovas- • Chronic obstructive pulmonary disease
cular disease
• Hyperthyroidism
• Assist in the diagnosis of nephrotic
• Liver disease (severe)
syndrome, hepatic disease, pancreatitis,
and thyroid disorders • Malabsorption and malnutrition syn-
dromes
• Evaluate the response to dietary
and drug therapy for hypercholes- • Myeloma
terolemia
• Pernicious anemia
• Investigate hypercholesterolemia in
• Polycythemia vera
light of family history of cardiovascular
disease • Severe illness
Cholesterol, Total 381
• Sideroblastic anemias before the procedure may cause the

• Tangier disease
• Thalassemia
• Waldenström’s macroglobulinemia Procedure ● ● ● ● ● ● ● ● ● ● ●
CRITICAL VALUES: N/A Pretest:

INTERFERING FACTORS: used to assess and monitor risk for
• Drugs that may increase cholesterol coronary artery disease.
levels include amiodarone, androgens, ➤ Obtain a history of the patient’s com-
catecholamines, cyclosporine, danazol, plaints, including a list of known
diclofenac, disulfiram, glucogenic cor- allergens (especially allergies or sen-
ticosteroids, ibuprofen, isotretinoin, sitivities to latex), and inform the
levodopa, methyclothiazide, micona- appropriate health care practitioner
zole (owing to castor oil vehicle, not the accordingly.
drug), nafarelin, nandrolone, some oral ➤ Obtain a history of the patient’s car-
contraceptives, oxymetholone, pheno- diovascular, gastrointestinal, hema-
barbital, phenothiazine, prochlorper- topoietic, and hepatobiliary systems,
azine, and sotalol. as well as results of previously per-
formed laboratory tests, surgical pro-
• Drugs that may decrease cholesterol cedures, and other diagnostic
levels include acebutolol, amiloride, procedures. The presence of other
aminosalicylic acid, ascorbic acid, risk factors, such as family history of
asparaginase, atenolol, atorvastatin, heart disease, smoking, obesity,
beclobrate, bezafibrate, carbutamide, diet, lack of physical activity, hyper-
cerivastatin, cholestyramine, ciprofi- tension, diabetes, previous myocar-
dial infarction, and previous vascular
brate, clofibrate, clonidine, colestipol, disease, should be investigated.
dextrothyroxine, doxazosin, enalapril, For related laboratory tests, refer to
estrogens, fenfluramine, fenofibrate, the Cardiovascular, Gastrointestinal,
fluvastatin, gemfibrozil, haloperidol, Hematopoietic, and Hepatobiliary
hydralazine, interferon, lovastatin, System tables.
neomycin, niacin, pravastatin, probu- ➤ Obtain a list of medications the
col, simvastatin, tamoxifen, terazosin, patient is taking, including herbs,
thyroxine, ursodiol, and verapamil. nutritional supplements, and nutra-
• Ingestion of alcohol 12 to 24 hours practitioner and laboratory should be
before the test can falsely elevate advised if the patient regularly uses
results. these products so that their effects
• Ingestion of drugs that alter cholesterol when reviewing results.
levels within 12 hours of the test may
give a false impression of cholesterol ➤ Review the procedure with the
levels, unless the test is done to evaluate imen collection takes approximately
such effects. 5 to 10 minutes. Address concerns
• Positioning can affect results; lower lev- about pain related to the procedure.
els are obtained if the specimen is from Explain to the patient that there may
a patient who has been supine for 20 venipuncture.
minutes.
➤ Instruct the patient to withhold
• Failure to follow dietary restrictions alcohol and drugs known to alter cho-
lesterol levels for 12 to 24 hours paper tape or other adhesive to

before specimen collection, at the hold pressure bandage in place, or
direction of the health care practi- replace with a plastic bandage.
tioner. ➤ Instruct the patient to resume usual
➤ There are no fluid or medication diet as directed by the health care
restrictions unless by medical direc- practitioner.
tion. ➤ Secondary causes for increased cho-
➤ Fasting 6 to 12 hours before speci- lesterol levels should be ruled out
men collection is required if triglyc- before therapy to decrease levels is
eride measurements are included; it initiated by use of drugs.
is recommended if cholesterol levels
➤ Nutritional considerations: Increases
alone are measured for screening.
in total cholesterol levels may be
Intratest: associated with coronary artery dis-
ease (CAD). Nutritional therapy is
➤ Ensure that the patient has com- recommended for patients identified
plied with dietary restrictions and to be at high risk for developing CAD.
pretesting preparations; assure that If overweight, the patient should be
food has been restricted for at encouraged to achieve a normal
least 6 to 12 hours prior to the pro- weight. The American Heart Associa-
cedure if triglycerides are to be tion Step 1 and Step 2 diets may be
measured. helpful in achieving a goal of lower-
➤ If the patient has a history of severe ing total cholesterol and triglyceride
allergic reaction to latex, care should levels. The Step 1 diet emphasizes a
be taken to avoid the use of equip- reduction in foods high in saturated
ment containing latex. fats and cholesterol. Red meats,
eggs, and dairy products are the
major sources of saturated fats and
cholesterol. If triglycerides are also
elevated, the patient should be
advised to eliminate or reduce alco-
➤ Observe standard precautions, and hol and simple carbohydrates from
follow the general guidelines in the diet. The Step 2 diet recom-
Appendix A. Positively identify the mends stricter reductions.
Numerous studies point to the
prevalence of excess body weight in
American children and adolescents.
Experts estimate that obesity is
tiger-top tube.
present in 25% of the population
➤ Remove the needle, and apply a ages 6 to 11 years. The medical,
pressure dressing over the puncture social, and emotional consequences
site. of excess body weight are signifi-
➤ Promptly transport the specimen to cant. Special attention should be
the laboratory for processing and given to instructing the child and
analysis. caregiver regarding health risks and
➤ The results are recorded manually or weight-control education.
in a computerized system for recall ➤ A written report of the examination
and postprocedure interpretation by will be sent to the requesting health
the appropriate health care practi- care practitioner, who will discuss
tioner. the results with the patient.
Post-test: ➤ Recognize anxiety related to test
results, and be supportive of fear of
➤ Observe venipuncture site for bleed- shortened life expectancy. Discuss
ing or hematoma formation. Apply the implications of abnormal test
Chromosome Analysis, Blood 383
results on the patient’s lifestyle. and determine the need for a change
Provide teaching and information in therapy. Evaluate test results in
regarding the clinical implications of relation to the patient’s symptoms
the test results, as appropriate. and other tests performed.
to counseling services. Provide con- Related laboratory tests:
tact information, if desired, for the
American Heart Association (http:// ➤ Related laboratory tests include
www.americanheart.org). antiarrhythmic drugs, apolipoprotein
A, apolipoprotein B, aspartate amino-
➤ Reinforce information given by transferase, atrial natriuretic peptide,
the patient’s health care provider blood gases, B-type natriuretic pep-
regarding further testing, treatment, tide, calcium, cholesterol (HDL and
or referral to another health care LDL), C-reactive protein, creatine
provider. Answer any questions or kinase and isoenzymes, glucose,
address any concerns voiced by the glycated hemoglobin, homocysteine,
patient or family. ketones, lactate dehydrogenase
➤ Depending on the results of this pro- and isoenzymes, lipoprotein electro-
cedure, additional testing may be phoresis, magnesium, myoglobin,
performed to evaluate or monitor potassium, triglycerides, and tro-
progression of the disease process ponin.
CHROMOSOME ANALYSIS, BLOOD

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Whole blood (2 mL) collected in green-top (sodium heparin)
tube.
REFERENCE VALUE: (Method: Tissue culture and microscopic analysis) No

chromosomal abnormalities identified.
DESCRIPTION & RATIONALE: Testing syndrome and abnormal sexual devel-

for birth defects as well as mental opment. Fluorescence in situ hyb-
and physical retardation can be ridization (FISH) testing is useful in
accomplished through the use of the detection of specific microdele-
several technologies. Chromosome tion syndromes (e.g., Prader-Willi,
analysis by phytohemagglutina- Angelman, Beckwith-Wiedemann,
tion assay is used to detect Down Smith-Magenis, DiGeorge, Williams,
Miller-Dieker) and other acquired • Evaluate congenital anomaly, delayed

chromosomal changes associated with development (physical or mental),
mental retardation, and ambiguous
hematologic disorders. Amniotic
sexual organs
fluid, chorionic villus sampling, and
cells from fetal tissue or products of • Investigate the carrier status of patients
conception can also be evaluated for or relatives with known genetic abnor-
chromosomal abnormalities. ■ malities
• Investigate the cause of multiple mis-
INDICATIONS: carriages
• Evaluate conditions related to cryp-
torchidism, hypogonadism, primary • Provide prenatal care or genetic coun-
amenorrhea, and infertility seling
RESULT: The following tables list some common genetic defects:
Autosomal
Syndrome Chromosome Defect Features
Beckwith- Duplication 11p15 Macroglossia, omphalocele,
Wiedemann earlobe creases
Cat’s-eye Trisomy 2q11 Anal atresia, coloboma
Cri du chat Deletion 5p Catlike cry, microcephaly,
hypertelorism, mental
retardation, retrognathia
Down Trisomy 21 Epicanthal folds, simian crease
of palm, flat nasal bridge,
mental retardation, congenital
heart disease
Edwards’ Trisomy 18 Micrognathia, clenched third/
fourth fingers with the fifth
finger overlapping, rocker-
bottom feet, mental retarda-
tion, congenital heart disease
Pallister-Killian Trisomy 12p Psychomotor delay, sparse
anterior scalp hair, micro-
gnathia, hypotonia
Patau Trisomy 13 Microcephaly, cleft palate or lip,
polydactyly, mental retar-
dation, congenital heart
disease
Warkam Mosaic trisomy 8 Malformed ears, bulbous nose,
deep palm creases, absent or
hypoplastic patellae
Wolf-Hirschhorn Deletion 4p Microcephaly, growth retar-
dation, mental retardation,
carp mouth
Chromosome Analysis, Blood 385
Sex-Chromosome
Syndrome Defect Features
XYY 47,XYY Tall, increased risk of behavior
problems
Klinefelter’s 47,XXY Hypogonadism, infertility,
underdeveloped secondary
sex characteristics, learning
disabilities
Triple X 47,XXX Increased risk of infertility and
learning disabilities
Ullrich-Turner 45,X Short, gonadal dysgenesis,
webbed neck, low posterior
hairline, renal and cardio-
vascular abnormalities

Nursing Implications and 5 to 10 minutes. Address concerns
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: be some discomfort during the
venipuncture.
used to evaluate suspected chromo- ➤ There are no food, fluid, or medica-
somal disorders. tion restrictions unless by medical
➤ Obtain a history of the patient’s com- direction.
allergens (especially allergies or sen- Intratest:
appropriate health care practitioner ➤ If the patient has a history of severe
accordingly. allergic reaction to latex, care should
reproductive system, family history
of known or suspected genetic dis- ➤ Instruct the patient to cooperate fully
orders, and results of previously per- and to follow directions. Direct the
formed laboratory tests, surgical patient to breathe normally and to
procedures, and other diagnostic avoid unnecessary movement.
procedures. For related laboratory ➤ Observe standard precautions, and
tests, refer to the Reproductive follow the general guidelines in
System table. Appendix A. Positively identify the
➤ Obtain a list of the medications the patient, and label the appropriate
patient is taking, including herbs, tubes with the corresponding patient
nutritional supplements, and nutra- demographics, date, and time of
ceuticals. The requesting health care collection. Perform a venipuncture;
practitioner and laboratory should be collect the specimen in a 5-mL
advised if the patient regularly uses green-top tube.
➤ Remove the needle, and apply a pres- mality is determined. Decisions

sure dressing over the puncture site. regarding elective abortion should
➤ Promptly transport the specimen to occur in the presence of both
the laboratory for processing and parents. Provide a nonjudgmental,
analysis. nonthreatening atmosphere for dis-
cussing the risks and difficulties of
➤ The results are recorded manually or delivering and raising a developmen-
in a computerized system for recall tally challenged infant, as well as
and postprocedure interpretation by exploring other options (termination
the appropriate health care practi- of pregnancy or adoption). It is also
tioner. important to discuss feelings the
mother and father may experience
Post-test: (e.g., guilt, depression, anger) if fetal
➤ Observe venipuncture site for bleed- abnormalities are detected. Educate
ing or hematoma formation. Apply the patient and family regarding
paper tape or other adhesive to hold access to counseling services, as
pressure bandage in place, or appropriate.
replace with a plastic bandage. ➤ Reinforce information given by the
➤ A written report of the examination patient’s health care provider regard-
will be sent to the requesting health ing further testing, treatment, or re-
care practitioner, who will discuss ferral to another health care provider.
the results with the patient. Answer any questions or address
➤ Recognize anxiety related to test or family.
results, and be supportive of the
sensitive nature of the testing. Dis- ➤ Depending on the results of this pro-
cuss the implications of abnormal cedure, additional testing may be
test results on the patient’s lifestyle. performed to evaluate or monitor
Provide teaching and information progression of the disease process
regarding the clinical implications and determine the need for a change
of the test results, as appropriate. in therapy. Evaluate test results in
Educate the patient regarding access relation to the patient’s symptoms
to counseling services. and other tests performed.
➤ Social and cultural considerations: Related laboratory tests:
Encourage the family to seek coun-
seling if they are contemplating preg- ➤ Related laboratory tests include
nancy termination or to seek genetic amniotic fluid analysis, chorionic
counseling if a chromosomal abnor- villus biopsy, and 1-fetoprotein.
CLOT RETRACTION
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Whole blood collected in a full 5-mL red-top tube.
Clot Retraction 387
REFERENCE VALUE: (Method: Macroscopic observation of sample) A normal

clot, gently separated from the side of the test tube and incubated at 37 C,
shrinks to about half of its original size within 1 hour. The result is a firm,
cylindrical fibrin clot that contains red blood cells and is sharply demarcated
from the clear serum. Complete clot retraction can take 6 to 24 hours.
DESCRIPTION & RATIONALE: The • Drugs that may produce a decreased
clot retraction test measures the ade- result include apronalide, carbenicillin,
quacy of platelet function by measur- and plicamycin.
ing the speed and extent of clot • Platelet count less than 100,000/L,
retraction. Normally, when blood acetylsalicylic acid therapy, altered
clots in a test tube, it retracts away fibrinogen/fibrin structure, hypofib-
from the sidewalls of the tube. rinogenemia, polycythemia or hemo-
Platelets play a major role in the clot concentration, and multiple myeloma
retraction process. When platelets are are conditions in which abnormal clot
decreased or function is impaired, retraction may occur, limiting the abil-
scant serum and a soft, plump, poorly ity to form a valid assessment of platelet
function.
demarcated clot form in the tube. In
addition to normal platelets, clot • Prompt and proper specimen process-
retraction depends on the contractile ing, storage, and analysis are important
protein thrombosthenin, magnesium, to achieve accurate results. Specimens
received in the laboratory more than 1
adenosine triphosphate (ATP), and
hour after collection should be rejected.
pyruvate kinase. Clot retraction is
also influenced by hematocrit and
by fibrinogen structure and concen- Nursing Implications and
tration. ■ Procedure ● ● ● ● ● ● ● ● ● ● ●
INDICATIONS: Pretest:
• Evaluate the adequacy of platelet func- ➤ Inform the patient that the test is
tion used to assist in the diagnosis of
bleeding disorders.
• Evaluate thrombocytopenia of
unknown origin ➤ Obtain a history of the patient’s
• Investigate the possibility of Glanz- allergens (especially allergies or sen-
mann’s disease sitivities to latex), and inform the
• Investigate suspected abnormalities of accordingly.
fibrinogen or fibrinolytic activity ➤ Obtain a history of the patient’s
hematopoietic system and results
RESULT of previously performed laboratory
Increased in: N/A diagnostic procedures. For related
laboratory tests, refer to the Hema-
Decreased in: Glanzmann’s topoietic System table.
thrombasthenia ➤ Note any recent procedures that can
CRITICAL VALUES: N/A ➤ Obtain a list of medications the
patient is taking, including herbs, and postprocedure interpretation by

nutritional supplements, and nutra- the appropriate health care practi-
ceuticals. The requesting health care tioner.
advised if the patient regularly uses Post-test:
can be taken into consideration ➤ Observe venipuncture site for bleed-
when reviewing results. ing or hematoma formation. Apply
paper tape or other adhesive to
➤ Review the procedure with the hold pressure bandage in place, or
patient. Inform the patient that spec- replace with a plastic bandage.
5 to 10 minutes. Address concerns ➤ Inform the patient with abnormal clot
about pain related to the procedure. retraction of the importance of tak-
Explain to the patient that there may ing precautions against bruising and
be some discomfort during the bleeding. These precautions may
venipuncture. include the use of a soft bristle tooth-
brush, use of an electric razor, avoid-
➤ There are no food, fluid, or medica- ance of constipation, avoidance of
tion restrictions unless by medical acetylsalicylic acid and similar prod-
direction. ucts, and avoidance of intramuscular
injections.
Intratest:
ment containing latex. ➤ Reinforce information given by
➤ Instruct the patient to cooperate fully the patient’s health care provider
and to follow directions. Direct the regarding further testing, treatment,
patient to breathe normally and to or referral to another health care
avoid unnecessary movement. provider. Answer any questions or
➤ Observe standard precautions, and address any concerns voiced by the
follow the general guidelines in patient or family.
demographics, date, and time of col- progression of the disease process
lection. Perform a venipuncture; col- and determine the need for a change
lect the specimen in a 5-mL red-top in therapy. Evaluate test results in
tube. relation to the patient’s symptoms
➤ Remove the needle, and apply a and other tests performed.
site. Related laboratory tests:
➤ Promptly transport the specimen to ➤ Related laboratory tests include
the laboratory within 1 hour of col- bleeding time, coagulation factor
lection for processing and analysis. XIII, complete blood count, fibrino-
➤ The results are recorded manually or gen, hematocrit, hemoglobin, and
in a computerized system for recall platelet count.
Coagulation Factors 389
COAGULATION FACTORS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: See table.

SPECIMEN: Whole blood in a completely filled 5-mL blue-top (sodium
citrate) tube.
REFERENCE VALUE: (Method: Photo-optical clot detection) Activity from

50% to 150%.
Preferred Name Synonym

Factor I Fibrinogen —
Factor II Prothrombin Prethrombin
Factor III Tissue factor Tissue thromboplastin
Factor IV Calcium Ca2
Factor V Proaccelerin Labile factor, accelerator
globulin (AcG)
Factor VII Proconvertin Stabile factor, serum
prothrombin
conversion accelerator,
autoprothrombin I
Factor VIII:C Antihemophilic factor Antihemophilic globulin
(AHF) (AHG), antihemophilic
factor A, platelet
cofactor 1
Factor IX Plasma thromboplastin Christmas factor,
component (PTC) antihemophilic factor
B, platelet cofactor 2
Factor X Stuart-Prower factor Autoprothrombin III,
thrombokinase
Factor XI Plasma thromboplastin Antihemophilic factor C
antecedent (PTA)
Factor XII Hageman factor Glass factor, contact
factor
Factor XIII Fibrin-stabilizing factor Laki-Lorand factor (LLF),
(FSF) fibrinase, plasma
transglutinase
Prekallikrein Fletcher factor
High-molecular-weight Fitzgerald factor, contact
kininogen (HMWK) activation cofactor,
Williams factor,
Flaujeac factor
RESULT
coagulation proteins respond to blood Increased in: N/A
vessel injury in a chain of events. The
Decreased in:
intrinsic and extrinsic pathways of sec-
ondary hemostasis are a series of reac- • Congenital deficiency
tions involving the substrate protein • Disseminated intravascular coagulation
fibrinogen, the coagulation factors • Liver disease
(also known as enzyme precursors or
zymogens), nonenzymatic cofactors CRITICAL VALUES: N/A
(Ca2), and phospholipid. The factors
were assigned Roman numerals in the INTERFERING FACTORS:
order of their discovery, not their place • Drugs that may increase factor
in the coagulation sequence. Factor VI II levels include fluoxymesterone,
was originally thought to be a separate methandrostenolone, nandrolone, and
clotting factor. It was subsequently oxymetholone.
proved to be the same as a modified • Drugs that may decrease factor II levels
form of Factor V, and therefore the include warfarin.
number is no longer used.
• Drugs that may increase factor V, VII,
The coagulation factors are formed
and X levels include anabolic steroids,
in the liver. They can be divided into fluoxymesterone, methandrostenolone,
three groups based on their common nandrolone, oral contraceptives, and
properties: oxymetholone.
1. The contact group is activated in • Drugs that may decrease factor V levels
vitro by a surface such as glass include streptokinase.
and is activated in vivo by
collagen. The contact group • Drugs that may decrease factor VII
includes factor XI, factor XII, levels include acetylsalicylic acid, as-
prekallikrein, and high-molecular- paraginase, cefamandole, ceftriaxone,
weight kininogen. dextran, dicumarol, gemfibrozil, oral
2. The prothrombin or vitamin contraceptives, and warfarin.
K–dependent group includes • Drugs that may increase factor VIII
factors II, VII, IX, and X. levels include chlormadinone.
3. The fibrinogen group includes
factors I, V, VIII, and XIII. They • Drugs that may decrease factor VIII
are the most labile of the levels include asparaginase.
factors and are consumed • Drugs that may increase factor IX
during the coagulation process. levels include chlormadinone and oral
The factors listed in the table contraceptives.
are the ones most commonly
measured. ■ • Drugs that may decrease factor IX lev-
els include asparaginase and warfarin.
INDICATIONS: • Drugs that may decrease factor X levels
• Identify the presence of inherited include chlormadinone, dicumarol,
bleeding disorders oral contraceptives, and warfarin.
• Identify the presence of qualitative or • Drugs that may decrease factor XI lev-
quantitative factor deficiency els include asparaginase and captopril.
Coagulation Factors 391
• Drugs that may decrease factor XII lev- time, clotting time, complete blood
els include captopril. count, partial thromboplastin time,
platelets, and prothrombin time), sur-
• Test results of patients on anticoagulant gical procedures, and other diagnos-
therapy are unreliable. tic procedures. For related laboratory
tests, refer to the Hematopoietic and
• Placement of tourniquet for longer Hepatobiliary System tables.
than 1 minute can result in venous sta-
sis and changes in the concentration of ➤ Obtain a list of medications the
plasma proteins to be measured. lant therapy, acetylsalicylic acid,
Platelet activation may also occur herbals, and nutraceuticals known
under these conditions, causing erro- to affect coagulation. It is recom-
neous results. mended that use of these sub-
stances be discontinued 14 days
• Vascular injury during phlebotomy can before dental or surgical procedures.
activate platelets and coagulation fac- The requesting health care practi-
tors, causing erroneous results. tioner and laboratory should be
• Hemolyzed specimens must be rejected advised if the patient regularly uses
because hemolysis is an indication can be taken into consideration
of platelet and coagulation factor when reviewing results.
activation.
• Icteric or lipemic specimens interfere patient. Inform the patient that spec-
with optical testing methods, produc- imen collection takes approximately
ing erroneous results. 5 to 10 minutes. Address concerns
• Incompletely filled collection tubes, Explain to the patient that there may
specimens contaminated with heparin, be some discomfort during the
clotted specimens, or unprocessed venipuncture.
specimens not delivered to the labora- ➤ There are no food, fluid, or medica-
tory within 1 hour of collection should tion restrictions unless by medical
be rejected. direction.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to detect factor deficiencies patient to breathe normally and to
and related coagulopathies. avoid unnecessary movement.
➤ Obtain a history of the patient’s lection. Perform a venipuncture; col-
hematopoietic and hepatobiliary sys- lect the specimen in a 5-mL blue-top
tems, any bleeding disorders, and tube. Important note: Two different
results of previously performed labo- concentrations of sodium citrate
ratory tests (especially bleeding preservative are currently added to
blue-top tubes for coagulation stud- hold pressure bandage in place, or

ies: 3.2% and 3.8%. The Clinical and replace with a plastic bandage.
Laboratory Standards Institute/CLSI ➤ Instruct the patient to report imme-
(formerly the National Committee diately any signs of unusual bleeding
for Clinical Laboratory Standards/ or bruising.
NCCLS) guideline for sodium citrate
is 3.2%. Laboratories establish refer- ➤ Inform the patient with decreased
ence ranges for coagulation testing factor levels of the importance of
based on numerous factors, includ- taking precautions against bruising
ing sodium citrate concentration, and bleeding. These precautions may
test equipment, and test reagents. It include the use of a soft bristle tooth-
is important to inquire from the labo- brush, use of an electric razor, avoid-
ratory which concentration it recom- ance of constipation, avoidance of
mends, because each concentration acetylsalicylic acid and similar prod-
will have its own specific reference ucts, and avoidance of intramuscular
range. When multiple specimens are injections.
drawn, the blue-top tube should be ➤ A written report of the examination
collected after sterile (i.e., blood cul- will be sent to the requesting health
ture) and red-top tubes. When coag- care practitioner, who will discuss
ulation testing is the only work to be the results with the patient.
done, an extra red-top tube should ➤ Reinforce information given by the
be collected before the blue-top tube patient’s health care provider regard-
to avoid contaminating the specimen ing further testing, treatment, or
with tissue thromboplastin. referral to another health care
➤ Remove the needle and apply a pres- provider. Answer any questions or
sure dressing over the puncture site. address any concerns voiced by the
patient or family.
analysis. The CLSI recommendation cedure, additional testing may be
for processed and unprocessed sam- performed to evaluate or monitor
ples stored in unopened tubes is that progression of the disease process
testing should be completed within and determine the need for a change
1 to 4 hours of collection. in therapy. Evaluate test results in
tioner. ➤ Related laboratory tests include
alanine aminotransferase, alkaline
Post-test: phosphatase, aspartate aminotrans-
ferase, clot retraction, copper, acti-
➤ Observe venipuncture site for bleed- vated partial thromboplastin time,
ing or hematoma formation. Apply plasminogen, protein C, prothrombin
paper tape or other adhesive to time, and vitamin K.
Cold Agglutinin Titer 393
COLD AGGLUTININ TITER

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Mycoplasma serology.

SPECIMEN: Serum (2 mL) collected in a red-top tube. The tube must be
placed in a water bath or heat block at 37C for 1 hour and allowed to clot
before the serum is separated from the red blood cells (RBCs).
REFERENCE VALUE: (Method: Patient serum containing autoantibodies

titered against type O RBCs at 2C to 8C. Type O cells are used because
they have no antigens on the cell membrane surface. Agglutination with
patient sera would not occur because of reaction between RBC blood type
antigens and patient blood type antibodies.) Negative: Single titer less than
1:32 or less than a fourfold increase in titer over serial samples.
DESCRIPTION & RATIONALE: Cold of complement on the cell wall, or

agglutinins are antibodies that cause they may return to the circulatory sys-
clumping or agglutination of RBCs at tem and be lysed in the spleen by
cold temperatures in individuals with macrophages.
certain conditions or who are infected The titer endpoint is the highest
by particular organisms. Cold agglu- dilution of serum that shows a spe-
tinins are associated with Mycoplasma cific antigen-antibody reaction. Single
pneumoniae infection. M. pneumoniae titers greater than 1:64, or a fourfold
has I antigen specificity to human increase in titer between specimens
RBC membranes. Fetal cells largely collected 5 or more days apart, are
contain i antigens, but by 18 months clinically significant. Patients affected
most cells carry the I antigen. The with primary atypical viral pneumo-
agglutinins are usually immunoglobu- nia exhibit a rise in titer 8 to 10 days
lin M (IgM) antibodies and cause after the onset of illness. IgM antibod-
agglutination of cells at temperatures ies peak in 12 to 25 days and begin to
in the range of 0C to 10C. The tem- diminish 30 days after onset. ■
perature of circulating blood in the
extremities may be lower than core INDICATIONS:
temperatures. RBCs of affected indi- • Assist in the confirmation of primary
viduals may agglutinate and obstruct atypical pneumonia, influenza, or pul-
blood vessels in fingers, toes, and ears, monary embolus
or they may initiate the complement • Provide additional diagnostic support
cascade. Affected cells may be lysed for cold agglutinin disease associated
immediately within the capillaries and with viral infections or lymphoreticular
blood vessels as a result of the action cancers
RESULT plaints, including a list of known

Increased in: sitivities to latex), and inform the
• Infectious mononucleosis
accordingly.
• Malaria ➤ Obtain a history of the patient’s
immune and respiratory systems,
• M. pneumoniae (primary atypical pneu- as well as results of previously
monia) performed laboratory tests, surgical
• Multiple myeloma procedures, and other diagnostic
• Raynaud’s disease (severe) tests, refer to the Immune and Res-
• Systemic lupus erythematosus
• Trypanosomiasis patient is taking, including herbs, nu-
tritional supplements, and nutra-
Decreased in: N/A ceuticals. The requesting health care
• Antibiotic use may interfere with or ➤ Note any recent medications that
decrease antibody production. can interfere with test results.
• A high antibody titer may interfere ➤ Review the procedure with the pa-
with blood typing and crossmatching tient. Inform the patient that multiple
procedures. specimens may be required. Inform
the patient that specimen collection
• High titers may appear spontaneously takes approximately 5 to 10 minutes.
in elderly patients and persist for many Address concerns about pain related
years. to the procedure. Explain to the
patient that there may be some dis-
• Prompt and proper specimen process- comfort during the venipuncture.
ing, storage, and analysis are important ➤ There are no food, fluid, or medica-
to achieve accurate results. Specimens tion restrictions (except antibiotics)
should always be transported to the unless by medical direction.
laboratory as quickly as possible after
collection. The specimen must clot in a Intratest:
37C water bath for 1 hour before sep- ➤ Ensure that the patient has complied
aration. Refrigeration of the sample with medication restrictions prior to
before serum separates from the RBCs the procedure.
may falsely decrease the titer. ➤ If the patient has a history of severe
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Instruct the patient to cooperate fully
used to assist in the diagnosis of pri- follow the general guidelines in
mary atypical pneumonia and other Appendix A. Positively identify the
viral/infectious diseases. patient, and label the appropriate
Collagen Crosslinked N-Telopeptide 395
demographics, date, and time of col- ➤ A written report of the examination

lection. Perform a venipuncture; col- will be sent to the requesting health
lect the specimen in a 5-mL red-top care practitioner, who will discuss
tube. the results with the patient.
➤ Remove the needle, and apply a pres- ➤ Reinforce information given by the
sure dressing over the puncture site. patient’s health care provider regard-
➤ Promptly transport the specimen to ing further testing, treatment, or
the laboratory for processing and referral to another health care
analysis. provider. Emphasize the need for the
➤ Inform the laboratory if the patient is patient to return in 7 to 14 days for
receiving antibiotics. a convalescent blood sample. An-
swer any questions or address any
➤ The results are recorded manually or concerns voiced by the patient or
in a computerized system for recall family.
the appropriate health care prac- ➤ Depending on the results of this
titioner. procedure, additional testing may be
Post-test: and determine the need for a change
➤ Observe venipuncture site for bleed- in therapy. Evaluate test results in
ing or hematoma formation. Apply relation to the patient’s symptoms
paper tape or other adhesive to and other tests performed.
hold pressure bandage in place, or
replace with a plastic bandage. Related laboratory tests:
➤ Instruct the patient to resume antibi- ➤ Related laboratory tests include
otics as directed by the health care arterial/alveolar oxygen ratio, blood
practitioner. gases, and complete blood count.
COLLAGEN CROSSLINKED
N-TELOPEPTIDE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: NTx.
SPECIMEN: Urine (2 mL) from a random specimen collected in a clean plas-
tic container.
Male 0–85 nmol bone collagen equivalents/mmol

creatinine
Female (premenopausal) 14–76 nmol bone collagen
equivalents/mmol creatinine
DESCRIPTION & RATIONALE: Osteo- A noninvasive test to detect the pres-

porosis is the most common bone dis- ence of collagen cross-linked N-
ease in the West. It is often called the telopeptide (NTx) is used to follow the
“silent disease” because bone loss progress of patients who have begun
occurs without symptoms. The forma- treatment for osteoporosis. NTx is
tion and maintenance of bone mass is formed when collagenase acts on bone.
dependent on a combination of fac- Small NTx fragments are excreted in
tors that include genetics, nutrition, the urine after bone resorption. A
exercise, and hormone function. desirable response, 2 to 3 months after
Normally the rate of bone formation therapy is initiated, is a 30% reduction
is equal to the rate of bone resorption. in NTx and a reduction of 50% below
After midlife, the rate of bone loss baseline by 12 months. ■
begins to increase. Osteoporosis is
more commonly identified in women INDICATIONS:
than in men. Other risk factors • Assist in the evaluation of osteoporosis
include thin, small-framed body struc- • Assist in the management and treat-
ture; family history of osteoporo- ment of osteoporosis
sis; diet low in calcium; white or
Asian race; excessive use of alcohol; • Monitor effects of estrogen replace-
cigarette smoking; sedentary lifestyle; ment therapy
long-term use of corticosteroids, thy-
RESULT
roid replacement medications, or
antiepileptics; history of bulimia, Increased in:
anorexia nervosa, chronic liver disease, • Hyperparathyroidism
or malabsorption disorders; and post-
menopausal state. Osteoporosis is a • Osteomalacia
major consequence of menopause in • Osteoporosis
women owing to the decline of estro-
gen production. Osteoporosis is rare • Paget’s disease
in premenopausal women. Estrogen
Decreased in:
replacement therapy (after meno-
• Effective therapy for osteoporosis
pause) is one strategy that has been
commonly employed to prevent osteo-
porosis, although its exact protective
mechanism is unknown. Results of INTERFERING FACTORS:
some recently published studies indi- • NTx levels are affected by urinary
cate that there may be significant excretion, and values may be influ-
adverse side effects to estrogen replace- enced by the presence of renal impair-
ment therapy; more research is needed ment or disease.
to understand the long-term effects
(positive and negative) of this therapy.
Other treatments include raloxifene Nursing Implications and
(selectively modulates estrogen recep- Procedure ● ● ● ● ● ● ● ● ● ● ●
tors), calcitonin (interacts directly

with osteoclasts), and bisphosphates Pretest:
(inhibit osteoclast-mediated bone ➤ Inform the patient that the test is
resorption). used to assist in the diagnosis of
Collagen Crosslinked N-Telopeptide 397
osteoporosis and evaluation of ➤ Promptly transport the specimen to

therapy. the laboratory for processing and
➤ Obtain a history of the patient’s com- analysis.
plaints, including a list of known ➤ The results are recorded manually
allergens, and inform the appropriate or in a computerized system for
health care practitioner accordingly. recall and postprocedure interpreta-
➤ Obtain a history of the patient’s tion by the appropriate health care
musculoskeletal and reproductive practitioner.
systems and results of previously
performed laboratory tests, surgical Post-test:
procedures. For related laboratory ➤ Instruct the patient to resume usual
tests, refer to the Musculoskeletal diet, fluids, medications, or activ-
and Reproductive System tables. ity, as directed by the health care
practitioner.
patient is taking, including herbs, ➤ Dietary considerations: Increased
nutritional supplements, and nutra- NTx levels may be associated with
ceuticals. The requesting health care osteoporosis. Nutritional therapy
practitioner and laboratory should be may be indicated for patients identi-
advised if the patient is regularly fied as being at high risk for develop-
using these products so that their ing osteoporosis. Educate the patient
effects can be taken into considera- about the National Osteoporosis
tion when reviewing results. Foundation’s guidelines regarding a
regular regimen of weight-bearing
exercises, limited alcohol intake,
avoidance of tobacco products, and
adequate dietary intake of vitamin D
(400 to 800 IU/d) and calcium (1200
to 1500 mg/d). Dietary calcium can
Explain to the patient that there
be obtained in animal or plant
should be no discomfort during the
sources. Milk and milk products, sar-
procedure.
dines, clams, oysters, salmon,
➤ Sensitivity to social and cultural rhubarb, spinach, beet greens, broc-
issues, as well as concern for mod- coli, kale, tofu, legumes, and fortified
esty, is important in providing psy- orange juice are high in calcium. Milk
chological support before, during, and milk products also contain vita-
and after the procedure. min D and lactose to assist in absorp-
➤ There are no food, fluid, or medication. Cooked vegetables yield more
tion restrictions unless by medical absorbable calcium than raw veg-
direction. etables. Patients should also be
informed of the substances that can
Intratest: inhibit calcium absorption by irre-
versibly binding to some of the cal-
➤ Instruct the patient to cooperate fully cium and making it unavailable for
and to follow directions. absorption, such as oxalates, which
➤ Observe standard precautions, and naturally occur in some vegetables;
follow the general guidelines in phytic acid, found in some cereals;
Appendix A. Positively identify the and excessive intake of insoluble
patient, and label the appropriate col- dietary fiber. Excessive protein intake
lection container with the correspon- also can affect calcium absorption
ding patient demographics, date, and negatively, especially if it is com-
time of collection. bined with foods high in phosphorus.
Vitamin D is synthesized by the skin
➤ Instruct the patient to collect a sec-
and is available in fortified dairy foods
ond-void morning specimen as fol-
and cod liver oil.
lows: (1) void and then drink a glass
of water; (2) wait 30 minutes, and ➤ A written report of the examination
then try to void again. will be sent to the requesting health
care practitioner, who will discuss ing further testing, treatment, or

the results with the patient. referral to another health care pro-
results, and be supportive of
patient or family.
impaired activity related to lack
of muscular control, perceived loss ➤ Depending on the results of this pro-
of independence, and fear of short- cedure, additional testing may be
ened life expectancy. Discuss the performed to evaluate or monitor
implications of abnormal test results progression of the disease process
on the patient’s lifestyle. Provide and determine the need for a change
teaching and information regarding in therapy. Evaluate test results in
the clinical implications of the test relation to the patient’s symptoms
results, as appropriate. Educate the and other tests performed.
ing services. Provide contact infor- Related laboratory tests:
mation, if desired, for the National
➤ Related laboratory tests include alka-
Osteoporosis Foundation (http://
line phosphatase, calcitonin, calcium
www.nof.org).
(blood and urine), creatinine, creati-
➤ Reinforce information given by the nine clearance, parathyroid hormone,
patient’s health care provider regard- phosphorus, and vitamin D.
COLONOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Full colonoscopy, lower endoscopy, lower

panendoscopy.

CONTRAST: Air.
DESCRIPTION & RATIONALE: Colo- beam for obliteration of tissue and

noscopy allows inspection of the control of bleeding. Mucosal surfaces
mucosa of the entire colon, ileocecal of the lower GI tract are examined for
valve, and terminal ileum using a flex- ulcerations, polyps, chronic diarrhea,
ible fiberoptic colonoscope inserted hemorrhagic sites, neoplasms, and
through the anus and advanced to the strictures. During the procedure, tis-
terminal ileum. The colonoscope is a sue samples may be obtained for cytol-
multichannel instrument that allows ogy, and some therapeutic procedures
viewing of the gastrointestinal (GI) may be performed, such as excision of
tract lining, insufflation of air, aspira- small tumors or polyps, coagulation of
tion of fluid, obtaining of tissue bleeding sites, and removal of foreign
biopsy samples, and passage of a laser bodies. ■
Colonoscopy 399
INDICATIONS: • Crohn’s disease

• Assess GI function in a patient with a • Diverticula
personal or family history of colon
cancer, polyps, or ulcerative colitis • Foreign bodies
• Confirm diagnosis of colon cancer and • Hemorrhoids
inflammatory bowel disease • Polyps
• Detect Hirschsprung’s disease and • Proctitis
determine the areas affected by the
• Tumors
disease
• Vascular abnormalities
• Determine cause of lower GI disorders,
especially when barium enema and
proctosigmoidoscopy are inconclusive
• Determine source of rectal bleeding INTERFERING FACTORS:
and perform hemostasis by coagulation
This procedure is
• Evaluate postsurgical status of colon contraindicated for:
resection • Patients with bleeding disorders or car-
• Evaluate stools that show a positive diac conditions
occult blood test, lower GI bleeding, or • Patients with bowel perforation, acute
change in bowel habits peritonitis, acute colitis, ischemic bowel
• Follow up on previously diagnosed and necrosis, toxic colitis, recent bowel
treated colon cancer surgery, advanced pregnancy, severe
cardiac or pulmonary disease, recent
• Investigate iron-deficiency anemia of myocardial infarction, known or sus-
unknown origin pected pulmonary embolus, and large
• Reduce volvulus and intussusception in abdominal aortic or iliac aneurysm
children • Patients who have had a colon anasto-
mosis within the past 14 to 21 days,
• Remove colon polyps
because an anastomosis may break
• Remove foreign bodies and sclerosing down with gas insufflation
strictures by laser
Factors that may
RESULT impair clear imaging:
Normal Findings: resulting from inadequate cleansing or
• Normal intestinal mucosa with no failure to restrict food intake before the
abnormalities of structure, function, or study
mucosal surface in the colon or termi-
nal ileum
ologic procedure
Abnormal Findings: • Metallic objects within the examina-
• Benign lesions tion field (e.g., jewelry, body rings),
• Bleeding sites
• Bowel distention
• Bowel infection or inflammation ographic equipment to accommodate
• Colitis
• Colon cancer poor-quality study
• Patients who are very obese, who the patient should wear a protective
may exceed the weight limit for the lead apron, stand behind a shield, or
equipment leave the area while the examination is
being done. Personnel working in the
area where the examination is being
their level of exposure to radiation.
because of age, significant pain, or Nursing Implications and
mental status Procedure ● ● ● ● ● ● ● ● ● ● ●
• Severe lower GI bleeding or the pres-

Pretest:
ence of feces, barium, blood, or blood
clots, which can interfere with visuali- ➤ Inform the patient that the procedure
zation assesses the colon.
• Spasm of the colon, which can mimic ➤ Obtain a history of the patient’s com-
plaints.
the radiographic signs of cancer (Note:
the use of intravenous [IV] glucagon ➤ Obtain a history of results of pre-
minimizes spasm) viously performed diagnostic pro-
• Inability of the patient to tolerate intro- laboratory tests. For related diagnos-
duction of or retention of barium, air, tic tests, refer to the Gastrointestinal
or both in the bowel System table.
Other considerations: formed before an upper gastroin-
• Complications of the procedure may testinal study or barium swallow.
include hemorrhage and cardiac ➤ Record the date of the last menstrual
arrhythmias. period and determine the possibility
• The procedure may be terminated if women.
chest pain or severe cardiac arrhythmias ➤ Obtain a list of the medications the
occur. patient is taking, including drugs that
affect bleeding, such as aspirin and
• Failure to follow dietary restrictions other salicylates.
cause the procedure to be canceled or ➤ Note intake of oral iron preparations
within 1 week before the procedure
repeated. because these cause black, sticky
• Bowel preparations that include laxa- feces that are difficult to remove
tives or enemas should be avoided in with bowel preparation.
pregnant patients or patients with ➤ Review the procedure with the
inflammatory bowel disease, unless patient. Explain to the patient that
specifically directed by a health care some pain may be experienced dur-
practitioner. ing the test, and there may be
• Consultation with a physician should purpose of the test and how the pro-
occur before the procedure for radia- cedure is performed. Inform the
tion safety concerns regarding younger patient that the procedure is per-
patients or patients who are lactating. formed in a GI lab, usually by a health
care practitioner and support staff,
• Risks associated with radiographic over- and takes approximately 30 to 60
exposure can result from frequent x-ray minutes.
procedures. Personnel in the room with ➤ Sensitivity to cultural and social
Colonoscopy 401
issues, as well as concern for mod- ➤ Instruct the patient to cooperate fully
esty, is important in providing psy- and to follow directions. Instruct the
chological support before, during, patient to remain still throughout
and after the procedure. the procedure because movement
➤ Instruct the patient to eat a low- produces unreliable results.
residue diet for several days before ➤ Obtain and record baseline vital
the procedure and to consume only signs.
clear liquids the evening before the ➤ An intravenous (IV) line may be
test. The patient should fast and started to allow infusion of a seda-
restrict fluids for 8 hours prior to the tive or IV fluids.
procedure. ➤ Administer medications, as ordered,
➤ Ensure that ordered laxatives have to reduce discomfort and to promote
been administered late in the after- relaxation and sedation.
noon of the day before the pro- ➤ The patient is placed on an examina-
cedure. tion table in the left lateral decubitus
➤ Inform the patient that it is important position and draped with the but-
that the bowel be cleaned thoroughly tocks exposed.
so that the physician can visualize ➤ The physician performs a visual
the colon. Inform the patient that a inspection of the perianal area and a
laxative and cleansing enema may be digital rectal examination.
needed the day before the proce-
dure, with cleansing enemas on the ➤ The patient is requested to bear
morning of the procedure, depending down as if having a bowel move-
on the institution’s policy. ment as the fiberoptic tube is in-
serted through the rectum.
➤ The scope is advanced through the
sigmoid. The patient’s position is
changed to supine to facilitate pas-
any medications.
sage into the transverse colon. Air is
insufflated through the tube during
Intratest: passage to aid in visualization.
➤ Ensure that the patient has complied ➤ The patient is instructed to take deep
with dietary, and medication restric- breaths to aid in movement of
tions and pretesting preparations for the scope downward through the
at least 6 hours prior to the pro- ascending colon to the cecum and
cedure. into the terminal portion of the ileum.
➤ Assess for completion of bowel ➤ Air is insufflated to distend the GI
preparation according to the institu- tract, as needed. Biopsies, cultures,
tion’s procedure. or any endoscopic surgery is per-
➤ Instruct the patient to remove jew- formed.
elry, including watches, credit cards, ➤ Foreign bodies or polyps are removed
and other metallic objects. and placed in appropriate specimen
➤ Have emergency equipment readily containers, labelled, and sent to the
available. laboratory.
➤ Photographs are obtained for future
reference.
to void prior to the procedure. ➤ At the end of the procedure, excess
air and secretions are aspirated
through the scope, and the colono-
scope is removed.
patient, and label the appropriate Post-test:
containers with the corresponding
patient demographics, date, and time ➤ Monitor the patient for signs of res-
of collection. piratory depression.
➤ Monitor vital signs and neurologic ➤ Encourage the patient to drink sev-
status every 15 minutes for 1 hour, eral glasses of water to help replace
then every 2 hours for 4 hours, and fluids lost during the preparation for
as ordered. Take temperature every 4 the test.
hours for 24 hours. Compare with ➤ Carefully monitor the patient for
baseline values. Notify the health fatigue and fluid and electrolyte
care practitioner if temperature is imbalance.
elevated. Protocols may vary from
facility to facility. ➤ A written report of the examina-
➤ Observe the patient until the effects
of the sedation have worn off.
➤ Instruct the patient to resume usual be sent to the requesting health care
diet, fluids, medications, or activity, practitioner, who will discuss the
as directed by the health care practi- results with the patient.
tioner.
➤ Monitor for any rectal bleeding. patient’s health care provider regard-
Instruct the patient to expect slight ing further testing, treatment, or
rectal bleeding for 2 days after referral to another health care pro-
removal of polyps or biopsy speci- vider. Answer any questions or
mens, but that an increasing amount address any concerns voiced by the
of bleeding or sustained bleeding patient or family.
should be reported to the physician
immediately. ➤ Depending on the results of this pro-
➤ Observe the patient for indications
of chest pain, abdominal pain or ten-
derness, or breathing problems. If
these symptoms are present or
increase in frequency or severity, the
change should be reported to a
physician immediately.
➤ Inform the patient that belching,
bloating, or flatulence is the result of Related diagnostic tests:
air insufflation. ➤ Related diagnostic tests include bar-
➤ Emphasize that any severe pain, ium enema, computed tomography
fever, difficulty breathing, or GI bleed- of the abdomen, magnetic reso-
ing must be reported to the physician nance imaging of the abdomen, and
immediately. proctosigmoidoscopy.
COLOR PERCEPTION TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Color blindness test.

AREA OF APPLICATION: Eyes.
CONTRAST: N/A.
Color Perception Test 403
DESCRIPTION & RATIONALE: Defects • Inability of the patient to cooperate
in color perception can be hereditary or remain still during the procedure
or aquired. The congenital defect for because of age, significant pain, or men-
color blindness is carried by the tal status
female, who is generally unaffected, • Inability of the patient to read
and expressed dominantly in males.
Color blindness occurs in 8% of males • Poor visual acuity or poor lighting
and 0.4% of females. Aquired color • Failure of the patient to wear corrective
blindness may occur as a result of dis- lenses (glasses or contact lenses)
eases of the optic nerve or retina. • Damaged or discolored test plates
Color blindness may be partial or
complete. The partial form is the
hereditary form, and in the majority Nursing Implications and
of patients the color deficiency is in Procedure ● ● ● ● ● ● ● ● ● ● ●
the red-green area of the spectrum.

Color perception tests are performed Pretest:
to determine the acuity of color dis- ➤ Inform the patient that the procedure
crimination. The most common test detects color vision impairment.
uses pseudoisochromic plates with ➤ Obtain a history of the patient’s com-
numbers or letters buried in a maze of plaints, including a list of known al-
dots. Misreading the numbers or let- lergens.
ters indicates a color perception defi- ➤ Obtain a history of the patient’s
ciency and may indicate color known or suspected vision loss,
changes in visual acuity, including
blindness, a genetic dysfunction, or
type and cause; use of glasses or
retinal pathology. ■ contact lenses; eye conditions with
treatment regimens; eye surgery;
INDICATIONS: and other tests and procedures to
assess and diagnose visual deficit.
• Detect deficiencies in color perception
• Evaluate because of family history of ously performed laboratory tests,
color visual defects surgical procedures, and other diag-
nostic procedures.
• Investigate suspected retinal pathology
affecting the cones patient is taking, including herbs,
RESULT ceuticals. The requesting health care
practitioner should be advised if the
patient regularly uses these products
Normal Findings:
so that their effects can be taken
• Normal visual color discrimination. No into consideration when reviewing
difficulty in identification of color results.
combinations. ➤ Review the procedure with the
patient. Ask the patient if he or she
Abnormal Findings: wears corrective lenses; also inquire
about the importance of color dis-
• Identification of some but not all
crimination in his or her work, as
colors. applicable. Address concerns about
pain related to the procedure. Explain
CRITICAL VALUES: N/A to the patient that no discomfort will
be experienced during the test. care practitioner specializing in this

Inform the patient that a technician, branch of medicine. The report will
optometrist, or physician performs be sent to the requesting health care
the test, in a quiet, darkened room, practitioner, who will discuss the
and that to evaluate both eyes, the results with the patient.
test can take 5 to 15 or up to 30 min- ➤ Recognize anxiety related to test
utes, depending on the complexity of results and be supportive of impaired
testing required. activity related to color vision loss.
➤ There are no food, fluid, or medica- Discuss the implications of abnormal
tion restrictions unless by medical test results on the patient’s lifestyle.
direction. Provide teaching and information
Intratest: the test results, as appropriate.
➤ Instruct the patient to cooperate fully ➤ Reinforce information given by the
and to follow directions. patient’s health care provider regard-
➤ Seat the patient comfortably. Oc- referral to another health care pro-
clude one eye and hold test booklet vider. Answer any questions or ad-
12 to 14 inches in front of the ex- dress any concerns voiced by the
posed eye. patient or family.
➤ Ask the patient to identify the num-
bers or letters buried in the maze of
dots or to trace the objects with a
hand-held pointed object.
➤ Repeat on the other eye. and determine the need for a change
➤ The results are recorded manually in therapy. Evaluate test results in
for recall and postprocedure interpre- relation to the patient’s symptoms
tation by the appropriate health care and other tests performed.
practitioner.
Post-test:
➤ A written report of the examina- refraction and slit-lamp biomicros-
tion will be completed by a health copy.
COLPOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Endometrial biopsy, cervical biopsy.

AREA OF APPLICATION: Vagina and cervix.
CONTRAST: None.
Colposcopy 405
Abnormal Findings:
DESCRIPTION & RATIONALE: In this • Atrophic changes
procedure, the vagina and cervix are
• Cervical erosion
viewed using a colposcope, a special
binocular microscope and light system • Cervical intraepithelial neoplasia
that magnifies the mucosal surfaces.
• Infection
Colposcopy is usually performed after
suspicious Papanicolaou (Pap) test • Inflammation
results or when suspected lesions can- • Invasive carcinoma
not be visualized fully by the naked
eye. The procedure is useful for iden- • Leukoplakia
tifying areas of cellular dysplasia and • Papilloma, including condyloma
diagnosing cervical cancer because it
provides the best view of the suspi- CRITICAL VALUES: N/A
cious lesion, ensuring that the most
representative area of the lesion is INTERFERING FACTORS:
obtained for cytologic analysis to con-
firm malignant changes. Colposcopy This procedure is
is also valuable for assessing women contraindicated for:
with a history of exposure to diethyl- • Patients who are pregnant or suspected
stilbestrol (DES) in utero. The goal is of being pregnant, unless the potential
to identify precursor changes in cervi- benefits of the procedure far outweigh
cal tissue before the changes advance the risks to the fetus and mother
from benign or atypical cells to cervi- • Patients with cardiac conditions
cal cancer. Photographs (cervicogra-
• Patients with bleeding disorders, espe-
phy) can also be taken of the cervix. ■ cially if cervical biopsy specimens are to
be obtained
INDICATIONS:
• Evaluate the cervix after abnormal Pap • Women who are currently men-
smear struating
• Evaluate vaginal lesions
Factors that may
• Localize the area from which cervical impair clear imaging:
biopsy samples should be obtained • Inadequate cleansing of the cervix of
because such areas may not be visible to secretions and medications
the naked eye
• Scarring of the cervix
• Monitor conservatively treated cervical
intraepithelial neoplasia • Patients who are very obese, who
• Monitor women whose mothers took
equipment
DES during pregnancy
RESULT which may produce poor visualization
Normal Findings:
• Normal appearance of the vagina and
or remain still during the proce-
cervix
dure because of age, significant pain,
• No abnormal cells or tissues or mental status
• Severe bleeding or the presence of feces, setting, usually by a health care prac-
blood, or blood clots, which can inter- titioner and support staff, and takes
fere with visualization approximately 30 to 60 minutes.
Other considerations: issues, as well as concern for mod-
• Complications of the procedure may esty, is important in providing psy-
include hemorrhage and cardiac arrhy- and after the procedure.
thmias.
• The procedure may be terminated if tion restrictions unless by medical
chest pain or severe cardiac arrhythmias direction.
occur. ➤ Explain to the patient that if a biopsy
is performed, she may feel men-
• Failure to follow dietary restrictions strual-like cramping during the pro-
and other pretesting preparations may cedure and experience a minimal
cause the procedure to be canceled or amount of bleeding.
repeated. ➤ Make sure a written and informed
Nursing Implications and any medications.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest: ➤ Instruct the patient to remove jew-
elry (including watches), credit cards,
and other metallic objects.
assesses the uterus and cervix.
➤ Obtain a history of the patient’s com- available.
plaints.
➤ Obtain a history of results of previ- foot coverings to wear and instructed
ously performed diagnostic pro- to void prior to the procedure.
cedures, surgical procedures, and ➤ Observe standard precautions, and
laboratory tests. For related diagnos- follow the general guidelines in
tic tests, refer to the Reproductive Appendix A. Positively identify the
System table. patient, and label the appropriate
➤ Record the date of the last menstrual containers with the corresponding
period and determine the possibil- patient demographics, date, and time
ity of pregnancy in perimenopausal of collection.
women. ➤ Instruct the patient to cooperate fully
➤ Obtain a list of the medications the and to follow directions. Instruct the
patient is taking, including drugs that patient to remain still throughout the
affect bleeding, such as aspirin and procedure because movement pro-
other salicylates. duces unreliable results.
➤ Obtain and record baseline vital
➤ Review the procedure with the signs.
patient. Explain to the patient that
some pain may be experienced dur- ➤ An intravenous (IV) line may be
ing the test, and there may be started to allow infusion of a seda-
moments of discomfort. Oral solu- tive or IV fluids.
tion may be ordered. Explain the pur- ➤ Administer medications, as ordered,
pose of the test and how the to reduce discomfort and to promote
procedure is performed. Inform the relaxation and sedation.
patient that the procedure is per- ➤ Place the patient in the lithotomy
formed in a GI lab or medical office position on the examining table and
Colposcopy 407
drape. Cleanse the external genitalia ➤ If a biopsy was performed, inform

with an antiseptic solution. the patient that a discharge may per-
➤ If a Pap smear is performed, the sist for a few days to a few weeks.
vaginal speculum is inserted, using ➤ Advise the patient to avoid strenu-
water as a lubricant. ous exercise 8 to 24 hours after the
➤ The cervix is swabbed with 3% procedure, and to avoid douching
acetic acid to remove mucus or any and intercourse for about 2 weeks
cream medication and to improve the or as directed by the health care
contrast between tissue types. The practitioner.
scope is positioned at the speculum ➤ Monitor for any bleeding. Instruct
and is focused on the cervix. The the patient to expect slight bleeding
area is examined carefully, using light for 2 days after removal of biopsy
and magnification. Photographs can specimens, but emphasize that per-
be taken for future reference. sistent vaginal bleeding or abnormal
➤ Tissues that appear abnormal or vaginal discharge, an increasing
atypical undergo biopsy using a for- amount of bleeding, abdominal pain,
ceps inserted through the speculum. and fever must be reported to the
Bleeding, which is common after health care practitioner immediately.
cervical biopsy, may be controlled by ➤ Observe the patient for indications
cautery, suturing, or application of of chest pain, abdominal pain or ten-
silver nitrate or ferric subsulfate derness, or breathing problems. If
(Monsel’s solution) to the site. these symptoms are present or
➤ The vagina is rinsed with sterile increase in frequency or severity, the
saline or water to remove the ace- change should be reported to the
tic acid and prevent burning after health care practitioner immediately.
the procedure. If bleeding persists, ➤ A written report of the examina-
a tampon may be inserted after tion will be completed by a health
removal of the speculum. care practitioner specializing in this
➤ Biopsy samples are placed in appro- branch of medicine. The report will
priate labelled containers with special be sent to the requesting health care
preservative solution, and promptly practitioner, who will discuss the
transported to the laboratory. results with the patient.
Post-test: patient’s health care provider regard-
➤ Monitor the patient for signs of res- referral to another health care pro-
piratory depression. vider. Answer any questions or ad-
➤ Monitor vital signs and neurologic dress any concerns voiced by the
status every 15 minutes for 1 hour, patient or family.
then every 2 hours for 4 hours, and ➤ Depending on the results of this pro-
as ordered. Take temperature every 4 cedure, additional testing may be
hours for 24 hours. Compare with needed to evaluate or monitor pro-
baseline values. Notify the health gression of the disease process and
care practitioner if temperature is determine the need for a change in
elevated. Protocols may vary from therapy. Evaluate test results in rela-
facility to facility. tion to the patient’s symptoms and
➤ Observe the patient until the effects other tests performed.
of the sedation if ordered have worn
off. Related diagnostic tests:
➤ Instruct the patient to remove the ➤ Related diagnostic tests include com-
vaginal tampon, if inserted, within 8 puted tomography of the abdomen,
to 24 hours; after that time, the magnetic resonance imaging of the
patient should wear pads if there is abdomen, and ultrasound of the
bleeding or drainage. pelvis.
COMPLEMENT C3 AND
COMPLEMENT C4
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: C3 and C4.

C3
SI Units
Newborn 57–116 mg/dL 570–1160 mg/L
6 mo–adult 74–166 mg/dL 740–1660 mg/L
Adult 83–177 mg/dL 830–1770 mg/L
C4
SI Units
Newborn 10–31 mg/dL 100–310 mg/L
6 mo–6 y 15–52 mg/dL 150–520 mg/L
7–12 y 19–40 mg/dL 190–400 mg/L
13–15 y 19–57 mg/dL 190–570 mg/L
16–18 y 19–42 mg/dL 190–420 mg/L
Adult 12–36 mg/dL 120–360 mg/L
DESCRIPTION & RATIONALE: Com- Circulating C3 is synthesized in the

plement proteins act as enzymes that liver and comprises 70% of the com-
aid in the immunologic and inflam- plement system, but cells in other tis-
matory response. The complement sues can also produce C3. C3 is an
system is an important mechanism for essential activating protein in the clas-
the destruction and removal of foreign sic and alternate complement cas-
materials. Serum complement levels cades. It is decreased in patients with
are used to detect autoimmune dis- immunologic diseases, in whom it is
eases. C3 and C4 are the most fre- consumed at an increased rate. C4 is
quently assayed complement proteins, produced primarily in the liver but
along with total complement. can also be produced by monocytes,
Complement C3 and Complement C4 409
fibroblasts, and macrophages. C4 par- INDICATIONS:

ticipates in the classic complement • Detect genetic deficiencies
pathway. ■ • Evaluate immunologic diseases
RESULT
Normal C4 and decreased C3 Acute glomerulonephritis, membranous

glomerulonephritis, immune complex
diseases, SLE, C3 deficiency
Decreased C4 and normal C3 Immune complex diseases, cryoglobu-
linemia, C4 deficiency, hereditary
angioedema
Decreased C4 and decreased C3 Immune complex diseases
Increased in: Post–streptococcal infection

• C3 and C4 Rheumatic arthritis
Acute-phase reactions
• C4
• C3 Angioedema (hereditary and
Amyloidosis acquired)
Cancer Autoimmune hemolytic anemia
Diabetes Autoimmune thyroiditis
Myocardial infarction Cryoglobulinemia
Pneumococcal pneumonia Glomerulonephritis
Pregnancy Juvenile dermatomyositis
heumatic disease Meningitis (bacterial, viral)
Thyroiditis Pneumonia
Viral hepatitis Streptococcal or staphylococcal
sepsis
• C4
Certain malignancies CRITICAL VALUES: N/A
Decreased in: INTERFERING FACTORS:
• C3 and C4 • Drugs that may increase C3 levels
Hereditary deficiency include cimetidine and cyclophos-
phamide.
Liver disease
Systemic lupus erythematosus • Drugs that may decrease C3 levels
(SLE) include danazol and phenytoin.
• C3 • Drugs that may increase C4 levels

include cimetidine, cyclophosphamide,
Chronic infection (bacterial,
parasitic, viral) and danazol.
Post–membranoproliferative • Drugs that may decrease C4 levels
glomerulonephritis include dextran and penicillamine.

➤ Inform the patient that the test is lection. Perform a venipuncture;
used to assist in the diagnosis of collect the specimen in a 5-mL red-
immunologic diseases in which com- top tube.
plement is consumed at an in-
creased rate or to detect inborn ➤ Remove the needle, and apply a
deficiency. pressure dressing over the puncture
site.
plaints, including a list of known ➤ Promptly transport the specimen to
allergens (especially allergies or sen- the laboratory for processing and
sitivities to latex), and inform the analysis.
appropriate health care practitioner ➤ The results are recorded manually
accordingly. or in a computerized system for
➤ Obtain a history of the patient’s recall and postprocedure interpreta-
immune system and results of previ- tion by the appropriate health care
ously performed laboratory tests, practitioner.
Post-test:
System table. ➤ Observe venipuncture site for bleed-
patient is taking, including herbs, paper tape or other adhesive to hold
nutritional supplements, and nutra- pressure bandage in place, or re-
ceuticals. The requesting health care place with a plastic bandage.
practitioner and laboratory should be ➤ A written report of the examination
advised if the patient regularly uses will be sent to the requesting health
these products so that their effects care practitioner, who will discuss
can be taken into consideration the results with the patient.
or family.
venipuncture. ➤ Depending on the results of this
➤ There are no food, fluid, or medica- procedure, additional testing may be
tion restrictions unless by medical performed to evaluate or monitor
direction. progression of the disease process
Intratest: in therapy. Evaluate test results in
➤ If the patient has a history of severe and other tests performed.
ment containing latex. Related laboratory tests:
➤ Instruct the patient to cooperate fully ➤ Related laboratory tests include anti-
and to follow directions. Direct the cardiolipin antibody, antinuclear anti-
patient to breathe normally and to bodies, erythrocyte sedimentation
avoid unnecessary movement. rate, and total complement.
Complement, Total 411
COMPLEMENT, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Total hemolytic complement, CH50, CH100.
REFERENCE VALUE: (Method: Quantitative hemolysis)

40–100 CH50 U/mL 40–100 CH50 kU/L
INDICATIONS:
DESCRIPTION & RATIONALE: The • Assist in the diagnosis of hereditary
complement system comprises pro- angioedema
teins that become activated and inter-
• Evaluate complement activity in auto-
act in a sequential cascade. The immune disorders
complement system is an important
part of the body’s natural defense • Evaluate and monitor therapy for sys-
against allergic and immune reactions. temic lupus erythematosus
It is activated by plasmin and is inter- • Screen for complement deficiency
related with the coagulation and fibri-
nolytic systems. Activation of the RESULT
complement system results in cell
Increased in:
lysis, release of histamine, chemotaxis
of white blood cells, increased vascular • Acute-phase immune response
permeability, and contraction of
Decreased in:
smooth muscle. The activation of this
• Autoimmune diseases
system can sometimes occur with
uncontrolled self-destructive effects • Autoimmune hemolytic anemia
on the body. In the serum comple- • Burns
ment assay, a patient’s serum is mixed
with sheep red blood cells coated with • Cryoglobulinemia
antibodies. If complement is present • Hereditary deficiency
in sufficient quantities, 50% of the • Infections (bacterial, parasitic, viral)
red blood cells are lysed. Lower
amounts of lysed cells are associated • Liver disease
with decreased complement levels. ■ • Malignancy
• Membranous glomerulonephritis can be taken into consideration

• Systemic lupus erythematosus patient. Inform the patient that spec-
• Trauma 5 to 10 minutes. Address concerns
• Vasculitis Explain to the patient that there may
INTERFERING FACTORS: tion restrictions unless by medical
• Drugs that may increase total comple- direction.
ment levels include cyclophosphamide
and danazol. Intratest:
• Specimen should not remain at room ➤ If the patient has a history of severe
temperature longer than 1 hour. allergic reaction to latex, care should
used to evaluate immune dieases Appendix A. Positively identify the
related to complement activity and patient, and label the appropriate
follow up on a patient’s response to tubes with the corresponding patient
therapy. demographics, date, and time of col-
➤ Obtain a history of the patient’s com- collect the specimen in a 5-mL red-
plaints, including a list of known top tube.
accordingly. site.

immune system and results of previ- the laboratory for processing and
ously performed laboratory tests, analysis.
surgical procedures, and other diag- ➤ The results are recorded manually
nostic procedures. For related labo- or in a computerized system for
ratory tests, refer to the Immune recall and postprocedure interpreta-
System table. tion by the appropriate health care
➤ Obtain a list of medications the practitioner.
practitioner and laboratory should be ➤ Observe venipuncture site for bleed-
these products so that their effects paper tape or other adhesive to
Complete Blood Count 413
hold pressure bandage in place, or cedure, additional testing may be

replace with a plastic bandage. performed to evaluate or monitor
referral to another health care pro- Related laboratory tests:
vider. Answer any questions or ➤ Related laboratory tests include anti-
address any concerns voiced by the nuclear antibodies, complement C3
patient or family. and C4, and erythrocyte sedimenta-
➤ Depending on the results of this pro- tion rate.
COMPLETE BLOOD COUNT

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CBC.
SPECIMEN: Whole blood from one full lavender-top (EDTA) tube or
Microtainer. Whole blood from a green-top (lithium or sodium heparin)
tube may be submitted, but the following automated values may not be
reported: white blood cell (WBC) count, WBC differential, platelet count,
and mean platelet volume.
REFERENCE VALUE: (Method: Automated, computerized multichannel
analyzers that sort and size cells on the basis of changes in either electrical
impedance or light pulses as the cells pass in front of a laser. Many of these
analyzers are capable of determining a five-part WBC differential.) This
battery of tests includes hemoglobin, hematocrit, red blood cell (RBC)
count, RBC morphology, RBC indices, RBC distribution width index
(RDW), platelet count, platelet size, WBC count, and WBC differential.
The five-part automated WBC differential identifies and enumerates
neutrophils, lymphocytes, monocytes, eosinophils, and basophils.
Hemoglobin (See “Hemoglobin” monograph for more

detailed information)
SI Units
Cord blood 13.5–20.5 g/dL 135–205 mmol/L
2 wk 13.4–19.8 g/dL 134–198 mmol/L
1 mo 10.7–17.1 g/dL 107–171 mmol/L
6 mo 11.1–14.4 g/dL 111–144 mmol/L
1y 11.3–14.1 g/dL 113–141 mmol/L
9–14 y 12.0–14.4 g/dL 120–144 mmol/L
Adult
Male 13.2–17.3 g/dL 132–173 mmol/L
Female 11.7–15.5 g/dL 117–155 mmol/L
Older adult
(65–74 y)
Male 12.6–17.4 g/dL 126–174 mmol/L
Female 11.7–16.1 g/dL 117–161 mmol/L
Hematocrit (See “Hematocrit” monograph for more

SI Units
Age Conventional Units(%) (Conventional Units 0.01*)
Cord blood 47–57 0.47–0.57
1d 51–65 0.51–0.65
2 wk 47–57 0.47–0.57
1 mo 38–52 0.38–0.52
6 mo 35–41 0.35–0.41
1y 37–41 0.37–0.41
10 y 36–42 0.36–0.42
Adult
Male 43–49 0.43–0.49
Female 38–44 0.38–0.44
*Volume fraction.
White Blood Cell Count and Differential (See “White Blood Cell Count and Cell Differential” monograph
for more detailed information)
SI Units
(Conventional
Age Units 1) Neutrophils Lymphocytes Monocytes Eosinophils Basophils
12/15/05
WBC Total Bands Segments

103/mm3 (Absolute) (Absolute) (Absolute) (Absolute) (Absolute) (Absolute) (Absolute)
or cells/L and % and % and % and % and % and % and %
Birth 0.0–30.0 (6.0–26.0) 61% (1.65) 9.1% (9.4) 52% (2.0–11) 31% (0.4–3.1) 5.8% (0.02–0.85) 2.2% (0–0.64) 0.6%
8:36 PM
1d 9.4–34.0 (5.0–21.0) 61% (1.75) 9.2% (9.8) 52% (2.0–11.5) 31% (0.2–3.1) 5.8% (0.02–0.95) 2.0% (0–0.30) 0.5%
2 wk 5.0–20.0 (1.0–9.5) 40% (0.63) 5.5% (3.9) 34% (2.0–17.0) 48% (0.2–2.4) 8.8% (0.07–1.0) 3.1% (0–0.23) 0.4%
1 mo 5.0–19.5 (1.0–9.0) 35% (0.49) 4.5% (3.3) 30% (2.5–16.5) 56% (0.15–2.0) 6.5% (0.07–0.90) 2.8% (0–0.20) 0.5%
6 mo 6.0–17.5 (1.0–8.5) 32% (0.45) 3.8% (3.3) 28% (4.0–13.5) 61% (0.1– 1.3) 4.8% (0.07–0.75) 2.5% (0–0.20) 0.4%
1y 6.0–17.5 (1.5–8.5) 31% (0.35) 3.1% (3.2) 28% (4.0–10.5) 61% (0.05–1.1) 4.8% (0.05–0.70) 2.6% (0–0.20) 0.4%
Page 415
10 y 4.5–13.5 (1.8–8.0) 54% (1.8–7.0) 3.0% (1.8–7.0) 51% (1.5–6.5) 38% (0–0.8) 4.3% (0–0.60) 2.4% (0–0.20) 0.5%
Adult 4.5–11.0 (1.8–7.7) 59% (0–0.7) 3.0% (1.8–7.0) 56% (1.0–4.8) 34% (0–0.8) 4.0% (0–0.45) 2.7% (0–0.20) 0.5%
415
Red Blood Cell Count (See “Red Blood Cell Count” monograph for
more detailed information)
SI Units
Cord blood 4.14–4.69 106 cells/mm3 4.14–4.69 1012 cells /L
1d 5.33–5.47 106 cells/mm3 5.33–5.47 1012 cells /L
2 wk 4.32–4.98 106 cells/mm3 4.32–4.98 1012 cells /L
1 mo 3.75–4.95 106 cells/mm3 3.75–4.95 1012 cells /L
6 mo 3.71–4.25 106 cells/mm3 3.71–4.25 1012 cells /L
1y 4.40–4.48 106 cells/mm3 4.40–4.48 1012 cells /L
10 y 4.75–4.85 106 cells/mm3 4.75–4.85 1012 cells /L
Adult
Male 4.71–5.14 106 cells/mm3 4.71–5.14 1012 cells /L
Female 4.20–4.87 106 cells/mm3 4.20–4.87 1012 cells /L
Red Blood Cell Indices (See “Red Blood Cell Indices” monograph for
more detailed information)
Age MCV (fl) MCH (pg/cell) MCHC (g/dL) RDW

Cord blood 107–119 35–39 32–34 14.9–18.7
1d 104–116 35–39 32–34 14.9–18.7
2 wk 95–117 29–35 28–32 14.9–18.7
1 mo 93–115 29–35 28–34 14.9–18.7
6 mo 82–100 24–30 28–32 14.9–18.7
1y 81–95 25–29 29–31 11.6–14.8
10 y 75–87 25–31 33–35 11.6–14.8
Adult
Male 85–95 28–32 33–35 11.6–14.8
Female 85–95 28–32 33–35 11.6–14.8
MCV mean corpuscular volume; MCH mean corpuscular hemoglobin; MCHC

mean corpuscular hemoglobin concentration; RDW RBC distribution width index.
Red Blood Cell Morphology (See “Red Blood Cell Morphology and
Inclusions” monograph for more detailed information)
Within
Normal
Morphology Limits 1 2 3 4
Size
Anisocytosis 0–5 5–10 10–20 20–50 Greater
than 50
Macrocytes 0–5 5–10 10–20 20–50 Greater
than 50
Microcytes 0–5 5–10 10–20 20–50 Greater
than 50
416
Within
Normal
Morphology Limits 1 2 3 4
Shape
Poikilocytes 0–2 3–10 10–20 20–50 Greater
than 50
Burr cells 0–2 3–10 10–20 20–50 Greater
than 50
Acanthocytes Less than 1 2–5 5–10 10–20 Greater
than 20
Schistocytes Less than 1 2–5 5–10 10–20 Greater
than 20
Dacryocytes 0–2 2–5 5–10 10–20 Greater
(teardrop cells) than 20
Codocytes 0–2 2–10 10–20 20–50 Greater
(target cells) than 50
Spherocytes 0–2 2–10 10–20 20–50 Greater
than 50
Ovalocytes 0–2 2–10 10–20 20–50 Greater
than 50
Stomatocytes 0–2 2–10 10–20 20–50 Greater
than 50
Drepanocytes Absent Reported as present or absent
(sickle cells)
Helmet cells Absent Reported as present or absent
Agglutination Absent Reported as present or absent
Rouleaux Absent Reported as present or absent
Hemoglobin Content
Hypochromia 0–2 3–10 10–50 50–75 Greater
than 75
Polychromasia
Adult Less than 1 2–5 5–10 10–20 Greater
than 20
Newborn 1–6 7–15 15–20 20–50 Greater
than 50
Red Blood Cell Inclusions (See “Red Blood Cell Morphology and
Inclusions” monograph for more detailed information)
Within
Normal
Inclusions Limits 1 2 3 4
Cabot’s rings Absent Reported as present or absent
Basophilic stippling 0–1 1–5 5–10 10–20 Greater
than 20
417
Within
Normal
Inclusions Limits 1 2 3 4
Howell-Jolly bodies Absent 1–2 3–5 5–10 Greater
than 10
Heinz bodies Absent Reported as present or absent
Hemoglobin C crystals Absent Reported as present or absent
Pappenheimer bodies Absent Reported as present or absent
Intracellular parasites Absent Reported as present or absent
(e.g., Plasmodium,
Babesia, trypanosomes)
Platelet Count (See “Platelet Count” monograph for more

Conventional SI Units
Age Units (Conventional Units 1) MPV (fl)
1–5 y 217–497 103/L/ mm3 217–497 109/L 7.2–10.0
Adult 150–450 103/L/ mm3 181–521 109/L 7.0–10.2
• Monitor blood loss and response to

DESCRIPTION & RATIONALE: A com- blood replacement
plete blood count (CBC) is a group of • Monitor the effects of physical or emo-
tests used for basic screening pur- tional stress
poses. It is probably the most widely
ordered laboratory test. Results pro- • Monitor fluid imbalances or treatment
for fluid imbalances
vide the enumeration of the
cellular elements of the blood, meas- • Monitor hematologic status during
urement of RBC indices, and deter- pregnancy
mination of cell morphology by • Monitor progression of nonhemato-
automation and evaluation of stained logic disorders, such as chronic obstruc-
smears. The results can provide valu- tive pulmonary disease, malabsorption
able diagnostic information regarding syndromes, cancer, and renal disease
the overall health of the patient and • Monitor response to chemotherapy and
the patient’s response to disease and evaluate undesired reactions to drugs
treatment. ■ that may cause blood dyscrasias
• Provide screening as part of a gen-
INDICATIONS: eral physical examination, especially on
• Detect hematologic disorder, neoplasm, admission to a health care facility or
leukemia, or immunologic abnormality before surgery
• Determine the presence of hereditary
hematologic abnormality
RESULT: See monographs titled “Hemo-
globin,” “Hematocrit,” “Red Blood Cell
• Evaluate known or suspected anemia Indices,” “Red Blood Cell Morphology
and related treatment and Inclusions,” “Red Blood Cell Count,”
Complete Blood Count 419
“Platelet Count,” and “White Blood Cell INTERFERING FACTORS:

Count and Cell Differential.” • Failure to fill the tube sufficiently (less
than three-fourths full) may yield inad-
Increased in: See equate sample volume for automated
above-listed monographs. analyzers and may be a reason for spec-
imen rejection.
Decreased in: See • Hemolyzed or clotted specimens
above-listed monographs. should be rejected for analysis.
• Elevated serum glucose or sodium lev-
CRITICAL VALUES els may produce elevated mean corpus-
cular volume values because of swelling
Hemoglobin: of erythrocytes.
• Less than 6 g/dL • Recent transfusion history should be
considered when evaluating the CBC.
• Greater than 18 g/dL
Hematocrit:
• Less than 18%
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Greater than 54% Pretest:

WBC count (on admission): used to evaluate numerous condi-
• Less than 2500/mm3 tions involving red blood cells, white
blood cells, and platelets. The test
• Greater than 30,000/mm3 is also used to indicate inflamma-
tion, infection, and response to
chemotherapy.
Platelet count: ➤ Obtain a history of the patient’s com-
• Less than 20,000/mm3 plaints, including a list of known
• Greater than 1,000,000/mm3 sitivities to latex), and inform the
Note and immediately report to the accordingly.
health care practitioner any critically
trointestinal, hematopoietic, imm-
symptoms. une, and respiratory systems, as well
The presence of abnormal cells, other as results of previously performed
morphologic characteristics, or cellular laboratory tests, surgical procedures,
inclusions may signify a potentially life- and other diagnostic procedures. For
threatening or serious health condition related laboratory tests, refer to
and should be investigated. Examples are the Gastrointestinal, Genitourinary,
the presence of sickle cells, moderate num- Hematopoietic, Immune, and Respi-
bers of spherocytes, marked schistocytosis, ratory System tables.
oval macrocytes, basophilic stippling, ➤ Obtain a list of medications the
eosinophil count greater than 10%, patient is taking, including herbs,
monocytosis greater than 15%, nucleated nutritional supplements, and nutra-
RBCs (if patient is not an infant), malarial practitioner and laboratory should be
organisms, hypersegmented neutrophils, advised if the patient regularly uses
agranular neutrophils, blasts or other these products so that their effects
immature cells, Auer rods, Döhle bodies, can be taken into consideration when
marked toxic granulation, or plasma cells. reviewing results.
➤ Review the procedure with the ➤ Remove the needle, and apply a
patient. Inform the patient that spec- pressure dressing over the puncture
imen collection takes approximately site.
5 to 10 minutes. Address concerns ➤ Promptly transport the specimen to
about pain related to the procedure. the laboratory for processing and
Explain to the patient that there may analysis.
venipuncture. ➤ The results are recorded manually or
➤ Sensitivity to social and cultural and postprocedure interpretation by
issues, as well as concern for mod- the appropriate health care practi-
esty, is important in providing psy- tioner.
➤ There are no food, fluid, or medica- Post-test:
tion restrictions unless by medical ➤ Observe venipuncture site for bleed-
direction. ing or hematoma formation. Apply
Intratest: replace with a plastic bandage.
➤ If the patient has a history of severe ➤ Nutritional considerations: Instruct
allergic reaction to latex, care should patients to consume a variety of
be taken to avoid the use of equip- foods within the basic food groups,
ment containing latex. maintain a healthy weight, be physi-
➤ Instruct the patient to cooperate fully cally active, limit salt intake, limit
and to follow directions. Direct the alcohol intake, and be a nonsmoker.
➤ Observe standard precautions, and care practitioner, who will discuss
follow the general guidelines in the results with the patient.
Appendix A. Positively identify the ➤ Reinforce information given by the
patient, and label the appropriate patient’s health care provider regard-
tubes with the corresponding patient ing further testing, treatment, or
demographics, date, and time of referral to another health care pro-
collection. Perform a venipuncture; vider. Answer any questions or ad-
collect the specimen in a 5-mL laven- dress any concerns voiced by the
der-top (EDTA) tube. An EDTA patient or family.
Microtainer sample may be obtained
from infants, children, and adults for ➤ Depending on the results of this
whom venipuncture may not be feasi- procedure, additional testing may be
ble. The specimen should be analyzed performed to evaluate or monitor
within 6 hours when stored at room progression of the disease process
temperature or within 24 hours if and determine the need for a change
stored at refrigerated temperature. If in therapy. Evaluate test results in
it is anticipated that the specimen relation to the patient’s symptoms
will not be analyzed within 4 to 6 and other tests performed.
hours, two blood smears should
be made immediately after the Related laboratory tests:
venipuncture and submitted with the
blood sample. Smears made from ➤ Related laboratory tests include
specimens older than 6 hours will erythropoietin, ferritin, hematocrit,
contain an unacceptable number of hemoglobin, iron/total iron-binding
misleading artifactual abnormalities capacity, platelet count, RBC count,
of the RBCs, such as echinocytes and RBC indices, RBC morphology and
spherocytes, as well as necrobiotic inclusions, reticulocyte count, and
WBCs. WBC count and cell differential.
Computed Tomography, Abdomen 421
COMPUTED TOMOGRAPHY,
ABDOMEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Computed axial tomography (CAT), computed

transaxial tomography (CTT), abdominal CT.
CONTRAST: Can be done with or without oral or intravenous (IV) iodinated
contrast medium.
DESCRIPTION & RATIONALE: Abdom- evaluation or orally for bowel and adja-
inal computed tomography (CT) is a cent structure evaluation. Images can
noninvasive procedure used to enhance be recorded on photographic or x-ray
certain anatomic views of the abdomi- film or stored in digital format as digi-
nal structures, but it becomes invasive tized computer data. Cine scanning is
when a contrast medium is used. The used to produce a series of moving
patient lies on a table and is moved in images of the area scanned. The CT
and out of a doughnut-like device scan can be used to guide biopsy nee-
called a gantry, which houses the x-ray dles into areas of abdominal tumors to
tube and associated electronics. The obtain tissue for laboratory analysis
scanner uses multiple x-ray beams and and to guide placement of catheters for
a series of detectors that rotate around drainage of intra-abdominal abscesses.
the patient to produce cross-sectional Tumors, before and after therapy, may
views in a three-dimensional fashion be monitored with CT scanning. ■
by detecting and recording differences
in tissue density after having an x-ray INDICATIONS:
beam passed through the tissues. These • Assist in differentiating between benign
density measurements are sent to a and malignant tumors
computer that produces a digital • Detect aortic aneurysms
image of the anatomy, enabling a • Detect tumor extension of masses and
physician to look at slices or thin sec- metastasis into the abdominal area
tions of certain anatomic views of the
• Differentiate aortic aneurysms from
liver, biliary tract, pancreas, kidneys, tumors near the aorta
spleen, intestines, and vascular system.
Differentiations can be made among • Differentiate between infectious and
inflammatory processes
solid, cystic, inflammatory, or vascular
lesions, and suspected hematomas • Evaluate cysts, masses, abscesses, renal
and aneurysms can be identified. Iodi- calculi, gastrointestinal (GI) bleeding
nated contrast medium is given intra- and obstruction, and trauma
venously for blood vessel and vascular • Evaluate retroperitoneal lymph nodes
• Monitor and evaluate the effective- • Elderly and other patients who are
ness of medical, radiation, or surgical chronically dehydrated before the
therapies test, because of their risk of contrast-
induced renal failure.
RESULT • Patients who are in renal failure.
Normal Findings: • Young patients (17 years old and
• Normal size, position, and shape of younger), unless the benefits of the x-
abdominal organs and vascular system ray diagnosis outweigh the risks of
exposure to high levels of radiation.
Abnormal Findings:
• Abdominal abscess Factors that may
• Abdominal aortic aneurysm
• Adrenal tumor or hyperplasia resulting from inadequate cleansing or
• Dilation of the common hepatic duct,
study
common bile duct, or gallbladder
• Hematomas, diverticulitis, gallstones
ologic procedure
• Hemoperitoneum
• Hepatic cysts or abscesses tion field (e.g., jewelry, body rings),
• Pancreatic pseudocyst
• Primary and metastatic neoplasms
• Renal calculi, bowel perforation, and ographic equipment to accommodate
GI bleeding and obstruction obese or thin patients, which can cause
• Splenic laceration, tumor, infiltration,
poor-quality study
and trauma
CRITICAL VALUES: N/A exceed the weight limit for the equip-
ment
• Patients with extreme claustrophobia
This procedure is unless sedation is given before the
contraindicated for: study
• Patients with allergies to shellfish • Incorrect positioning of the patient,
or iodinated dye. The contrast which may produce poor visualization
medium used may cause a life- of the area to be examined
threatening allergic reaction. Patients
with a known hypersensitivity to the • Inability of the patient to cooperate or
medium may benefit from premedica- remain still during the procedure
tion with corticosteroids or the use of because of age, significant pain, or
nonionic contrast medium. mental status
• Patients who are claustrophobic. Other considerations:
• Patients who are pregnant or suspected • Complications of the procedure in-
of being pregnant, unless the potential clude hemorrhage, infection at the IV
benefits of the procedure far outweigh needle insertion site, and cardiac
the risks to the fetus and mother. arrhythmias.
Computed Tomography, Abdomen 423
• The procedure may be terminated if ➤ Note any recent barium or other radi-
chest pain or severe cardiac arrhythmias ologic contrast procedures. Ensure
occur. that barium studies were performed
more than 4 days before the CT
• Failure to follow dietary restrictions scan.
and other pretesting preparations may ➤ Record the date of the last menstrual
cause the procedure to be canceled or period and determine the possibility
repeated. of pregnancy in perimenopausal
• Consultation with a health care women.
provider should occur before the proce- ➤ Obtain a list of the medications the
dure for radiation safety concerns patient is taking.
regarding younger patients or patients ➤ When contrast is used, patients
who are lactating. receiving metformin (glucophage) for
non–insulin-dependent (type 2) dia-
• Risks associated with radiographic over- betes should discontinue the drug on
exposure can result from frequent x-ray the day of the test and continue to
procedures. Personnel in the room with withhold it for 48 hours after the
the patient should wear a protective test. Failure to do so may result in
lead apron, stand behind a shield, or lactic acidosis.
leave the area while the examination is ➤ Review the procedure with the
being done. Personnel working in the patient. Explain to the patient that
area where the examination is being some pain may be experienced dur-
done should wear badges that reveal ing the test, and there may be
their level of exposure to radiation. moments of discomfort. Explain the
purpose of the test and how the pro-
cedure is performed. Inform the
Nursing Implications and formed in a radiology department,
Procedure ● ● ● ● ● ● ● ● ● ● ●
usually by a health care practitioner
and support staff, and takes approxi-
➤ Inform the patient that the procedure issues, as well as concern for mod-
assesses the abdomen. esty, is important in providing psy-
➤ Obtain a history of the patient’s and after the procedure.
➤ Explain that an IV line may be
inserted to allow infusion of IV fluids,
sitivities to iodine, seafood, or other
contrast medium, dye, or sedatives.
contrast mediums.
Usually contrast medium and normal
➤ Obtain a history of results of previ- saline are infused.
ously performed diagnostic proce- ➤ Inform the patient that he or she may
dures, surgical procedures, and experience nausea, a feeling of
laboratory tests. Include specific warmth, a salty or metallic taste, or a
tests as they apply (e.g., blood urea transient headache after injection of
nitrogen [BUN], creatinine, coagula- contrast medium, if given.
tion tests, platelets, bleeding time).
Ensure that the results of blood tests ➤ The patient may be requested to
are obtained and recorded before drink approximately 450 mL of a
the procedure, especially BUN and dilute barium solution (approximately
creatinine, if contrast medium is to 1% barium) beginning 1 hour before
be used. For related diagnostic tests, the examination. This is administered
refer to the Gastrointestinal, Hepato- to distinguish gastrointestinal organs
biliary, and Genitourinary System from the other abdominal organs.
tables. ➤ The patient should fast and restrict
fluids for 8 hours prior to the proce- ➤ If contrast is used, the contrast
dure. Instruct the patient to avoid medium is injected, and a rapid
taking anticoagulant medication or to series of images is taken during and
reduce dosage as ordered prior to after the filling of the vessels to be
the procedure. examined. Delayed images may be
➤ Instruct the patient to remove jew- taken to examine the vessels after a
elry (including watches), credit cards, time and to monitor the venous
keys, coins, cell phones, pagers, and phase of the procedure.
other metallic objects. ➤ Ask the patient to inhale deeply and
➤ Make sure a written and informed hold his or her breath while the x-ray
consent has been signed prior to the images are taken, and then to exhale
procedure and before administering after the images are taken.
any medications. ➤ Instruct the patient to take slow,
deep breaths if nausea occurs during
Intratest: the procedure. Monitor and adminis-
ter an antiemetic agent if ordered.
➤ Ensure that the patient has complied Ready an emesis basin for use.
with dietary, fluids, and medication
restrictions and pretesting prepara- ➤ Monitor the patient for complica-
tions; assure that food has been tions related to the procedure (e.g.,
restricted for at least 8 hours prior to allergic reaction, anaphylaxis, bron-
the procedure. Ensure that the chospasm) if contrast is used.
patient has removed all external ➤ The needle or vascular catheter is
metallic objects (jewelry, dentures, removed, and a pressure dressing is
etc.) prior to the procedure. applied over the puncture site.
➤ Have emergency equipment readily ➤ The results are recorded on film or
available. by automated equipment in a com-
➤ If the patient has a history of severe puterized system for recall and post-
allergic reactions to any substance or procedure interpretation by the
drug, administer ordered prophylac- appropriate health care practitioner.
the procedure. Use nonionic contrast Post-test:
medium for the procedure. ➤ Instruct the patient to resume usual
➤ Patients are given a gown, robe, and diet, fluids, medications, or activity,
foot coverings to wear and instructed as directed by the health care practi-
to void prior to the procedure. tioner. Renal function should be
➤ Observe standard precautions, and assessed before metformin is
follow the general guidelines in resumed, if contrast was used.
Appendix A. ➤ Monitor vital signs and neurologic
➤ Instruct the patient to cooperate fully status every 15 minutes for 30 min-
and to follow directions. Instruct the utes. Compare with baseline values.
patient to remain still throughout the Protocols may vary from facility to
procedure because movement pro- facility.
duces unreliable results. ➤ If contrast was used, observe for
➤ Establish an IV fluid line for the injec- delayed allergic reactions, such as
tion of contrast, emergency drugs, rash, urticaria, tachycardia, hyperp-
and sedatives. nea, hypertension, palpitations, nau-
➤ Administer an antianxiety agent, as sea, or vomiting.
ordered, if the patient has claustro- ➤ If contrast was used, advise the
phobia. Administer a sedative to a patient to immediately report symp-
child or to an uncooperative adult, as toms such as fast heart rate, diffi-
ordered. culty breathing, skin rash, itching or
➤ Place the patient in the supine posi- decreased urinary output.
tion on an exam table. ➤ Observe the needle/catheter inser-
Computed Tomography, Angiography 425
tion site for bleeding, inflammation, practitioner, who will discuss the
or hematoma formation. results with the patient.
➤ Instruct the patient to apply cold ➤ Depending on the results of this pro-
compresses to the puncture site, as cedure, additional testing may be
needed, to reduce discomfort or needed to evaluate or monitor pro-
edema. gression of the disease process and
➤ Instruct the patient to increase fluid
intake to help eliminate the contrast
medium, if used.
➤ Inform the patient that diarrhea may
occur after ingestion of oral contrast
medium. Related diagnostic tests:
➤ A written report of the examina- ➤ Related diagnostic tests include
tion will be completed by a health angiography of the abdomen; kidney,
care practitioner specializing in this ureter, and bladder film; magnetic
branch of medicine. The report will resonance imaging of the abdomen;
be sent to the requesting health care and ultrasound of the pelvis.
ANGIOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Computed axial tomography (CAT)

angiography, CTA.
AREA OF APPLICATION: Vessels.

CONTRAST: Intravenous (IV) iodinated contrast medium.
DESCRIPTION & RATIONALE: Com- and out of a doughnut-like device

puted tomography angiography called a gantry, which houses the x-ray
(CTA) is a noninvasive procedure that tube and associated electronics. The
enhances certain anatomic views of scanner uses multiple x-ray beams and
vascular structures. This procedure a series of detectors that rotate around
complements traditional angiography the patient to produce cross-sectional
and allows reconstruction of the views in a three-dimensional fashion
images in different planes and removal by detecting and recording differences
of surrounding structures, leaving in tissue density after having an x-ray
only the vessels to be studied. While beam passed through the tissues. CTA
lying on a table, the patient moves in uses spiral CT technology and collects
large amounts of data with each scan. RESULT

Retrospectively, the data can be
Normal Findings:
manipulated to produce the desired
image without exposure to additional • Normal size, position, and shape of vas-
cular structures
radiation or contrast medium. Multi-
planar reconstruction images are
Abnormal Findings:
reviewed by the physician at a com-
• Aortic aneurysm
puterized workstation. These images
are helpful when there are heavily cal- • Cysts or abscesses
cified vessels. The axial images give the • Emboli
most precise information regarding
the true percentage of stenosis, and • Hemorrhage
they can also evaluate intracerebral • Neoplasm
aneurysms. Small ulcerations and • Occlusion
plaque irregularity are readily seen
with CTA; the degree of stenosis can • Shunting
be estimated better with CTA because • Stenosis
of the increased number of imaging
planes. Density measurements are sent CRITICAL VALUES: N/A
to a computer that produces a digital
image of the anatomy, enabling a INTERFERING FACTORS:
physician to look at slices or thin sec-
tions of certain anatomic views of the This procedure is
vessels. Iodinated contrast medium is contraindicated for:
given intravenously for vascular evalu- • Patients with allergies to shellfish
ation. Images can be recorded on pho- or iodinated dye. The contrast
tographic or x-ray film or stored in
digital format as digitized computer known hypersensitivity to the medium
data. ■ may benefit from premedication with
corticosteroids or the use of nonionic
INDICATIONS: contrast medium.
• Detect aneurysms
• Patients who are claustrophobic.
• Detect embolism or other occlusions
• Detect fistula
• Detect stenosis benefits of the procedure far outweigh
• Detect vascular disease the risks to the fetus and mother.
• Differentiate aortic aneurysms from • Elderly and other patients who

tumors near the aorta are chronically dehydrated before
the test, because of their risk of con-
• Differentiate between vascular and trast-induced renal failure.
nonvascular tumors
• Evaluate atherosclerosis
• Young patients (17 years old and
• Evaluate hemorrhage or trauma younger), unless the benefits of the
• Monitor and evaluate the effectiveness x-ray diagnosis outweigh the risks of
of medical or surgical therapies exposure to high levels of radiation.
Computed Tomography, Angiography 427
Factors that may regarding younger patients or patients

impair clear imaging: who are lactating.
resulting from inadequate cleansing or • Risks associated with radiographic over-
failure to restrict food intake before the exposure can result from frequent x-ray
study procedures. Personnel in the room with
• Retained barium from a previous radi- lead apron, stand behind a shield, or
ologic procedure leave the area while the examination is
• Metallic objects within the examina- being done. Personnel working in the
tion field (e.g., jewelry, body rings), area where the examination is being
which may inhibit organ visualization done should wear badges that reveal
and can produce unclear images their level of exposure to radiation.

overexposure or underexposure and a Procedure ● ● ● ● ● ● ● ● ● ● ●
poor-quality study
Pretest:
may exceed the weight limit for the assesses the cardiovascular system.
equipment
• Patients with extreme claustrophobia complaints or clinical symptoms,
unless sedation is given before the including a list of known allergens,
study especially allergies or sensitivities to
iodine, seafood, or other contrast
• Incorrect positioning of the patient, mediums.
which may produce poor visualization ➤ Obtain a history of results of pre-
of the area to be examined viously performed diagnostic pro-
• Inability of the patient to cooperate cedures, surgical procedures, and
or remain still during the procedure laboratory tests. Include specific
tests as they apply (e.g., blood urea
because of age, significant pain, or nitrogen [BUN], creatinine, coagula-
mental status tion tests, platelets, bleeding time).
Ensure that the results of blood tests
Other considerations: are obtained and recorded before
• Complications of the procedure in- the procedure, especially BUN and
clude hemorrhage, infection at the IV creatinine, if contrast medium is to
needle insertion site, and cardiac be used. For related diagnostic tests,
arrhythmias. refer to the Cardiovascular System
table.
more than 4 days before the CT
• Failure to follow dietary restrictions scan.
cause the procedure to be canceled or ➤ Record the date of the last menstrual
repeated.
➤ Patients receiving metformin (glu- tions. Ensure that the patient has
cophage) for non–insulin-dependent removed all external metallic objects
(type 2) diabetes should discontinue (jewelry, dentures, etc.) prior to the
the drug on the day of the test and procedure.
continue to withhold it for 48 hours ➤ Have emergency equipment readily
after the test. Failure to do so may available.
➤ Review the procedure with the allergic reactions to any substance or
patient. Explain to the patient that drug, administer ordered prophylac-
some pain may be experienced dur- tic steroids or antihistamines before
ing the test, and there may be the procedure. Use nonionic contrast
moments of discomfort. Explain the medium for the procedure.
cedure is performed. Inform the ➤ Patients are given a gown, robe, and
patient that the procedure is per- foot coverings to wear and instructed
formed in a radiology department, to void prior to the procedure.
usually by a health care practitioner ➤ Observe standard precautions, and
and support staff, and takes approxi- follow the general guidelines in
mately 30 to 60 minutes. Appendix A.
➤ Sensitivity to cultural and social ➤ Instruct the patient to cooperate fully
issues, as well as concern for mod- and to follow directions. Instruct the
esty, is important in providing psy- patient to remain still throughout the
chological support before, during, procedure because movement pro-
and after the procedure. duces unreliable results.
➤ Explain that an IV line may be ➤ Establish an IV fluid line for the injec-
inserted to allow infusion of IV fluids, tion of contrast, emergency drugs,
contrast medium, dye, or sedatives. and sedatives.
saline are infused. ➤ Administer an antianxiety agent, as
➤ Inform the patient that he or she may
phobia. Administer a sedative to a
experience nausea, a feeling of
child or to an uncooperative adult, as
warmth, a salty or metallic taste, or a
ordered.
transient headache after injection of
contrast medium, if given. ➤ Place the patient in the supine posi-
tion on an exam table.
➤ The patient should fast and restrict
fluids for 8 hours prior to the proce- ➤ The contrast medium is injected, and
dure. Instruct the patient to avoid a rapid series of images is taken dur-
taking anticoagulant medication or to ing and after the filling of the vessels
reduce dosage as ordered prior to to be examined. Delayed images
the procedure. may be taken to examine the vessels
➤ Instruct the patient to remove jew- after a time and to monitor the
elry (including watches), credit cards, venous phase of the procedure.
keys, coins, cell phones, pagers, and ➤ Ask the patient to inhale deeply and
other metallic objects. hold his or her breath while the x-ray
➤ Make sure a written and informed images are taken, and then to exhale
consent has been signed prior to the after the images are taken.
procedure and before administering ➤ Instruct the patient to take slow,
any medications. deep breaths if nausea occurs during
the procedure. Monitor and adminis-
Intratest: ter an antiemetic agent if ordered.
➤ Ensure that the patient has complied Ready an emesis basin for use.
with dietary, fluids, and medication ➤ Monitor the patient for complica-
restrictions and pretesting preparations related to the procedure (e.g.,
Computed Tomography, Biliary Tract and Liver 429
allergic reaction, anaphylaxis, bron- ➤ Observe the needle/catheter inser-

chospasm). tion site for bleeding, inflammation,
➤ The needle or vascular catheter is or hematoma formation.
removed, and a pressure dressing ➤ Instruct the patient to apply cold
is applied over the puncture site. compresses to the puncture site, as
➤ The results are recorded on film needed, to reduce discomfort or
or by automated equipment in a edema.
computerized system, for recall and ➤ Instruct the patient to increase fluid
postprocedure interpretation by the intake to help eliminate the contrast
appropriate health care practitioner. medium.
Post-test: tion will be completed by a health
➤ Instruct the patient to resume usual care practitioner specializing in this
as directed by the health care prac- be sent to the requesting health care
titioner. Renal function should be practitioner, who will discuss the
assessed before metformin is results with the patient.
resumed. ➤ Depending on the results of this pro-
➤ Monitor vital signs and neurologic cedure, additional testing may be
status every 15 minutes for 30 min- needed to evaluate or monitor pro-
utes. Compare with baseline values. gression of the disease process and
Protocols may vary from facility to determine the need for a change in
facility. therapy. Evaluate test results in rela-
➤ Observe for delayed allergic reac- other tests performed.
cardia, hyperpnea, hypertension,
palpitations, nausea, or vomiting. Related diagnostic tests:
➤ Advise the patient to immediately ➤ Related diagnostic tests include an-
report symptoms such as fast heart giography of the specific area, mag-
rate, difficulty breathing, skin rash, netic resonance angiography, and
itching or decreased urinary output. ultrasound venous Doppler.
BILIARY TRACT AND LIVER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT), abdominal CT.
AREA OF APPLICATION: Liver, biliary tract, and adjacent structures.

CONTRAST: Can be done with or without intravenous (IV) iodinated
contrast medium.
• Detect dilation or obstruction of the

DESCRIPTION & RATIONALE: Com- biliary ducts with or without calcifica-
puted tomography (CT) of the liver tion or gallstone
and biliary tract is a noninvasive pro- • Detect liver abnormalities, such as cir-
cedure that enhances certain anatomic rhosis with ascites and fatty liver
views of these structures, but it
becomes invasive with the use of con- • Detect tumor extension of masses and
metastasis into the hepatic area
trast medium. The patient lies on a
table that moves in and out of a • Differentiate aortic aneurysms from
doughnut-like device called a gantry, tumors near the aorta
which houses the x-ray tube and asso- • Differentiate between obstructive and
ciated electronics. The scanner uses nonobstructive jaundice
multiple x-ray beams and a series of
• Differentiate infectious from inflam-
detectors that rotate around the matory processes
patient to produce cross-sectional
views in a three-dimensional fashion • Evaluate hepatic cysts, masses, ab-
by detecting and recording differences scesses, or hematomas, or hepatic
trauma
in tissue density after having an x-ray
beam passed through the tissues. • Monitor and evaluate effectiveness of
These density measurements are sent medical, radiation, or surgical therapies
to a computer that produces a digital
image of the anatomy, enabling a RESULT
physician to look at slices or thin sec- Normal Findings:
tions of certain anatomic views of the • Normal size, position, and contour of
liver, biliary tract, and vascular sys- the liver and biliary ducts
tem. Differentiations can be made
among solid, cystic, inflammatory, Abnormal Findings:
or vascular lesions, and suspected • Dilation of the common hepatic duct,
hematomas and aneurysms can be common bile duct, or gallbladder
identified. Iodinated contrast medium • Gallstones
is given intravenously for blood vessel
and vascular evaluation. Images can be • Hematomas
recorded on photographic or x-ray • Hepatic cysts or abscesses
film or stored in digital format as dig-
• Jaundice (obstructive or nonobstruc-
itized computer data. Cine scanning tive)
produces a series of moving images of
the area scanned. The CT scan can be • Primary and metastatic neoplasms
used to guide biopsy needles into areas
of suspected tumors to obtain tissue
for laboratory analysis and to guide INTERFERING FACTORS:
placement of catheters for drainage of
abscesses. Tumors, before and after This procedure is
therapy, may be monitored with CT contraindicated for:
scanning. ■ • Patients with allergies to shellfish
INDICATIONS: medium used may cause a life-threaten-
• Assist in differentiating between benign ing allergic reaction. Patients with a
and malignant tumors known hypersensitivity to the medium
may benefit from premedication with because of age, significant pain, or

corticosteroids or the use of nonionic mental status
contrast medium.
• Complications of the procedure include
• Patients who are pregnant or suspected hemorrhage, infection at the IV needle
of being pregnant, unless the potential insertion site, and cardiac arrhythmias.
• Elderly and other patients who occur.
are chronically dehydrated before
the test, because of their risk of • Failure to follow dietary restrictions
contrast-induced renal failure. and other pretesting preparations may
• Patients who are in renal failure. repeated.
• Young patients (17 years old and • Consultation with a health care pro-
younger), unless the benefits of the x- vider should occur before the proce-
ray diagnosis outweigh the risks of dure for radiation safety concerns
exposure to high levels of radiation. regarding younger patients or patients
who are lactating.
Factors that may
impair clear imaging: • Risks associated with radiographic over-
• Gas or feces in the gastrointestinal tract exposure can result from frequent x-ray
resulting from inadequate cleansing or procedures. Personnel in the room with
failure to restrict food intake before the the patient should wear a protective
study lead apron, stand behind a shield, or
• Retained barium from a previous radi- being done. Personnel working in the
ologic procedure area where the examination is being
• Metallic objects within the examina- done should wear badges that reveal
tion field (e.g., jewelry, body rings), their level of exposure to radiation.
• Improper adjustment of the radi- Procedure ● ● ● ● ● ● ● ● ● ● ●
obese or thin patients, which can cause Pretest:
poor-quality study ➤ Inform the patient that the procedure
assesses the liver, biliary tract and
• Patients who are very obese, who may adjacent structures.
exceed the weight limit for the equip- ➤ Obtain a history of the patient’s
ment complaints or clinical symptoms,
• Patients with extreme claustrophobia including a list of known allergens,
especially allergies or sensitivities to
unless sedation is given before the
study mediums.
• Incorrect positioning of the patient, ➤ Obtain a history of results of pre-
which may produce poor visualization viously performed diagnostic pro-
of the area to be examined cedures, surgical procedures, and
laboratory tests. Include specific
• Inability of the patient to cooperate or tests as they apply (e.g., blood
remain still during the procedure urea nitrogen [BUN], creatinine, coag-
ulation tests, platelets, bleeding fluids for 6 to 8 hours prior to the pro-
time). Ensure that the results of blood cedure. Instruct the patient to avoid
tests are obtained and recorded taking anticoagulant medication or to
before the procedure, especially BUN reduce dosage as ordered prior to
and creatinine, if contrast medium is the procedure.
to be used. For related diagnostic ➤ Instruct the patient to remove jew-
tests, refer to the Gastrointestinal, elry (including watches), credit cards,
Hepatobiliary, and Genitourinary keys, coins, cell phones, pagers, and
System tables. other metallic objects.
➤ Note any recent barium or other radi-
ologic contrast procedures. Ensure
that barium studies were performed
more than 4 days before the CT scan.
any medications.
period and determine the possibility Intratest:
➤ Obtain a list of the medications the with dietary, fluids, and medication
patient is taking. restrictions and pretesting prepara-
➤ When contrast is used, patients
restricted for at least 6 hours prior to
receiving metformin (glucophage) for
the procedure. Ensure that the
patient has removed all external
betes should discontinue the drug on
metallic objects (jewelry, dentures,
the day of the test and continue to
etc.) prior to the procedure.
withhold it for 48 hours after the test.
Failure to do so may result in lactic ➤ Have emergency equipment readily
acidosis. available.
➤ Review the procedure with the ➤ If the patient has a history of severe
patient. Explain to the patient that allergic reactions to any substance or
some pain may be experienced dur- drug, administer ordered prophylac-
ing the test, and there may be tic steroids or antihistamines before
moments of discomfort. Explain the the procedure. Use nonionic contrast
purpose of the test and how the pro- medium for the procedure.
cedure is performed. Inform the ➤ Patients are given a gown robe, and
and support staff, and takes approxi- ➤ Observe standard precautions, and
mately 30 to 60 minutes. follow the general guidelines in
Appendix A.
issues, as well as concern for mod- ➤ Instruct the patient to cooperate fully
esty, is important in providing psy- and to follow directions. Instruct the
chological support before, during, patient to remain still throughout the
and after the procedure. procedure because movement pro-
inserted to allow infusion of IV fluids, ➤ Establish an IV fluid line for the injec-
contrast medium, dye, or sedatives. tion of contrast, emergency drugs,
Usually contrast medium and normal and sedatives.
saline are infused. ➤ Administer an antianxiety agent, as
➤ Inform the patient that he or she may ordered, if the patient has claustro-
experience nausea, a feeling of phobia. Administer a sedative to a
warmth, a salty or metallic taste, or a child or to an uncooperative adult, as
transient headache after injection of ordered.
contrast medium, if given. ➤ Place the patient in the supine posi-
➤ The patient should fast and restrict tion on an exam table.
➤ If contrast is used, the contrast rash, urticaria, tachycardia, hyperp-

medium is injected, and a rapid nea, hypertension, palpitations, nau-
series of images is taken during and sea, or vomiting, if contrast medium
after the filling of the vessels to be was used.
examined. Delayed images may be ➤ If contrast was used, advise the
taken to examine the vessels after a patient to immediately report symp-
time and to monitor the venous toms such as fast heart rate, diffi-
phase of the procedure. culty breathing, skin rash, itching or
➤ Ask the patient to inhale deeply and decreased urinary output.
hold his or her breath while the x-ray ➤ Observe the needle/catheter inser-
images are taken, and then to exhale tion site for bleeding, inflammation,
after the images are taken. or hematoma formation.
➤ Instruct the patient to take slow, ➤ Instruct the patient to apply cold
deep breaths if nausea occurs during compresses to the puncture site, as
the procedure. Monitor and adminis- needed, to reduce discomfort or
ter an antiemetic agent if ordered. edema.
Ready an emesis basin for use.
➤ Monitor the patient for complica- intake to help eliminate the contrast
tions related to the procedure (e.g., medium, if used.
allergic reaction, anaphylaxis, bron-
chospasm) if contrast is used. ➤ Inform the patient that diarrhea may
occur after ingestion of oral contrast
➤ The needle or vascular catheter is media.
removed, and a pressure dressing is
applied over the puncture site. ➤ A written report of the examina-
➤ The results are recorded on film or care practitioner specializing in this
by automated equipment in a com- branch of medicine. The report will
puterized system, for recall and post- be sent to the requesting health care
procedure interpretation by the practitioner, who will discuss the
appropriate health care practitioner. results with the patient.
Post-test:
diet, fluids, medications, or activity, gression of the disease process and
as directed by the health care practi- determine the need for a change in
tioner. Renal function should be therapy. Evaluate test results in rela-
assessed before metformin is re- tion to the patient’s symptoms and
sumed, if contrast was used,. other tests performed.
status every 15 minutes for 30 min- Related diagnostic tests:
utes. Compare with baseline values. ➤ Related diagnostic tests include
Protocols may vary from facility to hepatobiliary scan; kidney, ureter,
facility. and bladder film; magnetic reso-
➤ If contrast was used, observe for nance imaging of the abdomen, and
delayed allergic reactions, such as ultrasound of the liver.
COMPUTED TOMOGRAPHY, BRAIN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Computed axial tomography (CAT) of the head,

computed transaxial tomography (CTT) of the head, brain CT.
AREA OF APPLICATION: Brain.

contrast medium.
DESCRIPTION & RATIONALE: Com- density tissue appears nearly white.

puted tomography (CT) of the brain These density measurements are sent
is a noninvasive procedure used to to a computer that produces a digital
assist in diagnosing abnormalities of image of the anatomy, enabling a
the head, brain tissue, cerebrospinal physician to look at slices or thin sec-
fluid, and blood circulation. Brain CT tions of certain anatomic views of the
becomes invasive if contrast medium brain and associated vascular system.
is used for image enhancement when Differentiations can be made among
pathology causing destruction of the solid, cystic, inflammatory, or vascular
blood-brain barrier is suspected. CT is lesions, and suspected hematomas or
useful for evaluating suspected brain aneurysms can be identified. The pro-
tumors, infarction, intracranial hem- cedure may be repeated after iodinated
orrhage, hematomas, arteriovenous contrast medium is given intra-
malformations, ventricular abnormali- venously for blood vessel and vascular
ties, aneurysms, and other vascular evaluation. Images can be recorded on
abnormalities. The patient lies on a photographic or x-ray film or stored in
table and is moved in and out of a digital format as digitized computer
doughnut-like device called a gantry, data. Cine scanning is used to produce
which houses the x-ray tube and asso- a series of moving images of the area
ciated electronics. The scanner uses scanned. Tumor progression, before
multiple x-ray beams and a series of and after therapy, and effectiveness of
detectors that rotate around the medical interventions may be moni-
patient to produce cross-sectional tored by CT scanning. ■
views in a three-dimensional fashion
by detecting and recording differences INDICATIONS:
in tissue density after having an x-ray • Detect the presence of a brain infec-
beam passed through the tissues. tion or inflammatory condition, such
Low-density tissue appears black on as abscess or necrosis, as evidenced by
decreased density on the image
the images, medium-density tissue
appears in shades of gray, and high- • Detect ventricular enlargement or dis-
Computed Tomography, Brain 435
placement by increased cerebrospinal • Arteriovenous malformations

fluid
• Cerebral atrophy
• Determine benign and cancerous
intracranial tumors and cyst formation, • Cerebral edema
as evidenced by changes in tissue densi- • Cerebral infarction
ties (white indicating increased dens-
ity, darker areas indicating decreased • Congenital abnormalities
density) • Craniopharyngioma
• Determine the cause of increased • Cysts
intracranial pressure
• Hematomas (e.g., epidural, subdural,
• Determine the presence and type of intracerebral)
hemorrhage in infants and children
experiencing signs and symptoms of • Hemorrhage
intracranial trauma, or of congenital • Hydrocephaly
conditions such as hydrocephalus and
arteriovenous malformations • Increased intracranial pressure or
trauma
• Determine the presence of multiple
sclerosis, as evidenced by sclerotic • Infection
plaques 3 to 4 mm in diameter • Sclerotic plaques suggesting multiple
• Determine the size and location of sclerosis
a lesion causing a stroke, such as an
• Tumor
infarct or hemorrhage
• Differentiate among hematoma loca- • Ventricular or tissue displacement or
tions after trauma (e.g., subdural, enlargement
epidural, cerebral), and determine the
extent of edema resulting from injury, CRITICAL VALUES: N/A
as evidenced by higher blood densities
compared with normal tissue INTERFERING FACTORS:
• Differentiate between cerebral infarc- This procedure is
tion and hemorrhage contraindicated for:
• Evaluate abnormalities of the middle • Patients with allergies to shellfish
ear ossicles, auditory nerve, and optic or iodinated dye. The contrast
nerve medium used may cause a life-threaten-
• Monitor and evaluate the effective- known hypersensitivity to the medium
ness of medical, radiation, or surgical may benefit from premedication with
therapies corticosteroids or the use of nonionic
contrast medium.
RESULT
Normal Findings: • Patients who are pregnant or suspected
• Normal size, position, and shape of of being pregnant, unless the potential
intracranial contents and vascular sys- benefits of the procedure far outweigh
tem the risks to the fetus and mother.
Abnormal Findings: • Elderly and other patients who
• Abscess
the test, because of their risk of
• Aneurysm contrast-induced renal failure.
• Patients who are in renal failure. and other pretesting preparations may
repeated.
younger), unless the benefits of the
x-ray diagnosis outweigh the risks of • Consultation with a health care
exposure to high levels of radiation. provider should occur before the proce-
dure for radiation safety concerns
resulting from inadequate cleansing or • Risks associated with radiographic
failure to restrict food intake before the overexposure can result from frequent
study x-ray procedures. Personnel in the
room with the patient should wear a
• Retained barium from a previous radi- protective lead apron, stand behind a
ologic procedure shield, or leave the area while the exam-
• Metallic objects within the examina- ination is being done. Personnel work-
tion field (e.g., jewelry, dentures, body ing in the area where the examination is
rings), which may inhibit organ visual- being done should wear badges that
ization and can produce unclear images reveal their level of exposure to radia-
tion.
overexposure or underexposure and a Nursing Implications and
poor-quality study Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients who are very obese, who may Pretest:

ment ➤ Inform the patient that the procedure
assesses the brain.
• Patients with extreme claustrophobia ➤ Obtain a history of the patient’s
unless sedation is given before the complaints or clinical symptoms,
study including a list of known allergens,
which may produce poor visualization mediums.
• Inability of the patient to cooperate or ously performed diagnostic pro-
remain still during the procedure cedures, surgical procedures, and
because of age, significant pain, or laboratory tests. Include specific
mental status tests as they apply (e.g., blood urea
nitrogen [BUN], creatinine, coagula-
Other considerations: tion tests, bleeding time). Ensure
that the results of blood tests are
• Complications of the procedure in- obtained and recorded before the
clude hemorrhage, infection at the IV procedure, especially BUN and crea-
needle insertion site, and cardiac tinine, if contrast medium is to be
arrhythmias. used. For related diagnostic tests,
refer to the Cardiovascular and
• The procedure may be terminated if Endocrine Systems tables.
occur. ➤ Note any recent barium or other radi-
• Failure to follow dietary restrictions that barium studies were performed
Computed Tomography, Brain 437
more than 4 days before the CT consent has been signed prior to the
scan. procedure and before administering
of pregnancy in perimenopausal Intratest:
women.
➤ Obtain a list of the medications the with medication restrictions and
patient is taking. pretesting preparations. Ensure that
➤ In case contrast is used, patients the patient has removed all external
receiving metformin (glucophage) for metallic objects (jewelry, dentures,
non–insulin-dependent (type 2) dia- etc.) prior to the procedure.
betes should discontinue the drug on ➤ Have emergency equipment readily
the day of the test and continue to available.
withhold it for 48 hours after the
test. Failure to do so may result in
lactic acidosis.
➤ Review the procedure with the tic steroids or antihistamines before
patient. Explain to the patient that the procedure. Use nonionic contrast
some pain may be experienced dur- medium for the procedure.
Appendix A.
patient that the procedure is per- ➤ Instruct the patient to cooperate fully
formed in a radiology department, and to follow directions. Instruct the
usually by a health care practitioner patient to remain still throughout the
and support staff, and takes approxi- procedure because movement pro-
mately 30 to 60 minutes. duces unreliable results.
➤ Sensitivity to cultural and social ➤ Establish an IV fluid line for the injec-
issues, as well as concern for mod- tion of contrast, emergency drugs,
esty, is important in providing psy- and sedatives.
chological support before, during, ➤ Administer an antianxiety agent, as
and after the procedure. ordered, if the patient has claustro-
➤ Explain that an IV line may be phobia. Administer a sedative to a
inserted to allow infusion of IV fluids, child or to an uncooperative adult, as
contrast medium, dye, or sedatives. ordered.
Usually contrast medium and normal ➤ Place the patient in the supine posi-
saline are infused. tion on an exam table.
➤ Inform the patient that he or she may ➤ If contrast is used, the contrast
experience nausea, a feeling of medium is injected, and a rapid
warmth, a salty or metallic taste, or a series of images is taken during and
transient headache after injection of after the filling of the vessels to be
contrast medium, if given. examined. Delayed images may be
➤ The patient should not fast or restrict taken to examine the vessels after a
fluids prior to the procedure. Instruct time and to monitor the venous
the patient to avoid taking anticoagu- phase of the procedure.
lant medication or to reduce dosage ➤ Ask the patient to inhale deeply and
as ordered prior to the procedure. hold his or her breath while the x-ray
➤ Instruct the patient to remove jew- images are taken, and then to exhale
elry, including watches, dentures, after the images are taken.
credit cards, keys, coins, cell phones, ➤ Instruct the patient to take slow,
pagers, and other metallic objects. deep breaths if nausea occurs during
➤ Make sure a written and informed the procedure. Monitor and adminis-
ter an antiemetic agent if ordered. toms such as fast heart rate, diffi-
Ready an emesis basin for use. culty breathing, skin rash, itching or
➤ Monitor the patient for complications decreased urinary output.
related to the procedure (e.g., aller- ➤ Observe the needle/catheter inser-
gic reaction, anaphylaxis, broncho- tion site for bleeding, inflammation,
spasm) if contrast is used. or hematoma formation.
➤ The needle or vascular catheter is ➤ Instruct the patient to apply cold
removed, and a pressure dressing is compresses to the puncture site, as
applied over the puncture site. needed, to reduce discomfort or
edema.
➤ The results are recorded on film or
by automated equipment in a com- ➤ Instruct the patient to increase fluid
puterized system for recall and post- intake to help eliminate the contrast
procedure interpretation by the medium, if used.
appropriate health care practitioner. ➤ A written report of the examina-
Post-test: care practitioner specializing in this
➤ Instruct the patient to resume med- be sent to the requesting health care
ications and activity, as directed by practitioner who will discuss the
the health care practitioner. Renal results with the patient.
function should be assessed before ➤ Depending on the results of this pro-
metformin is resumed, if contrast cedure, additional testing may be
was used. needed to evaluate or monitor pro-
➤ Monitor vital signs and neurologic gression of the disease process and
status every 15 minutes for 30 min- determine the need for a change in
utes. Compare with baseline values. therapy. Evaluate test results in rela-
Protocols may vary from facility to tion to the patient’s symptoms and
facility. other tests performed.
➤ If contrast was used, observe for
delayed allergic reactions, such as Related diagnostic tests:
rash, urticaria, tachycardia, hyperp- ➤ Related diagnostic tests include an-
nea, hypertension, palpitations, nau- giography of the carotids, computed
sea, or vomiting. tomography angiography, magnetic
➤ If contrast was used, advise the resonance angiography, and mag-
patient to immediately report symp- netic resonance imaging of the brain.
CARDIAC SCORING
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT), heart vessel calcium CT, cardiac plaque CT.

CONTRAST: None.
Computed Tomography, Cardiac Scoring 439
Of all myocardial infarctions (MIs),

DESCRIPTION & RATIONALE: Car- 45% occur in people younger
diac scoring is a noninvasive test for than age 65
quantifying coronary artery calcium Of women who have had MIs,
content. Coronary artery disease 44% will die within 1 year after
(CAD) occurs when the arteries that the attack
carry blood and oxygen to the heart Women are more likely to die of
heart disease than of breast
muscle become clogged or built up cancer
with plaque. Plaque buildup slows the
flow of blood to the heart muscle, • Family history of heart disease
causing ischemia and increasing the • Screening for coronary artery calcium
risk of heart failure. The procedure in patients with:
begins with a computed tomography Diabetes
(CT) scan of the heart. The patient High blood pressure
lies on a table and is moved in and out High cholesterol
of a doughnut-like device called a High-stress lifestyle
gantry, which houses the x-ray tube Overweight by 20% or more
and associated electronics. The scan- Personal history of smoking
ner uses multiple x-ray beams and a
Sedentary lifestyle
series of detectors that rotate around
the patient to produce cross-sectional • Screening for coronary artery plaque in
views in a three-dimensional fashion patients with chest pain of unknown
by detecting and recording differences cause
in plaque density after having an x-ray
beam passed through the tissues. The RESULT
scanner takes an image of the beating
Normal Findings:
heart while the patient holds his or
her breath for approximately 20 sec- • If the score is 100 or less, the probabil-
ity of having significant CAD is mini-
onds. The procedure requires no
mal or is unlikely to be causing a
contrast medium injections. These narrowing at the time of the examina-
density measurements are sent to a tion.
computer that produces a digital
analysis of the anatomy, enabling a Abnormal Findings:
physician to look at the quantified • If the score is between 101 and 400, a
amount of calcium (cardiac plaque significant amount of calcified plaque
score) in the coronary arteries. The was found in the coronary arteries.
data can be recorded on photographic There is an increased risk of a future
or x-ray film or stored in digital for- MI, and a medical assessment of car-
mat as digitized computer data. ■ diac risk factors needs to be done.
Additional testing may be needed.
INDICATIONS: • If the score is greater than 400, the pro-
• Detect and quantify coronary artery cedure has detected extensive calcified
calcium content plaque in the coronary arteries, which
CAD is the leading cause of death may have caused a critical narrowing of
in most industrialized nations the vessels. A full medical assessment is
Cardiac scoring is a more powerful needed as soon as possible. Further test-
predictor of CAD than cholesterol ing may be needed, and treatment may
screening be needed to reduce the risk of MI.
CRITICAL VALUES: N/A • Consultation with a health care

provider should occur before the proce-
INTERFERING FACTORS: dure for radiation safety concerns
regarding younger patients or patients
This procedure is who are lactating.
• Patients who are claustrophobic. exposure can result from frequent x-ray
• Patients who are pregnant or suspected procedures. Personnel in the room with
of being pregnant, unless the potential the patient should wear a protective
benefits of the procedure far outweigh lead apron, stand behind a shield, or
the risks to the fetus and mother. leave the area while the examination is
• Young patients (17 years old and area where the examination is being
younger), unless the benefits of the done should wear badges that reveal
x-ray diagnosis outweigh the risks of their level of exposure to radiation.
Factors that may

impair clear imaging: Nursing Implications and
• Retained barium or radiologic contrast Procedure ● ● ● ● ● ● ● ● ● ● ●
from a previous radiologic procedure

Pretest:
tion field (e.g., jewelry, body rings), assesses the coronary arteries.
plaints or clinical symptoms.
• Improper adjustment of the radi- ➤ Obtain a history of results of previ-
ographic equipment to accommodate ously performed diagnostic proce-
obese or thin patients, which can cause dures and surgical procedures. For
overexposure or underexposure and a related diagnostic tests, refer to the
poor-quality study Cardiovascular System table.
• Patients who are very obese, who may ologic contrast procedures. Ensure
exceed the weight limit for the equip- that barium studies were performed
ment more than 4 days before the CT
scan.
unless sedation is given before the ➤ Record the date of the last menstrual
study period and determine the possibility
• Incorrect positioning of the patient, women.
which may produce poor visualization ➤ Obtain a list of the medications the
of the area to be examined patient is taking.
• Inability of the patient to cooperate or ➤ Review the procedure with the
remain still during the procedure patient. Explain to the patient that
some pain may be experienced dur-
mental status moments of discomfort. Explain the
• The procedure may be terminated if patient that the procedure is per-
chest pain or severe cardiac arrhythmias formed in a radiology department,
occur. usually by a health care practitioner
Computed Tomography, Cardiac Scoring 441
and support staff, and takes approxi- ➤ Place the patient in the supine posi-
mately 15 to 30 minutes. tion on an exam table.
➤ Sensitivity to cultural and social ➤ A rapid series of images is taken of
issues, as well as concern for mod- the vessels to be examined. Ask the
esty, is important in providing psy- patient to inhale deeply and hold his
chological support before, during, or her breath while the x-ray images
and after the procedure. are taken, and then to exhale after
➤ The patient should not fast or restrict the images are taken.
fluids prior to the procedure. ➤ The results are recorded on film or
➤ Instruct the patient to remove jew- by automated equipment in a com-
elry (including watches), credit cards, puterized system for recall and post-
keys, coins, cell phones, pagers, and procedure interpretation by the
other metallic objects. appropriate health care practitioner.
Intratest: Post-test:
➤ Ensure that the patient has removed ➤ A written report of the examina-
all external metallic objects (jewelry, tion will be completed by a health
dentures, etc.) prior to the pro- care practitioner specializing in this
cedure. branch of medicine. The report will
➤ Have emergency equipment readily be sent to the requesting health care
available. practitioner, who will discuss the
and foot coverings to wear and ➤ Depending on the results of this pro-
instructed to void prior to the proce- cedure, additional testing may be
dure. needed to evaluate or monitor pro-
➤ Observe standard precautions, and determine the need for a change in
follow the general guidelines in therapy. Evaluate test results in rela-
Appendix A. tion to the patient’s symptoms and
➤ Instruct the patient to cooperate fully other tests performed.
procedure because movement pro- Related diagnostic tests:
duces unreliable results. ➤ Related diagnostic tests include chest
➤ Administer an antianxiety agent, as x-ray, coronary angiography, com-
ordered, if the patient has claustro- puted tomography of the thorax,
phobia. Administer a sedative to a echocardiogram, electrocardiography,
child or to an uncooperative adult, as lung scan, and magnetic resonance
ordered. imaging of the chest.
COLONOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT), CT virtual colonoscopy, CT colonography.
CONTRAST: Screening examinations are done without intravenous (IV)

iodinated contrast medium. Examinations done to clarify questionable or
abnormal areas may require IV iodinated contrast medium.
DESCRIPTION & RATIONALE: Com- The procedure is less invasive than con-
puted tomography (CT) colonoscopy ventional colonoscopy, with little risk
is a noninvasive technique that in- of complications and no recovery time.
volves examining the colon by taking CT colonoscopy can be done as an out-
multiple CT scans of the patient’s patient procedure, and the patient may
colon and rectum and using computer return to work or usual activities the
software to create three-dimensional same day.
images. The procedure is used to detect CT colonoscopy and conventional
polyps, which are growths of tissue in colonoscopy require the bowel to be
the colon or rectum. Some types of cleansed before the examination. The
polyps increase the risk of colon cancer, patient lies on a table and is moved in
especially if they are large or if a patient and out of a doughnut-like device
has several polyps. Compared to con- called a gantry, which houses the x-ray
ventional colonoscopy, CT colono- tube and associated electronics. The
scopy is less effective in detecting scanner uses multiple x-ray beams and
polyps smaller than 5 mm, more effec- a series of detectors that rotate around
tive when the polyps are between 5 and the patient to produce cross-sectional
9.9 mm, and most effective when the views in a three-dimensional fashion
polyps are 10 mm or larger. This test by detecting and recording differences
may be valuable for patients who have in densities in the colon after having
diseases rendering them unable to an x-ray beam passed through it. The
undergo conventional colonoscopy scanner takes an image of the colon
(e.g., bleeding disorders, lung or heart while the patient holds his or her
disease) and for patients who are breath for approximately 10 to 30 sec-
unable to undergo the sedation onds. The screening procedure
required for traditional colonoscopy. requires no contrast medium injec-
Computed Tomography, Colonoscopy 443
tions, but if a suspicious area or RESULT

abnormality is detected, a repeat series
of images may be completed after IV Normal Findings:
contrast medium is given. These den- • Normal colon and rectum, with no evi-
sity measurements are sent to a com- dence of polyps or growths
puter that produces a digital analysis
Abnormal Findings:
of the anatomy, enabling a physician
• Abnormal endoluminal wall of the
to look at slices or thin sections of cer-
colon
tain anatomic views of the colon and
vascular system. The data can be • Extraluminal extension of primary can-
recorded on photographic or x-ray cer
film or stored in digital format as dig- • Mesenteric and retroperitoneal lym-
itized computer data. A drawback of phadenopathy
CT colonoscopy is that polyp removal • Metachronous lesions
and biopsies of tissue in the colon
must be done using conventional • Metastases of cancer
colonoscopy. Therefore, if polyps are • Polyps or growths in colon or rectum
discovered during CT colonoscopy
• Tumor recurrence after surgery
and biopsy becomes necessary, the
patient must undergo bowel prepara- CRITICAL VALUES: N/A
tion a second time. ■
INDICATIONS: INTERFERING FACTORS:
• Detect polyps in the colon
This procedure is
• Evaluate the colon for metachronous contraindicated for:
lesions • Patients with allergies to shellfish
• Evaluate the colon in patients with or iodinated dye. The contrast
obstructing rectosigmoid disease medium used may cause a life-threaten-
• Evaluate polyposis syndromes known hypersensitivity to the medium
• Evaluate the site of resection for local may benefit from premedication with
recurrence of lesions corticosteroids or the use of nonionic
• Examine the colon in patients with contrast medium, if contrast is used.
heart or lung disease, patients unable to • Patients who are claustrophobic.
be sedated, and patients unable to
undergo colonoscopy • Patients who are pregnant or suspected
• Failure to visualize the entire colon benefits of the procedure far outweigh
during conventional colonoscopy the risks to the fetus and mother.
• Identify metastases
• Investigate cause of positive occult are chronically dehydrated before
blood test the test, because of their risk of
• Investigate further after an abnormal contrast-induced renal failure, if con-
barium enema trast is used.
• Investigate further when flexible sig- • Patients who are in renal failure, if
moidoscopy is positive for polyps contrast is used.
• Young patients (17 years old and cause the procedure to be canceled or
younger), unless the benefits of the repeated.
x-ray diagnosis outweigh the risks of • Consultation with a health care
exposure to high levels of radiation. provider should occur before the proce-
overexposure can result from frequent
x-ray procedures. Personnel in the
study
room with the patient should wear a
• Retained barium from a previous radi- protective lead apron, stand behind a
ologic procedure shield, or leave the area while the exam-
ination is being done. Personnel work-
ing in the area where the examination
that reveal their level of exposure to
radiation.
obese or thin patients, which can cause Nursing Implications and
poor-quality study
exceed the weight limit for the equip- ➤ Inform the patient that the procedure
ment assesses the colon.
• Patients with extreme claustrophobia ➤ Obtain a history of the patient’s
unless sedation is given before the complaints or clinical symptoms,
study including a list of known allergens,
• Incorrect positioning of the patient, iodine, seafood, or other contrast
which may produce poor visualization mediums.
of the area to be examined ➤ Obtain a history of results of previ-
• Inability of the patient to cooperate or dures, surgical procedures, and
remain still during the procedure laboratory tests. Include specific
because of age, significant pain, or tests as they apply (e.g., blood urea
mental status nitrogen [BUN], creatinine, coagula-
tion tests, bleeding time). Ensure
Other considerations: that the results of blood tests are
obtained and recorded before the
• Complications of the procedure procedure, especially BUN and crea-
include hemorrhage, infection at the tinine, if contrast medium is to be
IV needle insertion site, and cardiac used. For related diagnostic tests,
arrhythmias. refer to the Gastrointestinal System
table.
chest pain or severe cardiac arrhythmias ➤ Note any recent barium or other radi-
occur.
• Failure to follow dietary restrictions more than 4 days before the CT scan.
and other pretesting preparations may ➤ Record the date of the last menstrual
Computed Tomography, Colonoscopy 445
period and determine the possibility Intratest:

➤ Obtain a list of the medications the with dietary, fluids, and medication
patient is taking. restrictions and pretesting prepara-
➤ If contrast is used, patients receiving restricted for at least 6 hours prior to
metformin (glucophage) for non– the procedure. Ensure that the
insulin-dependent (type 2) diabetes patient has removed all external
should discontinue the drug on the metallic objects (jewelry, dentures,
day of the test and continue to with- etc.) prior to the procedure.
hold it for 48 hours after the test.
Failure to do so may result in lactic
available.
acidosis.
➤ Review the procedure with the allergic reactions to any substance or
patient. Explain to the patient that drug, administer ordered prophylac-
some pain may be experienced dur- tic steroids or antihistamines before
ing the test, and there may be the procedure. Use nonionic contrast
moments of discomfort. Explain the medium for the procedure.
purpose of the test and how the
procedure is performed. Inform the ➤ Patients are given a gown, robe, and
usually by a health care practitioner ➤ Observe standard precautions, and
and support staff, and takes approxi- follow the general guidelines in
mately 30 to 60 minutes. Appendix A.
➤ Sensitivity to cultural and social ➤ Instruct the patient to cooperate fully
issues, as well as concern for mod- and to follow directions. Instruct the
esty, is important in providing psy- patient to remain still throughout the
chological support before, during, procedure because movement pro-
and after the procedure. duces unreliable results.
➤ Explain that an IV line may be ➤ Establish an IV fluid line for the injec-
inserted to allow infusion of IV fluids, tion of contrast (if used), emergency
contrast medium, dye, or sedatives. drugs, and sedatives.
ordered.
contrast medium, if given.
fluids for 6 to 8 hours prior to the pro-
cedure. Instruct the patient to avoid ➤ The colon is distended with room air
taking anticoagulant medication or to or carbon dioxide by means of a rec-
reduce dosage as ordered prior to tal tube and balloon retention device.
the procedure. Maximal colonic distention is guided
by patient tolerance.
➤ Instruct the patient to remove jew-
elry (including watches), credit cards, ➤ If contrast is used, the contrast
keys, coins, cell phones, pagers, and medium is injected, and a rapid series
other metallic objects. of images is taken during and after
the filling of the vessels to be exam-
➤ Make sure a written and informed ined. Delayed images may be taken
consent has been signed prior to the to examine the vessels after a time
procedure and before administering and to monitor the venous phase of
any medications. the procedure.
➤ Ask the patient to inhale deeply and ➤ If contrast was used, advise the
hold his or her breath while the x-ray patient to immediately report symp-
images are taken, and then to exhale toms such as fast heart rate, diffi-
after the images are taken. culty breathing, skin rash, itching or
➤ The sequence of images is repeated decreased urinary output.
in the prone position. ➤ Observe the needle/catheter inser-
➤ Instruct the patient to take slow, tion site for bleeding, inflammation,
deep breaths if nausea occurs during or hematoma formation.
the procedure. Monitor and adminis- ➤ Instruct the patient to apply cold
ter an antiemetic agent if ordered. compresses to the puncture site, as
Ready an emesis basin for use. needed, to reduce discomfort or
➤ Monitor the patient for complica- edema.
tions related to the procedure (e.g., ➤ Instruct the patient to increase fluid
allergic reaction, anaphylaxis, bron- intake to help eliminate the contrast
chospasm) if contrast is used. medium, if used.
➤ The needle or vascular catheter is ➤ Inform the patient that diarrhea may
removed, and a pressure dressing occur after ingestion of oral contrast
is applied over the puncture site. media.
➤ The results are recorded on film or ➤ A written report of the examina-
by automated equipment in a com- tion will be completed by a health
puterized system for recall and post- care practitioner specializing in this
procedure interpretation by the branch of medicine. The report will
appropriate health care practitioner. be sent to the requesting health care
Post-test: results with the patient.
diet, fluids, medications, or activ-
ity, as directed by the health care
practitioner. Renal function should
be assessed before metformin is
resumed, if contrast was used.
➤ Monitor vital signs and neurologic other tests performed.
status every 15 minutes for 30 min-
utes. Compare with baseline values.
Protocols may vary from facility to Related diagnostic tests:
facility. ➤ Related diagnostic tests include bar-
➤ If contrast was used, observe for ium enema; colonoscopy; computed
delayed allergic reactions, such as tomography of the abdomen; kidney,
rash, urticaria, tachycardia, hyperp- ureter, and bladder (KUB) film; mag-
nea, hypertension, palpitations, nau- netic resonance imaging of the
sea, or vomiting, if contrast medium abdomen; proctosigmoidoscopy, and
was used. ultrasound of the pelvis.
Computed Tomography, Pancreas 447
PANCREAS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT).
AREA OF APPLICATION: Pancreas.

contrast medium.
DESCRIPTION & RATIONALE: Com- to a computer that produces a digital

puted tomography (CT) is a noninva- image of the anatomy, enabling the
sive procedure used to enhance certain radiologist to look at slices or thin sec-
anatomic views of the abdominal tions of certain anatomic views of the
structures, but it becomes an invasive pancreas and associated vascular sys-
procedure when contrast medium is tem. Differentiations can be made
used. CT of the pancreas aids in the among solid, cystic, inflammatory, or
diagnosis or evaluation of pancreatic vascular lesions. CT scanning can
cysts, pseudocysts, inflammation, tu- detect the swelling that accompanies
mors, masses, metastases, abscesses, acute inflammation of the gland and,
and trauma. In all but the thinnest or in chronic cases, the calcium deposits
most emaciated patients, the pancreas missed on other examinations. Intra-
is surrounded by fat that clearly venous iodinated contrast medium is
defines its margins. While lying on a given for blood vessel and vascular
table, the patient is moved in and out evaluation, and oral contrast medium
of a doughnut-like device called a is given for bowel and adjacent
gantry, which houses the x-ray tube structure evaluation. Images can be
and associated electronics. The scan- recorded on photographic or x-ray
ner uses multiple x-ray beams and a film or stored in digital format as dig-
series of detectors that rotate around itized computer data. Cine scanning
the patient to produce cross-sectional produces a series of moving images of
views in a three-dimensional fashion the scanned area. The CT scan can be
by detecting and recording differences used to guide biopsy needles into areas
in tissue densityafter having an x-ray of pancreatic masses to obtain tissue
beam passed through the tissues. for laboratory analysis and for place-
These density measurements are sent ment of needles to aspirate cysts or
abscesses. CT scanning can monitor known hypersensitivity to the medium

may benefit from premedication with
mass, cyst, or tumor growth and post-
therapy response. ■ contrast medium.
INDICATIONS: • Patients who are claustrophobic.
• Detect dilation or obstruction of the • Patients who are pregnant or suspected
pancreatic ducts of being pregnant, unless the potential
• Differentiate between pancreatic disor- benefits of the procedure far outweigh
ders and disorders of the retroperi- the risks to the fetus and mother.
toneum • Elderly and other patients who
• Evaluate benign or cancerous tumors or are chronically dehydrated before
metastasis to the pancreas the test, because of their risk of
contrast-induced renal failure.
• Evaluate pancreatic abnormalities (e.g.,
bleeding, pancreatitis, pseudocyst, ab- • Patients who are in renal failure.
scesses) • Young patients (17 years old and
• Evaluate unexplained weight loss, jaun- younger), unless the benefits of the
dice, and epigastric pain x-ray diagnosis outweigh the risks of
• Monitor and evaluate effectiveness of
medical or surgical therapies
Factors that may
RESULT
• Normal size, position, and contour of
study
the pancreas, which lies obliquely in
the upper abdomen • Retained barium from a previous radi-
ologic procedure
Abnormal Findings:
• Acute or chronic pancreatitis tion field (e.g., jewelry, body rings),
• Obstruction of the pancreatic ducts which may inhibit organ visualization
• Pancreatic abscesses
• Pancreatic carcinoma ographic equipment to accommodate
• Pancreatic pseudocyst obese or thin patients, which can cause
• Pancreatic tumor poor-quality study
CRITICAL VALUES: N/A • Patients who are very obese, who
INTERFERING FACTORS: equipment
• Patients with extreme claustropho-
This procedure is
bia unless sedation is given before the
study
or iodinated dye. The contrast • Incorrect positioning of the patient,
medium used may cause a life-threaten- which may produce poor visualization
ing allergic reaction. Patients with a of the area to be examined
Computed Tomography, Pancreas 449
• Inability of the patient to cooperate or cedures, surgical procedures, and

tion tests, bleeding time). Ensure that
the results of blood tests are obtained
Other considerations: and recorded before the procedure,
• Complications of the procedure include especially BUN and creatinine, if con-
hemorrhage, infection at the IV needle trast medium is to be used. For
related diagnostic tests, refer to the
insertion site, and cardiac arrhythmias.
Gastrointestinal, Hepatobiliary, and
• The procedure may be terminated if Genitourinary Systems tables.
chest pain or severe cardiac arrhythmias ➤ Note any recent barium or other radi-
occur. ologic contrast procedures. Ensure
• Failure to follow dietary restrictions more than 2 days before the CT scan.
cause the procedure to be canceled or period and determine the possibility
repeated. of pregnancy in perimenopausal
regarding younger patients or patients ➤ In case contrast is used, patients
who are lactating. receiving metformin (glucophage) for
• Risks associated with radiographic over- betes should discontinue the drug on
exposure can result from frequent x-ray the day of the test and continue to
procedures. Personnel in the room with withhold it for 48 hours after the
the patient should wear a protective test. Failure to do so may result in
lead apron, stand behind a shield, or lactic acidosis.
leave the area while the examination is ➤ Review the procedure with the
being done. Personnel working in the patient. Explain to the patient that
area where the examination is being some pain may be experienced dur-
their level of exposure to radiation. purpose of the test and how the pro-
Nursing Implications and formed in a radiology department,
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
assesses the abdomen and pancre- esty, is important in providing psy-
atic area. chological support before, during,
complaints or clinical symptoms, ➤ Explain that an IV line may be
including a list of known allergens, inserted to allow infusion of IV fluids,
especially allergies or sensitivities to contrast medium, dye, or sedatives.
iodine, seafood, or other contrast Usually contrast medium and normal
mediums. saline are infused.
➤ Obtain a history of results of previ- ➤ Inform the patient that he or she may
ously performed diagnostic pro- experience nausea, a feeling of
warmth, a salty or metallic taste, or a procedure because movement pro-

transient headache after injection of duces unreliable results.
contrast medium, if given. ➤ Establish intravenous fluid line for
➤ The patient may be requested to the injection of contrast, emergency
drink approximately 450 mL of a drugs, and sedatives.
dilute barium solution (approximately ➤ Administer an antianxiety agent, as
1% barium) beginning 1 hour before ordered, if the patient has claustro-
the examination. This is administered phobia. Administer a sedative to a
to distinguish GI organs from the child or to an uncooperative adult, as
other abdominal organs. ordered.
➤ The patient should fast and restrict ➤ Place the patient in the supine posi-
fluids for 8 hours prior to the proce- tion on an exam table.
dure. Instruct the patient to avoid
taking anticoagulant medication or to ➤ If contrast is used, the contrast
reduce dosage as ordered prior to medium is injected, and a rapid
the procedure. series of images is taken during and
after the filling of the vessels to be
➤ Instruct the patient to remove jew- examined. Delayed images may be
elry (including watches), credit cards, taken to examine the vessels after a
keys, coins, cell phones, pagers, and time and to monitor the venous
other metallic objects. phase of the procedure.
➤ Make sure a written and informed ➤ Ask the patient to inhale deeply and
consent has been signed prior to the hold his or her breath while the x-ray
procedure and before administering images are taken, and then to exhale
any medications. after the images are taken.
Intratest: deep breaths if nausea occurs during
➤ Ensure that the patient has complied the procedure. Monitor and adminis-
with dietary, fluids, and medication ter an antiemetic agent if ordered.
restrictions and pretesting prepara- Ready an emesis basin for use.
tions; assure that food has been ➤ Monitor the patient for complica-
restricted for at least 8 hours prior to tions related to the procedure (e.g.,
the procedure. Ensure that the allergic reaction, anaphylaxis, bron-
patient has removed all external chospasm) if contrast is used.
metallic objects (jewelry, dentures, ➤ The needle or vascular catheter is
etc.) prior to the procedure. removed, and a pressure dressing is
➤ Have emergency equipment readily applied over the puncture site.
available. ➤ The results are recorded on film or
➤ If the patient has a history of severe by automated equipment in a com-
allergic reactions to any substance or puterized system for recall and post-
drug, administer ordered prophylac- procedure interpretation by the
tic steroids or antihistamines before appropriate health care practitioner.
medium for the procedure. Post-test:
➤ Patients are given a gown, robe, and ➤ Instruct the patient to resume usual
foot coverings to wear and instructed diet, fluids, medications or activ-
to void prior to the procedure. ity, as directed by the health care
➤ Observe standard precautions, and practitioner. Renal function should
follow the general guidelines in be assessed before metformin is
Appendix A. resumed, if contrast was used.
➤ Instruct the patient to cooperate fully ➤ Monitor vital signs and neurologic
and to follow directions. Instruct the status every 15 minutes for 30 min-
patient to remain still throughout the utes. Compare with baseline values.
Computed Tomography, Pelvis 451
Protocols may vary from facility to occur after ingestion of oral contrast
facility. medium.
➤ If contrast was used, observe for ➤ A written report of the examina-
delayed allergic reactions, such as tion will be completed by a health
rash, urticaria, tachycardia, hyperp- care practitioner specializing in this
nea, hypertension, palpitations, nau- branch of medicine. The report will
sea, or vomiting. be sent to the requesting health care
➤ If contrast was used, advise the practitioner, who will discuss the
patient to immediately report symp- results with the patient.
toms such as fast heart rate, diffi- ➤ Depending on the results of this pro-
culty breathing, skin rash, itching or cedure, additional testing may be
decreased urinary output. needed to evaluate or monitor pro-
➤ Observe the needle/catheter inser- gression of the disease process and
tion site for bleeding, inflammation, determine the need for a change in
or hematoma formation. therapy. Evaluate test results in rela-
➤ Instruct the patient to apply cold other tests performed.
edema. Related diagnostic tests:
➤ Instruct the patient to increase fluid ➤ Related diagnostic tests include an-
intake to help eliminate the contrast giography of the abdomen, magnetic
medium, if used. resonance imaging of the abdomen,
➤ Inform the patient that diarrhea may and ultrasound of the pancreas.
COMPUTED TOMOGRAPHY, PELVIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT), pelvic CT.
AREA OF APPLICATION: Pelvis.
contrast medium.
DESCRIPTION & RATIONALE: Comp- lies on a table and moves in and out of
uted tomography (CT) of the pelvis is a doughnut-like device called a gantry,
a noninvasive procedure used to which houses the x-ray tube and asso-
enhance certain anatomic views of the ciated electronics. The scanner uses
pelvic structures, but it becomes an multiple x-ray beams and a series of
invasive procedure when intravenous detectors that rotate around the
contrast medium is used. The patient patient to produce cross-sectional
views in a three-dimensional fashion • Detect tumor extension of masses and

by detecting and recording differences metastasis into the pelvic area
in tissue density after having an x-ray • Differentiate infectious from inflam-
beam pass through them. These den- matory processes
sity measurements are sent to a com- • Evaluate pelvic lymph nodes
puter that produces a digital image of
the anatomy, enabling a physician to • Evaluate cysts, masses, abscesses, ure-
teral and bladder calculi, gastrointesti-
look at slices or thin sections of
nal bleeding and obstruction, and
certain anatomic views, as appropriate trauma
depending on gender, of the ovaries,
uterus, fallopian tubes, bladder, rec- • Monitor and evaluate effectiveness of
tum, sigmoid colon, prostate, seminal medical, radiation, or surgical therapies
vesicles, cervix, and associated vas-
RESULT
cular system and to determine the
presence and extent of malignancy. Normal Findings:
Differentiations can be made among • Normal size, position, and shape of
solid, cystic, inflammatory, or vascular pelvic organs and vascular system
lesions, and suspected hematomas
or aneurysms can be identified. Iodi- Abnormal Findings:
nated contrast medium is given intra- • Bladder calculi
venously for blood vessel and vascular
• Ectopic pregnancy
evaluation or orally for bowel and
adjacent structure evaluation. Images • Fibroid tumors
can be recorded on photographic or x- • Hydrosalpinx
ray film or stored in digital format as
• Ovarian cyst or abscess
digitized computer data. Cine scan-
ning produces a series of moving • Primary and metastatic neoplasms
images of the scanned area. The CT
scan can be used to guide biopsy nee- CRITICAL VALUES: N/A
dles into areas of suspected tumor to
obtain tissue for laboratory analysis
and to place catheters for drainage of This procedure is
abscesses. Tumor size, progression, and contraindicated for:
changes before and after therapy may • Patients with allergies to shellfish
be monitored with CT scanning. In or iodinated dye. The contrast
rare cases, CT pelvimetry may be per- medium used may cause a life-threaten-
formed on a pregnant woman whose ing allergic reaction. Patients with a
fetus is in a breech position. CT known hypersensitivity to the medium
pelvimetry measurements are accurate, may benefit from premedication with
and less radiation exposure occurs to corticosteroids or the use of nonionic
contrast medium.
the mother and the fetus than with
radiographic pelvimetry. ■ • Patients who are claustrophobic.
INDICATIONS: of being pregnant, unless the potential
• Assist in differentiating between benign benefits of the procedure far outweigh
and malignant tumors the risks to the fetus and mother.
• Elderly and other patients who • The procedure may be terminated if

are chronically dehydrated before chest pain or severe cardiac arrhythmias
the test, because of their risk of con- occur.
trast-induced renal failure. • Failure to follow dietary restrictions
• Patients who are in renal failure. and other pretesting preparations may
• Young patients (17 years old and repeated.
younger), unless the benefits of the x-
ray diagnosis outweigh the risks of • Consultation with a health care
exposure to high levels of radiation. provider should occur before the pro-
cedure for radiation safety concerns
• Gas or feces in the gastrointestinal tract • Risks associated with radiographic over-
resulting from inadequate cleansing or exposure can result from frequent x-ray
failure to restrict food intake before the procedures. Personnel in the room with
study the patient should wear a protective
• Metallic objects within the examina- area where the examination is being
tion field (e.g., jewelry, body rings), done should wear badges that reveal
which may inhibit organ visualization their level of exposure to radiation.
• Improper adjustment of the radi- Nursing Implications and
ographic equipment to accommodate Procedure ● ● ● ● ● ● ● ● ● ● ●
overexposure or underexposure and a Pretest:
poor-quality study
• Patients who are very obese, who may assesses the pelvis.
exceed the weight limit for the equip- ➤ Obtain a history of the patient’s
ment complaints or clinical symptoms,
• Patients with extreme claustropho- including a list of known allergens,
especially allergies or sensitivities
bia unless sedation is given before the
to iodine, seafood, or other contrast
study mediums.
• Incorrect positioning of the patient, ➤ Obtain a history of results of pre-
which may produce poor visualization viously performed diagnostic pro-
of the area to be examined cedures, surgical procedures, and
• Inability of the patient to cooperate or tests as they apply (e.g., blood urea
remain still during the procedure nitrogen [BUN], creatinine, coagula-
because of age, significant pain, or tion tests, bleeding time). Ensure
mental status that the results of blood tests are
Other considerations: procedure, especially BUN and crea-
tinine, if contrast medium is to be
• Complications of the procedure in- used. For related diagnostic tests,
clude hemorrhage, infection at the IV refer to the Gastrointestinal, Repro-
needle insertion site, and cardiac ductive, and Genitourinary System
arrhythmias. tables.
➤ Note any recent barium or other radi- cedure. Instruct the patient to avoid
ologic contrast procedures. Ensure taking anticoagulant medication or
that barium studies were performed to reduce dosage as ordered prior to
more than 4 days before the CT scan. the procedure.
➤ Record the date of the last menstrual ➤ Instruct the patient to remove jew-
period and determine the possibil- elry (including watches), credit cards,
ity of pregnancy in perimenopausal keys, coins, cell phones, pagers, and
women. other metallic objects.
➤ Obtain a list of the medications the ➤ Make sure a written and informed
patient is taking. consent has been signed prior to the
➤ In case contrast is used, patients procedure and before administering
receiving metformin (glucophage) for any medications.
betes should discontinue the drug on Intratest:
withhold it for 48 hours after the ➤ Ensure that the patient has complied
test. Failure to do so may result in with dietary, fluids, and medication
lactic acidosis. restrictions and pretesting prepara-
patient. Explain to the patient that
metallic objects (jewelry, dentures,
etc.) prior to the procedure.
cedure is performed. Inform the ➤ Have emergency equipment readily
patient that the procedure is per- available.
formed in a radiology department, ➤ If the patient has a history of severe
usually by a health care practitioner allergic reactions to any substance or
and support staff, and takes approxi- drug, administer ordered prophylac-
mately 30 to 60 minutes. tic steroids or antihistamines before
➤ Sensitivity to cultural and social the procedure. Use nonionic contrast
issues, as well as concern for mod- medium for the procedure.
esty, is important in providing psy- ➤ Patients are given a gown, robe, and
chological support before, during, foot coverings to wear and instructed
and after the procedure. to void prior to the procedure.
➤ Explain that an IV line may be ➤ Observe standard precautions, and
inserted to allow infusion of IV fluids, follow the general guidelines in
contrast medium, dye, or sedatives. Appendix A.
saline are infused. ➤ Instruct the patient to cooperate fully
➤ Inform the patient that he or she
may experience nausea, a feeling of
contrast medium, if given. ➤ Establish an IV fluid line for the injec-
➤ The patient may be requested to tion of contrast, emergency drugs,
drink approximately 450 mL of a and sedatives.
to distinguish gastrointestinal organs child or to an uncooperative adult, as
from the other abdominal organs. ordered.
fluids for 6 to 8 hours prior to the pro- tion on an exam table.
➤ If contrast is used, the contrast rash, urticaria, tachycardia, hyperp-

medium is injected, and a rapid nea, hypertension, palpitations, nau-
series of images is taken during and sea, or vomiting.
after the filling of the vessels to be ➤ If contrast was used, advise the
examined. Delayed images may be patient to immediately report symp-
taken to examine the vessels after a toms such as fast heart rate, diffi-
time and to monitor the venous culty breathing, skin rash, itching or
phase of the procedure. decreased urinary output.
➤ Ask the patient to inhale deeply and
hold his or her breath while the x-ray
images are taken, and then to exhale
➤ Instruct the patient to take slow, ➤ Instruct the patient to apply cold
deep breaths if nausea occurs during compresses to the puncture site, as
the procedure. Monitor and adminis- needed, to reduce discomfort or
ter an antiemetic agent if ordered. edema.
Ready an emesis basin for use. ➤ Instruct the patient to increase fluid
➤ Monitor the patient for complica- intake to help eliminate the contrast
tions related to the procedure (e.g., medium, if used.
allergic reaction, anaphylaxis, bron- ➤ Inform the patient that diarrhea may
chospasm) if contrast is used. occur after ingestion of oral contrast
➤ The needle or vascular catheter is medium.
removed, and a pressure dressing is ➤ A written report of the examination
applied over the puncture site. will be completed by a health care
➤ The results are recorded on film or practitioner specializing in this
by automated equipment in a com- branch of medicine. The report will
puterized system for recall and post- be sent to the requesting health care
procedure interpretation by the practitioner, who will discuss the
appropriate healthcare practitioner. results with the patient.
diet, fluids, medications, or activ- gression of the disease process and
ity, as directed by the health care determine the need for a change in
practitioner. Renal function should therapy. Evaluate test results in rela-
be assessed before metformin is tion to the patient’s symptoms and
resumed, if contrast was used. other tests performed.
status every 15 minutes for 30 min- Related diagnostic tests:
utes. Compare with baseline values. ➤ Related diagnostic tests include
Protocols may vary from facility to angiogram of the pelvis; kidney,
facility. ureter, and bladder film; magnetic
➤ If contrast was used, observe for resonance imaging of the abdomen,
delayed allergic reactions, such as and ultrasound of the pelvis.
PITUITARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT), pituitary CT.
AREA OF APPLICATION: Pituitary/brain.

contrast medium.
DESCRIPTION & RATIONALE: Com- and recording differences in tissue

puted tomography (CT) of the density after having an x-ray beam
pituitary is a noninvasive procedure passed through the tissues. These
that enhances certain anatomic views density measurements are sent to a
of the pituitary gland and perisellar computer that produces a digital image
region, but it becomes an invasive proof the anatomy, enabling a physician to
cedure when a contrast medium is look at slices or thin sections of certain
used. CT scanning is a safe and rapid anatomic views of the pituitary and
method for pituitary gland evaluation. associated vascular system. Differentia-
This procedure aids in the evaluation of tions can be made among solid, cystic,
pituitary adenoma, craniopharyn- inflammatory, or vascular lesions, and
gioma, meningioma, aneurysm, met- suspected hematomas and aneurysms
astatic disease, exophthalmos, and can be identified. The procedure may
cysts. It provides unique cross- be repeated after iodinated contrast
sectional anatomic information; it is medium is given intravenously for
also unsurpassed in evaluating lesions blood vessel and vascular evaluation.
containing calcium. Visualization of Images can be recorded on photo-
bony septa in the sphenoid sinus and graphic or x-ray film or stored in digital
evaluation for nonpneumatization of format as digitized computer data.
the sphenoid sinus are best performed Cine scanning produces a series of
with this procedure. The patient lies on moving images of the scanned area.
a table and moves in and out of a Tumors, before and after therapy, may
doughnut-like device called a gantry, be monitored by CT scanning. ■
which houses the x-ray tube and associ-
ated electronics. The scanner uses mul- INDICATIONS:
tiple x-ray beams and a series of • Assist in differentiating between benign
detectors that rotate around the patient and malignant tumors
to produce cross-sectional views in a • Detect aneurysms and vascular abnor-
three-dimensional fashion by detecting malities
Computed Tomography, Pituitary 457
• Detect congenital anomalies, such as • Patients who are pregnant or suspected

partially empty sella of being pregnant, unless the potential
• Detect tumor extension of masses and
metastasis
• Determine pituitary size and location are chronically dehydrated before
in relation to surrounding structures the test, because of their risk of con-
• Evaluate cysts, masses, abscesses, and trast-induced renal failure.
trauma • Patients who are in renal failure.
• Monitor and evaluate effectiveness of • Young patients (17 years old and
medical, radiation, or surgical therapies younger), unless the benefits of the
x-ray diagnosis outweigh the risks of
RESULT exposure to high levels of radiation.
Normal Findings: Factors that may

• Normal size, position, and shape of the impair clear imaging:
pituitary fossa, cavernous sinuses, and • Retained contrast from a previous radi-
vascular system ologic procedure
Abnormal Findings: tion field (e.g., jewelry, dentures, body
• Abscess rings), which may inhibit organ visual-
ization and can produce unclear images
• Adenoma
• Aneurysm ographic equipment to accommodate
• Chordoma obese or thin patients, which can cause
• Craniopharyngioma poor-quality study
• Cyst • Patients who are very obese, who
• Meningioma may exceed the weight limit for the
equipment
• Metastasis
• Pituitary hemorrhage unless sedation is given before the study
CRITICAL VALUES: N/A • Incorrect positioning of the patient,
INTERFERING FACTORS: of the area to be examined
This procedure is remain still during the procedure
contraindicated for: because of age, significant pain, or
• Patients with allergies to shellfish mental status
medium used may cause a life-threaten- Other considerations:
ing allergic reaction. Patients with a • Complications of the procedure include
known hypersensitivity to the medium hemorrhage, infection at the IV needle
may benefit from premedication with insertion site, and cardiac arrhythmias.
contrast medium.
• Patients who are claustrophobic. occur.
• Failure to follow dietary restrictions ➤ In case contrast is used, patients

and other pretesting preparations may receiving metformin (glucophage) for
cause the procedure to be canceled or non–insulin-dependent (type 2) dia-
repeated. betes should discontinue the drug on
• Consultation with a health care pro- withhold it for 48 hours after the
vider should occur before the proce- test. Failure to do so may result in
dure for radiation safety concerns lactic acidosis.
regarding younger patients or patients ➤ Review the procedure with the
who are lactating. patient. Explain to the patient that
• Risks associated with radiographic over- ing the test, and there may be
exposure can result from frequent x-ray moments of discomfort. Explain the
procedures. Personnel in the room with purpose of the test and how the pro-
the patient should wear a protective cedure is performed. Inform the
lead apron, stand behind a shield, or patient that the procedure is per-
leave the area while the examination is formed in a radiology department,
being done. Personnel working in the usually by a health care practitioner
area where the examination is being and support staff, and takes approxi-
done should wear badges that reveal mately 30 to 60 minutes.
their level of exposure to radiation. ➤ Sensitivity to cultural and social
Nursing Implications and chological support before, during and
Procedure ● ● ● ● ● ● ● ● ● ● ● after the procedure.
Pretest: inserted to allow infusion of IV fluids,
➤ Inform the patient that the procedure contrast medium, dye, or sedatives.
assesses the brain and pituitary. Usually contrast medium and normal
saline are infused.
complaints or clinical symptoms, ➤ Inform the patient that he or she may
including a list of known allergens, experience nausea, a feeling of
especially allergies or sensitivities to warmth, a salty or metallic taste, or a
iodine, seafood, or other contrast transient headache after injection of
mediums. contrast medium, if given.
➤ Obtain a history of results of previ- ➤ The patient should not fast or restrict
ously performed diagnostic proce- fluids prior to the procedure. Instruct
dures, surgical procedures, and the patient to avoid taking anticoagu-
laboratory tests. Include specific lant medication or to reduce dosage
tests as they apply (e.g., blood urea as ordered prior to the procedure.
nitrogen [BUN], creatinine, coagula- ➤ Instruct the patient to remove jew-
tion tests, bleeding time). Ensure elry (including watches), credit cards,
that the results of blood tests are keys, coins, cell phones, pagers, and
obtained and recorded before the other metallic objects.
procedure, especially BUN and crea-
tinine, if contrast medium is to be ➤ Make sure a written and informed
used. For related diagnostic tests, consent has been signed prior to the
refer to the Endocrine System table. procedure and before administering
any medications.
ity of pregnancy in perimenopausal Intratest:
➤ Obtain a list of the medications the with medication restrictions and
patient is taking. pretesting preparations. Ensure that
Computed Tomography, Pituitary 459
the patient has removed all external tions related to the procedure (e.g.,
metallic objects (jewelry, dentures, allergic reaction, anaphylaxis, bron-
etc.) prior to the procedure. chospasm) if contrast is used.
➤ Have emergency equipment readily ➤ The needle or vascular catheter is
available. removed, and a pressure dressing is
applied over the puncture site.
allergic reactions to any substance or ➤ The results are recorded on film
drug, administer ordered prophylac- or by automated equipment in a
tic steroids or antihistamines before computerized system for recall
the procedure. Use nonionic contrast and postprocedure interpretation
medium for the procedure. by the appropriate health care prac-
titioner.
Post-test:
➤ Observe standard precautions, and ➤ Instruct the patient to resume usual
follow the general guidelines in medications and activity, as directed
Appendix A. by the health care practitioner. Renal
function should be assessed before
➤ Instruct the patient to cooperate fully metformin is resumed, if contrast
and to follow directions. Instruct the was used.
procedure because movement pro- ➤ Monitor vital signs and neurologic
duces unreliable results. status every 15 minutes for 30 min-
➤ Establish an IV fluid line for the injec- Protocols may vary from facility to
tion of contrast, emergency drugs, facility.
and sedatives.
➤ Administer an antianxiety agent, as delayed allergic reactions, such as
ordered, if the patient has claustro- rash, urticaria, tachycardia, hyperp-
phobia. Administer a sedative to a nea, hypertension, palpitations, nau-
child or to an uncooperative adult, as sea, or vomiting.
ordered.
➤ If contrast was used, advise the
➤ Place the patient in the supine posi- patient to immediately report symp-
tion on an exam table. toms such as fast heart rate, diffi-
➤ If contrast is used, the contrast culty breathing, skin rash, itching or
medium is injected, and a rapid series decreased urinary output.
of images is taken during and after ➤ Observe the needle/catheter inser-
the filling of the vessels to be exam- tion site for bleeding, inflammation,
ined. Delayed images may be taken or hematoma formation.
to examine the vessels after a time
and to monitor the venous phase of ➤ Instruct the patient to apply cold
the procedure. compresses to the puncture site, as
➤ Ask the patient to inhale deeply and edema.
hold his or her breath while the x-ray
images are taken, and then to exhale
medium, if used.
deep breaths if nausea occurs
during the procedure. Monitor and
administer an antiemetic agent if
ordered. Ready an emesis basin
for use.
➤ Monitor the patient for complica- results with the patient.
➤ Depending on the results of this pro- Related diagnostic tests:

needed to evaluate or monitor pro- ➤ Related diagnostic tests include
gression of the disease process and CT angiography, CT of the brain,
determine the need for a change in positron emission tomography of the
therapy. Evaluate test results in rela- brain, magnetic resonance angiogra-
tion to the patient’s symptoms and phy, and magnetic resonance imag-
other tests performed. ing of the brain.
COMPUTED TOMOGRAPHY, RENAL

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Computed axial tomography (CAT), computed

transaxial tomography (CTT), kidney CT.
AREA OF APPLICATION: Kidney.

contrast medium.
DESCRIPTION & RATIONALE: Renal views in a three-dimensional fashion

computed tomography (CT) is a non- by detecting and recording differences
invasive procedure used to enhance in tissue density after having an x-ray
certain anatomic views of the renal beam passed through the tissues.
structures, but it becomes an invasive These density measurements are sent
procedure when a contrast medium is to a computer that produces a digital
used. CT scanning is a safe and rapid image of the anatomy, enabling a
method for renal evaluation that is physician to look at slices or thin sec-
independent of renal function. It pro- tions of certain anatomic views of the
vides unique cross-sectional anatomic kidneys and associated vascular sys-
information and is unsurpassed in tem. Differentiations can be made
evaluating lesions containing fat or among solid, cystic, inflammatory,
calcium. The patient lies on a table or vascular lesions, and suspected
and is moved in and out of a hematomas and aneurysms can be
doughnut-like device called a gantry, identified. The procedure is repeated
which houses the x-ray tube and asso- after iodinated contrast medium is
ciated electronics. The scanner uses given intravenously for blood vessel
multiple x-ray beams and a series of and vascular evaluation or orally for
detectors that rotate around the bowel and adjacent structure evalua-
patient to produce cross-sectional tion. Images can be recorded on pho-
Computed Tomography, Renal 461
tographic or x-ray film or stored in RESULT

digital format as digitized computer
data. Cine scanning produces a series Normal Findings:
of moving images of the area scanned. • Normal size, position, and shape of
The CT scan can be used to guide kidneys and vascular system
biopsy needles into areas of suspected
Abnormal Findings:
tumors to obtain tissue for laboratory
analysis and to guide placement • Adrenal tumor or hyperplasia
of catheters for drainage of renal • Congenital anomalies, such as polycys-
abscesses. Tumors, before and after tic kidney disease, horseshoe kidney,
therapy, may be monitored with CT absence of one kidney, or kidney dis-
scanning. ■ placement
• Dilation of the common hepatic duct,
INDICATIONS: common bile duct, or gallbladder
• Aid in the diagnosis of congenital
anomalies, such as polycystic kidney • Renal artery aneurysm
disease, horseshoe kidney, absence of • Renal calculi and ureteral obstruction
one kidney, or kidney displacement
• Renal cell carcinoma
• Aid in the diagnosis of perirenal
hematomas and abscesses and assist in • Renal cysts or abscesses
localizing for drainage
• Renal laceration, fracture, tumor, and
• Assist in differentiating between benign trauma
and malignant tumors
• Perirenal abscesses and hematomas
• Assist in differentiating between an
infectious and an inflammatory process • Primary and metastatic neoplasms
• Detect aneurysms and vascular abnor-
malities
• Detect bleeding or hyperplasia of the INTERFERING FACTORS:
adrenal glands
• Detect tumor extension of masses and This procedure is
metastasis into the renal area contraindicated for:
• Determine kidney size and location
in relation to the bladder in post-
transplant patients
• Determine presence and type of adre- known hypersensitivity to the medium
nal tumor, such as benign adenoma, may benefit from premedication with
cancer, or pheochromocytoma corticosteroids or the use of nonionic
• Evaluate abnormal fluid accumulation contrast medium.
around the kidney • Patients who are claustrophobic.
• Evaluate cysts, masses, abscesses, renal • Patients who are pregnant or suspected
calculi, obstruction, and trauma of being pregnant, unless the potential
• Evaluate spread of a tumor or invasion benefits of the procedure far outweigh
of nearby retroperitoneal organs the risks to the fetus and mother.
• Monitor and evaluate effectiveness of • Elderly and other patients who
medical, radiation, or surgical therapies are chronically dehydrated before
the test, because of their risk of • Failure to follow dietary restrictions

contrast-induced renal failure. and other pretesting preparations may
repeated.
• Young patients (17 years old and • Consultation with a health care
younger), unless the benefits of the x- provider should occur before the proce-
ray diagnosis outweigh the risks of dure for radiation safety concerns
exposure to high levels of radiation. regarding younger patients or patients
who are lactating.
Factors that may
impair clear imaging: • Risks associated with radiographic over-
• Gas or feces in the gastrointestinal tract exposure can result from frequent x-ray
resulting from inadequate cleansing or procedures. Personnel in the room with
failure to restrict food intake before the the patient should wear a protective
study lead apron, stand behind a shield, or
• Retained barium from a previous radi- being done. Personnel working in the
ologic procedure area where the examination is being
• Metallic objects within the examina- done should wear badges that reveal
tion field (e.g., jewelry, body rings), their level of exposure to radiation.
• Improper adjustment of the radi- Procedure ● ● ● ● ● ● ● ● ● ● ●
obese or thin patients, which can cause Pretest:
poor-quality study ➤ Inform the patient that the procedure
assesses the kidney.
exceed the weight limit for the equip- complaints or clinical symptoms, in-
ment cluding a list of known allergens,
• Patients with extreme claustrophobia especially allergies or sensitivities to
unless sedation is given before the iodine, seafood, or other contrast
mediums.
study
➤ Obtain a history of results of pre-
• Incorrect positioning of the patient, viously performed diagnostic pro-
which may produce poor visualization cedures, surgical procedures, and
of the area to be examined laboratory tests. Include specific
• Inability of the patient to cooperate or nitrogen [BUN], creatinine, coagula-
remain still during the procedure tion tests, bleeding time). Ensure
because of age, significant pain, or that the results of blood tests are
mental status obtained and recorded before the
procedure, especially BUN and crea-
Other considerations: tinine, if contrast medium is to be
• Complications of the procedure in- used. For related diagnostic tests,
clude hemorrhage, infection at the IV refer to the Gastrointestinal and Gen-
needle insertion site, and cardiac itourinary System tables.
arrhythmias. ➤ Note any recent barium or other radi-
• The procedure may be terminated if that barium studies were performed
chest pain or severe cardiac arrhythmias more than 4 days before the CT
occur. scan.
Computed Tomography, Renal 463
period and determine the possibility elry (including watches), credit cards,
of pregnancy in perimenopausal keys, coins, cell phones, pagers, and
➤ Obtain a list of the medications the ➤ Make sure a written and informed
patient is taking. consent has been signed prior to the
➤ In case contrast is used, patients procedure and before administering
receiving metformin (glucophage) for any medications.
betes should discontinue the drug on Intratest:
the day of the test and continue to ➤ Ensure that the patient has complied
withhold it for 48 hours after the with dietary, fluids, and medication
test. Failure to do so may result in restrictions and pretesting prepara-
lactic acidosis. tions; assure that food has been
➤ Review the procedure with the restricted for at least 6 hours prior to
patient. Explain to the patient that the procedure. Ensure that the pa-
some pain may be experienced dur- tient has removed all external metal-
ing the test, and there may be lic objects (jewelry, dentures, etc.)
moments of discomfort. Explain the prior to the procedure.
purpose of the test and how the pro- ➤ Have emergency equipment readily
cedure is performed. Inform the available.
formed in a radiology department, ➤ If the patient has a history of severe
usually by a health care practitioner allergic reactions to any substance or
and support staff, and takes approxi- drug, administer ordered prophylac-
mately 30 to 60 minutes. tic steroids or antihistamines before
➤ Sensitivity to cultural and social medium for the procedure.
esty, is important in providing psy- ➤ Patients are given a gown, robe, and
chological support before, during, foot coverings to wear and instructed
and after the procedure. to void prior to the procedure.
➤ Explain that an IV line may be ➤ Observe standard precautions, and
inserted to allow infusion of IV fluids, follow the general guidelines in
contrast medium, dye, or sedatives. Appendix A.
Usually contrast medium and normal ➤ Instruct the patient to cooperate fully
saline are infused. and to follow directions. Instruct the
➤ Inform the patient that he or she may patient to remain still throughout the
experience nausea, a feeling of procedure because movement pro-
warmth, a salty or metallic taste, or a duces unreliable results.
transient headache after injection of ➤ Establish an IV fluid line for the injec-
contrast medium, if given. tion of contrast, emergency drugs,
and sedatives.
➤ The patient may be requested to
drink approximately 450 mL of a ➤ Administer an antianxiety agent, as
dilute barium solution (approximately ordered, if the patient has claustro-
1% barium) beginning 1 hour before phobia. Administer a sedative to a
the examination. This is administered child or to an uncooperative adult, as
to distinguish gastrointestinal organs ordered.
from the other abdominal organs. ➤ Place the patient in the supine posi-
fluids for 6 to 8 hours prior to the pro- ➤ If contrast is used, the contrast
cedure. Instruct the patient to avoid medium is injected and a rapid series
taking anticoagulant medication or to of images is taken during and after
reduce dosage as ordered prior to the filling of the vessels to be exam-
the procedure. ined. Delayed images may be taken
to examine the vessels after a time ➤ If contrast was used, advise the
and to monitor the venous phase of patient to immediately report symp-
the procedure. toms such as fast heart rate, diffi-
➤ Ask the patient to inhale deeply and culty breathing, skin rash, itching or
hold his or her breath while the x-ray decreased urinary output.
images are taken, and then to exhale ➤ Observe the needle/catheter inser-
after the images are taken. tion site for bleeding, inflammation,
➤ Instruct the patient to take slow, or hematoma formation.
deep breaths if nausea occurs during ➤ Instruct the patient to apply cold
the procedure. Monitor and adminis- compresses to the puncture site, as
ter an antiemetic agent if ordered. needed, to reduce discomfort or
Ready an emesis basin for use. edema.
➤ Monitor the patient for complica- ➤ Instruct the patient to increase fluid
tions related to the procedure (e.g., intake to help eliminate the contrast
allergic reaction, anaphylaxis, bron- medium, if used.
chospasm) if contrast is used.
➤ Inform the patient that diarrhea may
➤ The needle or vascular catheter is occur after ingestion of oral contrast
removed, and a pressure dressing is medium.
by automated equipment in a com-
puterized system for recall and post-
procedure interpretation by the
appropriate health care practitioner.
Post-test:
➤ Depending on the results of this
➤ Instruct the patient to resume usual procedure, additional testing may be
diet, fluids, medications, or activity, needed to evaluate or monitor pro-
as directed by the health care practi- gression of the disease process and
tioner. Renal function should be determine the need for a change in
assessed before metformin is therapy. Evaluate test results in rela-
resumed, if contrast was used. tion to the patient’s symptoms and
➤ Monitor vital signs and neurologic other tests performed.
status every 15 minutes for 30 min-
Protocols may vary from facility to Related diagnostic tests:
facility. ➤ Related diagnostic tests include CT
➤ If contrast was used, observe for of the abdomen; intravenous pyelog-
delayed allergic reactions, such as raphy; kidney, ureter, and bladder
rash, urticaria, tachycardia, hyperp- film; magnetic resonance imaging of
nea, hypertension, palpitations, nau- the pelvis; and ultrasound of the
sea, or vomiting. kidney.
Computed Tomography, Spine 465
COMPUTED TOMOGRAPHY, SPINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT), spine CT, CT myelogram.
AREA OF APPLICATION: Spine.

contrast medium.
DESCRIPTION & RATIONALE: Com- Differentiations can be made among

puted tomography (CT) of the solid, cystic, inflammatory, or vascular
spine is a noninvasive procedure that lesions, and suspected hematomas
enhances certain anatomic views of and aneurysms can be identified.
the spinal structures, but it becomes Iodinated contrast medium is given
an invasive procedure when intra- intravenously for blood vessel and vas-
venous contrast medium is used. CT cular evaluation or orally for bowel
scanning is more versatile than con- and adjacent structure evaluation.
ventional radiography and can easily Images can be recorded on photo-
detect and identify tumors and their graphic or x-ray film or stored in dig-
types. The patient lies on a table and ital format as digitized computer data.
is moved in and out of a doughnut- Cine scanning produces a series of
like device called a gantry, which moving images of the scanned area.
houses the x-ray tube and associated CT scanning can be used to guide
electronics. The scanner uses multiple biopsy needles into areas of suspected
x-ray beams and a series of detectors tumor to obtain tissue for laboratory
that rotate around the patient to pro- analysis and to guide placement of
duce cross-sectional views in a three- catheters for drainage of abscesses.
dimensional fashion by detecting and Tumor size, progression, and prether-
recording differences in tissue density apy and post-therapy changes may be
after having an x-ray beam passed monitored with CT scanning. ■
through the tissues. These density
measurements are sent to a computer INDICATIONS:
that produces a digital image of the • Assist in differentiating between benign
anatomy, enabling a physician to look and malignant tumors
at slices or thin sections of certain • Detect congenital spinal anomalies,
anatomic views of the spine and asso- such as spina bifida, meningocele, and
ciated vascular system and to deter- myelocele
mine the extent of malignancy. • Detect herniated intervertebral disks
• Detect paraspinal cysts • Young patients (17 years old and

• Detect vascular malformations
• Monitor and evaluate effectiveness of exposure to high levels of radiation.
medical, radiation, or surgical therapies
Factors that may
• Normal density, size, position, and failure to restrict food intake before the
shape of spinal structures study
Abnormal Findings: ologic procedure
• Congenital spinal malformations, such
as meningocele, myelocele, or spina • Metallic objects within the examina-
bifida tion field (e.g., jewelry, body rings),
• Herniated intervertebral disks and can produce unclear images
• Paraspinal cysts • Improper adjustment of the radi-
• Spinal tumors obese or thin patients, which can cause
• Spondylosis (cervical or lumbar) overexposure or underexposure and a
poor-quality study
• Vascular malformations
CRITICAL VALUES: N/A exceed the weight limit for the equip-
ment
INTERFERING FACTORS: • Patients with extreme claustrophobia
unless sedation is given before the
This procedure is study
• Patients with allergies to shellfish which may produce poor visualization
or iodinated dye. The contrast of the area to be examined
ing allergic reaction. Patients with a • Inability of the patient to cooperate
known hypersensitivity to the medium or remain still during the procedure
may benefit from premedication with because of age, significant pain, or
corticosteroids or the use of nonionic mental status
contrast medium.
• Complications of the procedure include
• Patients who are pregnant or suspected hemorrhage, infection at the IV needle
of being pregnant, unless the potential insertion site, and cardiac arrhythmias.
• Elderly and other patients who occur.
• Patients who are in renal failure. repeated.
Computed Tomography, Spine 467
• Consultation with a health care ➤ Obtain a list of the medications the

provider should occur before the proce- patient is taking.
dure for radiation safety concerns ➤ In case contrast is used, patients
regarding younger patients or patients receiving metformin (glucophage) for
who are lactating. non–insulin-dependent (type 2) dia-
• Risks associated with radiographic over- the day of the test and continue to
exposure can result from frequent x-ray withhold it for 48 hours after the
procedures. Personnel in the room with test. Failure to do so may result in
the patient should wear a protective lactic acidosis.
lead apron, stand behind a shield, or ➤ Review the procedure with the
leave the area while the examination is patient. Explain to the patient that
being done. Personnel working in the some pain may be experienced dur-
area where the examination is being ing the test, and there may be
done should wear badges that reveal moments of discomfort. Explain the
formed in a radiology department,
Nursing Implications and usually by a health care practitioner
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that the procedure esty, is important in providing psy-
assesses the spine. chological support before, during,
complaints or clinical symptoms, ➤ Explain that an IV line may be
including a list of known allergens, inserted to allow infusion of IV fluids,
especially allergies or sensitivities to contrast medium, dye, or sedatives.
iodine, seafood, or other contrast Usually contrast medium and normal
➤ Obtain a history of results of pre-
viously performed diagnostic pro-
contrast medium, if given.
tion tests, bleeding time). Ensure ➤ The patient may be requested to
that the results of blood tests are drink approximately 450 mL of a
obtained and recorded before the dilute barium solution (approximately
procedure, especially BUN and crea- 1% barium) beginning 1 hour before
tinine, if contrast medium is to be the examination. This is administered
used. For related diagnostic tests, to distinguish gastrointestinal organs
refer to the Musculoskeletal System from the other abdominal organs.
table. ➤ The patient should fast and restrict
➤ Note any recent barium or other radi- fluids for 6 to 8 hours prior to the pro-
ologic contrast procedures. Ensure cedure. Instruct the patient to avoid
that barium studies were performed taking anticoagulant medication or
more than 4 days before the CT to reduce dosage as ordered prior to
scan. the procedure.
period and determine the possibil- elry (including watches), credit cards,
ity of pregnancy in perimenopausal keys, coins, cell phones, pagers, and
➤ Ensure that the patient has complied ter an antiemetic agent if ordered.
with dietary, fluids, and medication Ready an emesis basin for use.
tions; assure that food has been ➤ Monitor the patient for complica-
restricted for at least 6 hours prior to tions related to the procedure (e.g.,
the procedure. Ensure that the pa- allergic reaction, anaphylaxis, bron-
tient has removed all external metal- chospasm) if contrast is used.
lic objects (jewelry, dentures, etc.) ➤ The needle or vascular catheter is
prior to the procedure. removed, and a pressure dressing is
➤ Have emergency equipment readily applied over the puncture site.
available. ➤ The results are recorded on film or
➤ If the patient has a history of severe by automated equipment in a com-
medium for the procedure. Post-test:
foot coverings to wear and instructed diet, fluids, medications, or activity,
to void prior to the procedure. as directed by the health care practi-
➤ Observe standard precautions, and tioner. Renal function should be
follow the general guidelines in assessed before metformin is re-
Appendix A. sumed, if contrast was used.
➤ Instruct the patient to cooperate fully ➤ Monitor vital signs and neurologic
and to follow directions. Instruct the status every 15 minutes for 30 min-
patient to remain still throughout the utes. Compare with baseline values.
procedure because movement pro- Protocols may vary from facility to
duces unreliable results. facility.
➤ Establish an IV fluid line for the injec- ➤ If contrast was used, observe for
tion of contrast, emergency drugs, delayed allergic reactions, such as
and sedatives. rash, urticaria, tachycardia, hyperp-
nea, hypertension, palpitations, nau-
phobia. Administer a sedative to a ➤ If contrast was used, advise the
child or to an uncooperative adult, as patient to immediately report symp-
ordered. toms such as fast heart rate, diffi-
culty breathing, skin rash, itching or
tion on an exam table.
➤ If contrast is used, the contrast tion site for bleeding, inflammation,
medium is injected, and a rapid or hematoma formation.
series of images is taken during and
after the filling of the vessels to be ➤ Instruct the patient to apply cold
examined. Delayed images may be compresses to the puncture site, as
taken to examine the vessels after a needed, to reduce discomfort or
time and to monitor the venous edema.
phase of the procedure. ➤ Instruct the patient to increase fluid
Computed Tomography, Spleen 469
intake to help eliminate the contrast ➤ Depending on the results of this pro-
medium, if used. cedure, additional testing may be
➤ Inform the patient that diarrhea may needed to evaluate or monitor pro-
occur after ingestion of oral contrast gression of the disease process and
medium. determine the need for a change in
➤ A written report of the examination to the patient’s symptoms and
tion will be completed by a health other tests performed.
branch of medicine. The report will Related diagnostic tests:
practitioner, who will discuss the ➤ Related diagnostic tests include radi-
results with the patient. ography of the bones.
COMPUTED TOMOGRAPHY, SPLEEN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT), splenic CT.
AREA OF APPLICATION: Abdomen/spleen.

contrast medium.
DESCRIPTION & RATIONALE: Com- which houses the x-ray tube and asso-
puted tomography (CT) of the spleen ciated electronics. The scanner uses
is a noninvasive procedure that multiple x-ray beams and a series of
enhances certain anatomic views of detectors that rotate around the
the splenic structures, but it becomes patient to produce cross-sectional
an invasive procedure with the use of views in a three-dimensional fashion
contrast medium. The spleen is not by detecting and recording differences
often the organ of interest when in tissue density after having an x-ray
abdominal CT scans are obtained. beam passed through the tissues.
However, a wide variety of splenic These density measurements are sent
variations and abnormalities may be to a computer that produces a digital
detected on abdominal scans designed image of the anatomy, enabling a
to evaluate the liver, pancreas, or physician to look at slices or thin sec-
retroperitoneum. The patient lies on a tions of certain anatomic views of
table and is moved in and out of a the spleen and vascular system.
doughnut-like device called a gantry, Differentiations can be made among
Abnormal Findings:
solid, cystic, inflammatory, or vascular
lesions, and suspected hematomas and • Abdominal aortic aneurysm
aneurysms can be identified. CT is the • Hematomas
first choice in the evaluation of • Hemoperitoneum
abdominal trauma because of its diag-
nostic accuracy. Iodinated contrast • Primary and metastatic neoplasms
medium is given intravenously for • Splenic cysts or abscesses
blood vessel and vascular evaluation or
• Splenic laceration, tumor, infiltration,
orally for bowel and adjacent structure and trauma
evaluation. Images can be recorded on
photographic or x-ray film or stored
in digital format as digitized computer CRITICAL VALUES: N/A
data. Cine scanning produces a series
of moving images of the scanned area.
CT scanning can be used to guide This procedure is
biopsy needles into areas of tumor to contraindicated for:
obtain tissue for laboratory analysis • Patients with allergies to shellfish
and to guide placement of catheters or iodinated dye. The contrast
for drainage of abscesses. Tumors, medium used may cause a life-threaten-
before and after medical or surgical ing allergic reaction. Patients with a
therapy, may be monitored with CT known hypersensitivity to the medium
scanning. ■ may benefit from premedication with
contrast medium.
INDICATIONS:
• Assist in differentiating between benign • Patients who are claustrophobic.
and malignant tumors • Patients who are pregnant or suspected
• Detect tumor extension of masses and of being pregnant, unless the potential
metastasis benefits of the procedure far outweigh
• Differentiate infectious from inflam-
matory processes • Elderly and other patients who
• Evaluate cysts, masses, abscesses, and the test, because of their risk of
trauma contrast-induced renal failure.
• Evaluate the presence of an accessory • Patients who are in renal failure.
spleen, polysplenia, or asplenia • Young patients (17 years old and
• Evaluate splenic vein thrombosis younger), unless the benefits of the
• Monitor and evaluate effectiveness of exposure to high levels of radiation.
medical, radiation, or surgical therapies
Factors that may
• Normal size, position, and shape of the failure to restrict food intake before the
spleen and associated vascular system study
poor-quality study
Pretest:
assesses the abdomen and spleen.
ment
• Patients with extreme claustrophobia complaints or clinical symptoms,
unless sedation is given before the including a list of known allergens,
study especially allergies or sensitivities to
• Incorrect positioning of the patient, mediums.
of the area to be examined ➤ Obtain a history of results of previ-
• Inability of the patient to cooperate or dures, surgical procedures, and
tion tests, bleeding time). Ensure
that the results of blood tests are
• Complications of the procedure include procedure, especially BUN and crea-
hemorrhage`, infection at the IV needle tinine, if contrast medium is to be
insertion site, and cardiac arrhythmias. used. For related diagnostic tests,
refer to the Gastrointestinal, Hepa-
• The procedure may be terminated if tobiliary, and Genitourinary System
chest pain or severe cardiac arrhythmias tables.
occur.
• Failure to follow dietary restrictions ologic contrast procedures. Ensure
and other pretesting preparations may that barium studies were performed
cause the procedure to be canceled or more than 4 days before the CT
repeated. scan.
• Consultation with a health care period and determine the possibility
provider should occur before the proce- of pregnancy in perimenopausal
dure for radiation safety concerns women.
who are lactating. patient is taking.
• Risks associated with radiographic over- ➤ In case contrast is used, patients
exposure can result from frequent x-ray receiving metformin (glucophage) for
procedures. Personnel in the room with non–insulin-dependent (type 2) dia-
the patient should wear a protective betes should discontinue the drug on
the day of the test and continue to Intratest:

withhold it for 48 hours after the
test. Failure to do so may result in ➤ Ensure that the patient has complied
lactic acidosis. with dietary, fluids, and medication
➤ Review the procedure with the restrictions and pretesting prepara-
patient. Explain to the patient that tions; assure that food has been
some pain may be experienced dur- restricted for at least 6 hours prior to
ing the test, and there may be the procedure. Ensure that the
moments of discomfort. Explain the patient has removed all external
purpose of the test and how the pro- metallic objects (jewelry, dentures,
cedure is performed. Inform the etc.) prior to the procedure.
patient that the procedure is per- ➤ Have emergency equipment readily
formed in a radiology department, available.
usually by a health care practitioner ➤ If the patient has a history of severe
and support staff, and takes approxi- allergic reactions to any substance or
mately 30 to 60 minutes. drug, administer ordered prophylac-
➤ Sensitivity to cultural and social tic steroids or antihistamines before
issues, as well as concern for mod- the procedure. Use nonionic contrast
esty, is important in providing psy- medium for the procedure.
chological support before, during, ➤ Patients are given a gown, robe, and
and after the procedure. foot coverings to wear and instructed
➤ Explain that an IV line may be to void prior to the procedure.
inserted to allow infusion of IV fluids, ➤ Observe standard precautions, and
contrast medium, dye, or sedatives. follow the general guidelines in
Usually contrast medium and normal Appendix A.
saline are infused. ➤ Instruct the patient to cooperate fully
➤ Inform the patient that he or she and to follow directions. Instruct the
may experience nausea, a feeling of patient to remain still throughout the
warmth, a salty or metallic taste, or a procedure because movement pro-
transient headache after injection of duces unreliable results.
contrast medium, if given. ➤ Establish an IV fluid line for the injec-
➤ The patient may be requested to tion of contrast, emergency drugs,
drink approximately 900 mL of a and sedatives.
to distinguish gastrointestinal organs child or to an uncooperative adult, as
from the other abdominal organs. ordered.
fluids for 6 to 8 hours prior to the pro- tion on an exam table.
cedure. Instruct the patient to avoid ➤ If contrast is used, the contrast
taking anticoagulant medication or to medium is injected, and a rapid
reduce dosage as ordered prior to series of images is taken during and
the procedure. after the filling of the vessels to be
➤ Instruct the patient to remove jew- examined. Delayed images may be
elry (including watches), credit cards, taken to examine the vessels after a
➤ Instruct the patient to take slow, culty breathing, skin rash, itching or
deep breaths if nausea occurs during decreased urinary output.
the procedure. Monitor and adminis- ➤ Observe the needle/catheter inser-
ter an antiemetic agent if ordered. tion site for bleeding, inflammation,
Ready an emesis basin for use. or hematoma formation.
➤ Monitor the patient for complica-
tions related to the procedure (e.g.,
compresses to the puncture site,
as needed, to reduce discomfort or
edema.
➤ The needle or vascular catheter is
removed, and a pressure dressing is
medium, if used.
by automated equipment in a com- ➤ Inform the patient that diarrhea may
puterized system for recall and post- occur after ingestion of oral contrast
procedure interpretation by the medium.
appropriate health care practitioner. ➤ A written report of the examina-
Post-test: care practitioner specializing in this
➤ Instruct the patient to resume usual be sent to the requesting health
diet, fluids, medications or activ- care practitioner who will discuss
ity, as directed by the health care the results with the patient.
practitioner. Renal function should
be assessed before metformin is ➤ Depending on the results of this pro-
resumed, if contrast was used. cedure, additional testing may be
➤ Monitor vital signs and neurologic gression of the disease process and
status every 15 minutes for 30 min- determine the need for a change in
utes. Compare with baseline values. therapy. Evaluate test results in rela-
Protocols may vary from facility to tion to the patient’s symptoms and
facility. other tests performed.
delayed allergic reactions, such as
rash, urticaria, tachycardia, hyperp- Related diagnostic tests:
nea, hypertension, palpitations, nau- ➤ Related diagnostic tests include
sea, or vomiting. angiography of the abdomen; kidney,
➤ If contrast was used, advise the ureter, and bladder film; magnetic
patient to immediately report symp- resonance imaging of the abdomen;
toms such as fast heart rate, diffi- and ultrasound of the liver.
THORACIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

transaxial tomography (CTT), chest CT.
AREA OF APPLICATION: Thorax.

contrast medium.
DESCRIPTION & RATIONALE: Com- photographic or x-ray film or stored

puted tomography (CT) of the thorax in digital format as digitized computer
is more detailed than a chest x-ray. It data. Cine scanning is used to pro-
is a noninvasive procedure used to duce moving images of the heart. ■
enhance certain anatomic views of the
lungs, heart, and mediastinal struc- INDICATIONS:
tures. The patient lies on a table and is • Detect aortic aneurysms
moved in and out of a doughnut-like • Detect bronchial abnormalities, such as
device called a gantry, which houses stenosis, dilation, or tumor
the x-ray tube and associated electron- • Detect lymphomas, especially
ics. The scanner uses multiple x-ray Hodgkin’s disease
beams and a series of detectors that
rotate around the patient to produce • Detect mediastinal and hilar lym-
phadenopathy
cross-sectional views in a three-
dimensional fashion by detecting and • Detect primary and metastatic pul-
recording differences in tissue density monary, esophageal, or mediastinal
after having an x-ray beam passed tumors
through the tissues. These density • Detect tumor extension of neck mass
measurements are sent to a computer to thoracic area
that produces a digital image of the • Determine blood, fluid, or fat accumu-
anatomy, enabling a physician to look lation in tissues, pleuritic space, or
at slices or thin sections of certain vessels
anatomic views of the spine, spinal
cord, and lung areas. Iodinated con-
tumors near the aorta
trast medium is given intravenously
for blood vessel and vascular evalua- • Differentiate between benign tumors
tion or orally for esophageal evalua- (granulomas) and malignancies
tion. Images can be recorded on • Differentiate infectious from inflam-
Computed Tomography, Thoracic 475
matory processes (abscess, nodules, or • Patients who are claustrophobic.

pneumonitis)
• Differentiate tumor from tuberculosis of being pregnant, unless the potential
(which appears as coin-sized, calcified benefits of the procedure far outweigh
lesions) the risks to the fetus and mother.
• Evaluate cardiac chambers and pul- • Elderly and other patients who
monary vessels are chronically dehydrated before
• Evaluate the presence of plaque in car-
diac vessels
• Monitor and evaluate effectiveness of
medical or surgical therapeutic regimen • Young patients (17 years old and
younger), unless the benefits of the x-
RESULT ray diagnosis outweigh the risks of
Normal Findings:
• Normal size, position, and shape of Factors that may
chest organs, tissues, and structures impair clear imaging:
• Aortic aneurysm • Metallic objects within the examina-
• Chest lesions (benign lesions, neoplas- tion field (e.g., jewelry, body rings),
tic tumors, or metastatic mediastinal which may inhibit organ visualization
lesions to ribs or spine) and can produce unclear images
• Cysts or abscesses • Improper adjustment of the radi-
• Enlarged lymph nodes obese or thin patients, which can cause
• Esophageal pathology, including overexposure or underexposure and a
tumors poor-quality study
• Hodgkin’s disease • Patients who are very obese, who may
• Pleural effusion ment
• Pneumonitis • Patients with extreme claustrophobia
unless sedation is given before the study
INTERFERING FACTORS: which may produce poor visualization
This procedure is • Inability of the patient to cooperate or
contraindicated for: remain still during the procedure
• Patients with allergies to shellfish because of age, significant pain, or
or iodinated dye. The contrast mental status
ing allergic reaction. Patients with a Other considerations:
known hypersensitivity to the medium • Complications of the procedure in-
may benefit from premedication with clude hemorrhage, infection at the IV
corticosteroids or the use of nonionic needle insertion site, and cardiac
contrast medium. arrhythmias.
more than 4 days before the CT scan.
• Failure to follow dietary restrictions ➤ Record the date of the last menstrual
and other pretesting preparations may period and determine the possibility
cause the procedure to be canceled or of pregnancy in perimenopausal
repeated. women.
• Consultation with a health care ➤ Obtain a list of the medications the
provider should occur before the proce- patient is taking.
dure for radiation safety concerns ➤ In case contrast is used, patients
regarding younger patients or patients receiving metformin (glucophage) for
who are lactating. non–insulin-dependent (type 2) dia-
• Risks associated with radiographic over- the day of the test and continue to
exposure can result from frequent x-ray withhold it for 48 hours after the
procedures. Personnel in the room with test. Failure to do so may result in
the patient should wear a protective lactic acidosis.
lead apron, stand behind a shield, or ➤ Review the procedure with the
leave the area while the examination is patient. Explain to the patient that
being done. Personnel working in the some pain may be experienced dur-
area where the examination is being ing the test, and there may be
done should wear badges that reveal purpose of the test and how the pro-
their level of exposure to radiation. cedure is performed. Inform the
formed in a radiology department,
Nursing Implications and usually by a health care practitioner
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that the procedure esty, is important in providing psy-
assesses the chest. chological support before, during,
complaints or clinical symptoms, ➤ Explain that an IV line may be in-
including a list of known allergens, serted to allow infusion of IV fluids,
especially allergies or sensitivities contrast medium, dye, or sedatives.
to iodine, seafood, or other contrast Usually contrast medium and normal
➤ Obtain a history of results of previ- ➤ Inform the patient that he or she
ously performed diagnostic proce- may experience nausea, a feeling of
dures, surgical procedures, and warmth, a salty or metallic taste, or a
laboratory tests. Include specific transient headache after injection of
tests as they apply (e.g., blood urea contrast medium, if given.
tion tests, bleeding time). Ensure ➤ The patient should fast and restrict
that the results of blood tests are fluids for 6 to 8 hours prior to the pro-
obtained and recorded before the cedure. Instruct the patient to avoid
procedure, especially BUN and crea- taking anticoagulant medication or to
tinine, if contrast medium is to be reduce dosage as ordered prior to
used. For related diagnostic tests, the procedure.
refer to the Respiratory System ➤ Instruct the patient to remove jew-
table. elry (including watches), credit cards,
Computed Tomography, Thoracic 477
metallic objects (jewelry, dentures, ➤ The needle or vascular catheter is
etc.) prior to the procedure. removed, and a pressure dressing is
available. ➤ The results are recorded on film, or
by automated equipment in a com-
➤ If the patient has a history of severe puterized system for recall and post-
allergic reactions to any substance or procedure interpretation by the
drug, administer ordered prophylac- appropriate health care practitioner.
the procedure. Use nonionic contrast Post-test:
foot coverings to wear and instructed diet, fluids, medications, or activity,
to void prior to the procedure. as directed by the health care practi-
tioner. Renal function should be
➤ Observe standard precautions, and assessed before metformin is re-
follow the general guidelines in sumed, if contrast was used.
Appendix A.
➤ Instruct the patient to cooperate fully status every 15 minutes for 30 min-
and to follow directions. Instruct the utes. Compare with baseline values.
patient to remain still throughout the Protocols may vary from facility to
procedure because movement pro- facility.
➤ Establish an IV fluid line for the injec- delayed allergic reactions, such as
tion of contrast, emergency drugs, rash, urticaria, tachycardia, hyperp-
and sedatives. nea, hypertension, palpitations, nau-
ordered, if the patient has claustro- ➤ If contrast was used, advise the
phobia. Administer a sedative to a patient to immediately report symp-
child or to an uncooperative adult, as toms such as fast heart rate, diffi-
ordered. culty breathing, skin rash, itching or
tion on an exam table. ➤ Observe the needle/catheter inser-
➤ If contrast is used, the contrast tion site for bleeding, inflammation,
medium is injected, and a rapid or hematoma formation.
series of images is taken during and ➤ Instruct the patient to apply cold
after the filling of the vessels to be compresses to the puncture site, as
examined. Delayed images may be needed, to reduce discomfort or
taken to examine the vessels after a edema.
➤ Instruct the patient to increase fluid ➤ Depending on the results of this pro-
intake to help eliminate the contrast cedure, additional testing may be
medium, if used. needed to evaluate or monitor pro-
➤ Inform the patient that diarrhea may gression of the disease process and
occur after ingestion of oral contrast determine the need for a change in
medium. therapy. Evaluate test results in rela-
➤ A written report of the examina- other tests performed.
care practitioner specializing in this Related diagnostic tests:
be sent to the requesting health care ➤ Related diagnostic tests include
practitioner, who will discuss the chest x-ray, lung scan, and magnetic
results with the patient. resonance imaging of the chest.
COOMBS’ ANTIGLOBULIN, DIRECT

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Direct antiglobulin testing (DAT).

SPECIMEN: Serum (1 mL) collected in a red-top tube and whole blood
(1 mL) collected in lavender-top (EDTA) tube.
REFERENCE VALUE: (Method: Agglutination) Negative (no agglutination).
DESCRIPTION & RATIONALE: Direct specific antiglobulin reagents can be

antiglobulin testing (DAT) detects in used to determine whether the
vivo antibody sensitization of red patient’s RBCs are coated with IgG,
blood cells (RBCs). Immunoglobulin complement, or both. (See mono-
G (IgG) produced in certain disease graph titled “Blood Groups and
states or in response to certain drugs Antibodies” for more information
can coat the surface of RBCs, result- regarding transfusion reactions.) ■
ing in cellular damage and hemolysis.
When DAT is performed, RBCs are INDICATIONS:
taken from the patient’s blood sample, • Detect autoimmune hemolytic anemia
washed with saline to remove residual or hemolytic disease of the newborn
globulins, and mixed with anti–
human globulin reagent. If the • Evaluate suspected drug-induced
hemolytic anemia
anti–human globulin reagent causes
agglutination of the patient’s RBCs, • Evaluate transfusion reaction
Coombs’ Antiglobulin, Direct 479
RESULT • Cold agglutinins and large amounts of

paraproteins in the specimen may cause
Positive in: false-positive results.
• Anemia (autoimmune hemolytic, • Newborns’ cells may give negative
drug-induced) results in ABO hemolytic disease.
• Hemolytic disease of the newborn
• Infectious mononucleosis Nursing Implications and
• Lymphomas Procedure ● ● ● ● ● ● ● ● ● ● ●
• Mycoplasma pneumonia Pretest:

• Paroxysmal cold hemoglobinuria (idio- ➤ Inform the patient that the test is
pathic or disease related) used to detect associated conditions
or drug therapies that can result in
• Passively acquired antibodies from
cell hemolysis.
plasma products
• Post–cardiac vascular surgery plaints, including a list of known
• Systemic lupus erythematosus and sitivities to latex), and inform the
other connective tissue immune disor- appropriate health care practitioner
ders accordingly.
• Transfusion reactions (blood incompat- ➤ Obtain a history of the patient’s
ibility) hematopoietic system as well as
Negative in:
• Samples in which sensitization of ery- related laboratory tests, refer to the
throcytes has not occurred Hematopoietic System table.
➤ Obtain a list of all medications the
CRITICAL VALUES: N/A patient is taking, including herbs,
INTERFERING FACTORS: ceuticals. The requesting health care
• Drugs and substances that may cause a practitioner and laboratory should be
positive DAT include acetaminophen, advised if the patient is regularly
aminopyrine, aminosalicylic acid, using these products so that their
effects can be taken into considera-
ampicillin, antihistamines, aztreonam, tion when reviewing results.
cephalosporins, chlorinated hydrocar-
bon insecticides, chlorpromazine, ➤ Review the procedure with the
chlorpropamide, cisplatin, clonidine, imen collection takes approximately
dipyrone, ethosuximide, fenflura- 5 to 10 minutes. Address concerns
mine, hydralazine, hydrochloroth- about pain related to the procedure.
iazide, ibuprofen, insulin, isoniazid, Explain to the patient that there may
levodopa, mefenamic acid, melphalan, be some discomfort during the
methadone, methicillin, methyldopa, venipuncture. If a cord sample is to
moxalactam, penicillin, phenytoin, be taken from a newborn, inform par-
probenecid, procainamide, quinidine, ents that the sample will be obtained
quinine, rifampin, stibophen, strepto- at the time of delivery and will not
result in blood loss to the infant.
mycin, sulfonamides, and tetracycline.
• Wharton’s jelly may cause a false- tion restrictions unless by medical
positive DAT. direction.

Intratest:
➤ If the patient has a history of severe ➤ Note positive test results in cord
allergic reaction to latex, care should blood of neonate; also assess new-
be taken to avoid the use of equip- born’s bilirubin and hematocrit levels.
ment containing latex. Results may indicate the need for
➤ Instruct the patient to cooperate fully immediate exchange transfusion of
and to follow directions. Direct the fresh whole blood that has been
patient to breathe normally and to typed and crossmatched with the
avoid unnecessary movement. mother’s serum.
➤ Observe standard precautions, and ➤ Inform the postpartum patient of the
follow the general guidelines in implications of positive test results in
Appendix A. Positively identify the cord blood. Prepare the newborn for
patient, and label the appropriate exchange transfusion, on medical
tubes with the corresponding patient direction.
lect the specimen in a 5-mL red-top care practitioner, who will discuss
(serum) and lavender-top (whole the results with the patient.
blood) tube. Cord specimens are
obtained by inserting a needle
attached to a syringe into the umbili-
cal vein. The specimen is drawn into
the syringe and gently expressed into
the appropriate collection container.
➤ Remove the needle, and apply a patient or family.
site.
➤ Promptly transport the specimen to performed to evaluate or monitor
the laboratory for processing and progression of the disease process
analysis. and determine the need for a change
or in a computerized system for relation to the patient’s symptoms
recall and postprocedure interpreta- and other tests performed.
practitioner. Related laboratory tests:
Post-test: ➤ Related laboratory tests include

bilirubin, blood group and type,
➤ Observe venipuncture site for bleed- Coombs’ indirect antiglobulin (IAT),
ing or hematoma formation. Apply Ham’s test, haptoglobin, hematocrit,
paper tape or other adhesive to hold and hemoglobin.
Coombs’ Antiglobulin, Indirect 481
COOMBS’ ANTIGLOBULIN,
INDIRECT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Indirect antiglobulin test (IAT), antibody screen.

REFERENCE VALUE: (Method: Agglutination) Negative (no agglutination).
DESCRIPTION & RATIONALE: The monograph titled “Blood Groups and

indirect antiglobulin test (IAT) de- Antibodies” for more information
tects and identifies unexpected circu- regarding transfusion reactions.) ■
lating complement molecules or
antibodies in the patient’s serum. The INDICATIONS:
first use of this test was for the detec- • Detect other antibodies in maternal
tion and identification of anti-D blood that can be potentially harmful
using an indirect method. The test is to the fetus
now commonly used to screen a • Determine antibody titers in Rh-
patient’s serum for the presence of negative women sensitized by an
antibodies that may react against Rh-positive fetus
transfused red blood cells (RBCs). • Screen for antibodies before blood
During testing, the patient’s serum is transfusions
allowed to incubate with reagent
RBCs. The reagent RBCs used are • Test for the weak Rh-variant anti-
gen Du.
from group O donors and have most
of the clinically significant antigens RESULT
present (D, C, E c, e, K, M, N, S, s,
Fya, Fy,b Jk,a and Jkb). Antibodies Positive in:
present in the patient’s serum coat • Hemolytic anemia (drug-induced or
antigenic sites on the RBC mem- autoimmune)
brane. The reagent cells are washed
• Hemolytic disease of the newborn
with saline to remove any unbound
antibody. Antihuman globulin is • Incompatible crossmatch
added in the final step of the test. If • Maternal-fetal Rh incompatibility
the patient’s serum contained anti-
bodies, the antihuman globulin would Negative in:
cause the antibody-coated RBCs to • Samples in which the patient’s antibod-
stick together or agglutinate. (See ies exhibit dosage effects (i.e., stronger
reaction with homozygous than with herbs, nutritional supplements, and

heterozygous expression of an antigen) nutraceuticals. The requesting health
and reagent erythrocyte antigens con- care practitioner and laboratory
tain single-dose expressions of the cor- should be advised if the patient reg-
responding antigen (heterozygous) their effects can be taken into con-
• Samples in which reagent erythrocyte sideration when reviewing results.
antigens are unable to detect low- ➤ Review the procedure with the
prevalence antibodies patient. Inform the patient that spec-
• Samples in which sensitization of ery- 5 to 10 minutes. Address concerns
throcytes has not occurred (complete about pain related to the procedure.
absence of antibodies) Explain to the patient that there may
venipuncture.
INTERFERING FACTORS: direction.
• Drugs that may cause a positive IAT
include penicillin, phenacetin, quini-
dine, and rifampin. Intratest:
• Recent administration of dextran, ➤ If the patient has a history of severe

whole blood or fractions, or intra- be taken to avoid the use of equip-
venous contrast media can result in a ment containing latex.
false-positive reaction.
Nursing Implications and avoid unnecessary movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to check donor and recipient tubes with the corresponding patient
blood cells for antibodies prior to demographics, date, and time of col-
blood transfusion. lection. Perform a venipuncture; col-
lect the specimen in a 5-mL red-top
➤ Obtain a history of the patient’s com- tube.
➤ Remove the needle, and apply a
site.
➤ Obtain a history of the patient’s analysis.
hematopoietic system as well as
results of previously performed labo- ➤ The results are recorded manually
ratory tests, surgical procedures, or in a computerized system for
and other diagnostic procedures. For recall and postprocedure interpreta-
related laboratory tests, refer to the tion by the appropriate health care
Hematopoietic System table. practitioner.
interfere with test results. Post-test:
➤ Obtain a list of all the medica- ➤ Observe venipuncture site for bleed-
tions the patient is taking, including ing or hematoma formation. Apply
Copper 483

pressure bandage in place, or re- provider. Answer any questions or
place with a plastic bandage. address any concerns voiced by the
➤ Inform pregnant women that nega- patient or family.
tive tests during the first 12 weeks’ ➤ Depending on the results of this
gestation should be repeated at 28 procedure, additional testing may be
weeks to rule out the presence of an performed to evaluate or monitor
antibody. progression of the disease process
➤ Positive test results in pregnant and determine the need for a change
women after 28 weeks’ gestation in therapy. Evaluate test results in
indicate the need for antibody identi- relation to the patient’s symptoms
fication testing. and other tests performed.
will be sent to the requesting health Related laboratory tests:
care practitioner, who will discuss ➤ Related laboratory tests include
the results with the patient. bilirubin, blood group and type,
➤ Reinforce information given by the Coombs’ direct antiglobulin (DAT),
patient’s health care provider regard- haptoglobin, hematocrit, and hemo-
ing further testing, treatment, or globin.
COPPER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cu.
SPECIMEN: Serum (1 mL) collected in a royal blue–top, trace
element–free tube.
REFERENCE VALUE: (Method: Atomic absorption spectrophotometry)
Conventional SI Units
Age Units (Conventional Units 0.157)
Newborn–5 d 9–46 g/dL 1.4–7.2 mol/L
1–5 y 80–150 g/dL 12.6–23.6 mol/L
6–9 y 84–136 g/dL 13.2–21.4 mol/L
10–14 y 80–121 g/dL 12.6–19.0 mol/L
15–19 y 80–171 g/dL 10.1–18.4 mol/L
Adult
Men 70–140 g/dL 11.0–22.0 mol/L
Women 80–155 g/dL 12.6–24.3 mol/L
Pregnant women 118–302 g/dL 18.5–47.4 mol/L
Values for African Americans are 8% to 12% higher.
• Leukemia
DESCRIPTION & RATIONALE: Copper • Malignant neoplasms
is an important cofactor for the
enzymes that participate in the forma- • Myocardial infarction
tion of hemoglobin and collagen. • Pellagra
Copper is also a component of coagu-
• Poisoning from copper-contaminated
lation factor V, assists in the oxidation solutions or insecticides
of glucose, is required for melanin
pigment formation, is used to synthe- • Pregnancy
size ceruloplasmin, and is necessary • Pulmonary tuberculosis
for maintenance of myelin sheaths. • Rheumatic fever
Copper levels vary with intake. This
mineral is absorbed in the stomach • Rheumatoid arthritis
and duodenum, stored in the liver, • Systemic lupus erythematosus
and excreted in urine and in feces with • Thalassemias
bile salts. Copper deficiency results in
• Thyroid disease (hypothyroid or hyper-
neutropenia and a hypochromic,
thyroid)
microcytic anemia that is not respon-
sive to iron therapy. Other signs • Trauma
and symptoms of copper deficiency • Typhoid fever
include osteoporosis, depigmentation
• Use of copper intrauterine device
of skin and hair, impaired immune
system response, and possible neuro- Decreased in:
logic and cardiac abnormalities. ■ • Burns
INDICATIONS: • Chronic ischemic heart disease

• Assist in establishing a diagnosis of • Cystic fibrosis
Menkes disease
• Dysproteinemia
• Assist in establishing a diagnosis of
• Infants (especially premature infants)
Wilson’s disease
receiving milk deficient in copper
• Monitor patients receiving long-term
• Iron-deficiency anemias (some)
parenteral nutrition therapy
• Long-term total parenteral nutrition
RESULT • Malabsorption disorders (celiac disease,
tropical sprue)
Increased in:
• Malnutrition
• Anemias
• Menkes disease
• Ankylosing spondylitis
• Wilson’s disease
• Collagen diseases
• Complications of renal dialysis CRITICAL VALUES: N/A
• Hodgkin’s disease INTERFERING FACTORS:
• Infections • Drugs that may increase copper levels
include anticonvulsants and oral con-
• Inflammation traceptives.
Copper 485
• Drugs that may decrease copper levels be taken to avoid the use of equip-
include citrates, penicillamine, and val- ment containing latex.
proic acid. ➤ Instruct the patient to cooperate fully
• Excessive therapeutic intake of zinc patient to breathe normally and to
may interfere with intestinal absorption avoid unnecessary movement.
of copper.
follow the general guidelines in Ap-
pendix A. Positively identify the
Nursing Implications and patient, and label the appropriate
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: collection. Perform a venipuncture;
➤ Inform the patient that the test is royal blue–top, trace element–free
used to monitor exposure to copper. tube.
➤ Obtain a history of the patient’s ➤ Remove the needle, and apply a
complaints, including a list of known pressure dressing over the puncture
appropriate health care practitioner ➤ Promptly transport the specimen to
accordingly. the laboratory for processing and
analysis.
hematopoietic, hepatobiliary, and ➤ The results are recorded manually
immune systems, as well as results or in a computerized system for
of previously performed laboratory recall and postprocedure interpreta-
tests, surgical procedures, and other tion by the appropriate health care
diagnostic procedures. For related practitioner.
laboratory tests, refer to the Hema-
topoietic, Hepatobiliary, and Immune Post-test:
System tables.
nutritional supplements, and nutra- pressure bandage in place, or re-
ceuticals. The requesting health care place with a plastic bandage.
advised if the patient regularly uses ➤ Nutritional considerations: Instruct
these products so that their effects the patient with increased copper
can be taken into consideration levels to avoid foods rich in copper or
when reviewing results. increase intake of elements that
interfere with copper absorption, as
➤ Review the procedure with the appropriate. Organ meats, shellfish,
patient. Inform the patient that spec- nuts, and legumes are good sources
imen collection takes approximately of dietary copper. High intake of zinc,
5 to 10 minutes. Address concerns iron, calcium, and manganese inter-
about pain related to the procedure. feres with copper absorption. Cop-
Explain to the patient that there may per deficiency does not normally
be some discomfort during the occur in adults, but patients receiv-
venipuncture. ing long-term total parenteral nutri-
➤ There are no food, fluid, or medication should be evaluated if signs and
tion restrictions unless by medical symptoms of copper deficiency
direction. appear.
Intratest:
➤ If the patient has a history of severe care practitioner, who will discuss
allergic reaction to latex, care should the results with the patient.

referral to another health care pro- relation to the patient’s symptoms
vider. Answer any questions or ad- and other tests performed.
dress any concerns voiced by the
patient or family. Related laboratory tests:
➤ Depending on the results of this pro- ➤ Related laboratory tests include ceru-
cedure, additional testing may be loplasmin, complete blood count,
performed to evaluate or monitor liver biopsy, and zinc.
CORTISOL AND CHALLENGE TESTS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Hydrocortisone, compound F.

(1 mL) collected in green-top (heparin) tube is also acceptable. Care must
be taken to use the same type of collection container if serial measurements
are to be taken.
Medication Recommended
Procedure Administered Collection Times
ACTH stimulation, 1 g (low-dose 3 cortisol levels: baseline
rapid test protocol) immediately before bolus,
cosyntropin IM 30 min after bolus, and 60
min after bolus
CRH stimulation IV dose of 1 g/kg 8 cortisol and 8 ACTH levels:
ovine CRH at baseline collected 15 min
9 a.m. or 8 p.m. before injection, 0 minutes
before injection, and then
5, 15, 30, 60, 120, and 180
min after injection
Dexamethasone Oral dose of 1 mg Collect cortisol at 8 a.m. on
suppression dexamethasone the morning after the
(overnight) (Decadron) at 11 p.m. dexamethasone dose
Metyrapone Oral dose of 30 mg/kg Collect cortisol and ACTH at
stimulation metyrapone with 8 a.m. on the morning
(overnight) snack at midnight after the metyrapone dose
ACTH adrenocorticotropic hormone; CRH corticotropin-releasing hormone; IM

intramuscular; IV intravenous.
Cortisol and Challenge Tests 487

Cortisol
8 a.m. 5–25 g/dL 138–690 nmol/L
4 p.m. 3–16 g/dL 83–442 nmol/L
ACTH Challenge Tests
CRH stimulation 2–4 fold increase over 2–4 fold increase over
baseline ACTH or baseline value
cortisol level
Dexamethasone Suppressed
Cortisol less than Less than 83 nmol/L
3 g/dL next day
ACTH (Cosyntropin) Stimulated, Rapid Test
Cortisol greater than Greater than
20 g/dL 552 nmol/L
Metyrapone Stimulated
ACTH greater than Greater than
75 pg/mL 16.5 pmol/L
Cortisol less than Less than 83 nmol/L
3 g/dL next day
ACTH adrenocorticotropic hormone; CRH corticotropin-releasing hormone.
DESCRIPTION & RATIONALE: Cortisol levels occurring on awakening and

(hydrocortisone) is the predominant lowest levels occurring late in the day.
glucocorticoid secreted in response to Bursts of cortisol excretion can occur
stimulation by the hypothalamus and at night. Cortisol and ACTH test
pituitary adrenocorticotropic hor- results are evaluated together because
mone (ACTH). Cortisol stimulates they each control the other’s concen-
gluconeogenesis, mobilizes fats and trations (i.e., any change in one causes
proteins, antagonizes insulin, and sup- a change in the other). ACTH levels
presses inflammation. Measuring lev- exhibit a diurnal variation, peaking
els of cortisol in blood is the best between 6 and 8 a.m. and reaching the
indicator of adrenal function. Cortisol lowest point between 6 and 11 p.m.
secretion varies diurnally, with highest Evening levels are generally one-half to
two-thirds lower than morning levels. corticotropin-independent (carcinoma of

(See monograph titled “Adrenocorti- the lung or thyroid) causes of increased
cortisol levels. Metyrapone inhibits the
cotropic Hormone [and Challenge
conversion of 11-deoxycortisol to corti-
Tests].”) ■ sol. Cortisol levels should decrease to less
than 3 g/dL if normal pituitary stimula-
INDICATIONS: tion by ACTH occurs after an oral dose
• Detect adrenal hyperfunction (Cush- of metyrapone. Specimen collection and
ing’s syndrome) administration of the medication are per-
• Detect adrenal hypofunction (Addison’s formed as with the overnight dexametha-
disease) sone test.
RESULT: The dexamethasone suppression Increased in:

test is useful in differentiating the causes • Adrenal adenoma
for increased cortisol levels. Dexametha-
sone is a synthetic steroid that suppresses
secretion of ACTH. With this test, a • Ectopic ACTH production
baseline morning cortisol level is col-
• Hyperglycemia
lected, and the patient is given a 1-mg
dose of dexamethasone at bedtime. A sec- • Pregnancy
ond specimen is collected the following
• Stress
morning. If cortisol levels have not been
suppressed, adrenal adenoma may be sus-
Decreased in:
pected. The dexamethasone suppression
test also produces abnormal results in • Addison’s disease
patients with psychiatric illnesses. • Adrenogenital syndrome
The corticotropin-releasing hormone
(CRH) stimulation test works as well as • Hypopituitarism
the dexamethasone suppression test in
distinguishing Cushing’s disease from CRITICAL VALUES: N/A
conditions in which ACTH is secreted
ectopically. In this test, cortisol levels are
measured after an injection of CRH. A
cortisol levels include amphetamines,
fourfold increase in cortisol levels above
anticonvulsants, clomipramine, corti-
baseline is seen in Cushing’s disease. No
cotropin, cortisone, CRH, cyclic AMP,
increase in cortisol is seen if ectopic
ether, fenfluramine, hydrocortisone,
ACTH secretion is the cause.
insulin, lithium, methadone, metoclo-
The cosyntropin test is used when
pramide, naloxone, opiates, oral con-
adrenal insufficiency is suspected. Cosyn-
traceptives, prednisolone, ranitidine,
tropin is a synthetic form of ACTH. A
spironolactone, tetracosactrin, and
baseline cortisol level is collected before
vasopressin.
the injection of cosyntropin. Specimens
are subsequently collected at 30- and • Drugs and substances that may de-
60-minute intervals. If the adrenal glands crease cortisol levels include barbitu-
are functioning normally, cortisol levels rates, beclomethasone, betamethasone,
rise significantly after administration of clonidine, danazol, desoximetasone,
cosyntropin. desoxycorticosterone, dexamethasone,
The metyrapone stimulation test ephedrine, etomidate, fluocinolone,
is used to distinguish corticotropin- ketoconazole, levodopa, lithium, met-
dependent (pituitary Cushing’s disease hylprednisolone, metyrapone, mida-
and ectopic Cushing’s disease) from zolam, morphine, nitrous oxide,
Cortisol and Challenge Tests 489
oxazepam, phenytoin, ranitidine, and ➤ Review the procedure with the

trimipramine. patient. Inform the patient that multi-
ple specimens may be required.
• Test results are affected by the time this Inform the patient that specimen col-
test is done because cortisol levels vary lection takes approximately 5 to 10
diurnally. minutes. Address concerns about
pain related to the procedure.
• Stress and excessive physical activity Explain to the patient that there may
can produce elevated levels. be some discomfort during the
venipuncture.
• Normal values can be obtained in the
presence of partial pituitary deficiency. ➤ Sensitivity to social and cultural
• Recent radioactive scans within 1 week esty, is important in providing psy-
of the test can interfere with test results. chological support before, during,
• The metyrapone stimulation test
is contraindicated in patients with tion restrictions unless by medical
suspected adrenal insufficiency. direction.
• Metyrapone may cause gastroin- ➤ Drugs that enhance steroid metabo-
testinal distress and/or confusion. lism may be withheld by medical
Administer oral dose of metyrapone direction prior to metyrapone stimu-
with milk and snack. lation testing.
➤ Instruct the patient to minimize
stress to avoid raising cortisol levels.
Procedure ● ● ● ● ● ● ● ● ● ● ● Intratest:
Pretest: available.
➤ Inform the patient that the test is ➤ If the patient has a history of severe
used to asssit in the diagnosis of allergic reaction to latex, care should
adrenocortical insufficiency. be taken to avoid the use of equip-
➤ Obtain a history of the patient’s com- ment containing latex.
plaints, including a list of known ➤ Instruct the patient to cooperate fully
allergens (especially allergies or sen- and to follow directions. Direct the
sitivities to latex), and inform the patient to breathe normally and to
appropriate health care practitioner avoid unnecessary movement.
accordingly. ➤ Observe standard precautions, and
➤ Obtain a history of the patient’s follow the general guidelines in
endocrine system, as well as results Appendix A. Positively identify the
of previously performed laboratory patient, and label the appropriate
tests, surgical procedures, and other tubes with the corresponding patient
diagnostic procedures. For related demographics, date, and time of col-
laboratory tests, refer to the Endo- lection. Collect specimen between 6
crine System table. and 8 a.m., when cortisol levels are
➤ Obtain a list of medications the highest. Perform a venipuncture; col-
patient is taking, including herbs, lect the specimen in a 5-mL red- or
nutritional supplements, and nutra- tiger-top tube.
ceuticals. The requesting health care ➤ Adverse reactions to metyrapone
practitioner and laboratory should be include nausea and vomiting (N/V),
advised if the patient regularly uses abdominal pain, headache, dizziness,
these products so that their effects sedation, allergic rash, decreased
can be taken into consideration white blood cell count, or bone
when reviewing results. marrow depression. Signs and symp-
toms of overdose or acute adreno- care practitioner, who will discuss

cortical insuffiency include cardiac the results with the patient.
arrhythmias, hypotension, dehydra- ➤ Recognize anxiety related to test
tion, anxiety, confusion, weakness, results. Discuss the implications of
impairment of consciousness, N/V, abnormal test results on the
epigastric pain, diarrhea, hypona- patient’s lifestyle. Provide teaching
tremia, and hyperkalemia. and information regarding the clinical
➤ Remove the needle, and apply a implications of the test results, as
pressure dressing over the puncture appropriate. Educate the patient
site. regarding access to counseling
➤ Promptly transport the specimen to services.
the laboratory for processing and ➤ Reinforce information given by the
analysis. patient’s health care provider regard-
➤ The results are recorded manually ing further testing, treatment, or
or in a computerized system for referral to another health care pro-
recall and postprocedure interpreta- vider. Answer any questions or
tion by the appropriate health care address any concerns voiced by the
➤ Instruct the patient to resume usual progression of the disease process
medications, as directed by the and determine the need for a change
health care practitioner. in therapy. Evaluate test results in
➤ Observe venipuncture site for bleed- relation to the patient’s symptoms
ing or hematoma formation. Apply and other tests performed.
pressure bandage in place, or Related laboratory tests:
replace with a plastic bandage. ➤ Related laboratory tests include
➤ A written report of the examination ACTH, glucose, and glucose toler-
will be sent to the requesting health ance test.
C-PEPTIDE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Connecting peptide insulin, insulin C-peptide,

proinsulin C-peptide.
REFERENCE VALUE: (Method: Immunochemiluminometric assay, ICMA)

0.78–1.8 ng/mL 0.26–0.63 nmol/L
C-Peptide 491
• Oral hypoglycemic medication

DESCRIPTION & RATIONALE: C-
peptide is a biologically inactive pep- • Pancreas or beta cell transplants
tide formed when beta cells of the • Renal failure
pancreas convert proinsulin to insulin.
Most of C-peptide is secreted by the Decreased in:
kidneys. C-peptide levels usually cor- • Factitious hypoglycemia
relate with insulin levels and provide a • Insulin-dependent (type 1) diabetes
reliable indication of how well the
beta cells secrete insulin. Release of C- • Pancreatectomy
peptide is not affected by exogenous
insulin administration. C-peptide val- CRITICAL VALUES: N/A
ues double after stimulation with
glucose or glucagon. An insulin/ INTERFERING FACTORS:
• Drugs that may increase C-peptide lev-
C-peptide ratio less than 1.0 indicates
els include betamethasone, chloro-
endogenous insulin secretion, whereas quine, danazol, deferoxamine, ethinyl
a ratio of greater than 1.0 indicates an estradiol, oral contraceptives, pred-
excess of exogenous insulin. ■ nisone, and rifampin.
INDICATIONS: • Drugs that may decrease C-peptide lev-
• Assist in the diagnosis of insulinoma: els include atenolol and calcitonin.
Serum levels of insulin and C-peptide • C-peptide and endogenous insulin lev-
are elevated. els do not always correlate in obese
• Detect suspected factitious cause of patients.
hypoglycemia (excessive insulin admin- • Failure to follow dietary restrictions
istration): C-peptide levels do not in- before the procedure may cause the
crease with serum insulin levels. procedure to be canceled or repeated.
• Determine beta cell function when
insulin antibodies preclude accurate
measurement of serum insulin pro- Nursing Implications and
duction. Procedure ● ● ● ● ● ● ● ● ● ● ●
• Distinguish between insulin-dependent

(type 1) and non–insulin-dependent Pretest:
(type 2) diabetes (with C-peptide– ➤ Inform the patient that the test is pri-
stimulating test): Patients with diabetes marily used in the evaluation of hypo-
whose C-peptide stimulation level is glycemia.
greater than 18 ng/mL can be managed ➤ Obtain a history of the patient’s com-
without insulin treatment. plaints, including a list of known
• Evaluate hypoglycemia. sitivities to latex), and inform the
RESULT accordingly.
Increased in: ➤ Obtain a history of the patient’s
endocrine system and results of pre-
• Endogenous hyperinsulinism viously performed laboratory tests,
• Islet cell tumor surgical procedures, and other diag-
• Non–insulin-dependent (type 2) ratory tests, refer to the Endocrine
diabetes System table.
➤ Obtain a list of the medications the or in a computerized system for

patient is taking, including herbs, recall and postprocedure interpreta-
nutritional supplements, and nutra- tion by the appropriate health care
ceuticals. The requesting health care practitioner.
advised if the patient is regularly Post-test:
using these products so that their ➤ Observe venipuncture site for bleed-
effects can be taken into considera- ing or hematoma formation. Apply
tion when reviewing results. paper tape or other adhesive to
patient. Inform the patient that spec- replace with a plastic bandage.
imen collection takes approximately ➤ Instruct the patient to resume usual
5 to 10 minutes. Address concerns diet as directed by the health care
about pain related to the procedure. practitioner.
be some discomfort during the ➤ Nutritional considerations: Abnormal
venipuncture. C-peptide levels may be associ-
ated with diabetes. Instruct the dia-
➤ The patient should fast for at least 10 betic patient, as appropriate, in nutri-
hours before specimen collection. tional management of the disease.
➤ There are no fluid or medication Patients who adhere to dietary rec-
restrictions unless by medical ommendations report a better gen-
direction. eral feeling of health, better weight
management, greater control of glu-
Intratest: cose and lipid values, and improved
use of insulin. There is no “diabetic
➤ Ensure that the patient has complied diet”; however, there are many meal-
with dietary restrictions and pretest- planning approaches with nutritional
ing preparations; assure that food goals endorsed by the American
has been restricted for at least 10 Dietetic Association. The nutritional
hours prior to the procedure. requirements of each diabetic patient
➤ If the patient has a history of severe need to be determined individually
allergic reaction to latex, care should with the appropriate health care pro-
be taken to avoid the use of equip- fessionals, particularly health care
ment containing latex. workers trained in nutrition.
➤ Instruct the patient to cooperate fully ➤ Instruct the patient and caregiver to
and to follow directions. Direct the report signs and symptoms of hypo-
patient to breathe normally and to glycemia (weakness, confusion,
avoid unnecessary movement. diaphoresis, rapid pulse) or hyper-
glycemia (thirst, polyuria, hunger,
lethargy). Emphasize, as appropriate,
that good control of glucose levels
delays the onset and slows the pro-
gression of diabetic retinopathy,
nephropathy, and neuropathy.
lection. Perform a venipuncture; ➤ A written report of the examination
collect the specimen in a 5-mL red- will be sent to the requesting health
top tube. care practitioner, who will discuss
pressure dressing over the puncture ➤ Reinforce information given by the
site. patient’s health care provider regard-
➤ Promptly transport the specimen to referral to another health care pro-
the laboratory for processing and vider. Answer any questions or
analysis. address any concerns voiced by the
➤ The results are recorded manually patient or family.
C-Reactive Protein 493

performed to evaluate or monitor ➤ Related laboratory tests include
progression of the disease process cortisol, creatinine, creatinine clear-
and determine the need for a change ance, fructose, glucagon, glucose,
in therapy. Evaluate test results in glucose tolerance tests, glycated
relation to the patient’s symptoms hemoglobin, insulin, insulin antibod-
and other tests performed. ies, microalbumin, and urea nitrogen.
C-REACTIVE PROTEIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CRP.
REFERENCE VALUE: (Method: High-sensitivity immunoassay, nephelometry)
High-sensitivity immunoassay 1.0–3.0 mg/L

(cardiac applications)
Nephelometry Conventional Units

Adult 0–4.9 mg/L
DESCRIPTION & RATIONALE: C- process than ESR. CRP disappears

reactive protein (CRP) is a glycopro- from the serum rapidly when inflam-
tein produced by the liver in response mation has subsided. The inflamma-
to acute inflammation. The CRP tory process and its association with
assay is a nonspecific test that deter- atherosclerosis make the presence of
mines the presence (not the cause) of CRP, as detected by highly sensitive
inflammation; it is often ordered in CRP assays, a potential marker for
conjunction with erythrocyte sedi- coronary artery disease. It is believed
mentation rate (ESR). CRP assay is a that the inflammatory process may
more sensitive and rapid indicator of instigate the conversion of a stable
the presence of an inflammatory plaque to a weaker one that can rup-
ture and occlude an artery. Several oral contraceptives (progestogen effect),

major studies are in progress to con- penicillamine, pentopril, and sul-
fasalazine.
firm the correlation and to establish
standardized reference ranges for this • Nonsteroidal anti-inflammatory drugs,
purpose. ■ salicylates, and steroids may cause false-
negative results because of suppression
INDICATIONS: of inflammation.
• Assist in the differential diagnosis of • Falsely elevated levels may occur with
appendicitis and acute pelvic inflam- the presence of an intrauterine device.
matory disease
• Lipemic samples that are turbid in
appearance may be rejected for analysis
Crohn’s disease and ulcerative colitis
when nephelometry is the test method.
rheumatoid arthritis and uncompli-
cated systemic lupus erythematosus Nursing Implications and
(SLE) Procedure ● ● ● ● ● ● ● ● ● ● ●
• Assist in the evaluation of coronary

artery disease Pretest:
• Detect the presence or exacerbation of ➤ Inform the patient that the test is
inflammatory processes used to indicate nonspecific inflam-
matory response; the highly sensi-
• Monitor response to therapy for tive CRP is used to assess risk for
autoimmune disorders such as rheuma- cardiovascular and peripheral vascu-
toid arthritis lar disease.
RESULT complaints, including a list of known
• Acute bacterial infections appropriate health care practitioner
accordingly. The patient may com-
• Crohn’s disease
plain of pain related to the inflamma-
• Inflammatory bowel disease tory process in connective or other
tissues.
• Pregnancy (second half ) diovascular and immune systems, as
• Rheumatic fever well as results of previously per-
• Rheumatoid arthritis procedures, and other diagnos-
• SLE tic procedures. For related laboratory
tests, refer to the Cardiovascular and
• Syndrome X (metabolic syndrome) Immune System tables.
Decreased in: N/A
CRITICAL VALUES: N/A ceuticals. The requesting health care
INTERFERING FACTORS: advised if the patient regularly uses
• Drugs that may decrease CRP levels these products so that their effects
include aurothiomalate, methotrexate, can be taken into consideration
nonsteroidal anti-inflammatory drugs, when reviewing results.
C-Reactive Protein 495
➤ Review the procedure with the Post-test:

imen collection takes approximately ➤ Observe venipuncture site for bleed-
5 to 10 minutes. Address concerns ing or hematoma formation. Apply
about pain related to the procedure. paper tape or other adhesive to hold
Explain to the patient that there may pressure bandage in place, or re-
be some discomfort during the place with a plastic bandage.
➤ There are no food, fluid, or medica- will be sent to the requesting health
tion restrictions unless by medical care practitioner, who will discuss
direction. the results with the patient.
Intratest: patient’s health care provider regard-
➤ If the patient has a history of severe ing further testing, treatment, or re-
allergic reaction to latex, care should ferral to another health care provider.
be taken to avoid the use of equip- Answer any questions or address
ment containing latex. any concerns voiced by the patient
or family.
and to follow directions. Direct the ➤ Depending on the results of this pro-
patient to breathe normally and to cedure, additional testing may be
avoid unnecessary movement. performed to evaluate or monitor
➤ Observe standard precautions, and and determine the need for a change
follow the general guidelines in in therapy. Evaluate test results in
Appendix A. Positively identify the relation to the patient’s symptoms
patient, and label the appropriate and other tests performed.
demographics, date, and time of col- Related laboratory tests:
lect the specimen in a 5-mL red- or ➤ Related laboratory tests include
tiger-top tube. antiarrhythmic drugs, apolipoprotein
➤ Remove the needle, and apply a A, apolipoprotein B, aspartate amino-
pressure dressing over the puncture transferase, atrial natriuretic peptide,
site. blood gases, B-type natriuretic pep-
tide, calcium (blood and ionized),
➤ Promptly transport the specimen to cholesterol (total, HDL, and LDL),
the laboratory for processing and C-reactive protein, creatine kinase
analysis. and isoenzymes, ESR, glucose, gly-
➤ The results are recorded manually cated hemoglobin, homocysteine,
or in a computerized system for ketones, lactate dehydrogenase and
recall and postprocedure interpreta- isoenzymes, myoglobin, potassium,
tion by the appropriate health care triglycerides, troponin, and white
practitioner. blood cell count.
CREATINE KINASE AND ISOENZYMES

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CK and isos.

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Serial speci-
mens are highly recommended. Care must be taken to use the same type of
collection container if serial measurements are to be taken.
REFERENCE VALUE: (Method: Enzymatic for CK, electrophoresis for isoen-

zymes; enzyme immunoassay techniques are in common use for CK-MB)

Total CK
Newborn 3 adult values
Male (children and adult) 38–174 U/L
Female (children and adult) 26–140 U/L
CK isoenzymes by electrophoresis
CK-BB Absent
CK-MB Less than 4–6%
CK-MM 94–96%
CK-MB by immunoassay Less than 10 ng/mL
CK creatine kinase; CK-BB CK isoenzyme in brain; CK-MB CK isoenzyme in heart;

CK-MM CK isoenzyme in skeletal muscle.
DESCRIPTION & RATIONALE: Crea- frame. Measuring the serum levels can
tine kinase (CK) is an enzyme that help determine the extent and timing
exists almost exclusively in skeletal of the damage. Noting the presence of
muscle, heart muscle, and, in smaller the specific isoenzyme helps determine
amounts, in the brain. This enzyme the location of the tissue damage.
is important in intracellular storage Acute myocardial infarction (MI)
and energy release. Three isoenzymes, releases CK into the serum within the
based on primary location, have been first 48 hours; values return to normal
identified by electrophoresis: brain in about 3 days. The isoenzyme CK-
CK-BB, cardiac CK-MB, and skeletal MB appears in the first 6 to 24 hours
muscle CK-MM. When injury to these and is usually gone in 72 hours.
tissues occurs, the enzymes are released Recurrent elevation of CK suggests
into the bloodstream. Levels increase reinfarction or extension of ischemic
and decrease in a predictable time damage. Significant elevations of CK
Creatine Kinase and Isoenzymes 497
are expected in early phases of mus- • Head injury

cular dystrophy, even before the clini- • Hypothyroidism
cal signs and symptoms appear. CK
• Hypoxic shock
elevation diminishes as the disease
progresses and muscle mass decreases. • Infectious diseases
Differences in total CK with age and • Gastrointestinal (GI) tract infarction
gender relate to the fact that the pre-
dominant isoenzyme is muscular in • Loss of blood supply to any muscle
origin. Body builders have higher val- • Malignant hyperthermia
ues, whereas older individuals have
• MI
lower values because of deterioration
of muscle mass. • Muscular dystrophies
The use of the mass assay for CK- • Myocarditis
MB with cardiac troponin T, myoglo-
bin, and serial electrocardiograms in • Neoplasms of the prostate, bladder, and
the assessment of MI has largely GI tract
replaced the use of CK isoenzyme • Polymyositis
assay by electrophoresis. CK-MB mass
• Pregnancy
assays are more sensitive and rapid
than electrophoresis. The evaluation • Prolonged hypothermia
of serial samples for CK-MB is highly • Pulmonary edema
recommended. ■
• Pulmonary embolism
INDICATIONS: • Reye’s syndrome
• Assist in the diagnosis of acute MI and
evaluate cardiac ischemia (CK-MB) • Rhabdomyolysis
• Detect musculoskeletal disorders that • Surgery
do not have a neurologic basis, such as • Tachycardia
dermatomyositis or Duchenne’s mus-
cular dystrophy (CK-MM) • Tetanus
• Determine the success of coronary • Trauma
artery reperfusion after streptokinase
infusion or percutaneous transluminal Decreased in:
angioplasty, as evidenced by a decrease • Small stature
in CK-MB
• Sedentary lifestyle
RESULT
Increased in:
• Alcoholism
• Drugs that may increase total CK levels
• Brain infarction (extensive) include any intramuscularly injected
preparations because of tissue trauma
• Congestive heart failure
caused by injection.
• Delirium tremens
• Drugs that may decrease total CK
• Dermatomyositis levels include dantrolene and statins.

Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that the test is pri- avoid unnecessary movement.
marily used to assist in monitoring ➤ Observe standard precautions, and
MI and some disorders of the mus- follow the general guidelines in
culoskeletal system. Appendix A. Positively identify the
appropriate health care practitioner lect the specimen in a 5-mL red- or
accordingly. tiger-top tube.
➤ Obtain a history of the patient’s car- ➤ Remove the needle, and apply a
diovascular and musculoskeletal sys- pressure dressing over the puncture
tems, as well as results of previously site.
tests, refer to the Cardiovascular and
Musculoskeletal System tables. ➤ The results are recorded manually
➤ Obtain a list of the medications the recall and postprocedure interpreta-
patient is taking, including herbs, tion by the appropriate health care
nutritional supplements, and nutra- practitioner.
using these products so that their ➤ Observe venipuncture site for bleed-
effects can be taken into considera- ing or hematoma formation. Apply
tion when reviewing results. paper tape or other adhesive to
patient. Inform the patient that a replace with a plastic bandage.
series of samples will be required. ➤ Nutritional considerations: Increased
(Samples at time of admission and 2 CK levels may be associated with
to 4 hours, 6 to 8 hours, and 12 coronary artery disease (CAD). Nutri-
hours after admission are the mini- tional therapy is recommended for
mal recommendations. Additional individuals identified to be at high
samples may be requested.) Inform risk for developing CAD. If over-
the patient that specimen collection weight, the patient should be encour-
takes approximately 5 to 10 minutes. aged to achieve a normal weight. The
Address concerns about pain related American Heart Association Step 1
to the procedure. Explain to the and Step 2 diets may be helpful in
patient that there may be some dis- achieving a goal of lowering total cho-
comfort during the venipuncture. lesterol and triglyceride levels. The
➤ There are no food, fluid, or medica- Step 1 diet emphasizes a reduction in
tion restrictions unless by medical foods high in saturated fats and cho-
direction. lesterol. Red meats, eggs, and dairy
products are the major sources of
Intratest: saturated fats and cholesterol. If
triglycerides are also elevated, the
➤ If the patient has a history of severe patient should be advised to elimi-
allergic reaction to latex, care should nate or reduce alcohol and simple
Creatinine, Blood 499
carbohydrates from the diet. The address any concerns voiced by the
Step 2 diet recommends stricter patient or family.
reductions. ➤ Depending on the results of this pro-
results, and be supportive of fear of and other tests performed.
the implications of abnormal test Related laboratory tests:
antiarrhythmic drugs, apolipoprotein
A, apolipoprotein B, aspartate amino-
transferase, atrial natriuretic peptide,
blood gases, B-type natriuretic pep-
to counseling services. Provide con-
tide, calcium (blood and ionized),
tact information, if desired, for the
cholesterol (total, HDL and LDL),
American Heart Association (http://
C-reactive protein, glucose, glycated
www.americanheart.org).
hemoglobin, homocysteine, ketones,
➤ Reinforce information given by the lactate dehydrogenase and isoen-
patient’s health care provider regard- zymes, lipoprotein electrophoresis,
ing further testing, treatment, or magnesium, myoglobin, pericardial
referral to another health care fluid, potassium, triglycerides, and
provider. Answer any questions or troponin.
CREATININE, BLOOD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conventional Units 88.4)
1–5 y 0.3–0.5 mg/dL 27–44 mol/L
6–10 y 0.5–0.8 mg/dL 44–71 mol/L
Adult male 0.6–1.2 mg/dL 53–106 mol/L
Adult female 0.5–1.1 mg/dL 44–97 mol/L
• Acromegaly
DESCRIPTION & RATIONALE: Creati-
nine is the end product of creatine
metabolism. Creatine resides almost • Dehydration
exclusively in skeletal muscle, where it • Gigantism
participates in energy-requiring meta-
bolic reactions. In these processes, a • Hyperthyroidism
small amount of creatine is irre- • Poliomyelitis
versibly converted to creatinine, • Renal calculi
which then circulates to the kidneys
and is excreted. The amount of creati- • Renal disease, acute and chronic renal
nine generated in an individual is pro- failure
portional to the mass of skeletal • Rhabdomyolysis
muscle present and remains fairly con- • Shock
stant, unless there is massive muscle
damage resulting from crushing Decreased in:
injury or degenerative muscle disease. • Decreased muscle mass owing to debil-
Creatinine values also decrease with itating disease or increasing age
age owing to diminishing muscle • Inadequate protein intake
mass. Blood urea nitrogen (BUN) is
often ordered with creatinine for com- • Liver disease (severe)
parison. The BUN/creatinine ratio is • Muscular dystrophy
also a useful indicator of disease. The
• Pregnancy
ratio should be between 10:1 and
20:1. Creatinine is the ideal substance • Small stature
for determining renal clearance be-
cause a fairly constant quantity is pro- CRITICAL VALUES:
duced within the body. The creatinine Potential critical value is greater
than 7.4 mg/dL (nondialysis
clearance test measures a blood sample patient).
and a urine sample to determine the Note and immediately report to the
rate at which the kidneys are clearing health care practitioner any critically
creatinine from the blood; this increased values and related symptoms.
accurately reflects the glomerular fil- Chronic renal insufficiency is identified
tration rate. (See monograph titled by creatinine levels between 1.5 and 3.0
“Creatinine, Urine, and Creatinine mg/dL; chronic renal failure is present at
Clearance, Urine” for additional levels greater than 3.0 mg/dL.
information.) ■ Possible interventions may include
renal or peritoneal dialysis and organ
INDICATIONS: transplant, but early discovery of the
• Assess a known or suspected disorder cause of elevated creatinine levels might
involving muscles in the absence of avoid such drastic interventions.
renal disease
• Evaluate known or suspected impair- • Drugs and substances that may increase
ment of renal function creatinine levels include acebutolol,
acetaminophen (overdose), acetylsali-
RESULT cylic acid, aldatense, amikacin, amio-
Increased in: darone, amphotericin B, arginine,
Creatinine, Blood 501
arsenicals, ascorbic acid, asparaginase, performed laboratory tests, surgical

barbiturates, capreomycin, captopril, procedures, and other diagnostic
carbutamide, carvedilol, cephalothin, procedures. For related laboratory
chlorthalidone, cimetidine, cisplatin, tests, refer to the Genitourinary and
Musculoskeletal System tables.
clofibrate, colistin, corn oil (Lipomul),
cyclosporine, dextran, doxycycline, ➤ Obtain a list of medications the
enalapril, ethylene glycol, gentamicin, patient is taking, including herbs,
indomethacin, ipodate, kanamycin,
levodopa, mannitol, methicillin, meth- practitioner and laboratory should be
oxyflurane, mitomycin, neomycin, advised if the patient is regularly
netilmycin, nitrofurantoin, nonteroidal using these products so that their
anti-inflammatory drugs, oxyphenbu- effects can be taken into considera-
tazone, paromomycin, penicillin, pen- tion when reviewing results.
tamidine, phosphorus, plicamycin, ➤ Review the procedure with the
radiographic agents, semustine, strep- patient. Inform the patient that spec-
tokinase, streptozocin, tetracycline, imen collection takes approximately
thiazides, tobramycin, triamterene, 5 to 10 minutes. Address concerns
vancomycin, vasopressin, viomycin, about pain related to the procedure.
and vitamin D. Explain to the patient that there may
• Drugs that may decrease creatinine lev- venipuncture.
els include citrates, dopamine, ibupro- ➤ Sensitivity to social and cultural
fen, and lisinopril. issues, as well as concern for mod-
• High blood levels of bilirubin and chological support before, during,
glucose can cause false decreases in and after the procedure.
creatinine.
• A diet high in meat can cause increased tion restrictions unless by medical
creatinine levels. direction.
➤ Instruct the patient to refrain from
• Ketosis can cause a significant increase excessive exercise for 8 hours
in creatinine. before the test.
• Hemolyzed specimens are unsuitable
for analysis. Intratest:
with activity restrictions; assure that
Nursing Implications and activity has been restricted for at
least 8 hours prior to the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: allergic reaction to latex, care should
➤ Inform the patient that the test is ment containing latex.
used to assess kidney function. ➤ Instruct the patient to cooperate fully
➤ Obtain a history of the patient’s com- and to follow directions. Direct the
plaints, including a list of known patient to breathe normally and to
allergens (especially allergies or sen- avoid unnecessary movement.
sitivities to latex), and inform the ➤ Observe standard precautions, and
➤ Obtain a history of the patient’s gen- patient, and label the appropriate
itourinary and musculoskeletal sys- tubes with the corresponding patient
tems, as well as results of previously demographics, date, and time of
collection. Perform a venipuncture; itoring for malnutrition, especially

collect the specimen in a 5-mL red- among patients receiving long-term
or tiger-top tube. hemodialysis therapy.
➤ Remove the needle, and apply a ➤ A written report of the examination
pressure dressing over the punc- will be sent to the requesting health
ture site. care practitioner, who will discuss
➤ Promptly transport the specimen to the results with the patient.
➤ The results are recorded manually ing further testing, treatment, or re-
or in a computerized system for ferral to another health care provider.
recall and postprocedure interpreta- Answer any questions or address
tion by the appropriate health care any concerns voiced by the patient
practitioner. or family.
➤ Observe venipuncture site for bleed- progression of the disease process
ing or hematoma formation. Apply and determine the need for a change
paper tape or other adhesive to hold in therapy. Evaluate test results in
pressure bandage in place, or relation to the patient’s symptoms
replace with a plastic bandage. and other tests performed.
activity as directed by the health care Related laboratory tests:
practitioner. ➤ Related laboratory tests include
➤ Nutritional considerations: Increased anion gap, BUN/creatinine ratio, cre-
creatinine levels may be associated atinine clearance, electrolytes (blood
with kidney disease. The nutritional and urine), gentamicin, kidney stone
needs of patients with kidney dis- analysis, microalbumin, osmolality
ease vary widely and are in constant (blood and urine), tobramycin, urea
flux. Anorexia, nausea, and vomiting nitrogen (blood and urine), uric acid
commonly occur, prompting the (blood and urine), urine creatinine,
need for continuous nutritional mon- and vancomycin.
CREATININE, URINE, AND

CREATININE CLEARANCE, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Creatinine, Urine, and Creatinine Clearance, Urine 503
Age Conventional Units SI Units

Urine Creatinine (Conventional Units 8.84)
2–3 y 6–22 mg/kg/24 h 53–194 mol/kg/24 h
4–18 y 12–30 mg/kg/24 h 106–265 mol/kg/24 h
Adult male 14–26 mg/kg/24 h 124–230 mol/kg/24 h
Adult female 11–20 mg/kg/24 h 97–177 mol/kg/24 h
Creatinine Clearance (Conventional Units 0.0167)
Children 70–140 mL/min/1.73 m2 1.17–2.33 mL/s/1.73 m2
Adult male 85–125 mL/min/1.73 m2 1.42–2.08 mL/s/1.73 m2
Adult female 75–115 mL/min/1.73 m2 1.25–1.92 mL/s/1.73 m2
For each decade Decrease of 6–7 mL/min/ Decrease of 0.06–0.07
after 40 y 1.73 m2 mL/s/1.73 m2
INDICATIONS:
DESCRIPTION & RATIONALE: Creati- • Determine the extent of nephron dam-
nine is the end product of creatine age in known renal disease (at least
metabolism. Creatine resides almost 50% of functioning nephrons must be
exclusively in skeletal muscle, where it lost before values are decreased)
participates in energy-requiring meta- • Determine renal function before
bolic reactions. In these processes, a administering nephrotoxic drugs
small amount of creatine is irreversibly
converted to creatinine, which then • Evaluate accuracy of a 24-hour urine
collection, based on the constant level
circulates to the kidneys and is
of creatinine excretion
excreted. The amount of creatinine
generated in an individual is propor- • Evaluate glomerular function
tional to the mass of skeletal muscle • Monitor effectiveness of treatment in
present and remains fairly constant, renal disease
unless there is massive muscle damage
resulting from crushing injury or RESULT
degenerative muscle disease. Creati-
nine values decrease with advancing Increased in:
age owing to diminishing muscle mass. • Acromegaly
Although the measurement of urine
creatinine is an effective indicator of • Acute tubular necrosis
renal function, the creatinine clearance • Carnivorous diets
test is more precise. The creatinine
clearance test measures a blood sample
and a urine sample to determine the • Dehydration
rate at which the kidneys are clearing • Diabetes
creatinine from the blood; this accu-
rately reflects the glomerular filtration • Exercise
rate and is based on an estimate of • Exposure to nephrotoxic drugs and
body surface. ■ chemicals
• Gigantism Note and immediately report to the

health care practitioner any
• Glomerulonephritis critically increased values and
• Hypothyroidism related symptoms.
• Infections
• Neoplasms (bilateral renal) • Drugs that may increase urine
• Nephrosclerosis creatinine levels include ascorbic
acid, cefoxitin, cephalothin, corticos-
• Polycystic kidney disease teroids, fluoxymesterone, levodopa,
• Pyelonephritis methandrostenolone, methotrexate,
methyldopa, nitrofurans (including
• Renal artery atherosclerosis nitrofurazone), oxymetholone, phe-
• Renal artery obstruction nolphthalein, and prednisone.
• Renal disease • Drugs that may increase urine

creatinine clearance include enalapril,
• Renal vein thrombosis oral contraceptives, prednisone, and
• Shock and hypovolemia ramipril.
• Tuberculosis • Drugs that may decrease urine creati-

nine levels include anabolic steroids,
Decreased in: androgens, captopril, and thiazides.
• Acute or chronic glomerulonephritis • Drugs that may decrease the urine cre-
• Anemia atinine clearance include acetylsalicylic
acid, amphotericin B, carbenoxolone,
• Chronic bilateral pyelonephritis chlorthalidone, cimetidine, cisplatin,
• Hyperthyroidism cyclosporine, guancidine, ibuprofen,
indomethacin, mitomycin, oxyphen-
• Leukemia butazone, paromycin, probenecid
• Muscle wasting diseases (coadministered with digoxin), and
thiazides.
• Paralysis
• Excessive ketones in urine may cause
• Polycystic kidney disease falsely decreased values.
• Shock • Failure to follow proper technique in
• Urinary tract obstruction (e.g., from collecting 24-hour specimen may inval-
calculi) idate test results.
• Vegetarian diets • Failure to refrigerate specimen

throughout urine collection period
CRITICAL VALUES allows decomposition of creatinine,
Degree of impairment:
causing falsely decreased values.
Borderline: 62.5–80 mL/min/ • Consumption of large amounts of
1.73 m2 meat, excessive exercise, and stress
Slight: 52–62.5 mL/min/1.73 m2 should be avoided for 24 hours before
Mild: 42–52 mL/min/1.73 m2 the test.
Moderate: 28–42 mL/min/1.73 m2 • Failure to follow dietary restrictions
Marked: Less than 28 mL/min/ before the procedure may cause the
1.73 m2 procedure to be canceled or repeated.
Creatinine, Urine, and Creatinine Clearance, Urine 505
specimen can be left in the collection

Nursing Implications and device for a health care staff mem-
Procedure ● ● ● ● ● ● ● ● ● ● ● ber to add to the laboratory collec-
tion container.
Pretest: ➤ Sensitivity to social and cultural
➤ Inform the patient that the test is issues, as well as concern for mod-
used to assess renal function. esty, is important in providing psy-
➤ Obtain a history of the patient’s com- and after the procedure.
allergens (especially allergies or sen- ➤ There are no fluid or medication res-
sitivities to latex), and inform the trictions unless by medical direction.
appropriate health care practitioner ➤ Instruct the patient to refrain from
accordingly. eating meat during the test.
itourinary system and results of pre- Intratest:
viously performed laboratory tests,
surgical procedures, and other ➤ Ensure that the patient has complied
diagnostic procedures. For related with dietary and activity restrictions
laboratory tests, refer to the Geni- for 24 hours prior to the procedure;
tourinary System table. assure that ingestion of meat has
been restricted during the test.
patient is taking, including herbs, ➤ If the patient has a history of severe
nutritional supplements, and nutra- allergic reaction to latex, care should
ceuticals. The requesting health care be taken to avoid the use of equip-
practitioner and laboratory should be ment containing latex.
advised if the patient regularly uses ➤ Instruct the patient to cooperate fully
these products so that their effects and to follow directions.
when reviewing results. ➤ Observe standard precautions, and
➤ Review the procedure with the Appendix A. Positively identify the
patient. Provide a nonmetallic urinal, patient, and label the appropriate col-
bedpan, or toilet-mounted collection lection container with the correspon-
device. Address concerns about pain ding patient demographics, date, and
related to the procedure. Explain to time of collection.
Random specimen
➤ Usually a 24-hour time frame for (collect in early morning)
urine collection is ordered. Inform
the patient that all urine must be
Clean-catch specimen:
saved during that 24-hour period.
Instruct the patient not to void ➤ Instruct the male patient to (1) thor-
directly into the laboratory collection oughly wash his hands, (2) cleanse
container. Instruct the patient to the meatus, (3) void a small amount
avoid defecating in the collection into the toilet, and (4) void directly
device and to keep toilet tissue out into the specimen container.
of the collection device to prevent ➤ Instruct the female patient to (1)
contamination of the specimen. thoroughly wash her hands; (2)
Place a sign in the bathroom to cleanse the labia from front to back;
remind the patient to save all urine. (3) while keeping the labia separated,
➤ Instruct the patient to void all urine void a small amount into the toilet;
into the collection device and then to and (4) without interrupting the urine
pour the urine into the laboratory col- stream, void directly into the speci-
lection container. Alternatively, the men container.
Pediatric urine collector: collection period. If an indwelling uri-

➤ Put on gloves. Appropriately cleanse nary catheter is in place, the drain-
the genital area and allow the area to age bag must be kept on ice.
dry. Remove the covering over the ➤ Begin the test between 6 and 8 a.m.,
adhesive strips on the collector bag if possible. Collect first voiding and
and apply over the genital area. discard. Record the time the speci-
Diaper the child. When specimen is men was discarded as the beginning
obtained, place the entire collection of the timed collection period. The
bag in a sterile urine container. next morning, ask the patient to void
at the same time the collection was
Indwelling catheter: started and add this last voiding to
➤ Put on gloves. Empty drainage tube the container.
of urine. It may be necessary to ➤ If an indwelling catheter is in place,
clamp off the catheter for 15 to 30 replace the tubing and container sys-
minutes before specimen collection. tem at the start of the collection
Cleanse specimen port with antisep- time. Keep the container system on
tic swab, and then aspirate 5 mL of ice during the collection period, or
urine with a 21- to 25-gauge needle empty the urine into a larger con-
and syringe. Transfer urine to a ster- tainer periodically during the col-
ile container. lection period; monitor to ensure
Urinary catheterization: the test the next morning at the
➤ Place female patient in lithotomy same hour the collection was begun.
position or male patient in supine ➤ At the conclusion of the test, com-
position. Using sterile technique, pare the quantity of urine with the
open the straight urinary catheteriza- urinary output record for the collec-
tion kit and perform urinary catheter- tion; if the specimen contains less
ization. Place the retained urine in a than what was recorded as output,
sterile specimen container. some urine may have been dis-
Suprapubic aspiration:
➤ Include on the collection container’s
➤ Place the patient in a supine position. label the amount of urine, test start
Cleanse the area with antiseptic and and stop times, and any foods or
drape with sterile drapes. A needle is medications that can affect test
inserted through the skin into the results.
bladder. A syringe attached to the
needle is used to aspirate the urine ➤ Promptly transport the specimen to
sample. The needle is then removed the laboratory for processing and
and a sterile dressing is applied to analysis.
the site. Place the sterile sample in a ➤ The results are recorded manually
sterile specimen container. or in a computerized system for
➤ Do not collect urine from the pouch recall and postprocedure interpreta-
from the patient with a urinary diver- tion by the appropriate health care
sion (e.g., ilieal conduit). Instead, practitioner.
perform catheterization through the
stoma. Post-test:
➤ Obtain a clean 3-L urine specimen diet, medications, or activity, as dir-
container, toilet-mounted collection ected by the health care practitioner.
device, and plastic bag (for transport ➤ A written report of the examination
of the specimen container). The will be sent to the requesting health
specimen must be refrigerated or care practitioner, who will discuss
kept on ice throughout the entire the results with the patient.
Cryoglobulin 507
➤ Recognize anxiety related to test ➤ Depending on the results of this pro-

results. Discuss the implications of cedure, additional testing may be
abnormal test results on the performed to evaluate or monitor
patient’s lifestyle. Provide teaching progression of the disease process
and information regarding the clinical and determine the need for a change
implications of the test results, as in therapy. Evaluate test results in
appropriate. Educate the patient relation to the patient’s symptoms
regarding access to counseling and other tests performed.
services. Provide contact informa-
tion, if desired, for the National Related laboratory tests:
Kidney Foundation (http://www.kid- ➤ Related laboratory tests include
ney.org). anion gap, blood urea nitrogen
➤ Reinforce information given by the (BUN), BUN/creatinine ratio, creati-
patient’s health care provider regard- nine, electrolytes (blood and urine),
ing further testing, treatment, or re- gentamicin, kidney stone analysis,
ferral to another health care provider. microalbumin, osmolality (blood and
Answer any questions or address urine), tobramycin, urea nitrogen
any concerns voiced by the patient (blood and urine), uric acid (blood and
or family. urine), and vancomycin.
CRYOGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Cryo.
REFERENCE VALUE: (Method: Visual observation for changes in appearance)
Negative.
DESCRIPTION & RATIONALE: Cryo- for cold precipitation after 72 hours of

globulins are abnormal serum proteins storage at 4C. True cryoglobulins dis-
that cannot be detected by protein appear on warming to room tempera-
electrophoresis. Cryoglobulins cause ture, so in the second step of the
vascular problems because they can procedure, the sample is rewarmed to
precipitate in the blood vessels of the confirm reversibility of the reaction. ■
fingers when exposed to cold, causing
Raynaud’s phenomenon. They are INDICATIONS:
usually associated with immunologic • Assist in diagnosis of neoplastic dis-
disease. The laboratory procedure to eases, acute and chronic infections, and
detect cryoglobulins is a two-step collagen diseases
process. The serum sample is observed • Detect cryoglobulinemia in patients
with symptoms indicating or mimick-

ing Raynaud’s disease Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Monitor course of collagen and rheu-

matic disorders Pretest:
RESULT marily used to assist in identification
the presence of certain immunologic
Increased in: disorders.
• Type I cryoglobulin (monoclonal) ➤ Obtain a history of the patient’s
Chronic lymphocytic leukemia complaints, including a list of known
Lymphoma sitivities to latex), and inform the
Multiple myeloma appropriate health care practitioner
accordingly.
• Type II cryoglobulin (mixtures of mon-
oclonal immunoglobulin [Ig] M and ➤ Obtain a history of the patient’s
polyclonal IgG) immune system as well as results of
Autoimmune hepatitis tests, surgical procedures, and other
Rheumatoid arthritis diagnostic procedures. For related
Sjögren’s syndrome laboratory tests, refer to the Immune
System table.
Waldenström’s macroglobulinemia
• Type III cryoglobulin (mixtures of patient is taking, including herbs,
polyclonal IgM and IgG) nutritional supplements, and nutra-
Acute poststreptococcal ceuticals. The requesting health care
glomerulonephritis practitioner and laboratory should be
Chronic infection (especially these products so that their effects
hepatitis C) can be taken into consideration
Cirrhosis when reviewing results.
Endocarditis ➤ Review the procedure with the
Infectious mononucleosis patient. Inform the patient that spec-
Polymyalgia rheumatica 5 to 10 minutes. Address concerns
Rheumatoid arthritis about pain related to the procedure.
arcoidosis Explain to the patient that there may
Systemic lupus erythematosus be some discomfort during the
venipuncture.
Decreased in: N/A tion restrictions unless by medical
direction.
Intratest:
INTERFERING FACTORS: ➤ If the patient has a history of severe
• Testing the sample prematurely (before allergic reaction to latex, care should
total precipitation) may yield incorrect be taken to avoid the use of equip-
results. ment containing latex.
• Failure to maintain sample at normal ➤ Instruct the patient to cooperate fully
body temperature before centrifugation and to follow directions. Direct the
can affect results. avoid unnecessary movement.
• A recent fatty meal can increase turbid- ➤ Observe standard precautions, and
ity of the blood, decreasing visibility. follow the general guidelines in
Culture and Smear, Mycobacteria 509
Appendix A. Positively identify the will be sent to the requesting health

patient, and label the appropriate care practitioner, who will discuss
tubes with the corresponding patient the results with the patient.
demographics, date, and time of col- ➤ Reinforce information given by the
lection. Perform a venipuncture; patient’s health care provider regard-
collect the specimen in a 5-mL red- ing further testing, treatment, or
top tube. referral to another health care pro-
➤ Remove the needle, and apply a vider. Answer any questions or
pressure dressing over the puncture address any concerns voiced by the
site. patient or family.
➤ Promptly transport the specimen to ➤ Depending on the results of this pro-
the laboratory for processing and cedure, additional testing may be
analysis. performed to evaluate or monitor
➤ The results are recorded manually progression of the disease process
or in a computerized system for and determine the need for a change
recall and postprocedure interpreta- in therapy. Evaluate test results in
tion by the appropriate health care relation to the patient’s symptoms
practitioner. and other tests performed.

➤ Observe venipuncture site for bleed- ➤ Related laboratory tests include
ing or hematoma formation. Apply antinuclear antibody, hepatitis C
paper tape or other adhesive to antibody, IgA, IgG, IgM, immunofixa-
hold pressure bandage in place, or tion electrophoresis, protein, protein
replace with a plastic bandage. electrophoresis, and rheumatoid
➤ A written report of the examination factor.
CULTURE AND SMEAR,

MYCOBACTERIA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Acid-fast bacilli (AFB) culture and smear, tubercu-

losis (TB) culture and smear, Mycobacterium culture and smear.
SPECIMEN: Sputum (5 to 10 mL), bronchopulmonary lavage, tissue, mate-

rial from fine-needle aspiration.
REFERENCE VALUE: (Method: Culture on selected media, microscopic exami-

nation of sputum by acid-fast or auramine-rhodamine fluorochrome stain)
Rapid methods include: chemiluminescent-labeled DNA probes that target
ribosomal RNA of the Mycobacterium, radiometric carbon dioxide detection
from 14C-labeled media, polymerase chain reaction/amplification techniques.
Culture: No growth
Smear: Negative for AFB
DESCRIPTION & RATIONALE: A cul- areas, among prison populations, and

ture and smear test is used primarily among human immunodeficiency
to detect Mycobacterium tuberculosis, virus (HIV)–positive patients. Of
which is a tubercular bacillus. The cell great concern is the increase in antibi-
wall of this mycobacterium contains otic-resistant strains of M. tuberculosis.
complex lipids and waxes that do not HIV-positive patients often become ill
take up ordinary stains. Cells that from concomitant infections caused
resist decolorization by acid alcohol by M. tuberculosis and Mycobacterium
are termed acid fast. There are only a avium intracellulare. M. avium intra-
few groups of acid-fast bacilli (AFB); cellulare is acquired via the gastroin-
this characteristic is helpful in rapid testinal tract through ingestion of
identification so that therapy can be contaminated food or water. The
initiated in a timely manner. Smears organism’s waxy cell wall protects it
may be negative 50% of the time even from acids in the human digestive
though the culture develops positive tract. Isolation of mycobacteria in the
growth 3 to 8 weeks later. AFB cul- stool does not mean the patient has
tures are used to confirm positive and tuberculosis of the intestines because
negative AFB smears. M. tuberculosis mycobacteria in stool are most often
grows in culture slowly. Automated present in sputum that has been swal-
liquid culture systems, such as the lowed. ■
Bactec and MGIT (Becton Dickinson
and Company, 1 Becton Drive, INDICATIONS:
Franklin Lakes, NJ, 07417), have a • Assist in the diagnosis of mycobacte-
turnaround time of approximately 10 riosis
days. Results of tests by polymerase
• Assist in the diagnosis of suspected pul-
chain reaction culture methods are monary tuberculosis secondary to
available in 36 to 48 hours. acquired immunodeficiency syndrome
M. tuberculosis is transmitted via (AIDS)
the airborne route to the lungs. It
• Assist in the differentiation of tubercu-
causes areas of granulomatous inflam-
losis from carcinoma or bronchiectasis
mation, cough, fever, and hemoptysis.
It can remain dormant in the lungs • Investigate suspected pulmonary tuber-
for long periods. The incidence of culosis
tuberculosis has increased since the • Monitor the response to treatment for
late 1980s in depressed inner-city pulmonary tuberculosis
RESULT
Identified Primary Specimen

Organism Source Condition
Mycobacterium Sputum Opportunistic
avium intracellulare pulmonary infection
M. fortuitum Surgical wound, sputum Opportunistic infection
(usually pulmonary)
Identified Primary Specimen

Organism Source Condition
M. kansasii Sputum Pulmonary tuberculosis
M. tuberculosis Sputum Pulmonary tuberculosis
M. xenopi Sputum Pulmonary tuberculosis
CRITICAL VALUES: sitivities to latex), and inform the

Smear: Positive for AFB
accordingly. Obtain a history of the
Culture: Growth of pathogenic patient’s exposure to tuberculosis.
bacteria
➤ Obtain a history of the patient’s im-
Note and immediately report to the mune and respiratory systems, and
health care practitioner positive results results of previously performed labo-
and related symptoms. ratory tests, surgical procedures,
INTERFERING FACTORS: related laboratory tests, refer to the
• Specimen collection after initiation Immune and Respiratory System
of treatment with antituberculosis drug tables.
therapy may result in inhibited or no ➤ Obtain a list of medications the
growth of organisms. patient is taking, including herbs,
• Contamination of the sterile container
with organisms from an exogenous practitioner and laboratory should be
source may produce misleading results. advised if the patient is regularly
• Specimens received on a dry swab using these products so that their
should be rejected: A dry swab indicates effects can be taken into considera-
tion when reviewing results.
that the sample is unlikely to have been
collected properly or unlikely to con- ➤ Note any recent procedures that can
tain a representative quantity of signifi- interfere with test results.
cant organisms for proper evaluation. ➤ Review the procedure with the
patient. Reassure the patient that he
• Inadequate or improper (e.g., saliva) or she will be able to breathe during
samples should be rejected. the procedure if specimen collected
• Failure to follow dietary restrictions is accomplished via suction method.
before the procedure may cause the Ensure that oxygen has been admin-
istered 20 to 30 minutes before
procedure to be canceled or repeated. the procedure if the specimen is to
be obtained by tracheal suctioning.
Nursing Implications and to the procedure. Atropine is usually
Procedure ● ● ● ● ● ● ● ● ● ● ● given before bronchoscopy examina-
tions to reduce bronchial secretions
Pretest: and prevent vagally induced brady-
cardia. Meperidine (Demerol) or mor-
➤ Inform the patient that the test is pri- phine may be given as a sedative.
marily used to assist in the diagnosis Lidocaine is sprayed in the patient’s
of tuberculosis. throat to reduce discomfort caused
by the presence of the tube.
plaints, including a list of known ➤ Explain to the patient that the time it
allergens (especially allergies or sen- takes to collect a proper specimen
varies according to the level of coop- increasing fluid intake before retiring
eration of the patient and the speci- on the night before the test aids
men collection site. Emphasize that in liquefying secretions and may
sputum and saliva are not the same. make it easier to expectorate in the
Inform the patient that multiple spec- morning. Also explain that humidify-
imens may be required at timed ing inspired air also helps liquefy
intervals. Inform the patient that the secretions.
culture results will not be reported ➤ Other than antimicrobial drugs, there
for 3 to 8 weeks. are no medication restrictions, un-
➤ Sensitivity to social and cultural less by medical direction.
issues, as well as concern for mod- ➤ There are no food or fluid restric-
esty, is important in providing psy- tions, unless by medical direction.
and after the procedure. Intratest:
Bronchoscopy: ➤ Ensure that the patient has complied
➤ Make sure a written and informed tions; assure that food and fluids
consent has been signed prior to the have been restricted for at least 12
procedure and before administering hours prior to the bronchoscopy
any medications. procedure.
➤ Other than antimicrobial drugs, ➤ Have patient remove dentures, con-
there are no medication restrictions, tact lenses, eyeglasses, and jewelry.
unless by medical direction. Notify the physician if the patient
➤ The patient should fast and refrain has permanent crowns on teeth.
from drinking liquids beginning at Have the patient remove clothing
midnight the night before the proce- and change into a gown for the
dure. procedure.
Expectorated specimen: available. Keep resuscitation equip-
➤ Additional liquids the night before ment on hand in case of respiratory
may assist in liquefying secretions impairment or laryngospasm after
during expectoration the following the procedure.
morning. ➤ Avoid using morphine sulfate in
➤ Assist the patient with oral cleaning patients with asthma or other pul-
before sample collection to reduce monary disease. This drug can fur-
the amount of sample contamination ther exacerbate bronchospasms and
by organisms that normally inhabit respiratory impairment.
the mouth. ➤ If the patient has a history of severe
➤ Instruct the patient not to touch the allergic reaction to latex, care should
edge or inside of the container with be taken to avoid the use of equip-
the hands or mouth. ment containing latex.
➤ Other than antimicrobial drugs, ➤ Assist the patient to a comfortable
there are no medication restrictions, position, and direct the patient to
unless by medical direction. breath normally during the beginning
of the local anesthesia. Instruct the
➤ There are no food or fluid restric- patient to cooperate fully and to fol-
tions, unless by medical direction. low directions. Direct the patient to
breathe normally and to avoid unnec-
Tracheal Suctioning: essary movement during the local
➤ Assist in providing extra fluids, anesthetic and the procedure.
unless contraindicated, and proper ➤ Observe standard precautions, and
humidification to decrease tenacious follow the general guidelines in
secretions. Inform the patient that Appendix A. Positively identify the
patient, and label the appropriate col- peated before attempting to obtain
lection container with the correspon- the specimen.
ding patient demographics, date and ➤ Other methods may include obtain-
time of collection, and any medica- ing an order for an expectorant to
tion the patient is taking that may be administered with additional
interfere with test results (e.g., water approximately 2 hours before
antibiotics). attempting to obtain the specimen.
Chest percussion and postural
Bronchoscopy: drainage of all lung segments may
➤ Record baseline vital signs. also be employed. If the patient is
still unable to raise sputum, the use
➤ The patient is positioned in relation
of an ultrasonic nebulizer (“induced
to the type of anesthesia being used.
sputum”) may be necessary; this
If local anesthesia is used, the
is usually done by a respiratory
patient is seated and the tongue and
therapist.
oropharynx are sprayed and swab-
bed with anesthetic before the bron- Tracheal suctioning:
choscope is inserted. For general
anesthesia, the patient is placed in a ➤ Obtain the necessary equipment,
supine position with the neck hyper- including a suction device, suction
extended. After anesthesia, the kit, and Lukens tube or in-line trap.
patient is kept in supine or shifted to ➤ Position the patient with head ele-
a side-lying position and the bron- vated as high as tolerated.
choscope is inserted. After inspec-
➤ Put on sterile gloves. Maintain the
tion, the samples are collected from
dominant hand as sterile and the
suspicious sites by bronchial brush
nondominant hand as clean.
or biopsy forceps.
➤ Using the sterile hand, attach the
Expectorated specimen: suction catheter to the rubber tubing
of the Lukens tube or in-line trap.
➤ Ask the patient to sit upright, with Then attach the suction tubing to the
assistance and support (e.g., with an male adapter of the trap with the
overbed table) as needed. clean hand. Lubricate the suction
➤ Ask the patient to take two or three catheter with sterile saline.
deep breaths and cough deeply. Any ➤ Tell nonintubated patients to protrude
sputum raised should be expecto- the tongue and to take a deep breath
rated directly into a sterile sputum as the suction catheter is passed
collection container. through the nostril. When the cathe-
➤ If the patient is unable to produce ter enters the trachea, a reflex cough
the desired amount of sputum, sev- is stimulated; immediately advance
eral strategies may be attempted. the catheter into the trachea and
One approach is to have the patient apply suction. Maintain suction for
drink two glasses of water, and then approximately 10 seconds, but never
assume the position for postural longer than 15 seconds. Withdraw
drainage of the upper and middle the catheter without applying suc-
lung segments. Effective cough- tion. Separate the suction catheter
ing may be assisted by placing and suction tubing from the trap, and
either the hands or a pillow over the place the rubber tubing over the male
diaphragmatic area and applying adapter to seal the unit.
slight pressure. ➤ For intubated patients or patients
➤ Another approach is to place a vapor- with a tracheostomy, the previous
izer or other humidifying device at procedure is followed except that
the bedside. After sufficient expo- the suction catheter is passed
sure to adequate humidification, through the existing endotracheal
postural drainage of the upper and or tracheostomy tube rather than
middle lung segments may be re- through the nostril. The patient
should be hyperoxygenated before ➤ Observe for delayed allergic reac-

and after the procedure in accor- tions, such as rash, urticaria, tachy-
dance with standard protocols for cardia, hyperpnea, hypertension,
suctioning these patients. palpitations, nausea, or vomiting.
➤ Generally, a series of three to five ➤ Observe the patient for hemoptysis,
early morning sputum samples are difficulty breathing, cough, air
collected in sterile containers. If lep- hunger, excessive coughing, pain, or
rosy is suspected, obtain a smear absent breathing sounds over the
from nasal scrapings or a biopsy affected area. Report any symptoms
specimen from lesions in a sterile to the health care provider.
container. ➤ Evaluate the patient for symptoms
indicating the development of pneu-
General: mothorax, such as dyspnea, tachyp-
➤ Monitor the patient for complica- nea, anxiety, decreased breathing
tions related to the procedure (e.g., sounds, or restlessness. A chest x-
allergic reaction, anaphylaxis, bron- ray may be ordered to check for the
chospasm). presence of this complication.
➤ Promptly transport the specimen to ➤ Evaluate the patient for symptoms of
the laboratory for processing and empyema, such as fever, tachycar-
analysis. dia, malaise, or elevated white blood
cell count.
or in a computerized system for ➤ Administer antibiotic therapy if
recall and postprocedure interpreta- ordered. Remind the patient of the
tion by the appropriate health care importance of completing the entire
practitioner. course of antibiotic therapy, even if
Post-test:
➤ Nutritional considerations: Malnutri-
➤ Instruct the patient to resume pre- tion is commonly seen in patients
operative diet, as directed by the with severe respiratory disease for
health care practitioner. Assess numerous reasons, including fatigue,
the patient’s ability to swallow lack of appetite, and gastrointestinal
before allowing the patient to distress. Adequate intake of vitamins
attempt liquids or solid foods. A and C are also important to pre-
➤ Inform the patient that he or she may vent pulmonary infection and to
experience some throat soreness decrease the extent of lung tissue
and hoarseness. Instruct patient to damage.
treat throat discomfort with lozenges ➤ A written report of the examina-
and warm gargles when the gag tion will be completed by a health
reflex returns. care practitioner specializing in this
➤ Monitor vital signs and compare with branch of medicine. The report will
baseline values every 15 minutes for be sent to the requesting health care
1 hour, then every 2 hours for 4 practitioner, who will discuss the
hours, and then as ordered by the results with the patient.
health care practitioner. Monitor tem- ➤ Recognize anxiety related to test
perature every 4 hours for 24 hours. results. Discuss the implications
Notify the health care practitioner if of abnormal test results on the
temperature is elevated. Protocols patient’s lifestyle. Provide teaching
may vary from facility to facility. and information regarding the clinical
➤ Emergency resuscitation equipment implications of the test results,
should be readily available if the as appropriate. Educate the patient
vocal cords become spastic after regarding access to counseling
intubation. services.
Culture, Bacterial, Anal/Genital, Ear, Eye, Skin, and Wound 515
➤ Reinforce information given by the sponding literature provided by a

patient’s health care provider regard- pharmacist.
referral to another health care pro- ➤ Depending on the results of this pro-
vider. Instruct the patient to use cedure, additional testing may be
lozenges or gargle for throat discom- needed to evaluate or monitor pro-
fort. Inform the patient of smoking gression of the disease process and
cessation programs as appropriate. determine the need for a change in
The importance of following the pre- therapy. Evaluate test results in rela-
scribed diet should be stressed to tion to the patient’s symptoms and
the patient/caregiver. Educate the other tests performed.
ing services, as appropriate. Answer
any questions or address any con- Related laboratory tests:
cerns voiced by the patient or family. ➤ Related laboratory tests include anti–
➤ Instruct the patient in the use of any glomerular basement membrane
ordered medications. Explain the antibody, arterial/alveolar oxygen
importance of adhering to the ther- ratio, blood gases, chest x-ray, com-
apy regimen. As appropriate, instruct plete blood count, computed tomo-
the patient in significant side effects graphy of the thorax, lung scan,
and systemic reactions associated magnetic resonance imaging of the
with the prescribed medication. En- chest, culture, Gram/acid-fast stain,
courage him or her to review corre- cytology, and sputum findings.
CULTURE, BACTERIAL, ANAL/GENITAL,

EAR, EYE, SKIN, AND WOUND
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Sterile fluid or swab from affected area placed in transport media
tube provided by laboratory.
REFERENCE VALUE: (Method: Culture aerobic and/or anaerobic on selected

media; DNA probe assays are available for identification of Neisseria gonor-
rhoeae.) Negative: no growth of pathogens.
• Determine the cause of genital itching

DESCRIPTION & RATIONALE: When or purulent drainage
indicated by patient history, anal cul-
• Determine effective antimicrobial ther-
tures may be performed to isolate the apy specific to the identified pathogen
organism responsible for sexually
transmitted disease. Ear:
Ear and eye cultures are performed
• Isolate and identify organisms respon-
to isolate the organism responsible for sible for ear pain, drainage, or changes
chronic or acute infectious disease of in hearing
the ear and eye.
Skin and soft tissue samples from • Isolate and identify organisms responsi-
ble for outer-, middle-, or inner-ear
infected sites must be collected care-
infection
fully to avoid contamination from the
surrounding normal skin flora. Skin • Determine effective antimicrobial ther-
and tissue infections may be caused by apy specific to the identified pathogen
both aerobic and anaerobic organ-
Eye:
isms. Therefore, a portion of the sam-
ple should be placed in aerobic and a • Isolate and identify pathogenic micro-
portion in anaerobic transport media. organisms responsible for infection of
Care must be taken to use transport the eye
media that are approved by the labo- • Determine effective antimicrobial ther-
ratory performing the testing. apy specific to identified pathogen
A wound culture involves collecting
a specimen of exudates, drainage, or Skin:
tissue so that the causative organism • Isolate and identify organisms responsi-
can be isolated and pathogens identi- ble for skin eruptions, drainage, or
fied. Specimens can be obtained from other evidence of infection
superficial and deep wounds. • Determine effective antimicrobial ther-
Optimally, specimens should be apy specific to the identified pathogen
obtained before antibiotic use. The
method used to culture and grow the Sterile fluids:
organism depends on the suspected • Isolate and identify organisms before
infectious organism. There are trans- surrounding tissue becomes infected
port media specifically for bacterial
• Determine effective antimicrobial ther-
agents. The laboratory will select the
apy specific to the identified pathogen
appropriate media for suspect organ-
isms. The laboratory will initiate Wound:
antibiotic sensitivity testing if indi-
• Detect abscess or deep-wound infec-
cated by test results. Sensitivity testing
tious process
identifies the antibiotics to which
organisms are susceptible to ensure an • Determine if an infectious agent is the
effective treatment plan. ■ cause of wound redness, warmth, or
edema with drainage at a site
INDICATIONS • Determine presence of infectious
Anal/genital: agents in a stage 3 and stage 4 decubi-
tus ulcer
• Assist in the diagnosis of sexually trans-
mitted diseases • Isolate and identify organisms responsi-
ble for the presence of pus or other exu- CRITICAL VALUES: N/A
date in an open wound
• Determine effective antimicrobial ther- INTERFERING FACTORS:
apy specific to the identified pathogen • Failure to collect adequate specimen,
improper collection or storage tech-
nique, and failure to transport speci-
RESULT men in a timely fashion are causes for
specimen rejection.
• Pretest antimicrobial therapy will delay
Anal/Endocervical/Genital or inhibit the growth of pathogens.
Infections or carrier states are caused by • Testing specimens more than 1 hour
the following organisms: Gardnerella after collection may result in decreased
vaginalis, N. gonorrhoeae, toxin-produc- growth or nongrowth of organisms.
ing strains of Staphylococcus aureus, and
Treponema pallidum.
Ear Procedure ● ● ● ● ● ● ● ● ● ● ●
Commonly identified organisms include

Pretest:
Escherichia coli, Proteus spp., Pseudomonas
aeruginosa, Staphylococcus aureus, and - ➤ Inform the patient that the test is
hemolytic streptococci. used to identify pathogenic bacterial
organisms.
Eye ➤ Obtain a history of the patient’s com-
plaints, including a list of known al-
Commonly identified organisms include lergens, and inform the appropriate
Haemophilus influenzae, H. aegyptius, N. health care practitioner accordingly.
gonorrhoeae, Pseudomonas aeruginosa, ➤ Obtain a history of the patient’s
Staphylococcus aureus, and Streptococcus immune system and results of previ-
pneumoniae. ously performed laboratory tests,
Skin nostic procedures. Obtain, as appro-
priate, a history of sexual activity. For
Commonly identified organisms include related laboratory tests, refer to the
Bacteroides, Clostridium, Coryne- Immune System table.
bacterium, Pseudomonas, staphylococci, ➤ Obtain a list of the medications the
and group A streptococci. patient is taking, including herbs,
Sterile fluids ceuticals. The requesting health care
Commonly identified pathogens include advised if the patient regularly uses
Bacteroides, Enterococcus spp., E. coli, these products so that their effects
Pseudomonas aeruginosa, and Pep- can be taken into consideration
tostreptococcus spp. when reviewing results.
➤ Note any recent medications that
Wound can interfere with test results.
Aerobic and anaerobic microorganisms ➤ Review the procedure with the
can be identified in wound culture speci- imen collection takes approximately
mens. Commonly identified organisms 5 minutes. Address concerns about
include Clostridium perfringens, Klebsi- pain related to the procedure. Ex-
ella, Proteus, Pseudomonas, Staphylococcus plain to the patient that there may
aureus, and group A streptococci. be some discomfort during the
specimen collection. Instruct female up in stirrups. Drape the patient’s

patients not to douche for 24 hours legs to provide privacy and reduce
before a cervical or vaginal specimen chilling.
is to be obtained. ➤ Cleanse the external genitalia and
➤ Sensitivity to social and cultural perineum from front to back with
issues, as well as concern for mod- towelettes provided in culture kit.
esty, is important in providing psy- Using a Culturette swab, obtain a
chological support before, during, sample of the lesion or discharge
and after the procedure. from the urethra or vulva. Place the
➤ There are no food or fluid restrictions swab in the Culturette tube, and
unless by medical direction. squeeze the bottom of the tube to
release the transport medium.
Intratest: Ensure that the end of the swab is
immersed in the medium.
with medication restrictions prior to ➤ To obtain a vaginal and endocervical
the procedure. culture, insert a water-lubricated
vaginal speculum. Insert the swab
➤ Instruct the patient to cooperate fully into the cervical orifice and rotate
and to follow directions. Direct the the swab to collect the secretions
patient to breathe normally and to containing the microorganisms. Re-
avoid unnecessary movement. move and place in the appropriate
➤ Observe standard precautions, and culture medium. Material from the
follow the general guidelines in vagina can be collected by moving a
Appendix A. Positively identify the swab along the sides of the vaginal
patient, and label the appropriate mucosa. The swab is removed and
specimen containers with the cor- then placed in a tube of saline
responding patient demographics, medium.
specimen source (left or right as
appropriate), patient age and gender, Male patient
date and time of collection, and any ➤ To obtain a urethral culture, cleanse
medication the patient is taking that the penis (retracting the foreskin),
may interfere with the test results have the patient milk the penis to
(e.g. antibiotics). Do not freeze the express discharge from the urethra.
specimen or allow it to dry. Insert a swab into the urethral orifice
to obtain a sample of the discharge.
Anal Place the swab in the Culturette
➤ Place the patient in a lithotomy or tube, and squeeze the bottom of the
side-lying position and drape for pri- tube to release the transport
vacy. Insert the swab 1 inch into the medium. Ensure that the end of the
anal canal and rotate, moving it from swab is immersed in the medium.
side to side to allow it to come into
contact with the microorganisms. Ear
Remove the swab. Place the swab in ➤ Cleanse the area surrounding the
the Culturette tube, and squeeze site with a swab containing cleaning
the bottom of the tube to release the solution to remove any contaminat-
transport medium. Ensure that the ing material or flora that have col-
end of the swab is immersed in the lected in the ear canal. If needed,
medium. Repeat with a clean swab if assist the appropriate heath care
the swab is pushed into feces. practitioner in removing any ceru-
men that has collected.
Genital ➤ Insert a Culturette swab approxi-
mately 1/4 inch into the external ear
Female patient canal. Rotate the swab in the area
➤ Position the patient on the gyneco- containing the exudate. Carefully
logic examination table with the feet remove the swab, ensuring that it
does not touch the side or opening Wound

of the ear canal.
➤ Place the patient in a comfortable
➤ Place the swab in the Culturette position, and drape the site to be cul-
tube, and squeeze the bottom of tured. Cleanse the area around the
the tube to release the transport wound to remove flora indigenous to
medium. Ensure that the end of the the skin.
swab is immersed in the medium.
➤ Place a Culturette swab in a superfi-
Eye cial wound where the exudate is the
most excessive without touching the
➤ Pass a moistened swab over the wound edges. Place the swab in the
appropriate site, avoiding eyelid and Culturette tube, and squeeze the bot-
eyelashes unless those areas are tom of the tube to release the trans-
selected for study. Collect any visible port medium. Ensure that the end of
pus or other exudate. Place the swab the swab is immersed in the medium.
in the Culturette tube, and squeeze Use more than one swab and Cul-
the bottom of the tube to release the turette tube to obtain specimens from
transport medium. Ensure that other areas of the wound.
the end of the swab is immersed
➤ To obtain a deep wound specimen,
in the medium.
insert a sterile syringe and needle
➤ An appropriate health care practi- into the wound and aspirate the
tioner should perform procedures drainage. Following aspiration, inject
requiring eye scrapings. the material into a tube containing an
anaerobic culture medium.
Skin
➤ Assist the appropriate health care General:
practitioner in obtaining a skin sam- ➤ Promptly transport the specimen to
ple from several areas of the the laboratory for processing and
affected site. If indicated, the dark, analysis.
moist areas of the folds of the skin
and outer growing edges of the ➤ The results are recorded manually
infection where microorganisms are or in a computerized system for
most likely to flourish should be recall and postprocedure interpreta-
selected. Place the scrapings in a tion by the appropriate health care
collection container or spread on a practitioner.
slide. Aspirate any fluid from a pus-
tule or vesicle using a sterile needle
and tuberculin syringe. The exudate
Post-test:
will be flushed into a sterile collec- ➤ Instruct the patient to resume usual
tion tube. If the lesion is not fluid medication as directed by the health
filled, open the lesion with a scalpel care practitioner.
and swab the area with a sterile
cotton-tipped swab. Place the swab ➤ Instruct the patient to report symp-
in the Culturette tube, and squeeze toms such as pain related to tissue
the bottom of the tube to release the inflammation or irritation.
transport medium. Ensure that the ➤ Instruct the patient to begin antibi-
end of the swab is immersed in otic therapy, as prescribed. Instruct
the medium. the patient in the importance of com-
pleting the entire course of antibiotic
Sterile fluid therapy even if no symptoms are
present.
➤ Refer to related body fluid mono-
graphs (i.e., amniotic fluid, cere- ➤ Inform the patient that a repeat
brospinal fluid, pericardial fluid, culture may be needed in 1 week
peritoneal fluid, pleural fluid, synovial after completion of the antimicrobial
fluid) for specimen collection. regimen.
➤ Advise the patient that final test Wound

results may take 24 to 72 hours
➤ Instruct the patient in wound care
depending on the organism sus-
and nutritional requirements (e.g.,
pected, but that antibiotic therapy
protein, vitamin C) to promote
may be started immediately.
wound healing.
Anal/endocervical/genital General
➤ Inform the patient that final results ➤ A written report of the examination
may take from 24 hours to 4 weeks, will be sent to the requesting health
depending on the test performed. care practitioner, who will discuss
➤ Advise the patient to avoid sexual
contact until test results are avail- ➤ Recognize anxiety related to test
able. results. Discuss the implications
➤ Instruct the patient in vaginal sup- patient’s lifestyle. Provide teaching
pository and medicated cream instal- and information regarding the clinical
lation and administration of topical implications of the test results, as
medication to treat specific condi- appropriate.
tions, as indicated.
➤ Inform infected patients that all sex- patient’s health care provider regard-
ual partners must be tested for the ing further testing, treatment, or
microorganism. referral to another health care pro-
➤ Inform the patient that positive vider. Emphasize the importance of
culture findings for certain organ- reporting continued signs and symp-
isms must be reported to a local toms of the infection. Answer any
health department official, who will questions or address any concerns
question him or her regarding sexual voiced by the patient or family.
partners. ➤ Depending on the results of this
Offer support, as appropriate, to pa-
tients who may be the victims of
rape or sexual assault. Educate the
patient regarding access to coun-
seling services. Provide a nonjudg-
mental, nonthreatening atmosphere
for discussing the risks of sexu- Related laboratory tests:
ally transmitted diseases. It is also
important to address problems the ➤ Related laboratory tests include rele-
patient may experience (e.g., guilt, vant tissue biopsies, Gram stain, vi-
depression, anger). tamin C, and zinc.
CULTURE, BACTERIAL, BLOOD

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Culture, Bacterial, Blood 521
SPECIMEN: Whole blood collected in bottles containing standard aerobic

and anaerobic culture media; 10 to 20 mL for adult patients or 1 to 5 mL
for pediatric patients.
REFERENCE VALUE: (Method: Growth of organisms in standard culture

media identified by radiometric or infrared automation, or by manual read-
ing of subculture.) Negative: no growth of pathogens.
INDICATIONS:
DESCRIPTION & RATIONALE: Blood • Determine sepsis in the newborn as a
cultures are collected whenever bac- result of prolonged labor, early rupture
teremia or septicemia is suspected. of membranes, maternal infection, or
Although mild bacteremia is found in neonatal aspiration
many infectious diseases, a persistent, • Evaluate chills and fever in patients
continuous, or recurrent bacteremia with infected burns, urinary tract infec-
indicates a more serious condition tions, rapidly progressing tissue infec-
that may require immediate treat- tion, postoperative wound sepsis, and
ment. Early detection of pathogens in indwelling venous or arterial catheter
the blood may aid in making clinical • Evaluate intermittent or continuous
and etiologic diagnoses. temperature elevation of unknown
Blood culture involves the intro- origin
duction of a specimen of blood into • Evaluate persistent, intermittent fever
artificial aerobic and anaerobic growth associated with a heart murmur
culture medium. The culture is incu- • Evaluate a sudden change in pulse and
bated for a specific length of time, at temperature with or without chills and
a specific temperature, and under diaphoresis
other conditions suitable for the • Evaluate suspected bacteremia after
growth of pathogenic microorgan- invasive procedures
isms. Pathogens enter the bloodstream • Identify the cause of shock in the post-
from soft-tissue infection sites, con- operative period
taminated intravenous lines, or inva-
sive procedures (e.g., surgery, tooth RESULT
extraction, cystoscopy). A blood cul- Positive findings in:
ture may also be done with an antimi- • Bacteremia or septicemia: Aerobacter,
crobial removal device (ARD). This Bacteroides, Brucella, Clostridium per-
involves transferring some of the fringens, enterococci, Escherichia coli
blood sample into a special vial con- and other coliform bacilli, Haemophilus
taining absorbent resins that remove influenzae, Klebsiella, Listeria mono-
antibiotics from the sample before the cytogenes, Pseudomonas aeruginosa,
culture is performed. The laboratory Salmonella, Staphylococcus aureus,
will initiate antibiotic sensitivity test- Staphylococcus epidermidis, and -
hemolytic streptococci.
ing if indicated by test results.
Sensitivity testing identifies the anti- • Plague
biotics to which the organisms are • Malaria (by special request, a stained
susceptible to ensure an effective treat- capillary smear would be examined)
ment plan. ■ • Typhoid fever
Note: Candida albicans is a yeast that practitioner and laboratory should be

can cause disease and can be isolated by advised if the patient regularly uses
blood culture. these products so that their effects
CRITICAL VALUES:
Note and immediately report to the ➤ Note any recent medications that
health care practitioner positive results can interfere with test results.
and related symptoms. ➤ Review the procedure with the pa-
tient. Inform the patient that speci-
INTERFERING FACTORS: men collection takes approximately
• Pretest antimicrobial therapy will delay 5 minutes. Inform the patient that
or inhibit growth of pathogens. multiple specimens may be required
at timed intervals. Address concerns
• Contamination of the specimen by the about pain related to the procedure.
skin’s resident flora may invalidate Explain to the patient that there may
interpretation of test results. be some discomfort during the
venipuncture.
• An inadequate amount of blood or ➤ There are no food or fluid restrictions
number of blood specimens drawn for unless by medical direction.
examination may invalidate interpreta-
tion of results.
Intratest:
• Testing specimens more than 1 hour
➤ Ensure that the patient has com-
after collection may result in decreased plied with medication prior to the
growth or nongrowth of organisms. procedure.
• Negative findings do not ensure the ➤ If the patient has a history of severe
absence of infection. allergic reaction to iodine, care
should be taken to avoid the use
of iodine.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
used to identify pathogenic bacterial Appendix A. Positively identify the
organisms. patient, and label the appropriate
➤ Obtain a history of the patient’s com- specimen containers with the corre-
plaints, including a list of known sponding patient demographics, date
allergens (especially allergies or sen- and time of collection, and any med-
sitivities to iodine), and inform the ication the patient is taking that may
appropriate health care practitioner interfere with test results (e.g. antibi-
accordingly. otics). Perform a venipuncture; col-
lect the specimen in the appropriate
➤ Obtain a history of the patient’s blood culture collection container.
immune system and results of previ-
ously performed laboratory tests, ➤ The high risk for infecting a patient
surgical procedures, and other diag- by venipuncture can be decreased by
nostic procedures. For related labo- using an aseptic technique during
ratory tests, refer to the Immune specimen collection.
System table. ➤ The contamination of blood cultures
➤ Obtain a list of the medications the by skin and other flora can also be
patient is taking, including herbs, dramatically reduced by careful pre-
nutritional supplements, and nutra- paration of the puncture site and col-
ceuticals. The requesting health care lection containers before specimen
Culture, Bacterial, Blood 523
collection. Cleanse the rubber stop- pressure dressing over the punc-
pers of the collection containers with ture site.
the appropriate disinfectant as rec- ➤ Promptly transport the specimen to
ommended by the laboratory, allow the laboratory for processing and
to air-dry, and cleanse with 70% analysis.
alcohol. Once the vein has been
located by palpation, cleanse the site ➤ The results are recorded manu-
with 70% alcohol followed by swab- ally or in a computerized system for
bing with an iodine solution. The recall and postprocedure interpreta-
iodine should be swabbed in a circu- tion by the appropriate health care
lar concentric motion, moving out- practitioner.
ward or away from the puncture site. ➤ More than three sets of cultures per
The iodine should be allowed to day do not significantly add to the
completely dry before the sample is likelihood of pathogen capture. Cap-
collected. If the patient is sensitive ture rates are more likely affected by
to iodine, a double alcohol scrub or obtaining a sufficient volume of
green soap may be substituted. blood per culture.
➤ If collection is performed by directly ➤ The use of ARDs or resin bottles is
drawing the sample into a culture costly and controversial with respect
tube, fill the aerobic culture tube first. to their effectiveness versus stan-
dard culture techniques. They may be
➤ If collection is performed using a
useful in selected cases, such as
syringe, transfer the blood sample
when septicemia or bacteremia is
directly into each culture bottle.
suspected after antimicrobial therapy
➤ Remove the needle, and apply a has been initiated.
Disease Suspected Recommended Collection

Bacterial pneumonia, fever of 2 sets of cultures; each collected from
unknown origin, meningitis, a separate site, 30 minutes apart
osteomyelitis, sepsis
Acute or subacute endocarditis 3 sets of cultures; each collected from
a separate site, 60 minutes apart. If
cultures are negative after 24 to 48
hours, repeat collections
Septicemia, fungal or 2 sets of cultures; each collected from
mycobacterial infection in a separate site, 30 to 60 minutes
immunocompromised patient apart (laboratory may use a lysis
concentration technique to enhance
recovery)
Septicemia, bacteremia after 2 sets of cultures; each collected from
therapy has been initiated or a separate site, 30 to 60 minutes
request to monitor effectiveness apart (consider use of ARD to
of antimicrobial therapy enhance recovery)
Post-test: bleeding or hematoma formation.

Apply paper tape or other adhesive
➤ Instruct the patient to resume usual to hold pressure bandage in place, or
medication as directed by the health replace with a plastic bandage.
care practitioner. ➤ Instruct the patient to report symp-
➤ Cleanse the iodine from the collec- toms such as pain related to tissue
tion site. inflammation or irritation.
➤ Observe the venipuncture site for ➤ Instruct the patient to report fever,
chills, and other signs and symptoms implications of the test results, as
of acute infection to the health care appropriate.
practitioner. ➤ Reinforce information given by the
➤ Instruct the patient to begin antibi- patient’s health care provider regard-
otic therapy, as prescribed. Instruct ing further testing, treatment, or re-
the patient in the importance of ferral to another health care provider.
completing the entire course of Emphasize the importance of report-
antibiotic therapy even if no symp- ing continued signs and symptoms
toms are present. of the infection. Answer any ques-
tions or address any concerns voiced
➤ Inform the patient that preliminary by the patient or family.
results should be available in 24 to
72 hours, but final results are not ➤ Depending on the results of this
available for 5 to 7 days. procedure, additional testing may
be performed to evaluate or monitor
of abnormal test results on the pa-
tient’s lifestyle. Provide teaching and ➤ A related laboratory test is the com-
information regarding the clinical plete blood count.
CULTURE, BACTERIAL, SPUTUM

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Routine culture of sputum.

SPECIMEN: Sputum (10 to 15 mL).
REFERENCE VALUE: (Method: Aerobic culture on selective and
enriched media; microscopic examination of sputum by Gram stain.)
The presence of normal upper respiratory tract flora should be expected.
Tracheal aspirates and bronchoscopy samples can be contaminated with
normal flora, but transtracheal aspiration specimens should show no
growth. Normal respiratory flora include Neisseria catarrhalis, Candida
albicans, diphtheroids, -hemolytic streptococci, and some staphylococci.
The presence of normal flora does not rule out infection. A normal
Gram stain of sputum contains polymorphonuclear leukocytes, alveolar
macrophages, and a few squamous epithelial cells.
Culture, Bacterial, Sputum 525
power field (lpf ) indicates oral contam-

DESCRIPTION & RATIONALE: This ination, and the specimen should be
test involves collecting a sputum spec- rejected. The presence of many poly-
imen so the pathogen can be isolated morphonuclear neutrophils and few
and identified. The test results will squamous epithelial cells indicates that
reflect the type and number of organ- the specimen was collected from an
isms present in the specimen, as area of infection and is satisfactory for
further analysis.
well as the antibiotics to which the
identified pathogenic organisms are • Bacterial pneumonia can be caused by
susceptible. Sputum collected by ex- Streptococcus pneumoniae, Haemophilus
pectoration or suctioning with cathe- influenzae, staphylococci, and some
ters and by bronchoscopy cannot be gram-negative bacteria. Other patho-
gens that can be identified by cul-
cultured for anaerobic organisms;
ture are Corynebacterium diphtheriae,
instead, transtracheal aspiration or Klebsiella pneumoniae, and Pseudomonas
lung biopsy must be used. The labora- aeruginosa. Some infectious agents,
tory will initiate antibiotic sensitivity such as C. diphtheriae, are more fastidi-
testing if indicated by test results. ous in their growth requirements and
Sensitivity testing identifies antibiotics cannot be cultured and identified with-
to which the organisms are susceptible out special treatment. Suspicion of
to ensure an effective treatment plan. ■ infection by less commonly identified
and/or fastidious organisms must be
INDICATIONS: communicated to the laboratory to
ensure selection of the proper proce-
Culture: dure required for identification.
• Assist in the diagnosis of respiratory CRITICAL VALUES: N/A
infections, as indicated by the presence
or absence of organisms in culture INTERFERING FACTORS:
• Contamination with oral flora may
Gram Stain: invalidate results.
• Assist in the differentiation of gram- • Specimen collection after antibiotic
positive from gram-negative bacteria in therapy has been initiated may result in
respiratory infection inhibited or no growth of organisms.
• Assist in the differentiation of sputum
from upper respiratory tract secretions,
the latter being indicated by excessive Nursing Implications and
squamous cells or absence of polymor- Procedure ● ● ● ● ● ● ● ● ● ● ●
phonuclear leukocytes
Pretest:
• The major difficulty in evaluating used to identify pathogenic bacterial
results is in distinguishing organisms organisms.
infecting the lower respiratory tract
from organisms that have colonized but plaints, including a list of known
not infected the lower respiratory tract. allergens (especially allergies or sen-
Review of the Gram stain assists in this sitivities to latex), and inform the
process. The presence of greater than appropriate health care practitioner
25 squamous epithelial cells per low- accordingly.
➤ Obtain a history of the patient’s Bronchoscopy:

and results of previously performed ➤ Make sure a written and informed
laboratory tests, surgical proce- consent has been signed prior to
dures, and other diagnostic pro- the bronchoscopy/biopsy proce-
cedures. For related laboratory tests, dure and before administering any
refer to the Immune and Respiratory medications.
System tables. ➤ Other than antimicrobial drugs,
➤ Obtain a list of the medications there are no medication restrictions,
the patient is taking, including unless by medical direction.
herbs, nutritional supplements, and ➤ The patient should fast and refrain
nutraceuticals. The requesting health from drinking liquids beginning
care practitioner and laboratory at midnight the night before the
should be advised if the patient procedure.
that their effects can be taken Expectorated specimen:
➤ Additional liquids the night before
results.
may assist in liquefying secretions
➤ Note any recent medications that during expectoration the following
can interfere with test results. morning.
➤ Review the procedure with the ➤ Assist the patient with oral cleaning
patient. Reassure the patient that he before sample collection to reduce
or she will be able to breathe during the amount of sample contamination
the procedure if specimen collected by organisms that normally inhabit
is accomplished via suction method. the mouth.
Ensure that oxygen has been admin-
➤ Instruct the patient not to touch the
istered 20 to 30 minutes before
edge or inside of the container with
the procedure if the specimen is to
the hands or mouth.
be obtained by tracheal suction-
ing. Address concerns about pain ➤ Other than antimicrobial drugs,
related to the procedure. Atropine is there are no medication restrictions,
usually given before bronchoscopy unless by medical direction.
examinations to reduce bronchial ➤ There are no food or fluid restric-
secretions and prevent vagally tions, unless by medical direction.
induced bradycardia. Meperidine
(Demerol) or morphine may be given Tracheal suctioning:
as a sedative. Lidocaine is sprayed in
the patient’s throat to reduce dis- ➤ Assist in providing extra fluids, un-
comfort caused by the presence of less contraindicated, and proper
the tube. humidification to decrease tenacious
secretions. Inform the patient that
➤ Explain to the patient that the time it increasing fluid intake before retiring
takes to collect a proper specimen on the night before the test aids
varies according to the level of coop- in liquefying secretions and may
eration of the patient and the speci- make it easier to expectorate in the
men collection site. Emphasize that morning. Also explain that humidify-
sputum and saliva are not the same. ing inspired air also helps liquefy
Inform the patient that multiple spec- secretions.
imens may be required at timed
intervals. ➤ Other than antimicrobial drugs,
there are no medication restrictions,
➤ Sensitivity to social and cultural unless by medical direction.
esty, is important in providing psy- ➤ There are no food or fluid restric-
chological support before, during, tions, unless by medical direction.
and after the procedure. ➤ If the specimen is collected by
expectoration or tracheal suctioning, Collect the specimen in the appropri-

there are no food, fluid, or medica- ate sterile collection container.
tion restrictions (except antibiotics),
unless by medical direction. Bronchoscopy:
➤ Record baseline vital signs.
Intratest: ➤ The patient is positioned in rela-
tion to the type of anesthesia being
➤ Ensure that the patient has complied used. If local anesthesia is used, the
with dietary and medication restric- patient is seated and the tongue
tions; assure that food and fluids and oropharynx are sprayed and
have been restricted for at least 12 swabbed with anesthetic before the
hours prior to the bronchoscopy pro- bronchoscope is inserted. For gen-
cedure. eral anesthesia, the patient is placed
➤ Have patient remove dentures, con- in a supine position with the neck
tact lenses, eyeglasses, and jewelry. hyperextended. After anesthesia, the
Notify the physician if the patient patient is kept in supine or shifted to
has permanent crowns on teeth. a side-lying position and the bron-
Have the patient remove cloth- choscope is inserted. After inspec-
ing and change into a gown for the tion, the samples are collected from
procedure. suspicious sites by bronchial brush
or biopsy forceps.
available. Keep resuscitation equip- Expectorated specimen:
ment on hand in case of respiratory
impairment or laryngospasm after ➤ Ask the patient to sit upright, with
the procedure. assistance and support (e.g., with an
overbed table) as needed.
➤ Avoid using morphine sulfate in
➤ Ask the patient to take two or three
patients with asthma or other pul-
deep breaths and cough deeply. Any
monary disease. This drug can fur-
sputum raised should be expecto-
ther exacerbate bronchospasms and
rated directly into a sterile sputum
respiratory impairment.
collection container.
➤ If the patient has a history of severe ➤ If the patient is unable to produce
allergic reaction to latex, care should the desired amount of sputum, sev-
be taken to avoid the use of equip- eral strategies may be attempted.
ment containing latex. One approach is to have the patient
➤ Assist the patient to a comfortable drink two glasses of water, and
position and direct the patient to then assume the position for pos-
breath normally during the beginning tural drainage of the upper and
of the general anesthesia. Instruct middle lung segments. Effective
the patient to cooperate fully and coughing may be assisted by placing
to follow directions. Direct the either the hands or a pillow over the
patient to breathe normally and to diaphragmatic area and applying
avoid unnecessary movement during slight pressure.
the local anesthetic and the proce- ➤ Another approach is to place a vapor-
dure. izer or other humidifying device at
➤ Observe standard precautions and the bedside. After sufficient expo-
follow the general guidelines in sure to adequate humidification,
Appendix A. Positively identify the postural drainage of the upper and
patient, and label the appropriate middle lung segments may be repea-
tubes with the corresponding patient ted before attempting to obtain the
demographics, date and time of col- specimen.
lection, and any medication the ➤ Other methods may include obtain-
patient is taking that may interfere ing an order for an expectorant to
with test results (e.g., antibiotics). be administered with additional
water approximately 2 hours before early morning sputum samples are

attempting to obtain the speci- collected in sterile containers.
men. Chest percussion and postural
drainage of all lung segments General:
may also be employed. If the patient
is still unable to raise sputum,
the use of an ultrasonic nebulizer
(“induced sputum”) may be neces-
chospasm).
sary; this is usually done by a respi-
ratory therapist. ➤ Promptly transport the specimen
to the laboratory for processing and
Tracheal suctioning: analysis.
➤ Obtain the necessary equipment, or in a computerized system for
including a suction device, suction recall and postprocedure interpreta-
kit, and Lukens tube or in-line trap. tion by the appropriate health care
➤ Position the patient with head ele- practitioner.
vated as high as tolerated.
➤ Put on sterile gloves. Maintain the Post-test:
dominant hand as sterile and the
nondominant hand as clean. ➤ Instruct the patient to resume pre-
operative diet, as directed by the
➤ Using the sterile hand, attach the health care practitioner. Assess
suction catheter to the rubber tubing the patient’s ability to swallow
of the Lukens tube or in-line trap. before allowing the patient to
Then attach the suction tubing to the attempt liquids or solid foods.
male adapter of the trap with the
clean hand. Lubricate the suction ➤ Inform the patient that he or she may
catheter with sterile saline. experience some throat soreness
and hoarseness. Instruct patient to
➤ Tell nonintubated patients to pro- treat throat discomfort with lozenges
trude the tongue and to take a deep and warm gargles when the gag
breath as the suction catheter is reflex returns.
passed through the nostril. When the
catheter enters the trachea, a reflex ➤ Monitor vital signs and compare with
cough is stimulated; immediately baseline values every 15 minutes
advance the catheter into the trachea for 1 hour, then every 2 hours for 4
and apply suction. Maintain suction hours, and then as ordered by the
for approximately 10 seconds, but health care practitioner. Monitor tem-
never longer than 15 seconds. perature every 4 hours for 24 hours.
Withdraw the catheter without apply- Notify the health care practitioner if
ing suction. Separate the suction temperature is elevated. Protocols
catheter and suction tubing from the may vary from facility to facility.
trap, and place the rubber tubing over ➤ Emergency resuscitation equipment
the male adapter to seal the unit. should be readily available if the
➤ For intubated patients or patients vocal cords become spastic after
with a tracheostomy, the previous intubation.
procedure is followed except that the ➤ Observe for delayed allergic reac-
suction catheter is passed through tions, such as rash, urticaria, tachy-
the existing endotracheal or tra- cardia, hyperpnea, hypertension,
cheostomy tube rather than through palpitations, nausea, or vomiting.
the nostril. The patient should be ➤ Observe the patient for hemop-
hyperoxygenated before and after tysis, difficulty breathing, cough, air
the procedure in accordance with hunger, excessive coughing, pain, or
standard protocols for suctioning absent breathing sounds over the
these patients. affected area. Report any symptoms
➤ Generally, a series of three to five to the health care provider.
➤ Evaluate the patient for symptoms ➤ Reinforce information given by the

indicating the development of pneu- patient’s health care provider regard-
mothorax, such as dyspnea, tachyp- ing further testing, treatment, or
nea, anxiety, decreased breathing referral to another health care pro-
sounds, or restlessness. A chest x- vider. Instruct the patient to use
ray may be ordered to check for the lozenges or gargle for throat discom-
presence of this complication. fort. Inform the patient of smoking
➤ Evaluate the patient for symptoms of cessation programs as appropriate.
empyema, such as fever, tachycar- The importance of following the pre-
dia, malaise, or elevated white blood scribed diet should be stressed to
cell count. the patient/caregiver. Educate the
➤ Administer antibiotic therapy if or- ing services, as appropriate. Answer
dered. Remind the patient of the any questions or address any con-
importance of completing the entire cerns voiced by the patient or family.
signs and symptoms disappear be-
fore completion of therapy.
➤ Nutritional considerations: Malnutri- apy regimen. As appropriate, instruct
tion is commonly seen in patients the patient in significant side effects
with severe respiratory disease for and systemic reactions associated
numerous reasons including fatigue, with the prescribed medication. En-
lack of appetite, and gastrointestinal courage him or her to review corre-
distress. Adequate intake of vitamins sponding literature provided by a
A and C are also important to pre- pharmacist.
vent pulmonary infection and to ➤ Depending on the results of this pro-
decrease the extent of lung tissue cedure, additional testing may be
damage. needed to evaluate or monitor pro-
➤ A written report of the examina- gression of the disease process and
tion will be completed by a health determine the need for a change in
care practitioner specializing in this therapy. Evaluate test results in rela-
branch of medicine. The report will tion to the patient’s symptoms and
be sent to the requesting health care other tests performed.
results with the patient. Related laboratory tests:
➤ Recognize anxiety related to test ➤ Related laboratory tests include
results. Discuss the implications anti–glomerular basement mem-
of abnormal test results on the brane antibody, arterial/alveolar oxy-
patient’s lifestyle. Provide teaching gen ratio, blood gases, chest x-ray,
and information regarding the clinical complete blood count, computed
implications of the test results, as tomography of the thorax, lung scan,
appropriate. Educate the patient magnetic resonance imaging of the
regarding access to counseling chest, culture, Gram/acid-fast stain,
services. cytology, and sputum findings.
CULTURE, BACTERIAL, STOOL

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Fresh random stool collected in a clean plastic container.
REFERENCE VALUE: (Method: Culture on selective media for identification
of pathogens usually to include Salmonella, Shigella, Escherichia coli
O157:H7, Yersinia enterocolitica, and Campylobacter; latex agglutination or
enzyme immunoassay for Clostridium A and B toxins) Negative: No growth
of pathogens. Normal fecal flora is 96% to 99% anaerobes and 1% to 4%
aerobes. Normal flora present may include Bacteroides, Candida albicans,
Clostridium, Enterococcus, E. coli, Proteus, Pseudomonas, and Staphylococcus
aureus.
INDICATIONS:
DESCRIPTION & RATIONALE: Stool • Assist in establishing a diagnosis for
culture involves collecting a sample of diarrhea of unknown etiology
feces so that organisms present can be • Identify pathogenic organisms causing
isolated and identified. Certain bacte- gastrointestinal disease and carrier
ria are normally found in feces. states
However, when overgrowth of these
organisms occurs or pathologic organ- RESULT
isms are present, diarrhea or other
signs and symptoms of systemic infec-
• Bacterial infection: Aeromonas spp.,
tion occur. These symptoms are the
Bacillus cereus, Campylobacter, Clostrid-
result of damage to the intestinal tissue ium, E. coli, including serotype O157:
by the pathogenic organisms. Routine H7, Plesiomonas shigelloides, Salmonella,
stool culture normally screens for a Shigella, Yersinia, and Vibrio. Isolation of
small number of common pathogens, Staphylococcus aureus may indicate infec-
such as Campylobacter, Salmonella, and tion or a carrier state.
Shigella. Identification of other bacte-
• Botulism: Clostridium botulinum (the
ria is initiated by special request or bacteria must also be isolated from the
upon consultation with a microbiolo- food or the presence of toxin confirmed
gist when there is knowledge of special in the stool specimen).
circumstances. The laboratory will ini-
tiate antibiotic sensitivity testing if CRITICAL VALUES: Note and immedi-
indicated by test results. Sensitivity ately report to the health care practi-
testing identifies the antibiotics to tioner positive results for Salmonella,
which organisms are susceptible to Shigella, or Campylobacter and related
ensure an effective treatment plan. ■ symptoms.
Culture, Bacterial, Stool 531
INTERFERING FACTORS: ➤ Obtain a history of the patient’s

• A rectal swab does not provide an ade- travel to foreign countries.
quate amount of specimen for evalu- ➤ Obtain a list of the medications the
ating the carrier state and should be patient is taking, including herbs,
avoided in favor of a standard stool nutritional supplements, and nutra-
specimen. practitioner and laboratory should be
• A rectal swab should never be submitted advised if the patient regularly uses
for Clostridium toxin studies. Specimens these products so that their effects
for Clostridium toxins should be refrig- when reviewing results.
erated if they are not immediately
transported to the laboratory as toxins
can interfere with test results.
degrade rapidly.
➤ Review the procedure with the pa-
• A rectal swab should never be submit- tient. Address concerns about pain
ted for Campylobacter culture. Excessive related to the procedure. Explain to
exposure of the sample to air or room the patient that there may be some
temperature may damage this bac- discomfort during the specimen col-
lection. Inform the patient that speci-
terium so that it will not grow in the men collection takes approximately 5
culture. minutes.
• Therapy with antibiotics before speci- ➤ There are no food or fluid restric-
men collection may decrease the type tions, unless by medical direction.
and the amount of bacteria.
Intratest:
• Failure to transport the culture within
1 hour of collection or urine contami- ➤ Ensure that the patient has complied
nation of the sample may affect results. with medication restrictions prior to
the procedure.
• Barium and laxatives used less than 1 ➤ Instruct the patient to cooperate fully
week before the test may reduce bacte- and to follow directions. Direct the
rial growth. patient to breathe normally and to
Nursing Implications and pendix A. Positively identify the
Procedure ● ● ● ● ● ● ● ● ● ● ●
collection containers with the corre-
Pretest: sponding patient demographics, date
and time of collection, and any med-
➤ Inform the patient that the test is ication the patient is taking that may
used to identify pathogenic bacterial interfere with test results (e.g.,
organisms. antibiotics).
➤ Obtain a history of the patient’s com- ➤ Collect a stool specimen directly
plaints, including a list of known aller- into a clean container. If the patient
gens, and inform the appropriate requires a bedpan, make sure it is
health care practitioner accordingly. clean and dry, and use a tongue
➤ Obtain a history of the patient’s blade to transfer the specimen to the
gastrointestinal and immune system container. Make sure representative
and results of previously performed portions of the stool are sent for
laboratory tests, surgical procedures, analysis. Note specimen appearance
and other diagnostic procedures. For on collection container label.
related laboratory tests, refer to the ➤ Promptly transport the specimen
Gastrointestinal and Immune System to the laboratory for processing and
tables. analysis.
➤ The results are recorded manually or ➤ Recognize anxiety related to test

in a computerized system for recall results. Discuss the implications
and postprocedure interpretation of abnormal test results on the
by the appropriate health care prac- patient’s lifestyle. Provide teaching
titioner. and information regarding the clinical
Post-test: appropriate.
➤ Instruct the patient to resume usual ➤ Reinforce information given by
medication as directed by the health the patient’s health care provider
care practitioner. regarding further testing, treatment,
➤ Instruct the patient to report symp- provider. Emphasize the importance
toms such as pain related to tissue of reporting continued signs and
inflammation or irritation. symptoms of the infection. Answer
➤ Advise the patient that final test any questions or address any con-
results may take up to 72 hours but cerns voiced by the patient or family.
that antibiotic therapy may be started ➤ Depending on the results of this pro-
immediately. Instruct the patient cedure, additional testing may be
about the importance of completing performed to evaluate or monitor
the entire course of antibiotic therapy progression of the disease process
even if no symptoms are present. and determine the need for a change
Note: Antibiotic therapy is frequently in therapy. Evaluate test results in
contraindicated for Salmonella infec- relation to the patient’s symptoms
tion unless the infection has pro- and other tests performed.
gressed to a systemic state.
➤ A written report of the examination Related laboratory tests:
care practitioner, who will discuss ➤ Related laboratory tests include fecal
the results with the patient. analysis and ova and parasites.
CULTURE, BACTERIAL, THROAT

OR NASOPHARYNGEAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Routine throat culture.

SPECIMEN: Throat or nasopharyngeal swab.
REFERENCE VALUE: (Method: Aerobic culture) No growth.
DESCRIPTION & RATIONALE: The S. pyogenes is the organism that most

routine throat culture is a commonly commonly causes acute pharyngitis.
ordered test to screen for the presence The more dangerous sequelae of scar-
of group A -hemolytic streptococci. let fever, rheumatic heart disease, and
Culture, Bacterial, Throat or Nasopharyngeal 533
glomerulonephritis are less frequently INTERFERING FACTORS:

seen because of the early treatment • Contamination with oral flora may
of infection at the pharyngitis stage. invalidate results.
There are a number of other bacte- • Specimen collection after antibiotic
rial agents responsible for pharyn- therapy has been initiated may result in
gitis. Specific cultures can be set up inhibited or nongrowth of organisms.
to detect other pathogens such as
Bordetella, Corynebacteria, Haemophilus,
or Neisseria if they are suspected or Nursing Implications and
by special request from the health care Procedure ● ● ● ● ● ● ● ● ● ● ●
practitioner. Corynebacterium diphthe-

riae is the causative agent of diphthe- Pretest:
ria. Neisseria gonorrhoeae is a sexually ➤ Inform the patient that the test is
transmitted pathogen. In children, a used to identify pathogenic bacterial
organisms.
positive throat culture for Neisseria
usually indicates sexual abuse. The ➤ Obtain a history of the patient’s
laboratory will initiate antibiotic sen- allergens (especially allergies or sen-
sitivity testing if indicated by test sitivities to latex), and inform the
results. Sensitivity testing identifies appropriate health care practitioner
the antibiotics to which the organisms accordingly.
are susceptible to ensure an effective ➤ Obtain a history of the patient’s
treatment plan. ■ immune and respiratory systems and
ratory tests, surgical procedures, and
INDICATIONS: other diagnostic procedures. For
• Assist in the diagnosis of bacterial related laboratory tests, refer to the
Immune and Respiratory System
infections such as tonsillitis, diphtheria,
tables.
gonorrhea, or pertussis
• Assist in the diagnosis of upper respira- patient is taking, including herbs,
tory infections resulting in bronchitis, nutritional supplements, and nutra-
pharyngitis, croup, and influenza ceuticals. The requesting health care
• Isolate and identify group A - advised if the patient regularly uses
hemolytic streptococci as the cause of these products so that their effects
strep throat, acute glomerulonephritis, can be taken into consideration
scarlet fever, or rheumatic fever when reviewing results.
RESULT : Reports on cultures that are pos- ➤ Review the procedure with the
itive for group A -hemolytic strepto- patient. In cases of acute epiglottitis,
cocci are generally available within 24 to do not swab the throat! This can
48 hours. Cultures that report on normal cause a laryngospasm resulting in a
respiratory flora are issued after 48 loss of airway. A patient with epiglot-
hours. Culture results of no growth for titis will be sitting up and leaning
Corynebacterium require 72 hours to forward in the tripod position with
report; 48 hours are required to report the head and jaw thrusted forward to
negative Neisseria cultures. breathe. Address concerns about
pain related to the procedure. Ex-
plain to the patient that there may
CRITICAL VALUES: N/A be some discomfort during the
specimen collection. The time it end of the swab is immersed in the

takes to collect a proper specimen liquid transport medium.
varies according to the level of coop- ➤ Promptly transport the specimen to
eration of the patient. Inform the pa- the laboratory for processing and
tient that specimen collection takes analysis.
approximately 5 minutes.
➤ There are no food or fluid restrictions or in a computerized system for
unless by medical direction. recall and postprocedure interpreta-
➤ Sensitivity to social and cultural tion by the appropriate health care
issues, as well as concern for mod- practitioner.
chological support before, during, and Post-test:
after the procedure. ➤ Instruct the patient to resume usual
medication as directed by the health
Intratest: care practitioner.
➤ Ensure that the patient has complied ➤ Instruct the patient to notify the
with medication restrictions prior to health care practitioner immediately
the procedure. if difficulty in breathing or swallowing
➤ Have emergency equipment readily occurs or if bleeding occurs.
available. Keep resuscitation equip- ➤ Instruct the patient to perform
ment on hand in case of respiratory mouth care after the specimen has
impairment or laryngospasm after been obtained.
the procedure. ➤ Provide comfort measures and treat-
➤ Instruct the patient to cooperate fully ment such as antiseptic gargles,
and to follow directions. Direct the inhalants, and warm, moist applica-
patient to breathe normally and to tions as needed. A cool beverage
avoid unnecessary movement. may aid in relieving throat irritation
caused by coughing or suctioning.
follow the general guidelines in ➤ Administer antibiotic therapy if or-
Appendix A. Positively identify the dered. Remind the patient of the
patient, and label the appropriate col- importance of completing the entire
lection containers with the correspon- course of antibiotic therapy, even if
ding patient demographics, date and signs and symptoms disappear be-
time of collection, and any medica- fore completion of therapy.
tion the patient is taking that may ➤ Nutritional considerations: Dehydra-
interfere with test results (e.g., tion can been seen in patients with a
antibiotics). bacterial throat infection due to pain
➤ To collect the throat culture, tilt the with swallowing. Pain medications
patient’s head back. Swab both ton- reduce patient’s dysphagia and allow
sillar pillars and oropharynx with the for adequate intake of fluids and
sterile Culturette. A tongue depres- foods.
sor can be used to ensure that con- ➤ A written report of the examination
tact with the tongue and uvula is will be sent to the requesting health
avoided. care practitioner, who will discuss
➤ A nasopharyngeal specimen is col- the results with the patient.
lected through the use of a flexible ➤ Recognize anxiety related to test
probe inserted through the nose and results. Discuss the implications of
directed toward the back of the abnormal test results on the patient’s
throat. lifestyle. Provide teaching and infor-
➤ Place the swab in the Culturette tube mation regarding the clinical impli-
and squeeze the bottom of the cations of the test results, as
Culturette tube to release the liquid appropriate.
transport medium. Ensure that the ➤ Reinforce information given by the
Culture, Bacterial, Urine 535

ing further testing, treatment, or refer- performed to evaluate or monitor
ral to another health care provider. progression of the disease process
Instruct the patient to use lozenges and determine the need for a change
or gargle for throat discomfort. Inform in therapy. Evaluate test results in
the patient of smoking cessation pro- relation to the patient’s symptoms
grams as appropriate. Emphasize the and other tests performed
importance of reporting continued
signs and symptoms of the infection.
Answer any questions or address Related laboratory tests:
any concerns voiced by the patient or ➤ Related laboratory tests include
family. complete blood count and group A
➤ Depending on the results of this streptococcal screen.
CULTURE, BACTERIAL, URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Routine urine culture.

SPECIMEN: Urine (5 mL) collected in a sterile plastic collection container.
REFERENCE VALUE: (Method: Culture on selective and enriched media)
Negative: no growth.
Commonly detected organisms are

DESCRIPTION & RATIONALE: A urine those normally found in the
culture involves collecting a urine genitourinary tract, including
specimen so that the organism causing enterococci, Escherichia coli,
Klebsiella, Proteus, and
disease can be isolated and identified.
Pseudomonas. A culture
Urine can be collected by clean catch, showing multiple organisms
urinary catheterization, or suprapubic indicates a contaminated
aspiration. The severity of the infec- specimen.
tion or contamination of the speci- Colony counts of 100,000/mL or
men can be determined by knowing more indicate urinary tract
the type and number of organisms infection (UTI).
(colonies) present in the specimen. Colony counts of 1000/mL or less
The laboratory will initiate sensitivity suggest contamination resulting
from poor collection technique.
testing if indicated by test results.
Colony counts between 1000 and
Sensitivity testing identifies the anti-
10,000/mL may be significant
biotics to which the organisms are depending on a variety of
susceptible to ensure an effective treat- factors, including patient’s age,
ment plan. ■ gender, number of types of
organisms present, method of allergens, and inform the appropriate

specimen collection, and health care practitioner accordingly.
presence of antibiotics. ➤ Obtain a history of the patient’s gen-
itourinary and immune systems and
INDICATIONS: results of previously performed labo-
• Assist in the diagnosis of suspected ratory tests, surgical procedures, and
UTI other diagnostic procedures. For
• Determine the sensitivity of significant Genitourinary and Immune System
organisms to antibiotics tables.
• Monitor the response to UTI treatment ➤ Obtain a list of the medications the
Positive findings in: UTIs advised if the patient regularly uses
Negative findings in: N/A can be taken into consideration
CRITICAL VALUES: N/A ➤ Note any recent medications that
INTERFERING FACTORS: ➤ Review the procedure with the pa-
• Antibiotic therapy initiated before tient. Address concerns about pain
specimen collection may produce false- related to the procedure. Explain to
negative results. the patient that there may be some
discomfort during the specimen col-
• Improper collection techniques may lection. Inform the patient that speci-
result in specimen contamination. men collection depends on patient
• Specimen storage for longer than 30 cooperation and usually takes approx-
imately 5 to 10 minutes.
minutes at room temperature or 24
hours at refrigerated temperature may ➤ Sensitivity to social and cultural
result in overgrowth of bacteria and issues, as well as concern for mod-
false-positive results.
• Results of urine culture are often inter- and after the procedure.
preted along with routine urinalysis ➤ There are no food or fluid restric-
findings. tions, unless by medical direction.
• Discrepancies between culture and uri- ➤ Instruct the patient on clean-catch
procedure and provide necessary
nalysis may be reason to recollect the
supplies.
specimen.
Intratest:
Nursing Implications and ➤ Ensure that the patient has complied

with medication restrictions prior to
Procedure ● ● ● ● ● ● ● ● ● ● ●
the procedure.
➤ Inform the patient that the test is patient to breathe normally and to
used to identify pathogenic bacterial avoid unnecessary movement.
organisms. ➤ Observe standard precautions, and
➤ Obtain a history of the patient’s com- follow the general guidelines in
plaints, including a list of known Appendix A. Positively identify the
Culture, Bacterial, Urine 537
patient, and label the appropriate col- Suprapubic aspiration:

sponding patient demographics, date ➤ Place the patient in supine position.
and time of collection, method of Cleanse the area with antiseptic, and
specimen collection, and any med- drape with sterile drapes. A needle is
ications the patient has taken that inserted through the skin into the
may interfere with test results (e.g. bladder. A syringe attached to the
antibiotics). needle is used to aspirate the urine
sample. The needle is then removed
and a sterile dressing is applied to
the site. Place the sterile sample in a
➤ Instruct the male patient to (1) thor- sterile specimen container.
oughly wash his hands, (2) cleanse ➤ Do not collect urine from the pouch
the meatus, (3) void a small amount from a patient with a urinary diver-
into the toilet, and (4) void directly sion (e.g., ileal conduit). Instead, per-
into the specimen container. form catheterization through the
➤ Instruct the female patient to (1) thor- stoma.
oughly wash her hands; (2) cleanse
the labia from front to back; (3) while General:
keeping the labia separated, void a ➤ Promptly transport the specimen to
small amount into the toilet; and (4) the laboratory for processing and
without interrupting the urine stream, analysis. If a delay in transport is
void directly into the specimen con- expected, add an equal volume of
tainer. 50% alcohol to the specimen as a
preservative.
Pediatric urine collector:
➤ Put on gloves. Appropriately cleanse or in a computerized system for
the genital area, and allow the area recall and postprocedure interpreta-
to dry. Remove the covering over the tion by the appropriate health care
adhesive strips on the collector bag practitioner.
and apply over the genital area.
Diaper the child. When specimen is Post-test:
obtained, place the entire collection
bag in a sterile urine container. ➤ Instruct the patient to resume usual
medication as directed by the health
Indwelling catheter: care practitioner.
➤ Instruct the patient to report symp-
➤ Put on gloves. Empty drainage tube
toms such as pain related to tissue
of urine. It may be necessary to
inflammation, pain or irritation during
clamp off the catheter for 15 to 30
void, bladder spasms, or alterations
minutes before specimen collection.
in urinary elimination.
Cleanse specimen port with antisep-
tic swab, and then aspirate 5 mL of ➤ Observe for signs of inflammation if
urine with a 21- to 25-gauge needle the specimen is obtained by supra-
and syringe. Transfer urine to a sterile pubic aspiration.
container. ➤ Administer antibiotic therapy as
Urinary catheterization: importance of completing the entire
➤ Place female patient in lithotomy course of antibiotic therapy, even if
position or male patient in supine signs and symptoms disappear before
position. Using sterile technique, completion of therapy.
open the straight urinary catheteriza- ➤ Nutritional considerations: Instruct the
tion kit and perform urinary catheter- patient to increase water consump-
ization. Place the retained urine in a tion by drinking 8 to 12 glasses of
sterile specimen container. water to assist in flushing the urinary
tract. Instruct the patient to avoid and information regarding the clinical
alcohol, caffeine, and carbonated implications of the test results, as
beverages, which can cause bladder appropriate.
irritation.
➤ Prevention of UTIs includes increas- patient’s health care provider regard-
ing daily water consumption, urinating further testing, treatment, or re-
ing when urge occurs, wiping the ferral to another health care provider.
perineal area from front to back after Emphasize the importance of report-
urination/defecation, and urinating ing continued signs and symptoms
immediately after intercourse. Pre- of the infection. Instruct patient on
vention also includes maintaining the the proper technique for wiping the
normal flora of the body. Patients perineal area (front to back) after a
should avoid using spermicidal creams bowel movement. Answer any ques-
with diaphragms or condoms (when tions or address any concerns voiced
recommended by a health care practi- by the patient or family.
tioner), becoming constipated, douch-
ing, taking bubble baths, wearing ➤ Depending on the results of this pro-
tight- fitting garments, and using cedure, additional testing may be
deodorizing feminine hygiene prod- performed to evaluate or monitor
ucts that alter the body’s normal flora progression of the disease process
and increase susceptibility to UTIs. and determine the need for a change
➤ A written report of the examination relation to the patient’s symptoms
will be sent to the requesting health and other tests performed.
results. Discuss the implications ➤ Related laboratory tests include
of abnormal test results on the Gram stain, urinalysis, and white
patient’s lifestyle. Provide teaching blood cell count.
CULTURE, FUNGAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Hair, skin, nail, pus, sterile fluids, blood, bone marrow, stool,
bronchial washings, sputum, or tissue samples collected in a sterile plastic,
tightly capped container.
REFERENCE VALUE: (Method: Culture on selective media; macroscopic

and microscopic examination) No presence of fungi.
Culture, Fungal 539
Epidermophyton
DESCRIPTION & RATIONALE: Fungi, Trichophyton
organisms that normally live in soil,
can be introduced into humans • Skin
through the accidental inhalation of Actinomyces israelii
spores or inoculation of spores into tis- Candida albicans
sue through trauma. Individuals most Coccidioides immitis
susceptible to fungal infection usually Epidermophyton
are debilitated by chronic disease, are Microsporum
receiving prolonged antibiotic therapy, Trichophyton
or have impaired immune systems. • Tissue
Fungal diseases may be classified A. israelii
according to the involved tissue type:
Aspergillus
dermatophytoses involve superficial
Candida albicans
and cutaneous tissue; there are also
Nocardia
subcutaneous and systemic mycoses. ■
P. brasiliensis
INDICATIONS:
• Determine antimicrobial sensitivity of CRITICAL VALUES: N/A
the organism
• Isolate and identify organisms responsi-
INTERFERING FACTORS: Prompt and
proper specimen processing, storage, and
ble for nail infections or abnormalities
analysis are important to achieve accurate
• Isolate and identify organisms responsi- results.
ble for skin eruptions, drainage, or
other evidence of infection
RESULT Nursing Implications and

Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
• Blood
Candida albicans ➤ Inform the patient that the test is
used to identify pathogenic fungal
Histoplasma capsulatum organisms.
• Cerebrospinal fluid ➤ Obtain a history of the patient’s com-
Coccidioides immitis plaints, including a list of known aller-
Cryptococcus neoformans gens, and inform the appropriate
Members of the order Mucorales
➤ Obtain a history of the patient’s im-
Paracoccidioides brasiliensis
mune system and results of previ-
Sporothrix schenckii ously performed laboratory tests,
• Hair surgical procedures, and other diag-
Epidermophyton tory tests, refer to the Immune
Microsporum System table.
Trichophyton ➤ Obtain a list of the medications the
• Nails
Candida albicans ceuticals. The requesting health care
Cephalosporium practitioner and laboratory should be
advised if the patient regularly uses Hair:

these products so that their effects ➤ Fungi usually grow at the base of the
can be taken into consideration when hair shaft. Infected hairs can be iden-
reviewing results. tified by using a Wood’s lamp in a
➤ Note any recent medications that can darkened room. A Wood’s lamp pro-
interfere with test results. vides rays of ultraviolet light at a
wavelength of 366 nm, or 3660 Å.
➤ Review the procedure with the Infected hairs fluoresce a bright yel-
patient. Inform the patient that spec- low-green when exposed to light
imen collection takes approximately from the Wood’s lamp. Using tweez-
5 minutes. Address concerns about ers, pluck hair from skin.
to the patient that there may be some Nails:
discomfort during the specimen col-
➤ Ideally, softened material from the
lection.
nail bed is sampled from beneath the
➤ There are no food or fluid restrictions nail plate. Alternatively, shavings
unless by medical direction. from the deeper portions of the nail
itself can be collected.
➤ The potassium hydroxide (KOH)
Intratest:
test is used to indicate the presence
➤ Instruct the patient to cooperate fully of mycelium, mycelial fragments,
and to follow directions. Direct the spores, or budding yeast cells. A por-
patient to breathe normally and to tion of the specimen is mixed with
avoid unnecessary movement. 15% KOH on a glass slide, and then
the slide is covered and gently
➤ Observe standard precautions, and heated briefly. The slide is examined
follow the general guidelines in under a microscope for the presence
Appendix A. Instructions regarding of fungal elements.
the appropriate transport materials
for blood, bone marrow, bronchial Post-test:
washings, sputum, sterile fluids,
stool, and tissue samples should ➤ Instruct patient to begin antibiotic
be obtained from the laboratory. therapy, as prescribed. Instruct the
Positively identify the patient, and patient in the importance of complet-
label the appropriate collection con- ing the entire course of antibiotic
tainers with the corresponding therapy even if no symptoms are
patient demographics, date, and present.
time of collection. ➤ A written report of the examination
➤ Promptly transport the specimen to will be sent to the requesting health
the laboratory for processing and care practitioner, who will discuss
analysis. the results with the patient.
mation regarding the clinical impli-
practitioner.
cations of the test results, as
appropriate.
Skin:
➤ Clean the collection site with 70% patient’s health care provider regard-
alcohol. Scrape the peripheral margin ing further testing, treatment, or re-
of the collection site with a sterile ferral to another health care provider.
scalpel or wooden spatula. Place Emphasize the importance of report-
the scrapings in a sterile collection ing continued signs and symptoms
container. of the infection. Answer any ques-
Culture, Viral 541
tions or address any concerns voiced relation to the patient’s symptoms

by the patient or family. and other tests performed.
progression of the disease process ➤ Related laboratory tests include rele-
and determine the need for a change vant bacterial cultures, tissue biop-
in therapy. Evaluate test results in sies, and body fluid analysis.
CULTURE, VIRAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Urine, semen, blood, body fluid, stool, tissue, or swabs from the
affected site.
REFERENCE VALUE: (Method: Culture in special media, enzyme-linked
immunoassays, direct fluorescent antibody techniques, latex agglutination,
immunoperoxidase techniques) No virus isolated.
• Acute respiratory failure

DESCRIPTION & RATIONALE: Viruses, Hantavirus
the most common cause of human
infection, are submicroscopic organ- • Anorectal infections
isms that invade living cells. They can Herpes simplex virus (HSV)
be classified as either RNA- or DNA- Human papillomavirus
type viruses. Viral titers are highest in • Bronchitis
the early stages of disease before the Parainfluenza virus
host has begun to manufacture signif- Respiratory syncytial virus
icant antibodies against the invader. (RSV)
Specimens need to be collected as early
• Condylomata
in the disease process as possible. ■
Human papilloma DNA virus
INDICATIONS: Assist in the identification • Conjunctivitis/keratitis
of viral infection Adenovirus
Epstein-Barr virus
RESULT
HSV
Positive findings in: Measles virus
• Acquired immunodeficiency syndrome Parvovirus
Human immunodeficiency virus Rubella virus
(HIV) Varicella-zoster virus
• Croup • Myocarditis/pericarditis
Parainfluenza virus Coxsackievirus
RSV Echovirus
• Cutaneous infection with rash • Parotitis
Enteroviruses Mumps virus
HSV Parainfluenza virus
Varicella-zoster virus • Pharyngitis
• Encephalitis Adenovirus
Enteroviruses Coxsackievirus (group A)
Flaviviruses Epstein-Barr virus
HSV HSV
HIV Influenza virus
Measles virus Parainfluenza virus
Rabies virus Rhinovirus
Togaviruses • Pleurodynia
Coxsackievirus (group B)
• Febrile illness with rash
Coxsackieviruses • Pneumonia
Echovirus Adenovirus
Influenza virus
• Gastroenteritis Parainfluenza virus
Norwalk virus RSV
Rotavirus
• Upper respiratory tract infection
• Genital herpes Adenovirus
HSV-1 Coronavirus
HSV-2 Influenza virus
• Hemorrhagic cystitis Parainfluenza virus
Adenovirus RSV
Rhinovirus
• Hemorrhagic fever
Ebola virus CRITICAL VALUES: Positive RSV
Hantavirus culture should be reported immediately
Lassa virus to the requesting health care practitioner.
Marburg virus
INTERFERING FACTORS: Viral specimens
• Herpangina are unstable. Prompt and proper speci-
Coxsackievirus (group A) men processing, storage, and analysis are
important to achieve accurate results.
• Infectious mononucleosis
Cytomegalovirus
Epstein-Barr virus Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Meningitis
Coxsackieviruses Pretest:
Echovirus
HSV-2 used to identify pathogenic viral
Lymphocytic choriomeningitis virus organisms.
Culture, Viral 543
➤ Obtain a history of the patient’s sponding patient demographics, date

complaints, including a list of known and time of collection, exact site,
allergens (especially allergies or sen- contact person for notification of
sitivities to latex), and inform the results, and other pertinent informa-
appropriate health care practitioner tion (e.g., patient immunocompro-
accordingly. mised owing to organ transplant,
➤ Obtain a history of the patient’s gas- radiation, or chemotherapy).
trointestinal, genitourinary, immune, ➤ Instructions regarding the appropri-
reproductive, and respiratory sys- ate transport materials for blood,
tems and results of previously per- bronchial washings, sputum, sterile
formed laboratory tests, surgical fluids, stool, and tissue samples
procedures, and other diagnostic should be obtained from the labora-
procedures. For related laboratory tory. The type of applicator used to
tests, refer to the Gastrointestinal, obtain swabs should be verified by
Genitourinary, Immune, Reproduc- consultation with the testing labora-
tive, and Respiratory System tables. tory personnel.
➤ Obtain a list of the medications the ➤ The appropriate viral transport mate-
patient is taking, including herbs, rial should be obtained from the lab-
nutritional supplements, and nutra- oratory. Nasopharyngeal washings or
ceuticals. The requesting health care swabs for RSV testing should be
practitioner and laboratory should be immediately placed in cold viral
advised if the patient regularly uses transport media.
these products so that their effects ➤ Promptly transport the specimen to
can be taken into consideration the laboratory for processing and
when reviewing results. analysis.
➤ Note any recent medications that ➤ The results are recorded manually
can interfere with test results. or in a computerized system for re-
➤ Review the procedure with the call and postprocedure interpretation
patient. Inform the patient that spec- by the appropriate health care practi-
imen collection takes approximately tioner.
5 minutes. Address concerns about
pain related to the procedure. Explain Post-test:
to the patient that there may be
some discomfort during the speci- ➤ Nutritional considerations: Dehydra-
men collection. tion can been seen in patients with
viral infections due to loss of fluids
through fever, diarrhea, and/or vomit-
tion restrictions, unless by medical
ing. Antipyretic medication includes
direction.
acetaminophen to decrease fever
➤ Sensitivity to social and cultural and allow for adequate intake of flu-
issues, as well as concern for mod- ids and foods. Do not give acetyl-
esty, is important in providing psy- salicylic acid to patients with a viral
chological support before, during, illness as there is an increase risk of
and after the procedure. Reye’s syndome.
➤ Instruct the patient to cooperate fully care practitioner, who will discuss
and to follow directions. Direct the the results with the patient.
avoid unnecessary movement. results. Discuss the implications
➤ Observe standard precautions, and of abnormal test results on the
follow the general guidelines in patient’s lifestyle. Provide teaching
Appendix A. Positively identify the and information regarding the clinical
patient, and label the appropriate implications of the test results, as
collection containers with the corre- appropriate.

ing further testing, treatment, or refer- in therapy. Evaluate test results in
ral to another health care provider. relation to the patient’s symptoms
Answer any questions or address any and other tests performed.
concerns voiced by the patient or
family. Related laboratory tests:
➤ Depending on the results of this ➤ Related laboratory tests include rele-
procedure, additional testing may be vant tissue biopsy, bacterial cultures,
performed to evaluate or monitor and viral serology tests.
CYSTOMETRY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Urodynamic testing of bladder function, CMG.

AREA OF APPLICATION: Bladder, urethra.
CONTRAST: None.
DESCRIPTION & RATIONALE: Cys- be performed with cystoscopy and

tometry evaluates the motor and sen- sphincter electromyography. ■
sory function of the bladder when
incontinence is present or neurological INDICATIONS:
bladder dysfunction is suspected, and • Detect congenital urinary abnor-
monitors the effects of treatment for malities
the abnormalities. This noninvasive • Determine cause of bladder dysfunc-
manometric study measures the blad- tion and pathology
der pressure and volume characteristics
in centimeters of water (cm H2O) dur- • Determine cause of recurrent urinary
ing the filling and emptying phases. tract infections (UTIs)
The test provides information about • Determine cause of urinary retention
bladder structure and function that
• Determine type of incontinence: func-
can lead to uninhibited bladder con-
tional (involuntary and unpredictable),
tractions, sensations of bladder fullness reflex (involuntary when a specific vol-
and need to void, and ability to inhibit ume is reached), stress (weak pelvic
voiding. These abnormalities cause muscles), total (continuous and unpre-
incontinence and other impaired pat- dictable), urge (involuntary when
terns of micturition. Cystometry can urgency is sensed), and psychological
Cystometry 545
(e.g., dementia, confusion affecting Abnormal Findings:

awareness) • Flaccid bladder that fills without con-
tracting
• Determine type of neurogenic bladder
(motor or sensory) • Inability to perceive bladder fullness
• Evaluate the management of neurolog- • Inability to initiate or maintain urina-
ical bladder before surgical intervention tion without applying external pressure
• Evaluate postprostatectomy inconti- • Sensory or motor paralysis of bladder
nence • Total loss of conscious sensation and
• Evaluate signs and symptoms of uri- vesical control or uncontrollable mic-
nary elimination pattern dysfunction turition (incontinence)
• Evaluate urinary obstruction in male CRITICAL VALUES: N/A
patients experiencing urinary retention
• Evaluate the usefulness of drug therapy INTERFERING FACTORS:
on detrusor muscle function and tonic-
ity and on internal and external sphinc- This procedure is
ter function
• Patients with acute UTIs because the
• Evaluate voiding disorders associated study can cause infection to spread to
with spinal cord injury the kidneys
RESULT of being pregnant, unless the potential
Normal Findings: the risks to the fetus and mother
• Absence of residual urine (0 mL)
• Patients with urethral obstruction
• Normal sensory perception of bladder
fullness, desire to void, and ability to • Patients with cervical cord lesions
inhibit urination; appropriate response because they may exhibit autonomic
to temperature (hot and cold) dysreflexia, as seen by bradycardia,
flushing, hypertension, diaphoresis,
• Normal bladder capacity: 350 to 750 and headache
mL for men and 250 to 550 mL for
women • Inability to catheterize the patient
• Normal functioning bladder pressure: Factors that may impair

8 to 15 cm H2O examination results:
• Normal sensation of fullness: 40 to 100 • Inability of the patient to cooperate or
cm H2O or 300 to 500 mL remain still during the procedure
• Normal bladder pressure during void- mental status
ing: 30 to 40 cm H2O
• Inability of the patient to void in a
• Normal detrusor pressure: less than 10 supine position or straining to void
cm H2O during the study
• Normal urge to void: 150 to 450 mL • A high level of patient anxiety or
• Normal filling pattern embarrassment, which may interfere
with the study, making it difficult to
• Urethral pressure that is higher than distinguish whether the results are due
bladder pressure, ensuring continence to stress or organic pathology
• Administration of drugs that affect the patient that the procedure takes
bladder function, such as muscle relax- approximately 30 to 45 minutes.
ants or antihistamines ➤ Sensitivity to cultural and social
Nursing Implications and and after the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Instruct the patient to report pain,
sweating, nausea, headache, and the
Pretest: urge to void during the study.
➤ Inform the patient that the procedure ➤ There are no food, fluid, or medica-
assesses bladder function. tion restrictions, unless by medical
direction.
plaints or symptoms, including a list ➤ Make sure a written and informed
of known allergens, especially aller- consent has been signed prior to the
gies or sensitivities to latex, iodine, procedure and before administering
seafood, contrast medium, and dyes. any medications.
Determine the patient’s allergies or
sensitivities to anesthetics, anal- Intratest:
gesics, or antibiotics.
➤ Give the patient a gown and robe to
➤ Obtain a history of the patient’s gen- wear; ensure that the patient is
itourinary and renal systems as well draped during the procedure to avoid
as results of previously performed unnecessary exposure.
medical and surgical therapeutic
interventions. Assess hematologic ➤ Position the patient in a supine or
status, blood-clotting ability, and lithotomy position on the examining
urinalysis findings for abnormalities. table. If spinal cord injury is present,
For related diagnostic tests, refer to the patient can remain on a stretcher
the Genitourinary and Renal System in a supine position and be draped
tables. appropriately.
➤ Record the date of the last menstrual ➤ Ask the patient to void prior to the
period and determine the possibility procedure. During voiding, note char-
of pregnancy in perimenopausal acteristics such as start time; force
women. and continuity of the stream; volume
voided; presence of dribbling, strain-
➤ Obtain a list of the medications the ing, or hesitancy; and stop time.
patient is taking (e.g., antihistamines
and muscle relaxants). ➤ Instruct the patient to cooperate fully
➤ Review the procedure with the patient to remain still during the pro-
patient. Address concerns about pain cedure.
related to the procedure. Inform the
patient that the only discomfort he or ➤ Observe standard precautions, and
she will experience is the insertion of follow the general guidelines in
the urethral catheter, and that there Appendix A.
may be some sensation of pressure ➤ A urinary catheter is inserted into
and/or having to void. Explain that the bladder under sterile condi-
patient cooperation with positioning tions, and residual urine is measured
and activity before and during the and recorded. A test for sensory
test is crucial for achieving accurate response to temperature is done by
results. Inform the patient that the instilling 30 mL of room-temperature
procedure is performed in a special sterile water followed by 30 mL of
urology room or in a clinic setting by warm sterile water. Sensations are
the health care practitioner. Inform assessed and recorded.
Cystometry 547
➤ Fluid is removed from the bladder, dure every 15 minutes for 2 hours or
and the catheter is connected to a as directed. Elevated temperature
cystometer that measures the pres- may indicate infection. Notify the
sure. Sterile normal saline, distilled health care practitioner if tempera-
water, or carbon dioxide gas is ture is elevated. Protocols may vary
instilled in controlled amounts into from facility to facility.
the bladder. When the client indi- ➤ Inform the patient that he or she may
cates the urge to void, the bladder experience burning or discomfort on
is considered full. The patient is urination for a few voidings after the
instructed to void, and urination procedure.
amounts as well as start and stop
times are then recorded. ➤ Emphasize that persistent flank or
suprapubic pain, fever, chills, blood in
➤ Pressure and volume readings are the urine, difficulty urinating, or
recorded and graphed for response change in urinary pattern must be
to heat, full bladder, urge to void, and reported immediately to the health
ability to inhibit voiding. The patient is care practitioner.
requested to void without straining,
and pressures are taken and ➤ A written report of the examination
recorded during this activity. will be completed by a health care
➤ After completion of voiding, the blad- of medicine. The report will be sent
der is emptied of any other fluid, and to the requesting health care practi-
the catheter is withdrawn, unless tioner, who will discuss the results
further testing is planned. with the patient.
➤ If further testing is done to deter- ➤ Reinforce information given by the
mine if abnormal bladder function is patient’s health care provider regard-
being caused by muscle incompe- ing further testing, treatment, or refer-
tence or interruption in innerva- ral to another health care provider.
tion, anticholinergic medication (e.g., Answer any questions or address any
atropine) or cholinergic medication concerns voiced by the patient or
(e.g., bethanechol [Urecholine]) can family.
be injected and the study repeated in
20 or 30 minutes.
➤ The results are recorded manually needed to evaluate or monitor pro-
or in a computerized system for gression of the disease process and
recall and postprocedure interpreta- determine the need for a change in
tion by the appropriate health care therapy. Evaluate test results in rela-
practitioner. tion to the patient’s symptoms and
Post-test:
➤ Inform the patient that further exam-
inations may be necessary. ➤ Related diagnostic tests include
computed tomography of the pelvis,
➤ Monitor fluid intake and urinary out- intravenous pyelography, magnetic
put for 24 hours after the procedure. resonance imaging of the pelvis, and
➤ Monitor vital signs after the proce- ultrasound of the pelvis.
CYSTOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Cystoureterography, cystourethrography,

prostatography.
AREA OF APPLICATION: Bladder, urethra, ureteral orifices.

CONTRAST: None.
• Evacuate blood clots and perform ful-

DESCRIPTION & RATIONALE: Cys- guration of bleeding sites within the
toscopy provides direct visualization lower urinary tract
of the urethra, urinary bladder, and
• Evaluate changes in urinary elimina-
ureteral orifices—areas not usually tion patterns
visible with x-ray procedures. This
procedure is also used to obtain speci- • Evaluate the extent of prostatic hyper-
mens and treat pathology associated plasia and degree of obstruction
with the aforementioned structures. • Evaluate the function of each kidney by
Cystoscopy is accomplished by trans- obtaining urine samples via ureteral
urethral insertion of a cystoscope into catheters
the bladder. Rigid cystoscopes contain
• Evaluate urinary tract abnormalities
an obturator and a telescope with a such as dysuria, frequency, retention,
lens and light system; there are also inadequate stream, urgency, and incon-
flexible cystoscopes, which use fiber- tinence
optic technology. The procedure may
be performed during or after ultra- • Identify and remove polyps and small
tumors (including by fulguration) from
sonography or radiography, or dur-
the bladder
ing urethroscopy or retrograde
pyelography. ■ • Identify congenital anomalies, such
as duplicate ureters, ureteroceles,
INDICATIONS: urethral or ureteral strictures, divertic-
• Coagulate bleeding areas ula, and areas of inflammation or ulcer-
ation
• Determine the possible source of per-
sistent urinary tract infections • Implant radioactive seeds
• Determine the source of hematuria of • Place ureteral catheters to drain urine
unknown cause from the renal pelvis or for retrograde
• Differentiate, through tissue biopsy, pyelography
between benign and cancerous lesions • Place ureteral stents and resect prostate
involving the bladder gland tissue (transurethral resection of
• Dilate the urethra and ureters the prostate)
Cystoscopy 549
• Remove renal calculi from the bladder because of age, significant pain, or
or ureters mental status
• Resect small tumors
RESULT • Failure to follow dietary restrictions
Normal Findings: procedure to be canceled or repeated.
• Normal ureter, bladder, and urethral
structure
Abnormal Findings:
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Diverticulum of the bladder, fistula,

stones, and strictures Pretest:
• Inflammation or infection ➤ Inform the patient that the procedure
• Obstruction is used to evaluate and treat condi-
tions in the urinary tract.
• Polyps
• Prostatic hypertrophy or hyperplasia plaints or symptoms, including a list
• Renal calculi gies or sensitivities to latex, iodine,
• Tumors seafood, contrast medium, and dyes.
Determine the patient’s allergies or
• Ureteral or urethral stricture sensitivities to anesthetics, anal-
gesics, or antibiotics.
• Urinary tract malformation and con-
genital anomalies ➤ Obtain a history of results of pre-
CRITICAL VALUES: N/A laboratory tests. Assess hematologic
status and blood-clotting ability and
INTERFERING FACTORS: urinalysis findings for abnormalities.
For related diagnostic tests, refer to
This procedure is the Genitourinary System table.
contraindicated for: ➤ Review the procedure with the pa-
• Patients who are pregnant or suspected tient. Address concerns about pain
of being pregnant, unless the potential related to the procedure. Inform the
benefits of the procedure far outweigh patient that the procedure is gener-
the risks to the fetus and mother ally performed under general, spinal,
or local anesthesia. Explain to the
• Patients with bleeding disorders because patient that no pain will be experi-
instrumentation may lead to excessive enced during the test when general
bleeding from the lower urinary tract or spinal anesthesia is used, and that
any discomfort will be minimized
• Patients with acute cystitis or urethritis with local anesthetics. Inform the
because instrumentation could allow patient that he or she may feel some
bacteria to enter the bloodstream, result- sensation of pressure and/or hav-
ing in septicemia ing to void. Inform the patient that
the procedure is performed by a
health care practitioner in a special
Factors that may cystoscopy suite near or in the
impair examination results: operating room (or in a health care
• Inability of the patient to cooperate or practitioner’s office) and takes
remain still during the procedure approximately 30 to 60 minutes.
➤ Record the date of the last men- penile clamp may be used for male
strual period and determine the patients to aid in retention of anes-
possibility of pregnancy in perimeno- thetic.
pausal women.
➤ The physician inserts a cystoscope
➤ Restrict food and fluids for 8 hours or a urethroscope to examine the
if the patient is having general or urethra before cystoscopy. The ure-
spinal anesthesia. For local anesthe- throscope has a sheath that may be
sia, allow only clear liquids 8 hours left in place, and the cystoscope is
before the procedure. inserted through it, avoiding multiple
instrumentations.
issues, as well as concern for mod- ➤ After insertion of the cystoscope, a
esty, is important in providing psy- sample of residual urine may be
chological support before, during, and obtained for culture or other analysis.
after the procedure.
➤ The bladder is irrigated via an irri-
➤ Obtain and record the patient’s vital gation system attached to the scope.
signs. The irrigant is usually sterile water,
➤ Make sure a written and informed unless an isotonic solution, such as
consent has been signed prior to the mannitol, is used during transurethral
procedure and before administering resection procedures. The irrigation
any medications. fluid aids in bladder visualization.
➤ If a prostatic tumor is found, a biopsy
Intratest: specimen may be obtained by
means of a cytology brush or biopsy
➤ Ensure that the patient has complied forceps inserted through the scope.
with dietary restrictions; assure that If the tumor is small and localized, it
food has been restricted for at least can be excised and fulgurated. This
8 hours depending on the anesthetic procedure is termed transurethral
chosen for the procedure. resection of the bladder. Polyps can
➤ Administer ordered preoperative also be identified and excised.
sedation. ➤ Ulcers or bleeding sites can be ful-
➤ Give the patient a gown and robe to gurated using electrocautery.
wear; ensure that the patient is ➤ Renal calculi can be crushed and re-
draped during the procedure to avoid moved from the ureters and bladder.
unnecessary exposure.
➤ Ureteral catheters can be inserted
➤ Instruct the patient to void prior to via the scope to obtain urine samples
the procedure. from each kidney for comparative
➤ Observe standard precautions, and analysis and radiographic studies.
follow the general guidelines in ➤ Ureteral and urethral strictures can
Appendix A. Positively identify the also be dilated during this procedure.
lection container with the correspon- ➤ Upon completion of the examination
ding patient demographics, date, and and related procedures, the cysto-
time of collection. scope is withdrawn.
➤ Position patient on the examination ➤ Place obtained specimens in proper
table draped and with legs in stirrups. containers, label them properly, and
If general or spinal anesthesia is to immediately transport them to the
be used, it is administered before laboratory.
positioning the patient on the table.
➤ Cleanse external genitalia with anti- in a computerized system for recall
septic solution. If local anesthetic is and postprocedure interpretation by
used, it is instilled into the urethra the appropriate health care practi-
and retained for 5 to 10 minutes. A tioner.
Cystourethrography, Voiding 551
Post-test: ➤ Emphasize that persistent flank or

suprapubic pain, fever, chills, blood in
➤ Inform the patient that further exam- the urine, difficulty urinating, or
inations may be necessary to eval- change in urinary pattern must be
uate progression of the disease reported immediately to the health
process or to determine the need for care practitioner.
a change in therapy. ➤ A written report of the examination
➤ Instruct the patient to resume his or will be completed by a health care
her usual diet and medications, as practitioner specializing in this branch
directed by the health care provider. of medicine. The report will be sent
➤ Encourage the patient to drink to the requesting health care practi-
increased amounts of fluids (125 tioner, who will discuss the results
mL/h for 24 hours) after the proce- with the patient.
dure. ➤ Reinforce information given by the
➤ Monitor vital signs and neurologic patient’s health care provider regard-
status every 15 minutes for 1 hour, ing further testing, treatment, or refer-
then every 2 hours for 4 hours, and ral to another health care provider.
then as ordered by the health care Answer any questions or address any
practitioner. Take the temperature concerns voiced by the patient or
every 4 hours for 24 hours. Compare family.
with baseline values. Notify the ➤ Depending on the results of this pro-
health care practitioner if tempera- cedure, additional testing may be
ture is elevated. Protocols may vary needed to evaluate or monitor pro-
from facility to facility. gression of the disease process and
➤ Monitor fluid intake and urinary out- determine the need for a change in
put for 24 hours after the procedure. therapy. Evaluate test results in rela-
Decreased urine output may indicate tion to the patient’s symptoms and
bladder edema or perforation caused other tests performed.
by forceful advancement of instru-
mentation.
➤ Inform the patient that burning or dis-
comfort on urination can be experi- ➤ Related diagnostic tests include
enced for a few voidings after the computed tomography of the pelvis,
procedure and that the urine may be intravenous pyelography, magnetic
blood-tinged for the first and second resonance imaging of the pelvis, and
voidings after the procedure. ultrasound of the pelvis.
CYSTOURETHROGRAPHY, VOIDING
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Voiding cystography (VCU).

AREA OF APPLICATION: Bladder, urethra.
CONTRAST: Radiopaque iodine–based contrast medium.
• Hematomas
DESCRIPTION & RATIONALE: Voiding
• Neurogenic bladder
cystourethrography involves visualiza-
tion of the bladder filled with contrast • Pelvic tumors
medium instilled through a catheter by • Prostatic enlargement
use of a syringe or gravity, and, after the
catheter is removed, the excretion of • Ureteral stricture
the contrast medium. Excretion or • Ureterocele
micturition is recorded electronically • Urethral diverticula
or on videotape for confirmation or
exclusion of ureteral reflux and evalua- • Vesicoureteral reflux
tion of the urethra. Fluoroscopic films CRITICAL VALUES: N/A
or plain radiographs may also be taken
to record bladder filling and emptying. INTERFERING FACTORS:
This procedure is often used to evalu-
ate chronic urinary tract infections This procedure is
(UTIs). ■
INDICATIONS: or iodinated dye. The contrast me-
• Assess the degree of compromise of a dium used may cause a life-threatening
stenotic prostatic urethra allergic reaction. Patients with a known
hypersensitivity to the contrast medium
• Assess hypertrophy of the prostate may benefit from premedication with
lobes corticosteroids or the use of nonionic
• Assess ureteral stricture contrast medium.
• Confirm the diagnosis of congenital • Patients with bleeding disorders.
lower urinary tract anomaly
• Evaluate abnormal bladder emptying of being pregnant, unless the potential
and incontinence benefits of the procedure far outweigh
• Evaluate the effects of bladder trauma the risks to the fetus and mother.
• Evaluate possible cause of frequent • Patients with UTI, obstruction, or
UTIs injury.
• Evaluate the presence and extent of • Elderly and other patients who
ureteral reflux are chronically dehydrated before
the test, because of their risk of contrast-
• Evaluate the urethra for obstruction
induced renal failure.
and strictures
RESULT
Factors that may
Normal Findings: impair clear imaging:
• Normal bladder and urethra structure • Inability of the patient to cooperate or
and function remain still during the procedure
Abnormal Findings: mental status
• Bladder trauma
• Bladder tumors ographic equipment to accommodate
Cystourethrography, Voiding 553
obese or thin patients, which can cause gies or sensitivities to latex, iodine,
overexposure or underexposure and a seafood, contrast medium, and dyes.
poor-quality study ➤ Obtain a history of results of previ-
exceed the weight limit for the equip- laboratory tests. For related diagnos-
ment tic tests, refer to the Genitourinary
• Incorrect positioning of the patient, System table.
which may produce poor visualization ➤ Ensure that this procedure is per-
of the area to be examined formed before an upper gastroin-
testinal study or barium swallow.
resulting from inadequate cleansing or ➤ Record the date of the last menstrual
study women.
• Retained barium from a previous radi- ➤ Obtain a list of the medications the
ologic procedure patient is taking.
• Metallic objects within the examina- ➤ Review the procedure with the
tion field (e.g., jewelry, body rings), patient. Explain to the patient that
which may inhibit organ visualization some pain may be experienced dur-
and can produce unclear images ing the test, and there may be
Other considerations: cedure is performed. Inform the
• Consultation with a physician should patient that the procedure is per-
occur before the procedure for radia- formed in a radiology department,
tion safety concerns regarding younger usually by a technologist and support
patients or patients who are lactating. staff, and takes approximately 30 to
60 minutes.
overexposure can result from frequent issues, as well as concern for mod-
x-ray procedures. Personnel in the esty, is important in providing psy-
room with the patient should wear a chological support before, during,
protective lead apron, stand behind a and after the procedure.
shield, or leave the area while the exam- ➤ Instruct the patient to increase fluid
ination is being done. Personnel work- intake the day before the test, but to
ing in the area where the examination have only clear fluids 8 hours before
is being done should wear badges the test.
that reveal their level of exposure to ➤ Inform the patient that he or she may
radiation. receive a laxative the night before
the test or an enema or a cathartic
the morning of the test, as ordered.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: any medications.
assesses the urinary tract.
Intratest:
plaints or symptoms, including a list ➤ Ensure that the patient has complied
of known allergens, especially aller- with fluid restrictions. Assess for
completion of bowel preparation if taken or radiographic images of the

ordered. bladder and urethra are recorded.
➤ Remove patient’s clothing and any ➤ The procedure may be done on
metallic objects from the lower ab- women using a double balloon to
dominal area. occlude the bladder neck from above
➤ Give the patient a gown and robe and below the external meatus.
to wear; ensure that the patient is ➤ Monitor the patient for complica-
draped during the procedure to avoid tions related to the procedure (e.g.,
unnecessary exposure. allergic reaction, anaphylaxis, bron-
➤ Have the patient void before the pro- chospasm).
cedure. ➤ The results are recorded manually,
➤ Observe standard precautions, and on film, or by automated equipment
follow the general guidelines in in a computerized system for recall
Appendix A. Instruct the patient to and postprocedure interpretation by
cooperate fully and to follow direc- the appropriate health care practi-
tions. tioner.
➤ Insert a Foley catheter before the
Post-test:
procedure, if ordered. Inform the
patient that he or she may feel some ➤ Inform the patient that further exami-
pressure when the catheter is in- nations may be necessary to evaluate
serted and when the contrast medi- progression of the disease process
um is instilled through the catheter. or to determine the need for a change
➤ Administer an antihistamine or in therapy.
steroid, as ordered by a physician, for ➤ Instruct the patient to resume usual
patients with a known significant diet and medications, as directed by
allergic reaction to the intravenous the health care provider.
contrast medium.
➤ Place the patient on the table in a status every 15 minutes for 1 hour,
supine or lithotomy position. then every 2 hours for 4 hours, and
➤ A kidney, ureter, and bladder film or as ordered. Take temperature every 4
plain radiograph is taken to ensure hours for 24 hours. Compare with
that no barium or stool obscures baseline values. Notify the health care
visualization of the urinary system. practitioner if temperature is elevated.
Protocols may vary from facility to
➤ A catheter is filled with contrast
facility.
medium to eliminate air pockets and
is inserted until the balloon reaches ➤ Monitor for reaction to iodinated con-
the meatus. The patient is placed in trast medium, including rash, urticaria,
the right posterior oblique position tachycardia, hyperpnea, hypertension,
with the thigh drawn up to a 90° palpitations, nausea, or vomiting.
angle and, in men, the penis placed ➤ Maintain the patient on adequate hy-
along its axis. dration after the procedure. Encour-
➤ When three-fourths of the contrast age the patient to drink increased
medium has been injected, another amounts of fluids (125 mL/h for 24 h)
radiographic exposure is made while after the procedure to prevent stasis
the remainder of the contrast medi- and bacterial buildup.
um is injected. ➤ Monitor fluid intake and urinary out-
➤ Left lateral and oblique views may be put for 24 hours after the procedure.
necessary to visualize the area in Decreased urinary output may indi-
question. cate impending renal failure or edema
➤ If the patient is able to void, the caused by instrumentation.
catheter is removed and the patient ➤ Monitor for signs of sepsis: fever,
is asked to urinate while films are chills, and severe pelvic pain.
Cytology, Sputum 555

will be completed by a health care needed to evaluate or monitor pro-
practitioner specializing in this branch gression of the disease process and
of medicine. The report will be sent determine the need for a change in
to the requesting health care practi- therapy. Evaluate test results in rela-
tioner, who will discuss the results tion to the patient’s symptoms and
with the patient. other tests performed.
ing further testing, treatment, or re- Related diagnostic tests:
ferral to another health care provider. ➤ Related diagnostic tests include
Answer any questions or address computed tomography of the pelvis,
any concerns voiced by the patient or intravenous pyelography, magnetic
family. resonance imaging of the pelvis, and
➤ Depending on the results of this pro- ultrasound of the pelvis.
CYTOLOGY, SPUTUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Sputum (10 to 15 mL) collected on 3 to 5 consecutive
first-morning, deep-cough expectorations.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination)

Negative for abnormal cells, fungi, ova, and parasites.
DESCRIPTION & RATIONALE: Cytol- A description of the method of speci-

ogy is the study of the origin, struc- men collection by bronchoscopy and
ture, function, and pathology of cells. biopsy is found in the monograph
In clinical practice, cytologic exami- titled “Biopsy, Lung.” ■
nations are generally performed to
detect cell changes resulting from INDICATIONS:
neoplastic or inflammatory condi- • Assist in the diagnosis of lung cancer
tions. Sputum specimens for cytologic • Assist in the identification of Pneumo-
examinations may be collected by cystis carinii in persons with acquired
expectoration alone, by suctioning, by immunodeficiency syndrome
lung biopsy, during bronchoscopy, or • Detect known or suspected fungal or
by expectoration after bronchoscopy. parasitic infection involving the lung
• Detect known or suspected viral disease

involving the lung Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Screen cigarette smokers for neoplastic

(nonmalignant) cellular changes Pretest:
• Screen patients with history of acute ➤ Inform the patient that the test helps
or chronic inflammatory or infectious identify cellular changes associated
lung disorders, which may lead to benign with neoplasms or organisms that
atypical or metaplastic changes result in respiratory tract infections.
When the actual infectious organ-
isms are identified by cytology, tell
RESULT : (Method: Microscopic examina- the patient that the findings will be
tion) The method of reporting results of confirmed by culture.
cytology examinations varies according to
the laboratory performing the test. Terms plaints, including a list of known
used to report results may include nega- allergens (especially allergies or sen-
tive (no abnormal cells seen), inflamma- sitivities to latex), and inform the
tory, benign atypical, suspect for neoplasm, appropriate health care practitioner
and positive for neoplasm. accordingly.
Positive findings in: immune and respiratory systems,
• Infections caused by fungi, ova, or par- and results of previously performed
asites laboratory tests, surgical procedures,
• Lipoid or aspiration pneumonia, as related laboratory tests, refer to the
seen by lipid droplets contained in Immune and Respiratory System
macrophages tables.
• Neoplasms ➤ Obtain a list of the medications the

• Viral infections and lung disease nutritional supplements, and nutra-
CRITICAL VALUES: advised if the patient is regularly
If the patient becomes hypoxic or using these products so that their
cyanotic, remove catheter effects can be taken into considera-
immediately and administer tion when reviewing results.
oxygen. ➤ Note any recent procedures that can
If patient has asthma or chronic interfere with test results.
bronchitis, watch for aggravated
bronchospasms with use of tient. If the laboratory has provided a
normal saline or acetylcysteine in container with fixative, instruct the
an aerosol. patient that the fixative contents of
the specimen collection container
INTERFERING FACTORS: should not be ingested or otherwise
• Improper specimen fixation may be removed. Instruct the patient not to
cause for specimen rejection. touch the edge or inside of the spec-
imen container with the hands or
• Improper technique used to obtain mouth. Inform the patient that three
bronchial washing may be cause for samples may be required, on three
specimen rejection. separate mornings, either by passing
a small tube (tracheal catheter) and
• Failure to follow dietary restrictions adding suction or by expectoration.
before the procedure may cause the The time it takes to collect a proper
procedure to be canceled or repeated. specimen varies according to the
level of cooperation of the patient bronchoscopy or biopsy procedure

and the specimen collection proce- and before administering any med-
dure. Address concerns about pain ications.
related to the procedure. Atropine is
usually given before bronchoscopy Intratest:
examinations to reduce bronchial
secretions and to prevent vagally ➤ Ensure that the patient has complied
induced bradycardia. Meperidine with dietary restrictions; assure that
(Demerol) or morphine may be given food and liquids have been restricted
as a sedative. Lidocaine is sprayed in for at least 6 to 8 hours prior to the
the patient’s throat to reduce dis- procedure.
comfort caused by the presence of ➤ Have patient remove dentures, con-
the tube. tact lenses, eyeglasses, and jewelry.
➤ Reassure the patient that he or she Notify the physician if the patient
will be able to breathe during the pro- has permanent crowns on teeth.
cedure if specimen collected is Have the patient remove cloth-
accomplished via suction method. ing and change into a gown for the
Ensure that oxygen has been admin- procedure.
istered 20 to 30 minutes before the ➤ Have emergency equipment readily
procedure if the specimen is to be available. Keep resuscitation equip-
obtained by tracheal suctioning. ment on hand in the case of respira-
➤ Assist in providing extra fluids, tory impairment or laryngospasm
unless contraindicated, and proper after the procedure.
humidification to decrease tenacious ➤ Avoid using morphine sulfate in
secretions. Inform the patient that those with asthma or other pul-
increasing fluid intake before retiring monary disease. This drug can fur-
on the night before the test aids in ther exacerbate bronchospasms and
liquefying secretions and may make respiratory impairment.
it easier to expectorate in the morn-
ing. Also explain that humidifying ➤ If the patient has a history of severe
inspired air also helps to liquefy allergic reaction to latex, care should
secretions. be taken to avoid the use of equip-
➤ Assist with mouth care (brushing
teeth or rinsing mouth with water), if ➤ Assist the patient to a comfortable
needed, before collection so as not position, and direct the patient to
to contaminate the specimen by oral breath normally during the beginning
secretions. of the general anesthesia. Instruct
the patient to cooperate fully and to
➤ Sensitivity to social and cultural follow directions. Direct the patient
issues, as well as concern for mod- to breathe normally and to avoid
esty, is important in providing psy- unnecessary movement during the
chological support before, during and local anesthetic and the procedure.
➤ For specimens collected by suction- follow the general guidelines in
ing or expectoration without bron- Appendix A. Positively identify the
choscopy, there are no food, fluid, patient, and label the appropriate col-
or medication restrictions unless by lection container with the correspon-
medical direction. ding patient demographics, date and
time of collection, and any medica-
➤ Instruct the patient to fast and refrain
tion the patient is taking that may
from taking liquids from midnight the
interfere with tes results (e.g., anti-
night before if bronchoscopy or
biotics). Cytology specimens may
biopsy is to be performed.
also be expressed onto a glass slide
➤ Make sure a written and informed and sprayed with a fixative or 95%
consent has been signed prior to the alcohol.
Bronchoscopy: Chest percussion and postural drain-

age of all lung segments may also be
➤ Record baseline vital signs. employed. If the patient is still unable
➤ The patient is positioned in relation to raise sputum, the use of an ultra-
to the type of anesthesia being used. sonic nebulizer (“induced sputum”)
If local anesthesia is used, the pa- may be necessary; this is usually
tient is seated, and the tongue and done by a respiratory therapist.
oropharynx are sprayed and swab-
bed with anesthetic before the bron- Tracheal suctioning:
choscope is inserted. For general
anesthesia, the patient is placed in ➤ Obtain the necessary equipment,
a supine position with the neck hyper- including a suction device, suction
extended. After anesthesia, the pa- kit, and Lukens tube or in-line trap.
tient is kept in supine or shifted to ➤ Position the patient with head ele-
side-lying position, and the broncho- vated as high as tolerated.
scope is inserted. After inspection, ➤ Put on sterile gloves. Maintain the
the samples are collected from sus- dominant hand as sterile and the
picious sites by bronchial brush or nondominant hand as clean.
biopsy forceps.
➤ Using the sterile hand, attach the
Expectorated specimen: suction catheter to the rubber tubing
of the Lukens tube or in-line trap.
➤ Ask the patient to sit upright, with Then attach the suction tubing to the
assistance and support (e.g., with an male adapter of the trap with the
overbed table) as needed. clean hand. Lubricate the suction
➤ Ask the patient to take two or three catheter with sterile saline.
deep breaths and cough deeply. Any ➤ Tell nonintubated patients to protrude
sputum raised should be expecto- the tongue and to take a deep breath
rated directly into a sterile sputum as the suction catheter is passed
collection container. through the nostril. When the catheter
➤ If the patient is unable to produce enters the trachea, a reflex cough is
the desired amount of sputum, sev- stimulated; immediately advance the
eral strategies may be attempted. catheter into the trachea and apply
One approach is to have the patient suction. Maintain suction for approxi-
drink two glasses of water, and then mately 10 seconds, but never longer
assume the position for postural than 15 seconds. Withdraw the
drainage of the upper and middle catheter without applying suction.
lung segments. Effective coughing Separate the suction catheter and
may be assisted by placing either suction tubing from the trap, and
the hands or a pillow over the place the rubber tubing over the male
diaphragmatic area and applying adapter to seal the unit.
slight pressure. ➤ For intubated patients or patients
➤ Another approach is to place a vapor- with a tracheostomy, the previous
izer or other humidifying device at procedure is followed except that the
the bedside. After sufficient expo- suction catheter is passed through
sure to adequate humidification, pos- the existing endotracheal or trache-
tural drainage of the upper and ostomy tube rather than through the
middle lung segments may be nostril. The patient should be hy-
repeated before attempting to obtain peroxygenated before and after the
the specimen. procedure in accordance with stan-
dard protocols for suctioning these
➤ Other methods may include obtain-
patients.
ing an order for an expectorant to
be administered with additional ➤ Generally, a series of three to five
water approximately 2 hours before early morning sputum samples are
attempting to obtain the specimen. collected in sterile containers.
General: ➤ Evaluate the patient for symptoms

➤ Monitor the patient for complica- mothorax, such as dyspnea, tachyp-
tions related to the procedure (e.g., nea, anxiety, decreased breathing
allergic reaction, anaphylaxis, bron- sounds, or restlessness. A chest x-
chospasm). ray may be ordered to check for the
➤ Promptly transport the specimen presence of this complication.
to the laboratory for processing and ➤ Evaluate the patient for symptoms of
analysis. empyema, such as fever, tachycardia,
➤ The results are recorded manually malaise, or elevated white blood cell
or in a computerized system for count.
recall and postprocedure interpreta- ➤ Administer antibiotic therapy if
tion by the appropriate health care ordered. Remind the patient of the
practitioner. importance of completing the entire
Post-test: before completion of therapy.
➤ Nutritional considerations: Malnutri-
tion is commonly seen in patients
diet, as directed by the health care
with severe respiratory disease for
practitioner. Assess the patient’s abil-
numerous reasons including fatigue,
ity to swallow before allowing the
lack of appetite, and gastrointestinal
patient to attempt liquids or solid
distress. Adequate intake of vitamins
foods.
A and C are also important to prevent
➤ Inform the patient that he or she may pulmonary infection and to decrease
experience some throat soreness the extent of lung tissue damage.
and hoarseness. Instruct patient to ➤ A written report of the examina-
treat throat discomfort with lozenges tion will be completed by a health
and warm gargles when the gag care practitioner specializing in this
reflex returns. branch of medicine. The report will
➤ Monitor vital signs and compare with be sent to the requesting health care
baseline values every 15 minutes practitioner, who will discuss the
for 1 hour, then every 2 hours for 4 results with the patient.
hours, and then as ordered by the ➤ Recognize anxiety related to test
health care practitioner. Monitor tem- results, and be supportive of im-
perature every 4 hours for 24 hours. paired activity related to perceived
Notify the health care practitioner if loss of independence and fear of
temperature is elevated. Protocols shortened life expectancy. Discuss
may vary from facility to facility. the implications of abnormal test
➤ Emergency resuscitation equipment results on the patient’s lifestyle. Pro-
should be readily available if the vide teaching and information regard-
vocal cords become spastic after ing the clinical implications of the
intubation. test results, as appropriate. Educate
the patient regarding access to coun-
➤ Observe for delayed allergic reac- seling services. Provide contact infor-
tions, such as rash, urticaria, tachy- mation, if desired, for the American
cardia, hyperpnea, hypertension, Lung Association (http://www.lungusa.
palpitations, nausea, or vomiting. org).
➤ Observe the patient for hemoptysis, ➤ Reinforce information given by the
difficulty breathing, cough, air hunger, patient’s health care provider regard-
excessive coughing, pain, or absent ing further testing, treatment, or refer-
breathing sounds over the affected ral to another health care provider.
area. Report any symptoms to the Inform the patient of smoking cessa-
health care provider. tion programs, as appropriate. Inform
the patient with abnormal findings ➤ Depending on the results of this pro-
of the importance of medical follow- cedure, additional testing may be
up, and suggest ongoing support performed to evaluate or monitor
resources to assist in coping with progression of the disease process
chronic illness and possible early and determine the need for a change
death. Answer any questions or in therapy. Evaluate test results in
➤ Instruct the patient in the use of
any ordered medications. Explain the Related laboratory tests:
apy regimen. As appropriate, instruct ➤ Related laboratory tests include
the patient in significant side effects arterial/alveolar oxygen ratio, blood
and systemic reactions associated gases, complete blood count, com-
with the prescribed medication. En- puted tomography of the thorax, lung
courage him or her to review corre- scan, magnetic resonance imaging
sponding literature provided by a of the chest, Gram/acid-fast stain,
pharmacist. and relevant cultures.
CYTOLOGY, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Urine (180 mL for an adult or at least 10 mL for a child)
collected in a clean wide-mouth plastic container.
REFERENCE VALUE: (Method: Microscopic examination) No abnormal cells

or inclusions seen.
INDICATIONS:
DESCRIPTION & RATIONALE: Cyto- • Assist in the diagnosis of urinary tract
logy is the study of the origin, struc- diseases, such as cancer, cytomegalo-
ture, function, and pathology of cells. virus infection, and other inflamma-
In clinical practice, cytologic exami- tory conditions
nations are generally performed to
detect cell changes resulting from neo- RESULT
plastic or inflammatory conditions.
Cells from the epithelial lining of the Positive findings in:
urinary tract can be found in the • Cancer of the urinary tract
urine. Examination of these cells for
• Cytomegalic inclusion disease
abnormalities is useful with suspected
infection, inflammatory conditions, • Inflammatory disease of the urinary
or malignancy. ■ tract
Cytology, Urine 561
Negative findings in: N/A chological support before, during,

CRITICAL VALUES: N/A ➤ There are no food, fluid, or medica-
INTERFERING FACTORS: N/A direction.
➤ Instruct the patient on clean-catch
procedure and provide necessary
supplies.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest: ➤ If the patient has a history of severe
➤ Inform the patient that the test is be taken to avoid the use of equip-
used to identify the presence of neo- ment containing latex.
plasms of the urinary tract and assist ➤ Instruct the patient to cooperate fully
in the diagnosis of urinary tract infec- and to follow directions.
tions.
complaints, including a list of known Appendix A. Positively identify the
allergens (especially allergies or sen- patient, and label the appropriate
sitivities to latex), and inform the ap- tubes with the corresponding patient
propriate health care practitioner demographics, date and time of col-
accordingly. lection, method of specimen collec-
➤ Obtain a history of the patient’s tion, and any medications the patient
genitourinary and immune systems, has taken that may interfere with
as well as results of previously per- test results (e.g., antibiotics).
procedures, and other diagnostic Clean-catch specimen:
procedures. For related laboratory ➤ Instruct the male patient to (1) thor-
tests, refer to the Genitourinary and oughly wash his hands, (2) cleanse
Immune System tables. the meatus, (3) void a small amount
➤ Obtain a list of medications the into the toilet, and (4) void directly
patient is taking, including herbs, into the specimen container.
nutritional supplements, and nutra- ➤ Instruct the female patient to (1)
ceuticals. The requesting health care thoroughly wash her hands; (2)
practitioner and laboratory should cleanse the labia from front to back;
be advised if the patient regularly (3) while keeping the labia separated,
uses these products so that their void a small amount into the toilet;
effects can be taken into considera- and (4) without interrupting the urine
tion when reviewing results. stream, void directly into the speci-
➤ Note any recent procedures that can men container.
interfere with test results. Pediatric urine collector:
➤ Review the procedure with the ➤ Put on gloves. Appropriately cleanse
patient. If a catheterized specimen is the genital area, and allow the area
to be collected, explain this proce- to dry. Remove the covering over the
dure to the patient and obtain a adhesive strips on the collector bag
catheterization tray. Address con- and apply over the genital area.
cerns about pain related to the pro- Diaper the child. After obtaining the
cedure. Explain to the patient that specimen, place the entire collection
there may be some discomfort dur- bag in a sterile urine container.
ing the catheterization.
➤ Sensitivity to social and cultural Indwelling catheter:
issues, as well as concern for mod- ➤ Put on gloves. Empty drainage tube
esty, is important in providing psy- of urine. It may be necessary to
clamp off the catheter for 15 to 30 ➤ Instruct the patient to report symp-
minutes before specimen collection. toms such as pain related to tissue
Cleanse specimen port with antisep- inflammation, pain or irritation during
tic swab, and then aspirate 5 mL of void, bladder spasms, or alterations
urine with a 21- to 25-gauge needle in urinary elimination.
and syringe. Transfer urine to a sterile
➤ Observe for signs of inflammation if
container.
the specimen is obtained by supra-
Urinary catheterization: pubic aspiration.
➤ Place female patient in lithotomy ➤ Administer antibiotic therapy as

position or male patient in supine ordered. Remind the patient of the
position. Using sterile technique, importance of completing the entire
open the straight urinary catheteriza- course of antibiotic therapy, even if
tion kit and perform urinary catheter- signs and symptoms disappear
ization. Place the retained urine in a before completion of therapy.
sterile specimen container. ➤ A written report of the examination
Suprapubic aspiration: care practitioner, who will discuss
➤ Place the patient in supine position. the results with the patient.
Cleanse the area with antiseptic, and ➤ Recognize anxiety related to test
drape with sterile drapes. A needle is results, and be supportive of fear of
inserted through the skin into the shortened life expectancy. Discuss
bladder. A syringe attached to the the implications of abnormal test
needle is used to aspirate the urine results on the patient’s lifestyle.
sample. The needle is then removed Provide teaching and information
and a sterile dressing is applied to regarding the clinical implications of
the site. Place the sterile sample in a the test results, as appropriate.
sterile specimen container. Educate the patient regarding access
➤ Do not collect urine from the pouch to counseling services.
from a patient with a urinary diversion
(e.g., ileal conduit). Instead perform
catheterization through the stoma.
ing further testing, treatment, or refer-
General: ral to another health care provider.
➤ Promptly transport the specimen to any concerns voiced by the patient or
the laboratory for processing and family.
analysis. If a delay in transport is
expected, add an equal volume of ➤ Depending on the results of this pro-
50% alcohol to the specimen as a cedure, additional testing may be
preservative. performed to evaluate or monitor
tioner.

➤ Instruct the patient to resume usual ➤ Related laboratory tests include blad-
medication as directed by the health der cancer markers, kidney biopsy,
care practitioner. and Papanicolaou smear.
CYTOMEGALOVIRUS,
IMMUNOGLOBULIN G AND
IMMUNOGLOBULIN M
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CMV.
SPECIMEN: Serum (1 mL) collected in a plain red-top tube.
REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative
or less than a fourfold increase in titer.
• Determine susceptibility, particularly

DESCRIPTION & RATIONALE: Cyto- in pregnant women, immunocompro-
megalovirus (CMV) is a double- mised patients, and patients who
stranded DNA herpesvirus. The recently have received an organ trans-
incubation period for primary infec- plant
tion is 4 to 8 weeks. Transmission may • Screen blood for high-risk-category
occur by direct contact with oral, res- transfusion recipients
piratory, or venereal secretions and
excretions. CMV infection is of pri- RESULT
mary concern in pregnant or immuno-
compromised patients or patients who Positive findings in: CMV infection
have recently received an organ trans-
plant. Blood units are sometimes Negative findings in: N/A
tested for the presence of CMV if
patients in these high-risk categories CRITICAL VALUES: N/A
are the transfusion recipients. CMV
serology is part of the TORCH (toxo- INTERFERING FACTORS:
• False-positive results may occur in the
plasmosis, other [congenital syphilis
presence of rheumatoid factor.
and viruses], rubella, CMV, and her-
pes simplex type 2) panel used to test • False-negative results may occur if
pregnant women. CMV, as well as treatment was begun before antibodies
these other infectious agents, can cross developed or if the test was done less
than 6 days after exposure to the virus.
the placenta and result in congenital
malformations, abortion, or stillbirth.
The presence of immunoglobulin (Ig)
M antibodies indicates acute infec- Nursing Implications and
tion. The presence of IgG antibodies Procedure ● ● ● ● ● ● ● ● ● ● ●
indicates current or past infection. ■

Pretest:
• Assist in the diagnosis of congenital used to assist in the diagnosis of
CMV infection in newborns CMV infection.
563
plaints and history of exposure. demographics, date, and time of col-
Obtain a list of known allergens, lection. Perform a venipuncture; col-
especially allergies or sensitivities to lect the specimen in a 5-mL red-top
latex, and inform the appropriate tube.
health care practitioner accordingly. ➤ Remove the needle, and apply a
➤ Obtain a history of the patient’s pressure dressing over the puncture
immune and reproductive systems, site.
as well as results of previously per- ➤ Promptly transport the specimen to
formed laboratory tests, surgical the laboratory for processing and
procedures, and other diagnostic analysis.
tests, refer to the Immune and ➤ The results are recorded manually or
Reproductive System tables. in a computerized system for recall
Post-test:
advised if the patient is regularly ➤ Observe venipuncture site for bleed-
using these products so that their ing or hematoma formation. Apply
effects can be taken into considera- paper tape or other adhesive to
tion when reviewing results. hold pressure bandage in place, or
➤ Review the procedure with the replace with a plastic bandage.
patient. Inform the patient that multi- ➤ Instruct the patient in isolation pre-
ple specimens may be required. Any cautions during time of communica-
individual positive result should be bility or contagion.
repeated in 7 to 14 days to monitor
a change in titer. Inform the patient ➤ Emphasize the need to return to
that specimen collection takes approx- have a convalescent blood sample
imately 5 to 10 minutes. Address taken in 7 to 14 days.
concerns about pain related to the ➤ Warn the patient that there is a possi-
procedure. Explain to the patient that bility of false-negative or false-positive
there may be some discomfort dur- results.
➤ There are no food, fluid, or medica- will be sent to the requesting health
tion restrictions, unless by medical care practitioner, who will discuss
direction. the results with the patient.
Intratest: results if the patient is pregnant, and
offer support. Discuss the implica-
➤ If the patient has a history of severe tions of abnormal test results on the
allergic reaction to latex, care should patient’s lifestyle. Provide teaching
be taken to avoid the use of equip- and information regarding the clini-
ment containing latex. cal implications of the test results,
➤ Instruct the patient to cooperate fully as appropriate. Educate the patient
and to follow directions. Direct the regarding access to counseling
patient to breathe normally and to services.
avoid unnecessary movement. ➤ Reinforce information given by the
➤ Observe standard precautions, and patient’s health care provider regard-
follow the general guidelines in ing further testing, treatment, or
Appendix A. Positively identify the referral to another health care
patient, and label the appropriate provider. Answer any questions or
D-Dimer 565

progression of the disease process ➤ Related laboratory tests include her-
and determine the need for a change pesvirus viral culture, rubella anti-
in therapy. Evaluate test results in body, and Toxoplasma antibody.
D-DIMER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Dimer, fibrin degradation fragment.

SPECIMEN: Plasma (1 mL) collected in a completely filled blue-top
(sodium citrate) tube.
REFERENCE VALUE: (Method: Latex semiquantitative screen or quantitative
enzyme-linked immunosorbent assay [ELISA])
Semiquantitative: No fragments detected
Quantitative: Less than 250 ng/mL
• Assist in the evaluation of pulmonary

DESCRIPTION & RATIONALE: The embolism
D-dimer is an asymmetric carbon com-
pound formed by a cross-link between RESULT: The sensitivity and specificity of
the assay varies among test kits and
two identical fibrin molecules. The
between test methods (e.g., latex vs.
test is specific for secondary fibrinoly- ELISA).
sis because the cross-linkage occurs
with fibrin and not fibrinogen. A pos- Increased in:
itive test is presumptive evidence of • Arterial or venous thrombosis
disseminated intravascular coagula-
• DVT
tion (DIC). ■
• DIC
INDICATIONS: • Neoplastic disease
• Assist in the detection of DIC and deep
venous thrombosis (DVT) • Pre-eclampsia
• Assist in the evaluation of myocardial • Pregnancy (late and postpartum)
infarction (MI) and unstable angina
• Pulmonary embolism
• Assist in the evaluation of possible
veno-occlusive disease associated with • Recent surgery (within 2 days)
sequelae of bone marrow transplant • Secondary fibrinolysis
Decreased in: N/A gens (especially allergies or sensi-

tivities to latex), and inform the
CRITICAL VALUES: N/A accordingly.
INTERFERING FACTORS: ➤ Obtain a history of hematologic dis-
eases and recent surgery.
• High rheumatoid factor titers can cause ➤ Obtain a history of the patient’s car-
a false-positive result. diovascular, hematopoietic, and res-
• Increased CA 125 levels can cause a piratory systems, as well as results
false-positive result.
• Drugs that may cause an increase in diagnostic procedures. For related
plasma D-dimer include those adminis- laboratory tests, refer to the Cardio-
tered for antiplatelet therapy. vascular, Hematopoietic, and Res-
• Drugs that may cause a decrease in ➤ Obtain a list of the medications the
plasma D-dimer include pravastatin patient is taking, including herbs,
and warfarin. nutritional supplements, and nutra-
• Placement of tourniquet for longer
than 1 minute can result in venous sta- advised if the patient is regularly
sis and changes in the concentration of using these products so that their
plasma proteins to be measured. effects can be taken into considera-
Platelet activation may also occur tion when reviewing results.
under these conditions, causing erro- ➤ Review the procedure with the
neous results. patient. Inform the patient that spec-
• Vascular injury during phlebotomy can imen collection takes approximately
activate platelets and coagulation fac- about pain related to the procedure.
tors, causing erroneous results. Explain to the patient that there may
• Hemolyzed specimens must be rejected be some discomfort during the
because hemolysis is an indication of venipuncture.
platelet and coagulation factor activa- ➤ There are no food, fluid, or medica-
tion. tion restrictions, unless by medical
direction.
• Incompletely filled tubes contaminated
with heparin or clotted specimens must Intratest:
be rejected.
• Icteric or lipemic specimens interfere allergic reaction to latex, care should
with optical testing methods, produc- be taken to avoid the use of equip-
ing erroneous results. ment containing latex.
Procedure ● ● ● ● ● ● ● ● ● ● ●
used in the evaluation of acute MI tubes with the corresponding patient
and DIC and to detect DVT. demographics, date, and time of col-
plaints, including a list of known aller- lect the specimen in a 5-mL blue-top
D-Dimer 567
tube. Fill the tube completely. ➤ The results are recorded manually or
Important note: Two different concen- in a computerized system for recall
trations of sodium citrate preserva- and postprocedure interpretation by
tive are currently added to blue-top the appropriate health care practi-
tubes for coagulation studies: 3.2% tioner.
and 3.8%. The Clinical and Laboratory
Standards Institute/CLSI (formerly Post-test:
the National Committee for Clinical
Laboratory Standards/NCCLS) guide-
line for sodium citrate is 3.2%. Labo-
ratories establish reference ranges
pressure bandage in place, or replace
for coagulation testing based on
with a plastic bandage.
numerous factors, including sodium
citrate concentration, test equip- ➤ A written report of the examination
ment, and test reagents. It is impor- will be sent to the requesting health
tant to inquire from the laboratory care practitioner, who will discuss the
which concentration it recommends, results with the patient.
because each concentration will have ➤ Reinforce information given by the
its own specific reference range. patient’s health care provider regard-
➤ When multiple specimens are drawn, ing further testing, treatment, or refer-
the blue-top tube should be collected ral to another health care provider.
after sterile (i.e., blood culture) and Answer any questions or address
nonadditive red-top tubes. When any concerns voiced by the patient or
coagulation testing is the only work to family.
be done, an extra red-top tube should ➤ Depending on the results of this pro-
be collected before the blue-top tube cedure, additional testing may be
to avoid contaminating the specimen performed to evaluate or monitor
with tissue thromboplastin, which progression of the disease process
can falsely decrease values. and determine the need for a change
➤ Remove the needle, and apply a pres- in therapy. Evaluate test results in
sure dressing over the puncture site. relation to the patient’s symptoms
analysis. The CLSI recommendation
for processed and unprocessed sam- ➤ Related laboratory tests include acti-
ples stored in unopened tubes is that vated partial thromboplastin time,
testing should be completed within 1 fibrin split products, fibrinogen, plate-
to 4 hours. let count, and prothrombin time.
DEHYDROEPIANDROSTERONE
SULFATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: DHEAS.
(1 mL) collected in lavender-top (ethylenediaminetetra-acetic [EDTA])
tube is also acceptable.
Conventional SI Units (Conversion

Age Units Factor 0.027)
Newborn
Male 108–406 g/dL 2.9–10.9 mol/L
Female 10–248 g/dL 0.3–6.7 mol/L
6–9 y 25–145 mg/dL 0.07–3.9 mmol/L
10–11 y
Male 15–115 g/dL 0.4–3.1 mol/L
Female 15–260 g/dL 0.4–7.0 mol/L
12–17 y
Male 20–555 g/dL 0.5–15.0 mol/L
Female 20–535 g/dL 0.5–14.4 mol/L
19–30 y
Male 125–619 g/dL 3.4–16.7 mol/L
Female 29–781 g/dL 0.8–21.1 mol/L
31–50 y
Male 59–452 g/dL 1.6–12.2 mol/L
Female 12–379 g/dL 0.8–10.2 mol/L
51–60 y
Male 20–413 g/dL 0.5–11.1 mol/L
61–83 y
Male 10–285 g/dL 0.3–7.7 mol/L
Postmenopausal
woman 30–260 mg/dL 0.8–7.0 mmol/L
DESCRIPTION & RATIONALE: Dehy- teroids. DHEAS is a metabolite of

droepiandrosterone sulfate (DHEAS) DHEA, the principal adrenal andro-
is the major precursor of 17-ketos- gen. DHEAS is primarily synthesized
Dehydroepiandrosterone Sulfate 569
in the adrenal gland, with a small INTERFERING FACTORS:

amount secreted by the ovaries. It is • Drugs that may increase DHEAS levels
secreted in concert with cortisol, under include clomiphene, corticotropin,
danazol, DHEA, mifepristone, and
the control of adrenocorticotropic
nitrendipine.
hormone (ACTH) and prolactin.
Excessive production causes masculin- • Drugs that may decrease DHEAS levels
ization in women and children. include carbamazepine, dexametha-
sone, ketoconazole, oral contraceptives,
DHEAS has replaced measurement of
and phenytoin.
urinary 17-ketosteroids in the estima-
tion of adrenal androgen production. ■ • Recent radioactive scans or radiation
within 1 week before the test can inter-
INDICATIONS: fere with test results when radioim-
• Assist in the evaluation of androgen munoassay is the test method.
excess, including congenital adrenal
hyperplasia, adrenal tumor, and Stein-
Leventhal syndrome Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Evaluate women with infertility, amen-
orrhea, or hirsutism Pretest:
used to assist in identifying the
Increased in: cause for infertility, amenorrhea, or
hirsutism.
• Anovulation
• Cushing’s syndrome complaints, including a list of known
• Ectopic ACTH-producing tumors sitivities to latex), and inform the
• Hirsutism appropriate health care practitioner
accordingly.
• Hyperprolactinemia ➤ Obtain a history of the patient’s
• Polycystic ovary endocrine system, as well as phase
of menstrual cycle and results of pre-
• Stein-Leventhal syndrome viously performed laboratory tests,
• Virilizing adrenal tumors nostic procedures. For related labora-
tory tests, refer to the Endocrine
Decreased in: System table.
• Addison’s disease ➤ Note any recent procedures that can
• Adrenal insufficiency (primary or sec- interfere with test results.
ondary) ➤ Obtain a list of the medications the
• Aging adults nutritional supplements, and nutra-
• Hyperlipidemia ceuticals. The requesting health care
• Pregnancy advised if the patient regularly uses
• Psoriasis can be taken into consideration
• Psychosis when reviewing results.
CRITICAL VALUES: N/A patient. Inform the patient that spec-
imen collection takes approximately in a computerized system for recall

5 to 10 minutes. Address concerns and postprocedure interpretation by
about pain related to the procedure. the appropriate health care practi-
Explain to the patient that there may tioner.
venipuncture.
Post-test:
tion restrictions, unless by medical ➤ Observe venipuncture site for bleed-
direction. ing or hematoma formation. Apply
Intratest: pressure bandage in place, or re-
place with a plastic bandage.
➤ If the patient has a history of severe ➤ A written report of the examination
allergic reaction to latex, care should will be sent to the requesting health
be taken to avoid the use of equip- care practitioner, who will discuss
ment containing latex. the results with the patient.
and to follow directions. Direct the patient’s health care provider regard-
patient to breathe normally and to ing further testing, treatment, or
avoid unnecessary movement. referral to another health care pro-
➤ Observe standard precautions, and vider. Answer any questions or
follow the general guidelines in Ap- address any concerns voiced by the
pendix A. Positively identify the pa- patient or family.
tient, and label the appropriate tubes ➤ Depending on the results of this pro-
with the corresponding patient cedure, additional testing may be
demographics, date, and time of performed to evaluate or monitor
collection. Perform a venipuncture; progression of the disease process
collect the specimen in a 5-mL red- and determine the need for a change
or tiger-top tube. in therapy. Evaluate test results in
➤ Remove the needle, and apply a relation to the patient’s symptoms
pressure dressing over the puncture and other tests performed.
site.
➤ Promptly transport the specimen to Related laboratory tests:
the laboratory for processing and ➤ Related laboratory tests include
analysis. ACTH, cortisol, prolactin, and testos-
➤ The results are recorded manually or terone.
DRUGS OF ABUSE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Amphetamines Ethanol
Barbiturates Opiates
Benzodiazepines Phencyclidine
Cannabinoids Tricyclic Antidepressants
Cocaine
Drugs of Abuse 571
SYNONYMS/ACRONYMS: Amphetamines, barbiturates, benzodiazepines

(tranquilizers), cannabinoids (THC), cocaine, ethanol (alcohol, ethyl alco-
hol, ETOH), phencyclidine (PCP), opiates (heroin), tricyclic antidepressants
(TCA)
SPECIMEN: For ethanol, serum (1 mL) collected in a red-top tube; plasma

(1 mL) collected in gray-top (sodium fluoride/potassium oxalate) tube is
also acceptable. For drug screen, urine (15 mL) collected in a clean plastic
container. Gastric contents (20 mL) may also be submitted for testing.
Workplace drug-screening programs, because of the potential medicolegal
consequences associated with them, require collection of urine and blood spec-
imens using a chain of custody protocol. The protocol provides securing the sam-
ple in a sealed transport device in the presence of the donor and a
representative of the donor’s employer, such that tampering would be obvious.
The protocol also provides a written document of specimen transfer from
donor to specimen collection personnel, to storage, to analyst, and to disposal.
REFERENCE VALUE: (Method: Spectrophotometry for ethanol; immunoassay

for drugs of abuse)
Ethanol: None detected
Drug screen: None detected
INDICATIONS:
DESCRIPTION & RATIONALE: Drug • Differentiate alcohol intoxication from
abuse continues to be one of the most diabetic coma, cerebral trauma, or drug
significant social and economic prob- overdose
lems in the United States. The
• Investigate suspected drug abuse
National Institute for Drug Abuse
(NIDA) has identified opiates, cocaine, • Investigate suspected drug overdose
cannabinoids, amphetamines, and
• Investigate suspected noncompliance
phencyclidines (PCPs) as the most with drug or alcohol treatment pro-
commonly abused illicit drugs. Etha- gram
nol is the most commonly encoun-
tered legal substance of abuse. Chronic • Monitor ethanol levels when admin-
alcohol abuse can lead to liver disease, istered to treat methanol intoxica-
tion
high blood pressure, cardiac disease,
and birth defects. ■ • Routine workplace screening
Cutoff Concentrations for Drugs of Abuse Recommended by NIDA

Amphetamines 1000 ng/mL
Barbiturates 300 ng/mL
Benzodiazepines 300 ng/mL
Cannabinoids 50 ng/mL
Cocaine 300 ng/mL
Opiates 300 ng/mL
Phencyclidine 25 ng/mL
Tricyclic antidepressants 1000 ng/mL
RESULT: A urine screen merely identifies piratory support, administration of acti-

the presence of these substances in urine; vated charcoal with a cathartic such as
it does not indicate time of exposure, sorbitol, gastric lavage and suction, admin-
amount used, quality of the source used, istration of intravenous nutrition and elec-
or level of impairment. Positive screens trolytes, and acidification of the urine to
should be considered presumptive. Drug- promote PCP excretion.
specific confirmatory methods should be Cocaine intoxication causes short-term
used to investigate questionable results of symptoms of CNS stimulation, hyperten-
a positive urine screen. sion, tachypnea, mydriasis, and tachycar-
dia. Possible interventions include emesis
CRITICAL VALUES: (if orally ingested and if the patient has a
Note and immediately report to the gag reflex and normal CNS function),
health care practitioner any critically gastric lavage (if orally ingested), whole-
increased values and related symptoms. bowel irrigation (if packs of the drug were
The legal limit for ethanol intoxication ingested), airway protection, cardiac sup-
varies from state to state, but in most states port, and administration of diazepam or
greater than 100 mg/dL (0.1G%) is con- phenobarbital for convulsions. The use of
sidered impaired for driving. Levels -blockers is contraindicated.
greater than 300 mg/dL are associated with Amphetamine intoxication causes psy-
amnesia, vomiting, double vision, and choses, tremors, convulsions, insomnia,
hypothermia. Levels of 400 to 700 mg/dL tachycardia, dysrhythmias, impotence,
are associated with coma and may be fatal. cerebrovascular accident, and respiratory
Possible interventions for ethanol toxicity failure. Possible interventions include
include administration of tap water or 3% emesis (if orally ingested and if the
sodium bicarbonate lavage, breathing sup- patient has a gag reflex and normal CNS
port, and hemodialysis (usually indicated function), administration of activated
only if levels exceed 300 mg/dL). charcoal followed by magnesium citrate
Barbiturate and benzodiazepine intoxi- cathartic, acidification of the urine to
cation causes central nervous system promote excretion, and administration of
(CNS) depression, which may progress liquids to promote urinary output.
to respiratory failure, hypotension, coma, Heroin is an opiate that at toxic levels
and death. Do not induce emesis because causes bradycardia, flushing, itching, hypo-
of the risk of aspiration. Possible interven- tension, hypothermia, and respiratory
tions include airway protection, adminis- depression. Possible interventions include
tration of oxygen, gastric lavage with water airway protection and the administration
or saline (up to 24 hours after ingestion), of naloxone (Narcan).
administration of activated charcoal, and Tricyclic antidepressant intoxication
monitoring CNS depression. causes confusion, agitation, hallucinations,
PCP intoxication causes a variety of seizures, dysrhythmias, hyperthermia,
symptoms depending on the stage of in- dilation of the pupils, and coma. Possible
toxication. Stage I includes psychiatric interventions may include administration
signs, muscle spasms, fever, tachycardia, of activated charcoal; gastric lavage with
flushing, small pupils, salivation, nausea, saline; intravenous administration of phy-
and vomiting. Stage II includes stupor, sostigmine (to counteract coma, hyperten-
convulsions, hallucinations, increased heart sion, respiratory depression, and seizures);
rate, and increased blood pressure. Stage administration of bicarbonate (to control
III includes further increases of heart rate dysrhythmia); administration of propra-
and blood pressure that may culminate in nolol, lidocaine, or phenytoin to control
cardiac and respiratory failure. Possible convulsions; and monitoring cardiac
interventions may include providing res- function.
Drugs of Abuse 573
INTERFERING FACTORS: takes approximately 5 to 10 minutes

• Codeine-containing cough medicines but may vary depending on the level
of patient cooperation. Address con-
and antidiarrheal preparations, as well
cerns about pain related to the pro-
as ingestion of large amounts of poppy cedure. Explain to the patient that
seeds, may produce a false-positive opi- there may be some discomfort dur-
ate result. ing the venipuncture but there
• Adulterants such as bleach or other should be no discomfort during urine
specimen collection.
strong oxidizers can produce erroneous
urine drug screen results. ➤ Sensitivity to social and cultural
• Ethanol is a volatile substance, and esty, is important in providing psy-
specimens should be stored in a tightly chological support before, during,
stoppered container to avoid falsely and after the procedure.
decreased values. ➤ There are no food, fluid, or medica-
tion restrictions.
Nursing Implications and consent has been signed prior to the
Procedure ● ● ● ● ● ● ● ● ● ● ● procedure.
Pretest: Intratest:
➤ Inform the patient that the test is ➤ If the patient has a history of severe
used to rapidly identify commonly allergic reaction to latex, care should
abused drugs in suspected drug over- be taken to avoid the use of equip-
dose or for routine workplace drug ment containing latex.
screening. ➤ Instruct the patient to cooperate fully
➤ Obtain a history of the patient’s and to follow directions. Direct the
complaints, including a list of known patient receiving venipuncture to
allergens (especially allergies or sen- breathe normally and to avoid unnec-
sitivities to latex), and inform the essary movement.
appropriate health care practitioner ➤ Observe standard precautions, and
accordingly. follow the general guidelines in
➤ Obtain a history of previously per- Appendix A. Positively identify the
formed laboratory tests, surgical patient, and label the appropriate col-
procedures, and other diagnostic lection containers with the corre-
procedures. For related laboratory sponding patient demographics, date,
tests, refer to the Therapeutic/ and time of collection. For ethanol
Toxicology table. level, use a non–alcohol-containing
➤ Obtain a list of the medications the solution to cleanse the venipuncture
patient is taking, including herbs, site before specimen collection.
nutritional supplements, and nutra- Perform a venipuncture, as appropri-
ceuticals. The requesting health care ate; collect the specimen in a 5-mL
practitioner and laboratory should be red-top tube. Cadaver blood is taken
advised if the patient regularly uses from the aorta. For a urine drug
these products so that their effects screen, instruct the patient to obtain
can be taken into consideration when a clean-catch urine specimen.
reviewing results. ➤ Remove the needle, as appropriate,
➤ Review the entire procedure with the and apply a pressure dressing over
patient, especially if the circum- the puncture site.
stances require collection of urine
and blood specimens using a chain Clean-catch specimen:
of custody protocol. Inform the ➤ Instruct the male patient to (1) thor-
patient that specimen collection oughly wash his hands, (2) cleanse
the meatus, (3) void a small amount will be sent to the requesting health
into the toilet, and (4) void directly care practitioner, who will discuss
into the specimen container. the results with the patient. Ensure
➤ Instruct the female patient to (1) thor- that results are communicated to the
oughly wash her hands; (2) cleanse proper individual, as indicated in the
the labia from front to back; (3) while chain of custody protocol.
keeping the labia separated, void a ➤ Recognize anxiety related to test
small amount into the toilet; and (4) results. Discuss the implications
without interrupting the urine stream, of abnormal test results on the
void directly into the specimen con- patient’s lifestyle. Provide teaching
tainer. and information regarding the clinical
➤ Follow the chain of custody protocol, implications of the test results, as
if required. Monitor specimen collec- appropriate. Educate the patient
tion, labeling, and packaging to pre- regarding access to counseling serv-
vent tampering. This protocol may ices. Provide support and information
vary by institution. regarding detoxification programs, as
appropriate.
in a computerized system for recall and referral to another health care pro-
postprocedure interpretation by the vider. Answer any questions or ad-
appropriate health care practitioner. dress any concerns voiced by the
patient or family.
Post-test: ➤ Depending on the results of this
➤ Observe venipuncture site for bleed- performed to evaluate or monitor pro-
ing or hematoma formation. Apply gression of the disease process and
paper tape or other adhesive to hold determine the need for a change in
pressure bandage in place, or replace therapy. Evaluate test results in rela-
with a plastic bandage. tion to the patient’s symptoms and
➤ A written report of the examination other tests performed.
D-XYLOSE TOLERANCE TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Plasma (1 mL) collected in gray-top (fluoride/oxalate) tube and
urine (10 mL from a 5-hour collection) from a timed collection in a clean
amber plastic container.

D-Xylose Tolerance Test 575
Conventional
Dose by Age Units SI Units
(Conventional Units
Plasma 0.0666)
Adult dose
25 g Greater than 25 mg/dL Greater than 1.7 mmol/L
5g Greater than 20 mg/dL Greater than 1.3 mmol/L
Pediatric dose
0.5 g/kg (max. 25 g) Greater than 30 mg/dL Greater than 2.0 mmol/L
(Conventional Units
Urine 6.66)
Adult dose
25 g Greater than 4 g/5 h Greater than 26.6
collection mmol/5 h
5g Greater than 1.2 g/5 h Greater than 8 mmol/5 h
collection
Pediatric dose
0.5 g/kg (max. 25 g) Greater than Greater than 16%–33%
16%–33% of dose of dose
• Parasitic infestations (Giardia, schisto-

DESCRIPTION & RATIONALE: The D- somiasis, hookworm)
xylose tolerance test is used to screen
• Postoperative period after massive resec-
for intestinal malabsorption of carbo- tion of the intestine
hydrates. D-Xylose is a pentose sugar
not normally present in the blood in • Radiation enteritis
significant amounts. It is partially • Scleroderma
absorbed when ingested and normally
• Small bowel ischemia
passes unmetabolized in the urine. ■
• Tropical sprue
INDICATIONS: Assist in the diagnosis of • Whipple’s disease
malabsorption syndromes
• Zollinger-Ellison syndrome
RESULT
Increased in: N/A
Decreased in: • Drugs that may increase urine D-xylose
• Amyloidosis levels include phenazopyridine.
• Bacterial overgrowth • Drugs and substances that may de-

crease urine D-xylose levels include
• Eosinophilic gastroenteritis acetylsalicylic acid, aminosalicylic acid,
arsenicals, colchicine, digitalis, ethion-
• Lymphoma
amide, gold, indomethacin, isocarbox-
• Nontropical sprue (celiac disease, azid, kanamycin, monoamine oxidase
gluten-induced enteropathy) inhibitors, neomycin, and phenelzine.
• Poor renal function or vomiting may device and to keep toilet tissue out
cause low urine values. of the collection device to prevent
Place a sign in the bathroom to
remind the patient to save all urine.
Nursing Implications and ➤ Instruct the patient to void all urine
Procedure ● ● ● ● ● ● ● ● ● ● ●
pour the urine into the laboratory col-
Pretest: lection container. Alternatively, the
➤ Inform the patient that the test is device for a health care staff mem-
used to assist in the diagnosis of ber to add to the laboratory collec-
intestinal malabsorption syndromes. tion container.
➤ Obtain a history of the patient’s com- ➤ Sensitivity to social and cultural
plaints, including a list of known issues, as well as concern for mod-
allergens (especially allergies or sen- esty, is important in providing psy-
sitivities to latex), and inform the chological support before, during,
appropriate health care practitioner and after the procedure.
accordingly.
➤ Numerous medications (e.g., acetyl-
➤ Obtain a history of the patient’s gas- salicylic acid, indomethacin, neo-
trointestinal system and results of mycin) interfere with the test and
previously performed laboratory should be withheld, by medical direc-
tests, surgical procedures, and other tion, for 24 hours before testing.
➤ There are no fluid restrictions, unless
laboratory tests, refer to the Gastro-
intestinal System table.
➤ The patient should fast for at least 12
➤ Obtain a list of the medications the hours before the test. In addition, the
patient is taking, including herbs, patient should refrain from eating
nutritional supplements, and nutra- foods containing pentose sugars
ceuticals. The requesting health care such as fruits, jams, jellies, and
practitioner and laboratory should be pastries.
can be taken into consideration Intratest:
when reviewing results. ➤ Ensure that the patient has complied
➤ Review the procedure with the with dietary and medication restric-
patient. Inform the patient that activ- tions; assure that food has been
ity will be restricted during the test. restricted for at least 12 hours prior
Obtain the pediatric patient’s weight to the procedure and medications
to calculate dose of D-xylose to be have been witheld, by medical direc-
administered. Inform the patient that tion, for 24 hours prior to the proce-
blood specimen collection takes dure.
approximately 5 to 10 minutes. Ad- ➤ If the patient has a history of severe
dress concerns about pain related to allergic reaction to latex, care should
the procedure. Explain to the patient be taken to avoid the use of equip-
that there may be some discomfort ment containing latex.
during the venipuncture.
➤ Inform the patient that all urine for a and to follow directions. Direct the
5-hour period must be saved. Provide patient to breathe normally and to
a nonmetallic urinal, bedpan, or toilet- avoid unnecessary movement.
mounted collection device. ➤ Observe standard precautions, and
➤ Instruct the patient not to void follow the general guidelines in
directly into the laboratory collection Appendix A. Positively identify the
container. Instruct the patient to patient, and label the appropriate
avoid defecating in the collection tubes with the corresponding patient
D-Xylose Tolerance Test 577
demographics, date, and time of urinary output record for the collec-
collection. Perform a venipuncture; tion; if the specimen contains less
collect the specimen in a 5-mL red- than what was recorded as output,
or tiger-top tube. some urine may have been dis-
➤ Remove the needle, and apply a pres- carded, thus invalidating the test.
sure dressing over the puncture site. ➤ Include on the collection container’s
label the amount of urine, test start
Timed specimen: and stop times, and ingestion of any
foods or medications that could af-
➤ Obtain a clean 3-L urine specimen fect test results.
device, and plastic bag (for transport ➤ Promptly transport the specimens
of the specimen container). The spec- to the laboratory for processing and
imen must be refrigerated or kept analysis.
on ice throughout the entire collec- ➤ The results are recorded manually or
tion period. If an indwelling urinary in a computerized system for recall
catheter is in place, the drainage bag and postprocedure interpretation by
must be kept on ice. the appropriate health care practi-
➤ Begin the test between 6 a.m. and 8 tioner.
a.m., if possible. Remind the patient
to remain supine and at rest through- Post-test:
out the duration of the test. Instruct ➤ Observe venipuncture site for bleed-
the patient to collect all urine for a 5- ing or hematoma formation. Apply
hour period after administration of paper tape or other adhesive to hold
the D-xylose. pressure bandage in place, or replace
➤ Adults are given a 25-g dose of D- with a plastic bandage.
xylose dissolved in 250 mL of water ➤ Instruct the patient to resume usual
to take orally. The dose for pediatric medications, as directed by the
patient is calculated by weight up to health care practitioner.
a maximum of 25 g. The patient
should drink an additional 250 mL of ➤ Nutritional considerations: Decreased
D-Xylose levels may be associated
water as soon as the D-xylose solu-
tion has been taken. Some adult with gastrointestinal disease. Nutri-
patients with severe symptoms may tional therapy may be indicated in the
be given a 5-g dose, but the test presence of malabsorption disorders.
results are less sensitive at the lower Encourage the patient, as appropriate,
dose. to consult with a qualified nutrition
specialist to plan a lactose- and
➤ If an indwelling catheter is in place, gluten-free diet. This dietary planning
replace the tubing and container sys- is complex because patients are
tem at the start of the collection often malnourished and have related
time. Keep the container system nutritional problems.
on ice during the collection period
or empty the urine into a larger con- ➤ A written report of the examination
tainer periodically during the col- will be sent to the requesting health
lection period; monitor to ensure care practitioner, who will discuss
continued drainage. the results with the patient.
➤ Blood samples are collected 1 hour ➤ Recognize anxiety related to test
postdose for pediatric patients and 2 results. Discuss the implications of
hours postdose for adults. abnormal test results on the patient’s
➤ Direct the patient to breathe nor- mation regarding the clinical impli-
mally and to avoid unnecessary cations of the test results, as
movement. Perform a venipuncture, appropriate. Offer support to help the
and collect the specimen in a 5-mL patient and/or caregiver cope with
gray-top tube. the long-term implications of a chron-
➤ At the conclusion of the test, com- ic disorder and related lifestyle
pare the quantity of urine with the changes. Educate the patient regard-
ing access to counseling services, as progression of the disease process

appropriate. and determine the need for a change
patient or family. ➤ Related laboratory tests include fecal
➤ Depending on the results of this pro- analysis, fecal fat, intestinal biopsy,
cedure, additional testing may be lactose tolerance, and sweat chlo-
performed to evaluate or monitor ride.
ECHOCARDIOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Doppler echo, Doppler ultrasound of

the heart, echo.
AREA OF APPLICATION: Chest/thorax.
CONTRAST: Can be done with or without noniodinated contrast
medium (microspheres).
DESCRIPTION & RATIONALE: Echo- ducer over areas of the chest. Electro-
cardiography, a noninvasive ultra- cardiography and phonocardiography
sound procedure, uses high-frequency can be done simultaneously to corre-
sound waves of various intensities to late the findings with the cardiac
assist in diagnosing cardiovascular dis- cycle. These procedures can be done at
orders. The procedure records the the bedside or in a specialized depart-
echoes created by the deflection of an ment, health care practitioner’s office,
ultrasonic beam off the cardiac struc- or clinic.
tures and allows visualization of the Included in the study are the M-
size, shape, position, thickness, and mode method, which produces a lin-
movement of all four valves, atria, ear tracing of timed motions of the
ventricular and atria septa, papillary heart, its structures, and associated
muscles, chordae tendineae, and ven- measurements over time; and the two-
tricles. This study can also determine dimensional method, using real-time
blood-flow velocity and direction and Doppler color-flow imaging with
the presence of pericardial effusion pulsed and continuous-wave Doppler
during the movement of the trans- spectral tracings, which produces a
Echocardiography 579
cross-section of the structures of the bers and determine if hypertrophic car-

heart and their relationship to one diomyopathy or congestive heart fail-
ure is present
another, including changes in the coro-
nary vasculature, velocity and direc- RESULT
tion of blood flow, and areas of
eccentric blood flow. Doppler color- Normal Findings:
flow imaging may also be helpful in • Normal appearance in the size, posi-
depicting the function of biological tion, structure, and movements of the
and prosthetic valves. heart valves visualized and recorded in
Cardiac contrast medium is used to a combination of ultrasound modes;
aid in the diagnosis of intracardiac and normal heart muscle walls of both
shunt and tricuspid valve regurgita- ventricles and left atrium, with ade-
quate blood filling. Established values
tion. The contrast agent is injected
for the measurement of heart activities
intravenously and outlines the cham- obtained by the study may vary by
bers of the heart. ■ health care practitioner and institution.
INDICATIONS: Abnormal Findings:
• Detect atrial tumors (myxomas) • Aortic valve abnormalities
• Detect subaortic stenosis as evidenced • Cardiac neoplasm
either by displacement of the anterior
atrial leaflet or by a reduction in aortic • Cardiomyopathy
valve flow, depending on the obstruc-
• Congenital heart defect
tion
• Detect ventricular or atrial mural • Congestive heart failure
thrombi and evaluate cardiac wall • Coronary artery disease
motion after myocardial infarction
• Endocarditis
• Determine the presence of pericardial
effusion, tamponade, and pericarditis • Mitral valve abnormalities
• Determine the severity of valvular • Myxoma
abnormalities such as stenosis, pro- • Pericardial effusion, tamponade, and
lapse, and regurgitation pericarditis
• Evaluate congenital heart disorders • Pulmonary hypertension
• Evaluate endocarditis
• Pulmonary valve abnormalities
• Evaluate or monitor prosthetic valve
function • Septal defects
• Evaluate the presence of shunt flow and • Ventricular hypertrophy

continuity of the aorta and pulmonary • Ventricular or atrial mural thrombi
artery
• Evaluate unexplained chest pain, elec- CRITICAL VALUES: N/A
trocardiographic changes, and abnor-
mal chest x-ray (e.g., enlarged cardiac INTERFERING FACTORS:
silhouette)
Factors that may
• Evaluate ventricular aneurysms and/or impair clear imaging:
thrombus • Incorrect placement of the transducer
• Measure the size of the heart’s cham- over the desired test site
• Retained barium from a previous radi- ➤ Note any recent procedures that can
ologic procedure interfere with test results (i.e., bar-
ium procedures, surgery, or biopsy).
• Patients who are dehydrated, resulting There should be 24 hours between
in failure to demonstrate the bound- administration of barium and this
aries between organs and tissue struc- test.
tures ➤ Record the date of the last menstrual
• Metallic objects within the examina- of pregnancy in perimenopausal
tion field (e.g., jewelry, body rings), women.
which may inhibit organ visualization ➤ Obtain a list of the medications the
and can produce unclear images patient is taking.
• Improper adjustment of the ultrasound ➤ Review the procedure with the
equipment to accommodate obese or patient. Address concerns about pain
thin patients, which can cause a poor- related to the procedure. Explain to
quality study the patient that some pain may be
experienced during the test, and
• The presence of chronic obstructive there may be moments of discom-
pulmonary disease or use of mechanical fort. Explain the purpose of the test
ventilation, which increases the air and how the procedure is performed.
between the heart and chest wall (hy- Inform the patient that the procedure
is performed in an ultrasound or car-
perinflation) and can attenuate the
diology department, usually by a
ultrasound waves technologist, and takes approxi-
• The presence of arrhythmias mately 30 to 60 minutes.
• Patients who are very obese, who may inserted to allow infusion of IV fluids,
exceed the weight limit for the equip- contrast medium, dye, or sedatives.
ment ➤ Sensitivity to social and cultural
• Incorrect positioning of the patient, issues, as well as concern for mod-
which may produce poor visualization esty, is important in providing psy-
• Inability of the patient to cooperate ➤ Instruct the patient to remove jew-
or remain still during the procedure elry, body rings, and other metallic
because of age, significant pain, or men- objects.
tal status ➤ There are no food or fluid restric-
tions, unless by medical direction.

Procedure ● ● ● ● ● ● ● ● ● ● ●
available.
Pretest:
➤ Inform the patient that the procedure foot coverings to wear and instructed
assesses cardiac function. to void prior to the procedure.
plaints or clinical symptoms. follow the general guidelines in Ap-
➤ Obtain a history of results of previ- pendix A.
ously performed diagnostic proce- ➤ Instruct the patient to cooperate fully
dures, surgical procedures, and and to follow directions. Instruct the
laboratory tests. For related diagnos- patient to remain still throughout the
tic tests, refer to the Cardiovascular procedure because movement pro-
System table. duces unreliable results. Ask the pa-
Echocardiography 581
tient to breathe normally during the tion by the appropriate health care
examination. practitioner.
➤ Place the patient in a supine position
on a flat table with foam wedges to Post-test:
help maintain position and immobi-
lization. ➤ When the study is completed, re-
➤ Expose the chest, and attach electro- move the gel from the skin.
cardiogram leads for simultaneous ➤ A written report of the examination
tracings, if desired. will be completed by a health care
➤ Apply conductive gel to the chest practitioner specializing in this branch
slightly to the left of the sternum. of medicine. The report will be sent
Place the transducer on the chest to the requesting health care practi-
surface along the left sternal border, tioner, who will discuss the results
the subxiphoid area, suprasternal with the patient.
notch, and supraclavicular areas to ➤ Reinforce information given by the
obtain views and tracings of the por- patient’s health care provider regard-
tions of the heart. Scan the areas by ing further testing, treatment, or re-
systematically moving the probe in a ferral to another health care provider.
perpendicular position to direct the Answer any questions or address
ultrasound waves to each part of the any concerns voiced by the patient or
heart. These can be viewed immedi- family.
ately and recorded on moving graph
paper (M-mode) or videotape (two- ➤ Depending on the results of this pro-
dimensional). cedure, additional testing may be
➤ To obtain different views or informa- gression of the disease process and
tion about heart function, position determine the need for a change in
the patient on the left side and/or sit- therapy. Evaluate test results in rela-
ting up, or request that the patient tion to the patient’s symptoms and
breathe slowly or hold the breath other tests performed.
during the procedure. To evaluate
heart function changes, the patient
may be asked to inhale amyl nitrate Related diagnostic tests:
(vasodilator).
➤ Administer contrast medium, if or- chest x-ray, computed tomography
dered. A second series of images is scan of the thorax, magnetic re-
obtained. sonance imaging of the chest,
➤ The results are recorded on x-ray film myocardial perfusion scan, and posi-
or in a computerized system for tron emission tomography of the
recall and postprocedure interpreta- heart.
ECHOCARDIOGRAPHY,
TRANSESOPHAGEAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Echo, TEE.

CONTRAST: Can be done with or without noniodinated contrast medium
(microspheres).
DESCRIPTION & RATIONALE: Trans- care unit, in whom the transmission

esophageal echocardiography (TEE) is of waves to and from the chest has
performed to assist in the diagnosis of been compromised and more defini-
cardiovascular disorders when non- tive information is needed. The
invasive echocardiography is contra- images obtained by TEE have better
indicated or does not reveal enough resolution than those obtained by rou-
information to confirm a diagnosis. tine transthoracic echocardiography
Noninvasive echocardiography may because TEE uses higher frequency
be an inadequate procedure for sound waves and offers closer proxim-
patients who are obese, have chest ity of the transducer to the cardiac
wall structure abnormalities, or have structures. Cardiac contrast medium
chronic obstructive pulmonary disease is used to improve the visualization of
(COPD). TEE provides a better view viable myocardial tissue within the
of the posterior aspect of the heart, heart. ■
including the atrium and aorta. It is
done with a transducer attached to a INDICATIONS:
gastroscope that is inserted into the • Confirm diagnosis if conventional echo-
cardiography does not correlate with
esophagus. The transducer and the
other findings
ultrasound instrument allow the beam
to be directed to the back of the heart. • Detect and evaluate congenital heart
The echoes are amplified and recorded disorders
on a screen for visualization, and • Detect atrial tumors (myxomas)
recorded on graph paper or videotape. • Detect or determine the severity of
The depth of the endoscope and valvular abnormalities and regurgita-
movement of the transducer is con- tion
trolled to obtain various images of the • Detect subaortic stenosis as evidenced
heart structures. TEE is usually per- by displacement of the anterior atrial
formed during surgery; it is also used leaflet and reduction in aortic valve
on patients who are in the intensive flow, depending on the obstruction
Echocardiography, Transesophageal 583
• Detect thoracic aortic dissection and • Congestive heart failure

coronary artery disease (CAD)
• Mitral valve abnormalities
• Detect ventricular or atrial mural
thrombi and evaluate cardiac wall mo- • Myocardial infarction
tion after myocardial infarction • Myxoma
• Determine the presence of pericardial • Pericardial effusion
effusion
• Pulmonary hypertension
• Evaluate aneurysms and ventricular
thrombus • Pulmonary valve abnormalities
• Evaluate or monitor biological and • Septal defects
prosthetic valve function • Shunting of blood flow
• Evaluate septal defects • Thrombus
• Measure the size of the heart’s cham- • Ventricular hypertrophy
bers and determine if hypertrophic car-
diomyopathy or congestive heart failure • Ventricular or atrial mural thrombi
is present
• Monitor cardiac function during open
heart surgery (most sensitive method INTERFERING FACTORS:
for monitoring ischemia)
• Re-evaluate after inadequate visualiza- This procedure is
tion with conventional echocardiogra- contraindicated for:
phy as a result of obesity, trauma to or • Patients with significant esophageal
deformity of the chest wall, or lung hy- pathology (procedure may cause bleed-
perinflation associated with COPD ing)
RESULT Factors that may

Normal Findings: • Incorrect placement of the transducer
• Normal appearance of the size, posi- over the desired test site
tion, structure, movements of the heart
valves and heart muscle walls, and • Retained barium from a previous radi-
chamber blood filling; and no evidence ologic procedure
of valvular stenosis or insufficiency, car- • Patients who are dehydrated, resulting
diac tumor, foreign bodies, or CAD. in failure to demonstrate the bound-
The established values for the measure- aries between organs and tissue struc-
ment of heart activities obtained by the tures
study may vary by health care practi-
tioner and institution. • Laryngospasm, dysrhythmias, or eso-
phageal bleeding
Abnormal Findings: • Known upper esophageal pathology
• Aneurysm
• Conditions such as esophageal dyspha-
• Aortic valve abnormalities gia and irradiation of the mediastinum
• CAD • Improper adjustment of the ultrasound
equipment to accommodate obese or
• Cardiomyopathy
thin patients, which can cause a poor-
• Congenital heart defects quality study
• The presence of COPD or use of ➤ Review the procedure with the pa-
mechanical ventilation, which increases tient. Address concerns about pain
the air between the heart and chest wall related to the procedure. Explain to
(hyperinflation) and can attenuate the the patient that some pain may be
ultrasound waves there may be moments of discom-
• The presence of arrhythmias fort during insertion of the scope.
Lidocaine is sprayed in the patient’s
• Patients who are very obese, who may throat to reduce discomfort caused
exceed the weight limit for the equip- by the presence of the endoscope.
ment Explain the purpose of the test and
how the procedure is performed.
• Inability of the patient to cooperate or Inform the patient that the procedure
remain still during the procedure be- is performed in a ultrasound or cardi-
cause of age, significant pain, or mental ology department, usually by a tech-
status nologist, and takes approximately 30
to 60 minutes.
Other considerations: may be inserted to allow infusion of
• Failure to follow dietary restrictions IV fluids, contrast medium, dye, or
before the procedure may cause the pro- sedatives.
cedure to be canceled or repeated. ➤ Sensitivity to social and cultural
chological support before, during and
Nursing Implications and after the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ The patient should fast and refrain
from drinking liquids for 8 hours
Pretest: before the procedure.
➤ Inform the patient that the procedure ➤ Obtain and record the patient’s vital
assesses cardiac function. signs.
➤ Obtain a history of the patient’s com- ➤ Make sure a written and informed
plaints or clinical symptoms. consent has been signed prior to the
➤ Obtain a history of results of previ- procedure and before administering
ously performed diagnostic proce- any medications.
laboratory tests. For related diagnos- Intratest:
tic tests, refer to the Cardiovascular
System table.
➤ Note any recent procedures that can food has been restricted for at least
interfere with test results (i.e., bar- 8 hours depending on the anesthetic
ium procedures, surgery, or biopsy). chosen for the procedure.
There should be 24 hours between ➤ Have emergency equipment readily
administration of barium and this available.
test.
➤ Record the date of the last menstrual and foot coverings to wear and
period and determine the possibility instructed to void prior to the pro-
of pregnancy in perimenopausal cedure.
women.
➤ Obtain a list of the medications the follow the general guidelines in Ap-
patient is taking. pendix A.
Echocardiography, Transesophageal 585

Post-test:
patient to remain still throughout the ➤ Instruct the patient to resume usual
procedure because movement pro- diet and activity 4 to 6 hours after the
duces unreliable results. test, as directed by the health care
➤ Remove dentures from the patient’s practitioner.
mouth. ➤ Instruct patient to treat throat dis-
comfort with lozenges and warm gar-
➤ Monitor pulse oximetry to determine gles when the gag reflex returns.
oxygen saturation in sedated pa-
tients. ➤ Monitor vital signs and neurologic
➤ Expose the chest, and attach electro- then every 2 hours for 4 hours, and
cardiogram leads for simultaneous as ordered. Take temperature every 4
tracings, if desired. hours for 24 hours. Compare with
➤ Spray or swab the patient’s throat baseline values. Notify the health
with a local anesthetic, and place the care practitioner if temperature is
oral bridge device in the mouth to elevated. Protocols may vary from
prevent biting of the endoscope. facility to facility.
➤ Place the patient in a left side-lying will be completed by a health care
position on a flat table with foam practitioner specializing in this branch
wedges that will help maintain posi- of medicine. The report will be sent
tion and immobilization. The pharyn- to the requesting health care practi-
geal area is anesthetized and the tioner, who will discuss the results
endoscope with the ultrasound with the patient.
device attached to its tip is inserted
30 to 50 cm to the posterior area of ➤ Reinforce information given by the
the heart, as in any esophagogastro- patient’s health care provider regard-
duodenoscopy procedure. ing further testing, treatment, or refer-
ral to another health care provider.
➤ Ask the patient to swallow as the Answer any questions or address
scope is inserted. When the trans- any concerns voiced by the patient or
ducer is in place, the scope is manip- family.
ulated by controls on the handle to ➤ Depending on the results of this pro-
obtain scanning that provides real- cedure, additional testing may be
time images of the heart motion and needed to evaluate or monitor pro-
recordings of the images for viewing. gression of the disease process and
Actual scanning is usually limited to determine the need for a change in
15 minutes or until the desired num- therapy. Evaluate test results in rela-
ber of image planes is obtained at tion to the patient’s symptoms and
different depths of the scope. other tests performed.
➤ Administer contrast medium, if
ordered. A second series of images Related diagnostic tests:
is obtained.
➤ The results are recorded on x-ray chest x-ray, computed tomography of
film or in a computerized system for the thorax, magnetic resonance
recall and postprocedure interpreta- imaging of the chest, myocardial per-
tion by the appropriate health care fusion scan, and positron emission
practitioner. tomography of the heart.
ELECTROCARDIOGRAM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: ECG, VCG, EKG.

CONTRAST: None.
DESCRIPTION & RATIONALE: The are located within the right and left
cardiac muscle consists of three layers ventricles. The impulses continue to
of cells—the inner layer called the the cardiac muscle cells by terminal
endocardium, the middle layer called fibers called Purkinje fibers. The ECG
the myocardium, and the outer layer is a graphic display of the electrical
called the epicardium. The systolic activity of the heart, which is ana-
phase of the cardiac cycle reflects the lyzed by time intervals and segments.
contraction of the myocardium, Continuous tracing of the cardiac
whereas the diastolic phase takes place cycle activities is captured as heart
when the heart relaxes to allow blood cells are electrically stimulated, caus-
to rush in. All muscle cells have a ing depolarization and movement of
characteristic rate of contraction called the activity through the cells of the
depolarization. Therefore, the heart myocardium.
will maintain a predetermined heart The ECG study is completed by
rate unless other stimuli are received. using 12 electrodes attached to the
The monitoring of pulse and blood skin surface to obtain the total electri-
pressure evaluates only the mechanical cal activity of the heart. Each lead
activity of the heart. The electrocar- records the electrical potential
diogram (ECG), a noninvasive study, between the limbs or between the
measures the electrical currents or heart and limbs. The ECG machine
impulses that the heart generates dur- records and marks the 12 leads on the
ing a cardiac cycle (see figure of a nor- strip of paper in the machine in
mal ECG at end of monograph). proper sequence, usually 6 inches of
Electrical impulses travel through a the strip for each lead. The ECG pat-
conduction system beginning with the tern, called a heart rhythm, is recorded
sinoatrial (SA) node and moving to by a machine as a series of waves,
the atrioventricular (AV) node via intervals, and segments, each of which
internodal pathways. From the AV pertains to a specific occurrence dur-
node, the impulses travel to the bun- ing the contraction of the heart. The
dle of His and onward to the right and ECG tracings are recorded on graph
left bundle branches. These bundles paper using vertical and horizontal
Electrocardiogram 587
lines for analysis and calculations of • Monitor ECG changes during an

exercise test
time, measured by the vertical lines (1
mm apart and 0.04 seconds per line), • Monitor rhythm changes during the
and of voltage, measured by the hori- recovery phase after an MI
zontal lines (1 mm apart and 0.5 mV
per 5 squares). A pulse rate can be cal- RESULT
culated from the ECG strip to obtain
Normal Findings:
the beats per minute. The P wave rep-
• Normal heart rate according to age:
resents the depolarization of the atrial range of 60 to 100 beats/min in adults
myocardium; the QRS complex repre-
sents the depolarization of the ventric- • Normal, regular rhythm and wave de-
ular myocardium; the P-R interval flections with normal measurement of
ranges of cycle components and height,
represents the time from beginning of
depth, and duration of complexes as
the excitation of the atrium to the follows:
beginning of the ventricular excitation;
P wave: 0.12 seconds or 3 small
and the ST segment has no deflection blocks with amplitude of 2.5 mm
from baseline, but in an abnormal state Q wave: less than 0.04 mm
may be elevated or depressed. An abnor- R wave: 5 to 27 mm amplitude,
mal rhythm is called an arrhythmia. ■ depending on lead
T wave: 1 to 13 mm amplitude,
INDICATIONS: depending on lead
• Assess the extent of congenital heart
QRS complex: 0.12 seconds or 3
disease small blocks
• Assess the extent of myocardial infarc- ST segment: 1 mm
tion (MI) or ischemia, as indicated by
abnormal ST segment, interval times, Abnormal Findings:
and amplitudes • Arrhythmias.
• Assess the function of heart valves • Atrial or ventricular hypertrophy.
• Assess global cardiac function • Bundle branch block.
• Detect arrhythmias, as evidenced by • Electrolyte imbalances.
abnormal wave deflections • MI or ischemia.
• Detect pericarditis, shown by ST seg- • Pericarditis.
ment changes or shortened P-R interval
• Pulmonary infarction.
• Determine electrolyte imbalances, as
evidenced by short or prolonged Q-T • P wave: An enlarged P wave deflection
interval could indicate atrial enlargement. An
absent or altered P wave could suggest
• Determine hypertrophy of the chamber that the electrical impulse did not come
of the heart or heart hypertrophy, as from the SA node.
evidenced by P or R wave deflections
• P-R interval: An increased interval
• Evaluate and monitor cardiac pace- could imply a conduction delay in the
maker function AV node.
• Evaluate and monitor the effect of • QRS complex: An enlarged Q wave
drugs, such as digitalis, antiarrhyth- may indicate an old infarction; an
mics, or vasodilating agents enlarged deflection could indicate ven-
tricular hypertrophy. Increased time

duration may indicate a bundle branch Nursing Implications and
block. Procedure ● ● ● ● ● ● ● ● ● ● ●
• ST segment: A depressed ST segment Pretest:

indicates myocardial ischemia. An ele-
vated ST segment may indicate an a- ➤ Inform the patient that the procedure
cute MI or pericarditis. A prolonged assesses cardiac function.
ST segment may indicate hypocalcemia ➤ Obtain a history of the patient’s
or hypokalemia (short segment). complaints or symptoms, including
cardiac disease and present cardio-
• T wave: A flat or inverted T wave may vascular status. Ask if the patient has
indicate myocardial ischemia, infarc- had a heart transplant or pacemaker
tion, or hypokalemia. A tall T wave implanted.
may indicate hyperkalemia. ➤ Obtain a history of results of pre-
CRITICAL VALUES: N/A cedures, surgical procedures, and
laboratory tests. For related diagnos-
INTERFERING FACTORS: tic tests, refer to the Cardiovascular
System table.
results of the examination: ➤ Obtain a list of the medications the
patient is taking.
• Anatomic variation of the heart (i.e.,
the heart may be rotated in both the ➤ Review the procedure with the
horizontal and frontal planes) patient. Address concerns about pain
• Distortion of cardiac cycles due to the patient that there should be no
age, sex, weight, or a medical condition discomfort during the procedure.
(e.g., infants, women [may exhibit slight Inform the patient that the procedure
ST segment depression], obese pa- takes approximately 15 minutes.
tients, pregnant patients, patients with ➤ Record baseline vital signs.
ascites)
➤ No food, fluid, or medication restric-
• High intake of carbohydrates or elec- tions exist, unless by medical direc-
trolyte imbalances of potassium or cal- tion.
cium ➤ Sensitivity to cultural and social
• Improper placement of electrodes or issues, as well as concern for mod-
inadequate contact between skin and esty, is important in providing psy-
electrodes because of insufficient con- chological support before, during and
ductive gel or poor placement, which
can cause ECG tracing problems
Intratest:
• ECG machine malfunction or interfer-
ence from electromagnetic waves in the ➤ Have the patient remove clothing to
vicinity the waist and shoes and any hosiery.
Patients may want to wear a gown
• Inability of the patient to remain still (open to the front).
during the procedure, because move-
ment, muscle tremor, or twitching can follow the general guidelines in Ap-
affect accurate test recording pendix A.
• Increased patient anxiety, causing hy- ➤ Instruct the patient to lie very still in
perventilation or deep respirations a relaxed position during the study
• Medications such as barbiturates and and to refrain from tensing muscles
after electrode placement. Direct the
digitalis
• Strenuous exercise before the procedure avoid touching the bed or couch.
Electrocardiogram 589
➤ Place patient in a supine position. Ex- ➤ Monitor vital signs and compare with
pose and appropriately drape the baseline values. Protocols may vary
chest, arms, and legs. from facility to facility.
➤ Prepare the skin surface with alcohol ➤ Instruct the patient to immediately
and remove excess hair. Shaving may notify a health care practitioner of
be necessary. Dry skin sites. chest pain, changes in pulse rate, or
➤ Apply the electrodes in the proper shortness of breath.
position. When placing the six unipo- ➤ A written report of the examination
lar chest leads, place V1 at the fourth will be completed by a health care
intercostal space at the border of the practitioner specializing in this branch
right sternum, V2 at the fourth inter- of medicine. The report will be sent
costal space at the border of the left to the requesting health care practi-
sternum, V3 between V2 and V4, V4 at tioner, who will discuss the results
the fifth intercostal space at the mid- with the patient.
clavicular line, V5 at the left anterior ➤ Recognize anxiety related to the test
axillary line at the level of V4 horizon- results and be supportive of per-
tally, and V6 at the level of V4 horizon- ceived loss of independence and fear
tally and at the left midaxillary line. of shortened life expectancy. Dis-
The wires are connected to the cuss the implications of abnormal
matched electrodes and the ECG test results on the patient’s lifestyle.
machine. Chest leads (V1, V2, V3, V4, Provide teaching and information
V5, and V6) record data from the hor- regarding the clinical implications of
izontal plane of the heart. the test results, as appropriate.
➤ Place three limb bipolar leads (two
electrodes combined for each) on the
arms and legs. Lead I is the combi-
nation of two arm electrodes, lead II
is the combination of right arm and
left leg electrodes, and lead III is the
any concerns voiced by the patient or
combination of left arm and left leg
family.
electrodes. Limb leads (I, II, III, aV L,
aVF, and aVR) record data from the ➤ Instruct the patient or caregiver in
frontal plane of the heart. the use of any ordered medications.
➤ The machine is set and turned on Explain the importance of adhering
after the electrodes, grounding, con- to the therapy regimen. As appropri-
nections, paper supply, computer, ate, instruct the patient in significant
and data storage device are checked. side effects and systemic reactions
associated with the prescribed med-
➤ If the patient has any chest discom- ication. Encourage him or her to
fort or pain during the procedure, review corresponding literature pro-
mark the ECG strip indicating that vided by a pharmacist.
occurrence.
➤ The results are recorded on a paper cedure, additional testing may be
strip for postprocedure interpretation performed to evaluate or monitor
by the appropriate health care practi- progression of the disease process
➤ When the procedure is complete, and other tests performed.
remove the electrodes and clean the
skin where the electrode pads were Related diagnostic tests:
applied. ➤ Related diagnostic tests include
➤ Evaluate the results in relation to pre- coronary angiography, echocardio-
viously performed ECGs. Denote car- gram, myocardial perfusion scan of
diac rhythm abnormalities on the the heart, and positron emission
strip. tomography scan of the heart.
R
5 mm (0.2 sec)
PR (1 mm)
Segment
0.04
ST sec
Segment
PR Interval Q
S
QRS
Complex
QT Interval
ELECTROENCEPHALOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Sonogram (for sleep disturbances), EEG.

CONTRAST: None.
DESCRIPTION & RATIONALE: Electro- ferent frequencies and amplitudes of

encephalography (EEG) is a noninva- the brain’s electrical activity to the
sive study that measures the brain’s EEG machine, which records the
electrical activity and records that results in graph form on a moving
activity on graph paper. These electri- paper strip. This procedure can evalu-
cal impulses arise from the brain cells ate responses to various stimuli, such
of the cerebral cortex. Electrodes, as flickering light, hyperventilation,
placed at 8 to 20 sites (or pairs of sites) auditory signals, or somatosensory sig-
on the patient’s scalp, transmit the dif- nals generated by skin electrodes. The
Electroencephalography 591
procedure is usually performed in a RESULT

room designed to eliminate electrical
Normal Findings:
interference and minimize distrac-
tions. EEG can be done at the bed- • Normal occurrences of alpha, beta,
theta, and delta waves (rhythms vary-
side, especially to confirm brain death.
ing depending on the patent’s age)
A physician analyzes the waveforms.
The test is used to detect epilepsy, • Normal frequency, amplitude, and char-
intracranial abscesses, or tumors; to acteristics of brain waves
evaluate cerebral involvement due to
Abnormal Findings:
head injury or meningitis; and to mon-
itor for cerebral tissue ischemia during • Abscess
surgery when cerebral vessels must be • Brain death
occluded. EEG is also used to confirm • Cerebral infarct
brain death, which can be defined as
absence of electrical activity in the • Encephalitis
brain. To evaluate abnormal EEG • Glioblastoma and other brain tumors
waves further, the patient may be con-
• Head injury
nected to an ambulatory EEG system
similar to a Holter monitor for the • Hypocalcemia or hypoglycemia
heart. Patients keep a journal of their • Intracranial hemorrhage
activities and any symptoms that occur
• Meningitis
during the monitoring period. ■
• Migraine headaches
INDICATIONS: • Narcolepsy
• Confirm brain death
• Seizure disorders (grand mal, focal,
• Confirm suspicion of increased intra- temporal lobe, myoclonic, petit mal)
cranial pressure caused by trauma or
disease • Sleep apnea
• Detect cerebral ischemia during endar-
terectomy
• Detect intracranial cerebrovascular INTERFERING FACTORS:
lesions, such as hemorrhages and in-
farcts Factors that may impair the
results of the examination:
• Detect seizure disorders and identify
focus of seizure and seizure activity, as
remain still during the procedure be-
evidenced by abnormal spikes and
cause of age, significant pain, or mental
waves recorded on the graph
status
• Determine the presence of tumors,
• Drugs and substances such as sedatives,
abscesses, or infection
anticonvulsants, anxiolytics, and alco-
• Evaluate the effect of drug intoxication hol, and stimulants such as caffeine and
on the brain nicotine
• Evaluate sleeping disorders, such as sleep • Hypoglycemic or hypothermic states
apnea and narcolepsy
• Hair that is dirty, oily, or sprayed or
• Identify area of abnormality in dementia treated with hair preparations
given a drug to induce sleep during

Nursing Implications and the study.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Instruct the patient to clean the hair
and to refrain from using hair sprays,
Pretest: creams, or solutions before the test.
➤ Inform the patient that the procedure ➤ Instruct the patient to refrain from
is performed to measure electrical drinking caffeine-containing bever-
activity of the brain. ages for 8 hours before the proce-
dure, and to eat a meal before the
➤ Obtain a history of the patient’s neu- study.
rologic system, known or suspected
seizure conditions, intracranial abnor- ➤ Under medical direction, the patient
malities, traumatic incidents to head, should avoid sedatives, anticonvul-
and sleep disorders, as well as sants, anxiolytics, alcohol, and stimu-
the results of previously performed lants such as caffeine and nicotine
laboratory tests, surgical procedures, for 24 to 48 hours before the test.
and other diagnostic procedures. For ➤ Instruct the patient to limit sleep to 5
related diagnostic tests, refer to the hours for an adult and 7 hours for a
Musculoskeletal System table. child the night before the study.
➤ Obtain a list of the medications the Young infants and children should not
patient is taking, including herbs, be allowed to nap before the study.
nutritional supplements, and nutra- ➤ Sensitivity to cultural and social
ceuticals. The requesting health care issues, as well as concern for mod-
practitioner and laboratory should be esty, is important in providing psy-
advised if the patient regularly uses chological support before, during and
these products so that their effects after the procedure.
➤ Review the procedure with the procedure and before administering
patient. Address concerns about pain any medications.
related to the procedure. Assure the
patient that there is no discomfort Intratest:
during the procedure, but that, if
needle electrodes are used, a slight ➤ Ensure that caffeine-containing bev-
pinch may be felt. Explain the pur- erages were withheld for 8 hours
pose of the test and how the proce- before the procedure, and that a
dure is performed. Explain that meal was ingested before the study.
electricity flows from the patient’s ➤ Ensure that all substances with the
body, not into the body, during the potential to interfere with test results
procedure. Explain that the proce- are withheld for 24 to 48 hours be-
dure reveals brain activity only, not fore the test.
thoughts, feelings, or intelligence.
➤ Ensure that the patient is able to
relax; report any extreme anxiety or
is performed in a neurodiagnostic
restlessness.
department, usually by a technolo-
gist and support staff, and takes ➤ Ensure that hair is clean and free of
approximately 30 to 60 minutes. hair sprays, creams, or solutions.
➤ Inform the patient that he or she may ➤ Observe standard precautions, and
be asked to alter breathing pattern; follow the general guidelines in Ap-
be asked to follow simple com- pendix A.
mands such as opening or closing ➤ Place the patient in the supine posi-
eyes, blinking, or swallowing; be tion in a bed or in a semi-Fowler’s
stimulated with bright light; or be position on a recliner in a special
Electroencephalography 593
room protected from any noise or Bedside rails are put in the raised
electrical interferences that could af- position for safety.
fect the tracings. ➤ Instruct the patient to resume med-
➤ Remind the patient to relax and not ications, as directed by the health
to move any muscles or parts of the care practitioner.
face or head. The technician should ➤ Instruct the patient to report any
be able to observe the patient for seizure activity.
movements or other interferences ➤ A written report of the examination
through a window into the test room. will be completed by a health care
➤ The electrodes are prepared and practitioner specializing in this branch
applied to the scalp. Electrodes are of medicine. The report will be sent
placed in as many as 16 locations to the requesting health care practi-
over the frontal, temporal, parietal, tioner, who will discuss the results
and occipital areas, and amplifier with the patient.
wires are attached. An electrode is ➤ Recognize anxiety related to test
also attached to each earlobe as results, and be supportive of per-
grounding electrodes. At this time, a ceived loss of independent function.
baseline recording can be made with Discuss the implications of abnormal
the patient at rest. test results on the patient’s lifestyle.
➤ Recordings are made with the Provide teaching and information
patient at rest and with eyes closed. regarding the clinical implications of
The test recordings are stopped the test results, as appropriate.
about every 5 minutes to allow the ➤ Reinforce information given by the
patient to move. Recordings are also patient’s health care provider regard-
made during a drowsy and sleep ing further testing, treatment, or re-
period, depending on the patient’s ferral to another health care provider.
clinical condition and symptoms. Answer any questions or address
➤ Procedures (e.g., stroboscopic light any concerns voiced by the patient or
stimulation, hyperventilation to in- family.
duce alkalosis, and sleep induction ➤ Instruct the patient in the use of any
by administration of sedative to de- ordered medications. Explain the
tect abnormalities that occur only importance of adhering to the ther-
during sleep) may be done to bring apy regimen. As appropriate, instruct
out abnormal electrical activity or the patient in significant side effects
other brain abnormalities. and systemic reactions associated
➤ Observations for seizure activity are
carried out during the study, and a
description and time of activity is
pharmacist.
noted by the technician.
➤ The results are recorded on a paper cedure, additional testing may be
strip for postprocedure interpretation performed to evaluate or monitor
by the appropriate health care practi- progression of the disease process
➤ When the procedure is complete,
remove electrodes from the hair and Related diagnostic tests:
remove paste by cleansing with oil or ➤ Related diagnostic tests include
witch hazel. computed tomography of the brain
➤ If a sedative was given during the and magnetic resonance imaging of
test, allow the patient to recover. the brain.
ELECTROMYOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Electrodiagnostic study, neuromuscular junction

testing, EMG.
AREA OF APPLICATION: Muscles.

CONTRAST: None.
DESCRIPTION & RATIONALE: Electro- detected with minimal or maximal

myography (EMG) measures skeletal muscle contractions. The differences
muscle activity during rest, voluntary in the size and numbers of activity
contraction, and electrical stimula- potentials during voluntary contrac-
tion. Percutaneous extracellular needle tions determine whether the muscle
electrodes containing fine wires are weakness is a disease of the striated
inserted into selected muscle groups muscle fibers or cell membranes (myo-
to detect neuromuscular abnormali- genic), or a disease of the lower motor
ties and measure nerve and electrical neuron (neurogenic). Nerve conduc-
conduction properties of skeletal tion studies (electroneurography) are
muscles. The electrical potentials are commonly done in conjunction with
amplified, displayed on a screen in electromyelography; the combination
waveforms, and electronically re- of the procedures is known as elec-
corded, similar to electrocardiography. tromyoneurography. The examina-
Comparison and analysis of the tion’s major use lies in differentiating
amplitude, duration, number, and among the following disease classes:
configuration of the muscle activity primary myopathy, peripheral motor
provide diagnostic information about neuron disease, and disease of the
the extent of nerve and muscle in- neuromuscular junction. ■
volvement in the detection of primary
muscle diseases, including lower motor INDICATIONS:
neuron, anterior horn cell, or neuro- • Assess primary muscle diseases affect-
muscular junction diseases; defective ing striated muscle fibers or cell mem-
transmission at the neuromuscular brane, such as muscular dystrophy or
junction; and peripheral nerve dam- myasthenia gravis
age or disease. Responses of a relaxed
• Detect muscle disorders caused by dis-
muscle are electrically silent, but eases of the lower motor neuron involv-
spontaneous muscle movement such ing the motor neuron on the anterior
as fibrillation and fasciculation can be horn of the spinal cord, such as anterior
detected in a relaxed, denervated poliomyelitis, amyotrophic lateral scle-
muscle. Muscle action potentials are rosis, amyotonia, and spinal tumors
Electromyography 595
• Detect muscle disorders caused by Multiple sclerosis

diseases of the lower motor neuron Muscular dystrophy
involving the nerve root, such as Myasthenia gravis
Guillain-Barré syndrome, herniated Myopathy
disc, or spinal stenosis
Polymyositis
• Detect neuromuscular disorders, such Radiculopathy
as peripheral neuropathy caused by dia- Traumatic injury
betes or alcoholism, and locate the site
of the abnormality CRITICAL VALUES: N/A
• Determine if a muscle abnormality is
caused by the toxic effects of drugs INTERFERING FACTORS:
(e.g., antibiotics, chemotherapy) or
toxins (e.g., Clostridium botulinum, This procedure is
snake venom, heavy metals) contraindicated for:
• Patients with extensive skin infection
• Differentiate between primary and sec-
ondary muscle disorders or between • Patients receiving anticoagulant therapy
neuropathy and myopathy • Patients with an infection at the sites of
• Differentiate secondary muscle disor- electrode placement
ders caused by polymyositis, sarcoido-
sis, hypocalcemia, thyroid toxicity, Factors that may impair the
tetanus, and other disorders
• Monitor and evaluate progression of remain still during the procedure be-
myopathies or neuropathies, including cause of age, significant pain, or mental
confirmation of diagnosis of carpal tun- status
nel syndrome
• Age-related decreases in electrical ac-
RESULT tivity
• Medications such as muscle relaxants,
Normal Findings: cholinergics, and anticholinergics
• Normal muscle electrical activity dur- • Improper placement of surface or nee-
ing rest and contraction states dle electrodes
Abnormal findings and possible
meanings:
• Evidence of neuromuscular disorders or
Procedure ● ● ● ● ● ● ● ● ● ● ●
primary muscle disease (note: findings
must be correlated with the patient’s Pretest:
history, clinical features, and results of
other neurodiagnostic tests): ➤ Inform the patient that the procedure
Amyotrophic lateral sclerosis is performed to measure electrical
activity of the muscles.
Bell’s palsy
➤ Obtain a history of neuromuscular
Beriberi and neurosensory status, diseases
Carpal tunnel syndrome or conditions that affect muscle
Dermatomyositis function, level of muscular function
Diabetic peripheral neuropathy and range of motion, and trau-
matic events, as well as the results of
Eaton-Lambert syndrome previously performed laboratory
Guillain-Barré syndrome tests, surgical procedures, and other
diagnostic procedures. For related instructions given to contract mus-

diagnostic tests, refer to the Mus- cles during the procedure.
culoskeletal System table.
➤ Place the patient in a supine or sitting
➤ Obtain a list of the medications the position depending on the location of
patient is taking, especially medica- the muscle to be tested. Ensure that
tions known to affect bleeding inclu- the area or room is protected from
ding anticoagulants, aspirin and other noise or metallic interference that
salicylates, etc. may affect the test results.
tient. Address concerns about pain
related to the procedure. Inform the
pendix A.
patient that as many as 10 electrodes
may be inserted at various locations ➤ Administer mild analgesic (adult) or
on the body. Warn the patient that sedative (children), as ordered, to
the procedure may be uncomfort- promote a restful state before the
able, but that an analgesic or seda- procedure.
tive will be administered. Inform the ➤ Cleanse the skin thoroughly with
patient that the procedure is per- alcohol pads, as necessary.
formed in a special laboratory by a
health care practitioner and takes ➤ An electrode is applied to the skin
approximately 1 hour to complete, to ground the patient, and then 24-
but can take up to 3 hours depending gauge needles containing a fine-wire
on the patient’s condition. electrode are inserted into the mus-
➤ Instruct the patient to refrain from cle. The electrical potentials of the
smoking and drinking caffeine- muscle are amplified, displayed on a
containing beverages for 3 hours screen, and electronically recorded.
before the procedure. ➤ During the test, muscle activity is
➤ Under medical direction, the patient tested while the patient is at rest,
should avoid muscle relaxants, cholin- during incremental needle insertion,
ergics, and anticholinergics for 3 to 6 and during varying degrees of mus-
days before the test. cle contraction.
➤ Assess for the ability to comply with ➤ Ask the patient to alternate between
directions given for exercising during a relaxed and a contracted muscle
the test. state, or to perform progressive mus-
➤ Make sure a written and informed cle contractions while the potentials
consent has been signed prior to the are being measured.
procedure and before administering ➤ The results are recorded manually or
any medications. in a computerized system for recall
Intratest: the appropriate health care practi-
tioner.
➤ Ensure that the patient has refrained
from smoking and drinking caffeine-
containing beverages for 3 hours be- Post-test:
fore the procedure.
➤ Ensure that medications such as remove the electrodes and clean the
muscle relaxants, cholinergics, and skin where the electrode was applied.
anticholinergics have been withheld,
as ordered. ➤ Monitor electrode sites for bleeding,
hematoma or inflammation.
➤ Have patient remove clothing and
any hosiery. Patients are given a ➤ If residual pain is noted after the pro-
gown to wear and instructed to void cedure, instruct the patient to apply
prior to the procedure. warm compresses and to take anal-
➤ Ask the patient to remain very still gesics, as ordered.
and relaxed and to cooperate with ➤ Instruct the patient to resume usual
Electromyography, Pelvic Floor Sphincter 597
diet, medication, and activity, as di- ing further testing, treatment, or refer-
rected by the health care practitioner. ral to another health care provider.
➤ A written report of the examination Answer any questions or address
will be completed by a health care any concerns voiced by the patient or
practitioner specializing in this branch family.
of medicine. The report will be sent ➤ Depending on the results of this pro-
to the requesting health care practi- cedure, additional testing may be
tioner, who will discuss the results performed to evaluate or monitor
with the patient. progression of the disease process
➤ Recognize anxiety related to test re- and determine the need for a change
sults, and be supportive of perceived in therapy. Evaluate test results in
loss of independent function. Discuss relation to the patient’s symptoms
the implications of abnormal test re- and other tests performed.
sults on the patient’s lifestyle. Provide
teaching and information regarding Related diagnostic tests:
the clinical implications of the test ➤ Related diagnostic tests include
results, as appropriate. computed tomography of the brain
➤ Reinforce information given by the and magnetic resonance imaging of
patient’s health care provider regard- the brain.
ELECTROMYOGRAPHY,
PELVIC FLOOR SPHINCTER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Electrodiagnostic study, rectal electromyography.

AREA OF APPLICATION: Sphincter muscles.
CONTRAST: None.
INDICATIONS: Evaluate neuromuscular

DESCRIPTION & RATIONALE: Pelvic dysfunction and incontinence
floor sphincter electromyography, also
known as rectal electromyography, is CRITICAL VALUES: N/A
performed to measure electrical activ-
ity of the external urinary sphincter. INTERFERING FACTORS:
This procedure, often done in con- This procedure is
junction with cystometry and voiding contraindicated for:
urethrography as part of a full uro- • Patients who are pregnant or suspected
dynamic study, helps to diagnose of being pregnant, unless the potential
neuromuscular dysfunction and incon- benefits of the procedure far outweigh
tinence. ■ the risks to the fetus and mother.
Factors that may impair the minimal during the catheter inser-
results of the examination: tion. Inform the patient that the pro-
• Inability of the patient to cooperate or cedure is performed in a special
remain still during the procedure be- laboratory by a health care practi-
tioner and takes about 30 minutes to
complete.
status
➤ Under medical direction, the patient
• Age-related decreases in electrical activity should avoid muscle relaxants, cholin-
ergics, and anticholinergics for 3 to 6
• Medications such as muscle relaxants, days before the test.
cholinergics, and anticholinergics
➤ Assess for ability to comply with
directions given for exercising during
Other considerations: the test.
• Failure to follow dietary restrictions be- ➤ The patient should fast and refrain
fore the procedure may cause the pro- from drinking liquids for 8 hours prior
cedure to be canceled or repeated. to the procedure.
Nursing Implications and procedure and before administering
any medications.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: Intratest:
➤ Inform the patient that the procedure ➤ Ensure that the patient has complied
is performed to measure electrical with dietary, fluids, and medication
activity of the pelvic floor muscles. restrictions and pretesting prepara-
tions.
➤ Obtain a history of neuromuscular
and neurosensory status, diseases or ➤ Ask the patient to void immediately
conditions that affect muscle func- before the test.
tion, level of muscular function and ➤ Place the patient in a supine position
range of motion, and traumatic on the examining table and place a
events, as well as the results of drape over the patient, exposing the
previously performed laboratory perineal area.
➤ Ask the patient to remain very still
and relaxed and to cooperate with
diagnostic tests, refer to the Geni-
instructions given to contract mus-
tourinary and Musculoskeletal Sys-
cles during the procedure.
tem tables.
patient is taking, especially medica- Appendix A.
tions known to affect bleeding inclu-
ding anticoagulants, aspirin and other ➤ Two skin electrodes are positioned
salicylates, etc. slightly to the left and right of the
perianal area and a grounding elec-
➤ Ensure that the patient has refrained trode is placed on the thigh.
from smoking and drinking caffeine-
containing beverages for 3 hours be- ➤ If needle electrodes are used, they
fore the procedure. are inserted into the muscle sur-
rounding the urethra.
patient. Address concerns about pain ➤ Muscle activity signals are recorded
related to the procedure. Warn the as waves, which are interpreted for
patient that the procedure may be number and configurations in diag-
uncomfortable, but that an analgesic nosing urinary abnormalities.
or sedative will be administered. ➤ An indwelling urinary catheter is
Assure the patient that the pain is inserted, and the bulbocavernosus
Electromyography, Pelvic Floor Sphincter 599
reflex is tested; the patient is ➤ If tested with needle electrodes,

instructed to cough while the cathe- warn female patients to expect
ter is gently pulled. hematuria after the first voiding.
➤ Voluntary control is tested by re- ➤ Advise the patient to report symp-
questing the patient to contract and toms of urethral irritation, such as
relax the muscle. Electrical activity is dysuria, persistent or prolonged
recorded during this period of relax- hematuria, and urinary frequency.
ation with the bladder empty. ➤ A written report of the examination
➤ The bladder is filled with sterile will be completed by a health care
water at a rate of 100 mL/min while practitioner specializing in this branch
the electrical activity during filling is of medicine. The report will be sent
recorded. to the requesting health care practi-
➤ The catheter is removed; the patient
with the patient.
is then placed in a position to void
and is asked to urinate and empty ➤ Recognize anxiety related to test
the full bladder. This voluntary urina- results, and be supportive of per-
tion is then recorded until com- ceived loss of independent function.
pleted. The complete procedure Discuss the implications of abnormal
includes recordings of electrical sig- test results on the patient’s lifestyle.
nals before, during, and at the end of Provide teaching and information re-
urination. garding the clinical implications of
in a computerized system for recall ➤ Reinforce information given by the
and postprocedure interpretation by patient’s health care provider regard-
the appropriate health care practi- ing further testing, treatment, or re-
tioner. ferral to another health care provider.
any concerns voiced by the patient or
Post-test: family.
➤ Instruct the patient to resume usual ➤ Depending on the results of this
diet, fluids, medications or activity, procedure, additional testing may be
as directed by the health care practi- needed to evaluate or monitor pro-
tioner. gression of the disease process and
➤ Monitor vital signs and neurologic determine the need for a change in
status every 15 minutes for 1 hour, therapy. Evaluate test results in rela-
then every 2 hours for 4 hours, and tion to the patient’s symptoms and
as ordered. Take temperature every 4 other tests performed.
hours for 24 hours. Compare with
baseline values. Protocols may vary Related diagnostic tests:
from facility to facility. ➤ Related diagnostic tests include
➤ Instruct the patient to increase fluid cystometry, cystoscopy, and intra-
intake unless contraindicated. venous pyelography.
ELECTRONEUROGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Electrodiagnostic study, nerve conduction

study, ENG.
AREA OF APPLICATION: Muscles.

CONTRAST: None.
DESCRIPTION & RATIONALE: Electro- conjunction with electromyography

neurography (ENG) is performed to in a combined test called electromy-
identify peripheral nerve injury, to oneurography. ■
differentiate primary peripheral nerve
pathology from muscular injury, and INDICATIONS: Confirm diagnosis of
to monitor response of the nerve peripheral nerve damage or trauma
injury to treatment. A stimulus is
applied through a surface electrode RESULT
over a nerve. After a nerve is electri-
cally stimulated proximally, the time Normal Findings:
for the impulse to travel to a second or • No evidence of peripheral nerve injury
distal site is measured. Because the or disease. Variable readings depend on
the nerve being tested. For patients age
conduction study of a nerve can vary
3 years and older, the maximum con-
from nerve to nerve, it is important to duction velocity is 40 to 80 millisec-
compare the results of the affected onds; for infants and the elderly, the
side to those of the contralateral side. values are divided by 2.
The results of the stimulation are
shown on a monitor, but the actual Abnormal Findings:
velocity must be calculated by divid- • Carpal tunnel syndrome
ing the distance in meters between the
• Diabetic neuropathy
stimulation point and the response
point, by the time between the stimu- • Guillain-Barré syndrome
lus and response. Traumatic nerve • Herniated disk disease
transection, contusion, or neuropathy
• Muscular dystrophy
will usually cause maximal slowing of
conduction velocity in the affected • Myasthenia gravis
side compared with that in the normal • Poliomyelitis
side. A velocity greater than normal
does not indicate a pathologic condi- • Tarsal tunnel syndrome
tion. This test is usually performed in • Thoracic outlet syndrome
Electroneurography 601
CRITICAL VALUES: N/A tion restrictions unless by medical

direction.
INTERFERING FACTORS: ➤ Make sure a written and informed
Factors that may impair the procedure and before administering
results of the examination: any medications.
Intratest:
or remain still during the procedure
because of age, significant pain, or ➤ Have patient remove clothing and
mental status any hosiery. Patients are given a
gown to wear and instructed to void
• Age-related decreases in electrical prior to the procedure.
activity ➤ Place the patient in a supine or sitting
• Poor electrode conduction or failure position, depending on the location
to obtain contralateral value for com- of the muscle to be tested.
parison ➤ Observe standard precautions, and
Appendix A.
Nursing Implications and ➤ Shave the extremity in the area to be
Procedure ● ● ● ● ● ● ● ● ● ● ●
stimulated, and cleanse the skin
thoroughly with alcohol pads.
Pretest: ➤ Apply electrode gel and place a
recording electrode at a known dis-
➤ Inform the patient that the procedure tance from the stimulation point.
is performed to measure electrical Measure the distance between the
activity of the muscles. stimulation point and the site of the
➤ Obtain a history of neuromuscular recording electrode in centimeters.
and neurosensory status, diseases ➤ Place a reference electrode nearby
or conditions that affect muscle func- on the skin surface.
tion, level of muscular function and
➤ The nerve is electrically stimulated
range of motion, and traumatic events,
by a shock-emitter device; the time
as well as the results of previously
between nerve impulse and electri-
cal contraction, measured in millisec-
procedures, and other diagnostic pro-
onds (distal latency), is shown on a
cedures. For related diagnostic tests,
monitor.
refer to the Musculoskeletal System
table. ➤ The nerve is also electrically stimu-
lated at a location proximal to the
➤ Obtain a list of the medications the area of suspected injury or disease.
patient is taking.
➤ The time required for the impulse to
➤ Review the procedure with the travel from the stimulation site to
patient. Address concerns about pain location of the muscle contraction
related to the procedure. Inform the (total latency) is recorded in millisec-
patient that the procedure may be onds.
uncomfortable because of a mild
electrical shock, but that the electri- ➤ Calculate the conduction velocity.
cal shock is brief and is not harmful. The conduction velocity is converted
Inform the patient that the procedure to meters per second and computed
is performed in a special laboratory using the following equation:
by a physiatrist or neurologist and
Conduction velocity
takes approximately 15 minutes to
(in meters per second)
complete, but can take longer
depending on the patient’s condition. [distance (in meters)]

➤ There are no food, fluid, or medica- [total latency – distal latency]
Post-test: ceived loss of independent function.

Discuss the implications of abnormal
➤ When the procedure is complete, test results on the patient’s lifestyle.
remove the electrodes and clean the Provide teaching and information
skin where the electrodes were regarding the clinical implications of
applied. the test results, as appropriate.
➤ Monitor electrode sites for inflamma- ➤ Reinforce information given by the
tion. patient’s health care provider regard-
➤ If residual pain is noted after the pro- ing further testing, treatment, or refer-
cedure, instruct the patient to apply ral to another health care provider.
warm compresses and to take anal- Answer any questions or address
gesics, as ordered. any concerns voiced by the patient or
family.
diet, medication, and activity, as ➤ Depending on the results of this pro-
directed by the health care practi- cedure, additional testing may be
will be completed by a health care in therapy. Evaluate test results in
practitioner specializing in this branch relation to the patient’s symptoms
of medicine. The report will be sent and other tests performed.
with the patient. Related diagnostic tests:
➤ Recognize anxiety related to test ➤ Related diagnostic tests include elec-
results, and be supportive of per- tromyography.
EOSINOPHIL COUNT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Eos count, total eosinophil count.

SPECIMEN: Whole blood (1 mL) collected in a lavender-top
(EDTA) tube.
REFERENCE VALUE: (Method: Manual count using eosinophil stain and

hemocytometer or automated analyzer)
Absolute count: 50 to 350/mm3
Relative percentage: 1% to 4%
DESCRIPTION & RATIONALE: Eosi- antibody complexes and response to

nophils are white blood cells whose allergy-inducing substances and para-
function is phagocytosis of antigen- sites. Eosinophils have granules that
Eosinophil Count 603
contain histamine used to kill foreign • Polycythemia vera

cells in the body. Eosinophils also • Rheumatoid arthritis
contain proteolytic substances that
• Rhinitis
damage parasitic worms. The binding
of histamine to receptor sites on cells • Sarcoidosis
results in smooth muscle contraction • Splenectomy
in the bronchioles and upper respira-
tory tract, constriction of pulmonary • Tuberculosis
vessels, increased mucus production,
and secretion of acid by the cells that Decreased in:
line the stomach. Eosinophil counts • Aplastic anemia
can increase to greater than 30% of • Eclampsia
normal in parasitic infections; how-
• Infections (shift to the left)
ever, a significant percentage of chil-
dren with visceral larva migrans • Stress
infestations have normal eosinophil
counts. ■ CRITICAL VALUES: N/A
INDICATIONS: Assist in the diagnosis of INTERFERING FACTORS:
conditions such as allergies, parasitic • Numerous drugs and substances can
infections, drug reactions, collagen dis- cause an increase in eosinophil levels as
eases, Hodgkin’s disease, and myeloprolif- a result of an allergic response or hyper-
erative disorders sensitivity reaction. These include ace-
tophenazine, allopurinol, aminosalicylic
RESULT acid, ampicillin, butaperazine, capre-
omycin, carisoprodol, cephaloglycin,
Increased in: cephaloridine, cephalosporins, cepha-
• Addison’s disease pirin, cephradine, chloramphenicol,
clindamycin, cloxacillin, dapsone, epi-
• Allergy cillin, erythromycin, fluorides, gold,
• Asthma imipramine, iodides, kanamycin, mefe-
namic acid, methicillin, methyldopa,
• Cancer minocycline, nalidixic acid, niridazole,
• Dermatitis nitrofurans (including nitrofurantoin),
nonsteroidal anti-inflammatory drugs,
• Drug reactions nystatin, oxamniquine, penicillin, pen-
• Eczema icillin G, procainamide, ristocetin,
streptokinase, streptomycin, tetracy-
• Hay fever cline, triamterene, tryptophan, and
• Hodgkin’s disease viomycin.
• Hypereosinophilic syndrome • Drugs that can cause a decrease in

eosinophil levels include acetylsalicylic
• Löffler’s syndrome acid, amphotericin B, corticotropin,
desipramine, glucocorticoids, hydrocor-
• Myeloproliferative disorders
tisone, interferon, niacin, prednisone,
• Parasitic infection (visceral larva and procainamide.
migrans)
• Clotted specimens should be rejected
• Pernicious anemia for analysis.
• Specimens more than 4 hours old ➤ There are no food, fluid, or medica-
should be rejected for analysis. tion restrictions, unless by medical
direction.
• There is a diurnal variation in
eosinophil counts. The count is lowest Intratest:
in the morning and continues to rise
throughout the day until midnight.
Therefore, serial measurements should be taken to avoid the use of equip-
be performed at the same time of day ment containing latex.
for purposes of continuity.
Pretest: Appendix A. Positively identify the pa-
tient, and label the appropriate tubes
➤ Inform the patient that the test is with the corresponding patient demo-
used to assist in the diagnosis of graphics, date, and time of collec-
conditions related to immune re- tion. Perform a venipuncture; collect
sponse, such as allergy or parasitic the specimen in a 5-mL lavender-top
infection. (EDTA) tube.
➤ Obtain a history of the patient’s com- ➤ Remove the needle, and apply a
plaints, including a list of known pressure dressing over the puncture
analysis.
hematopoietic, immune, and respira- ➤ The results are recorded manually or
tory systems, as well as results of in a computerized system for recall
previously performed laboratory and postprocedure interpretation by
tests, surgical procedures, and other the appropriate health care practi-
diagnostic procedures. For related tioner.
Hematopoietic, Immune, and Respi- Post-test:
ratory System tables.
➤ Obtain a list of the medications the ing or hematoma formation. Apply
nutritional supplements, and nutra- pressure bandage in place, or
ceuticals. The requesting health care replace with a plastic bandage.
➤ Nutritional considerations: Consider-
ation should be given to diet if food
allergies are present.
when reviewing results. ➤ Instruct the patient with an elevated
eosinophil count to report any signs
or symptoms of infection, such as
fever.
5 to 10 minutes. Address concerns ➤ Instruct the patient with an elevated
about pain related to the procedure. count to rest and take medications
Explain to the patient that there may as prescribed, to increase fluid intake
be some discomfort during the as appropriate, and to monitor tem-
venipuncture. perature.
Erythrocyte Protoporphyrin, Free 605

➤ Reinforce information given by the and other tests performed.
vider. Answer any questions or ➤ Related laboratory tests include
address any concerns voiced by the allergen-specific immunoglobulin E
patient or family. (IgE), complete blood count, fecal
➤ Depending on the results of this pro- analysis, hypersensitivity pneumoni-
cedure, additional testing may be tis screen, IgE, ova and parasites,
performed to evaluate or monitor and stool culture.
ERYTHROCYTE
PROTOPORPHYRIN, FREE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Free erythrocyte protoporphyrin (FEP).

SPECIMEN: Whole blood (1 mL) collected in lavender-top
(ethylenediaminetetra-acetic acid [EDTA]) or green-top (heparin) tube.
REFERENCE VALUE: (Method: Fluorometry)
SI Units combines with iron to form the heme

Conventional (Conventional portion of hemoglobin. Protopor-
Units Units 0.0178) phyrin converts to bilirubin, com-
17–77 g/dL 0.3–1.37 bines with albumin, and remains
of packed mol/L of unconjugated in the circulation after
cells packed cells hemoglobin breakdown. Increased
amounts of protoporphyrin can be
detected in erythrocytes, urine, and
stool in conditions interfering with
DESCRIPTION & RATIONALE: The heme synthesis. Protoporphyria is an
free erythrocyte protoporphyrin test autosomal dominant disorder in
measures the concentration of proto- which increased amounts of protopor-
porphyrin in red blood cells. Proto- phyrin are secreted and excreted; the
porphyrin comprises the predominant disorder is thought to be the result of
porphyrin in red blood cells, which an enzyme deficiency. Protoporphyria

causes photosensitivity and may lead
to cirrhosis of the liver and cholelithi- sitivities to latex), and inform the
asis as a result of protoporphyrin appropriate health care practitioner
deposits. ■ accordingly.
INDICATIONS: results of previously performed labo-
• Assist in the diagnosis of erythropoietic ratory tests, surgical procedures, and
protoporphyrias other diagnostic procedures. For
• Assist in the differential diagnosis of related laboratory tests, refer to the
Hematopoietic System table.
iron deficiency in pediatric patients
• Evaluate lead poisoning patient is taking, including herbs,
Increased in: advised if the patient regularly uses
• Anemia of chronic disease these products so that their effects
• Conditions with marked erythropoiesis when reviewing results.
(e.g., hemolytic anemias) ➤ Review the procedure with the
• Erythropoietic protoporphyria imen collection takes approximately
• Iron-deficiency anemias 5 to 10 minutes. Address concerns
• Lead poisoning Explain to the patient that there may
• Some sideroblastic anemias venipuncture.
Decreased in: N/A tion restrictions, unless by medical
direction.
Intratest:
• Drugs that may increase erythrocyte allergic reaction to latex, care should
protoporphyrin levels include barbitu- be taken to avoid the use of equip-
rates, chlorpropamide, oral contracep- ment containing latex.
tives, sulfomethane, and tolbutamide. ➤ Instruct the patient to cooperate fully
• The test is unreliable in infants less patient to breathe normally and to
than 6 months of age. avoid unnecessary movement.
Nursing Implications and Appendix A. Positively identify the pa-
Procedure ● ● ● ● ● ● ● ● ● ● ● tient, and label the appropriate tubes
with the corresponding patient demo-
Pretest: graphics, date, and time of collection.
Perform a venipuncture; collect the
➤ Inform the patient that the test is specimen in a 5-mL lavender-top tube.
used to detect lead toxicity and to Specimens should be protected from
monitor chronic lead exposure. It is light.
also used to differentiate disorders in ➤ Remove the needle, and apply a
heme and globin production. pressure dressing over the puncture
➤ Obtain a history of the patient’s site.
Erythrocyte Sedimentation Rate 607
➤ Promptly transport the specimen to patient’s health care provider regard-

the laboratory for processing and ing further testing, treatment, or re-
analysis. ferral to another health care provider.
➤ The results are recorded manually or Answer any questions or address
in a computerized system for recall any concerns voiced by the patient or
and postprocedure interpretation by family.
the appropriate health care practi- ➤ Depending on the results of this pro-
tioner. cedure, additional testing may be
➤ Observe venipuncture site for bleed- in therapy. Evaluate test results in
ing or hematoma formation. Apply relation to the patient’s symptoms
paper tape or other adhesive to hold and other tests performed.
will be sent to the requesting health ➤ Related laboratory tests include
care practitioner, who will discuss hematocrit, hemoglobin, iron/total
the results with the patient. iron-binding capacity, lead, and urine
➤ Reinforce information given by the porphyrins.
ERYTHROCYTE SEDIMENTATION RATE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Sed rate, ESR.

SPECIMEN: Whole blood (5 mL) collected in a lavender-top (ethylenedi-
aminetetra-acetic acid [EDTA]) tube for the modified Westergren method
or gray-top (3.8% sodium citrate) tube for the original Westergren method.
REFERENCE VALUE: (Method: Westergren)
Age Male Female

Newborn 0–2 mm/h 0–2 mm/h
Less than 50 y 0–15 mm/h 0–25 mm/h
50 y and older 0–20 mm/h 0–30 mm/h
DESCRIPTION & RATIONALE: The tion of red blood cells (RBCs) in an

erythrocyte sedimentation rate (ESR) anticoagulated whole blood sample
is a measure of the rate of sedimenta- over a specified period of time. The
basis of the ESR test is the alteration RESULT

of blood proteins by inflammatory
Increased in:
and necrotic processes that cause the
RBCs to stick together, become heav- • Acute myocardial infarction
ier, and rapidly settle at the bottom of • Anemia
a vertically held, calibrated tube over
• Carcinoma
time. In general, relatively little set-
tling occurs in normal blood because • Cat scratch fever
normal RBCs do not form rouleaux • Collagen diseases, including systemic
and would not stack together, increas- lupus erythematosus (SLE)
ing their mass and rate of sedimen-
tation. The sedimentation rate is
proportional to the size or mass of the • Endocarditis
falling RBCs and is inversely propor- • Heavy metal poisoning
tional to plasma viscosity. The test is a
nonspecific indicator of disease but is • Increased plasma protein level
fairly sensitive and is frequently the • Infections (e.g., pneumonia, syphilis)
earliest indicator of widespread
• Inflammatory diseases
inflammatory reaction due to infec-
tion or autoimmune disorders. Pro- • Lymphoma
longed elevations are also present in • Lymphosarcoma
malignant disease. The ESR can also
• Multiple myeloma
be used to monitor the course of a dis-
ease and the effectiveness of therapy. • Nephritis
The two most commonly used meth- • Pregnancy
ods to measure the ESR are the
Westergren (or modified Westergren) • Pulmonary embolism
method and the Wintrobe hematocrit • Rheumatic fever
method. ■
INDICATIONS: • Subacute bacterial endocarditis
• Assist in the diagnosis of acute infec- • Temporal arteritis
tion, such as tuberculosis or tissue
necrosis • Toxemia
• Assist in the diagnosis of acute inflam- • Tuberculosis
matory processes • Waldenström’s macroglobulinemia
• Assist in the diagnosis of chronic infec-
tions Normal in:
• Assist in the diagnosis of rheumatoid or
autoimmune disorders • Glucose-6-phosphate dehydrogenase
deficiency
• Assist in the diagnosis of temporal
arthritis and polymyalgia rheumatica • Hemoglobin C disease
• Hypofibrinogenemia
• Monitor inflammatory and malignant
disease • Polycythemia
Erythrocyte Sedimentation Rate 609
• Sickle cell anemia has been stored at room temperature;

delays in testing may result in decreased
• Spherocytosis
values. If a delay in testing is antici-
pated, refrigerate the sample at 2C to
Decreased in:
4C; stability at refrigerated tempera-
• Conditions resulting in high hemoglo- ture is reported to be extended up to 12
bin and RBC count hours. Refrigerated specimens should
• Elevated blood glucose be brought to room temperature before
testing.
INTERFERING FACTORS: Nursing Implications and
• Some drugs cause an SLE-like syn- Procedure ● ● ● ● ● ● ● ● ● ● ●
drome that results in a physiologic

increase in ESR. These include anti- Pretest:
convulsants, hydrazine derivatives,
nitrofurantoin, procainamide, and quini- ➤ Inform the patient that the test is a
dine. Other drugs that may cause an nonspecific indicator of inflamma-
tion.
increased ESR include acetylsalicylic
acid, cephalothin, cephapirin, cyclo- ➤ Obtain a history of the patient’s
sporin A, dextran, and oral contracep- complaints, including a list of known
tives. sitivities to latex), and inform the
• Drugs that may cause a decrease in ESR appropriate health care practitioner
include aurothiomalate, corticotropin, accordingly.
cortisone, and quinine. ➤ Obtain a history of infectious, auto-
immune, or neoplastic diseases.
• Menstruation may cause falsely in-
creased test results. ➤ Obtain a history of the patient’s
hematopoietic, immune, and res-
• Prolonged tourniquet constriction piratory systems, as well as results
around the arm may cause hemocon- of previously performed laboratory
centration and falsely low values. tests, surgical procedures, and other
• The Westergren and modified Wester- laboratory tests, refer to the Hema-
gren methods are affected by heparin, topoietic, Immune, and Respiratory
which causes a false elevation in values. System tables.
• Bubbles in the Westergren tube or ➤ Obtain a list of the medications the
pipette, or tilting the measurement col- patient is taking, including herbs,
umn more than 3 from vertical, will nutritional supplements, and nutra-
falsely increase the values. ceuticals. The requesting health care
• Movement or vibration of the surface advised if the patient regularly uses
on which the test is being conducted these products so that their effects
will affect the results. can be taken into consideration
• Inaccurate timing will invalidate test
results. patient. Inform the patient that spec-
• Specimens that are clotted, hemolyzed, imen collection takes approximately
or insufficient in volume should be 5 to 10 minutes. Address concerns
rejected for analysis. about pain related to the procedure.
• The test should be performed within 4 be some discomfort during the veni-
hours of collection when the specimen puncture.
➤ There are no food, fluid, or medica- the appropriate health care practi-
tion restrictions, unless by medical tioner.
direction.
Post-test:
Intratest:
➤ If the patient has a history of severe ing or hematoma formation. Apply
allergic reaction to latex, care should paper tape or other adhesive to hold
be taken to avoid the use of equip- pressure bandage in place, or
ment containing latex. replace with a plastic bandage.
➤ Instruct the patient to cooperate fully ➤ A written report of the examination
and to follow directions. Direct the will be sent to the requesting health
patient to breathe normally and to care practitioner, who will discuss
avoid unnecessary movement. the results with the patient.
➤ Observe standard precautions, and ➤ Reinforce information given by the
follow the general guidelines in patient’s health care provider regard-
Appendix A. Positively identify the ing further testing, treatment, or
patient, and label the appropriate referral to another health care
tubes with the corresponding patient provider. Answer any questions or
demographics, date, and time of address any concerns voiced by the
collection. Perform a venipuncture; patient or family.
collect the specimen in a 5-mL gray- ➤ Depending on the results of this pro-
top (sodium citrate) tube if the cedure, additional testing may be
Westergren method will be used. performed to evaluate or monitor
Collect the specimen in a 5-mL pur- progression of the disease process
ple-top (EDTA) tube if the modified and determine the need for a change
Westergren method will be used. in therapy. Evaluate test results in
➤ Remove the needle, and apply a relation to the patient’s symptoms
pressure dressing over the puncture and other tests performed.
site.
➤ Promptly transport the specimen to Related laboratory tests:
the laboratory for processing and ➤ Related laboratory tests include
analysis. complete blood count, C-reactive
➤ The results are recorded manually or protein, rheumatoid factor, micro-
in a computerized system for recall organism-specific serologies, and re-
and postprocedure interpretation by lated cultures.
ERYTHROPOIETIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: EPO.
Erythropoietin 611
SI Units
• Secondary polycythemia (high-altitude
Conventional (Conventional
hypoxia, chronic obstructive pul-
Units Units 1)
monary disease, pulmonary fibrosis)
5–36 mU/mL 5–36 U/L Decreased in:

• Chemotherapy
• Primary polycythemia
• Renal failure
DESCRIPTION & RATIONALE: Erythro-
poietin (EPO) is a glycoprotein pro-
duced mainly by the kidney. Its
function is to stimulate the bone mar- INTERFERING FACTORS:
row to make red blood cells. EPO lev- • Drugs that may increase EPO levels
els fall after removal of the kidney but include anabolic steroids.
do not disappear completely. It is • Drugs that may decrease EPO levels
thought that small amounts of EPO include amphotericin B, cisplatin,
may be produced by the liver. enalapril, estrogens, and theophylline.
Erythropoiesis is regulated by EPO • Blood transfusions may also decrease
and tissue PO2. When PO2 is normal, EPO levels.
EPO levels decrease; when PO2 falls,
EPO secretion occurs and EPO levels
increase. ■ fere with test results when radioim-
INDICATIONS:
• Assist in assessment of anemia of end-
stage renal disease Nursing Implications and
• Assist in the diagnosis of EPO-produc- Procedure ● ● ● ● ● ● ● ● ● ● ●
ing tumors
Pretest:
• Evaluate the presence of rare anemias
• Monitor patients receiving EPO therapy used in the evaluation of anemias.
RESULT plaints, including a list of known
• After moderate bleeding in an other- appropriate health care practitioner
wise healthy patient accordingly.
• Anemias hematopoietic and genitourinary sys-
• Hepatoma tems, as well as results of previously
• Kidney transplant rejection procedures, and other diagnostic
• Nephroblastoma tests, refer to the Hematopoietic and
• Pheochromocytoma Genitourinary System tables.
• Polycystic kidney disease interfere with test results.
• Pregnancy ➤ Obtain a list of the medications the
patient is taking, including herbs, ➤ The results are recorded manually or

nutritional supplements, and nutra- in a computerized system for recall
ceuticals. The requesting health care and postprocedure interpretation by
practitioner and laboratory should be the appropriate health care practi-
advised if the patient regularly uses tioner.
when reviewing results. Post-test:
➤ Review the procedure with the ➤ Observe venipuncture site for bleed-
patient. Inform the patient that spec- ing or hematoma formation. Apply
imen collection takes approximately paper tape or other adhesive to hold
5 to 10 minutes. Address concerns pressure bandage in place, or re-
about pain related to the procedure. place with a plastic bandage.
Explain to the patient that there may ➤ A written report of the examination
be some discomfort during the will be sent to the requesting health
venipuncture. care practitioner, who will discuss
tion restrictions, unless by medical ➤ Reinforce information given by the
Intratest: referral to another health care pro-
➤ If the patient has a history of severe vider. Answer any questions or
allergic reaction to latex, care should address any concerns voiced by the
be taken to avoid the use of equip- patient or family.
ment containing latex. ➤ Depending on the results of this pro-
➤ Instruct the patient to cooperate fully cedure, additional testing may be
and to follow directions. Direct the performed to evaluate or monitor
patient to breathe normally and to progression of the disease process
avoid unnecessary movement. and determine the need for a change
➤ Observe standard precautions, and relation to the patient’s symptoms
follow the general guidelines in and other tests performed.
tubes with the corresponding patient Related laboratory tests:
lection. Perform a venipuncture; col- ➤ Related laboratory tests include bone
lect the specimen in a 5-mL red- or marrow biopsy, complete blood
tiger-top tube. count, creatinine, creatinine clear-
ance, ferritin, hemoglobin, hemat-
➤ Remove the needle, and apply a pres- ocrit, iron/total iron-binding capacity,
sure dressing over the puncture site. microalbumin, red blood cell count,
➤ Promptly transport the specimen to red blood cell indices, red blood cell
the laboratory for processing and morphology and inclusions, urea
analysis. nitrogen, and vitamin B12.
Esophageal Manometry 613
ESOPHAGEAL MANOMETRY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Esophageal function study, esophageal acid study

(Tuttle test), acid reflux test, Bernstein test (aid perfusion), esophageal
motility study.
AREA OF APPLICATION: Esophagus.
CONTRAST: Done with or without noniodinated contrast medium.
• Aid in the diagnosis of esophagitis, evi-

DESCRIPTION & RATIONALE: Eso- denced by decreased motility
phageal manometry (EM) consists of
• Aid in the diagnosis of GER, evidenced
a group of invasive studies performed
by low pressure in EM, decreased pH
to assist in diagnosing abnormalities in acidity test, and pain in acid reflux
of esophageal muscle function and and perfusion tests
esophageal structure. These studies
measure esophageal pressure, the • Differentiate between esophagitis or
effects of gastric acid in the esophagus, cardiac condition as the cause of epi-
gastric pain
lower esophageal sphincter pressure,
and motility patterns that result dur- • Evaluate pyrosis and dysphagia to
ing swallowing. EM can be used to determine if the cause is GER or
document and quantify gastroe- esophagitis
sophageal reflux (GER). It is indicated
when a patient is experiencing diffi- RESULT
culty swallowing, heartburn, regurgi-
Normal Findings:
tation, or vomiting; or has chest pain
• Acid clearing: fewer than 10 swallows
for which no diagnosis has been
found. Tests performed in combina- • Acid perfusion: no GER
tion with EM include the acid reflux, • Acid reflux: no regurgitation into the
acid clearing, and acid perfusion esophagus
(Bernstein) tests. ■
• Bernstein test: negative
INDICATIONS: • Esophageal secretions: pH 5 to 6
• Aid in the diagnosis of achalasia, evi-
• Esophageal sphincter pressure: 10 to 20
denced by increased pressure in EM
mm Hg
• Aid in the diagnosis of chalasia in chil-
dren, evidenced by decreased pressure Abnormal Findings:
in EM
• Achalasia (sphincter pressure of 50
• Aid in the diagnosis of esophageal scle-
mm Hg)
roderma, evidenced by decreased pres-
sure in EM • Chalasia
• Esophageal scleroderma complaints, including a list of known

• Esophagitis sitivities to latex, iodine, seafood,
contrast medium, and dyes.
• GER (sphincter pressure of 0 to 5 mm
Hg, pH of 1 to 3) ➤ Obtain a history of the patient’s res-
piratory and gastrointestinal sys-
• Hiatal hernia tems, and results of previously
performed diagnostic procedures,
• Progressive systemic sclerosis (sclero- surgical procedures, and laboratory
derma) tests. For related diagnostic tests,
refer to the Respiratory and Gastro-
• Spasms intestinal System tables.
CRITICAL VALUES: N/A formed before an upper gastroin-
INTERFERING FACTORS: ➤ Record the date of the last menstrual
This procedure is of pregnancy in perimenopausal
contraindicated for: women.
• Patients with unstable cardiopulmonary ➤ Obtain a list of the medications the
status, blood coagulation defects, recent patient is taking.
gastrointestinal surgery, esophageal ➤ Review the procedure with the
varices, or bleeding patient. Address concerns about pain
Factors that may impair the the patient that some pain may be
results of the examination: experienced during the test, and
• Inability of the patient to cooperate or there may be moments of discom-
fort and gagging when the scope is
inserted, but there are no complica-
because of age, significant pain, or tions resulting from the procedure
mental status and the throat will be anesthetized
• Administration of medications (e.g., with a spray or swab. Explain the pur-
pose of the test and how the proce-
sedatives, antacids, anticholinergics,
dure is performed. Inform the patient
cholinergics, corticosteroids) that can that the procedure is performed in an
change pH or relax the sphincter mus- endoscopy suite by a health care
cle, causing inaccurate results practitioner, under local anesthesia,
and takes approximately 30 to 45
Other considerations: minutes.
• Failure to follow dietary restrictions ➤ Inform the patient that dentures and
before the procedure may cause the eyewear will be removed before the
procedure to be canceled or repeated. test.
➤ Inform the patient that he or she will
not be able to speak during the pro-
Nursing Implications and cedure, but that breathing will not be
affected.
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: may be started to allow for the infu-
sion of a sedative or IV fluids.
➤ Inform the patient that the procedure ➤ Sensitivity to cultural and social
assesses the esophagus. issues, as well as concern for mod-
➤ Obtain a history of the patient’s esty, is important in providing psy-
Esophageal Manometry 615
chological support before, during and ➤ Spray or swab the oropharynx with a
after the procedure. topical local anesthetic.
➤ The patient should fast and refrain ➤ Provide an emesis basin for the
from drinking liquids for 6 to 8 hours increased saliva and encourage the
before the test. patient to spit out the saliva because
➤ Under medical direction, the patient the gag reflex may be impaired.
should withhold medications for 24 ➤ During the procedure, monitor the
hours before the study; special ar- patient to prevent aspiration of stom-
rangements may be necessary for ach contents into the lungs. Note any
diabetic patients. change in respirations (dyspnea,
➤ Obtain and record baseline vital tachypnea, adventitious sounds).
signs. ➤ Suction the mouth, pharynx, and tra-
➤ Make sure a written and informed chea, and administer oxygen as
consent has been signed prior to the ordered.
any medications. Esophageal manometry:
➤ One or more small tubes are inserted
Intratest: through the nose into the esophagus
and stomach.
with dietary, fluids, and medication ➤ A small transducer is attached to the
restrictions and pretesting prepara- ends of the tubes; pressures are
tions. measured at the lower esophageal
sphincter, and intraluminal pressures
➤ Keep resuscitation equipment on as well as regularity and duration of
hand in the case of respiratory peristaltic contractions are meas-
impairment or laryngospasm after ured.
the procedure.
➤ The patient is asked to swallow small
amounts of water or flavored gelatin.
patients with asthma or other pul-
monary disease. This drug can fur- ➤ Pressures are taken and recorded,
ther exacerbate bronchospasms and and a motility pattern is recorded on
respiratory impairment. a graph.
➤ Have patient remove dentures, con-
tact lenses, eyeglasses, and jewelry. Esophageal acid and
Notify the physician if the patient has clearing (Tuttle test):
permanent crowns on teeth. Have
the patient remove clothing and ➤ With the tube in place, a pH elec-
change into a gown for the proce- trode probe is inserted into the
dure. esophagus with Valsalva maneuvers
performed to stimulate reflux of
➤ Have the patient void before the pro- stomach contents into the esopha-
cedure begins. gus.
➤ Instruct the patient to cooperate fully ➤ If acid reflux is absent, 100 mL of
and to follow directions. Instruct the 0.1% hydrochloric acid is instilled
patient to remain still throughout the into the stomach during a 3-minute
procedure because movement pro- period, and then the pH measure-
duces unreliable results. ment is repeated.
➤ Observe standard precautions, and ➤ To determine acid clearing, hydro-
follow the general guidelines in chloric acid is instilled into the esoph-
Appendix A. agus and the patient is asked to
➤ Start an IV line and administer swallow while the probe measures
ordered sedation. the pH.
Acid perfusion 15 respirations per minute) every 15

(Bernstein test): minutes for 2 hours. Resuscitation
equipment should be available.
➤ A catheter is inserted through the
nose into the esophagus and the ➤ Observe the patient for indications of
patient is asked to inform the techni- perforation: painful swallowing with
cian when pain is experienced. neck movement, substernal pain
with respiration, shoulder pain, dysp-
➤ Normal saline solution is allowed to nea, abdominal or back pain, cyano-
drip into the catheter at about 10 sis, and fever.
mL/min. Then hydrochloric acid is
allowed to drip into the catheter. ➤ Emphasize that any severe pain,
fever, difficulty breathing, or expecto-
➤ Pain experienced when the hydro-
ration of blood must be reported to
chloric acid is instilled determines
the health care practitioner immedi-
the presence of an esophageal
ately.
abnormality. If no pain is experi-
enced, symptoms are the result of ➤ A written report of the examination
some other condition. will be completed by a health care
General: of medicine. The report will be sent
with the patient.
the appropriate health care practi- ➤ Reinforce information given by the
tioner. patient’s health care provider regard-
Post-test: referral to another health care pro-
➤ Do not allow the patient to eat or address any concerns voiced by the
drink until the gag reflex returns; patient or family.
then allow the patient to eat lightly
for 12 to 24 hours. ➤ Depending on the results of this pro-
activity, medication, and diet 24 gression of the disease process and
hours after the examination or as tol- determine the need for a change in
erated, as directed by the health care therapy. Evaluate test results in rela-
practitioner. tion to the patient’s symptoms and
➤ Tell the patient to expect some throat other tests performed.
soreness and possible hoarseness.
Advise the patient to use warm gar-
gles, lozenges, or ice packs to the Related diagnostic tests:
neck; or to drink cool fluids to allevi- ➤ Related diagnostic tests include chest
ate throat discomfort. x-ray, computed tomography of the
➤ Monitor the patient for signs of thorax, lung scan, and magnetic res-
respiratory depression (less than onance imaging of the chest.
Esophagogastroduodenoscopy 617
ESOPHAGOGASTRODUODENOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Esophagoscopy, gastroscopy, upper GI

endoscopy, EGD.
AREA OF APPLICATION: Esophagus, stomach, and upper duodenum.

CONTRAST: Done without contrast.
• Detect upper GI inflammatory disease

DESCRIPTION & RATIONALE: Eso-
phagogastroduodenoscopy (EGD) • Determine the presence and location of
acute upper GI bleeding
allows direct visualization of the upper
gastrointestinal (GI) tract mucosa, • Evaluate the extent of esophageal
which includes the esophagus, stom- injury after ingestion of chemicals
ach, and upper portion of the duode- • Evaluate stomach or duodenum after
num, by means of a flexible endoscope. surgical procedures
The standard flexible fiberoptic endo- • Evaluate suspected gastric outlet obstruc-
scope contains three channels that tion
allow passage of the instruments • Identify tissue abnormalities and
needed to perform therapeutic or diag- obtain biopsy specimens
nostic procedures, such as biopsies or • Investigate the cause of dysphagia,
cytology washings. The endoscope, a dyspepsia, and epigastric pain
multichannel instrument, allows visu-
alization of the GI tract linings, insuf- RESULT
flation of air, aspiration of fluid,
Normal Findings:
removal of foreign bodies by suction or
by snare or forceps, and passage of a • Esophageal mucosa is normally yellow-
pink. At about 9 inches from the inci-
laser beam for obliteration of abnor-
sor teeth, a pulsation indicates the
mal tissue or control of bleeding. location of the aortic arch. The gastric
Direct visualization yields greater diag- mucosa is orange-red and contains
nostic data than is possible through rugae. The proximal duodenum is red-
radiologic procedures, and therefore dish and contains a few longitudinal
EGD is rapidly replacing upper GI folds, whereas the distal duodenum has
series as the diagnostic procedure of circular folds lined with villi. No
choice. ■ abnormal structures or functions are
observed in the esophagus, stomach, or
INDICATIONS: duodenum.
• Assist in differentiating between benign Abnormal Findings:
and neoplastic tumors • Acute and chronic gastric and duode-
• Detect gastric or duodenal ulcers nal ulcers
• Diverticular disease • Incorrect positioning of the patient,

• Duodenitis
• Esophageal varices
• Esophageal or pyloric stenosis remain still during the procedure
• Esophagitis or strictures
mental status
• Gastritis
• Hiatal hernia
• Mallory-Weiss syndrome chest pain or severe cardiac arrhythmias
occur.
• Tumors (benign or malignant)
CRITICAL VALUES: N/A and other pretesting preparations may
INTERFERING FACTORS: repeated.
This procedure is
• Patients who have had surgery involv- Procedure ● ● ● ● ● ● ● ● ● ● ●
ing the stomach or duodenum, which
can make locating the duodenal papilla Pretest:
difficult
• Patients with a bleeding disorder assesses the esophagus and upper
• Patients with unstable cardiopulmo- gastrointestinal tract.
nary status, blood coagulation defects, ➤ Obtain a history of the patient’s
or cholangitis, unless the patient complaints, including a list of known
received prophylactic antibiotic ther- allergens, especially allergies or sen-
apy before the test (otherwise the contrast medium, and dyes.
examination must be rescheduled)
• Patients with unstable cardiopulmo- trointestinal system, and results of
nary status, blood coagulation defects, previously performed diagnostic pro-
known aortic arch aneurysm, large cedures, surgical procedures, and
esophageal Zenker’s diverticulum, laboratory tests. For related diagnos-
recent GI surgery, esophageal varices,
System table.
or known esophageal perforation
Factors that may
• Gas or food in the gastrointestinal tract period and determine the possibility
resulting from inadequate cleansing or of pregnancy in perimenopausal
failure to restrict food intake before the women.
study ➤ Obtain a list of the medications the
• Retained barium from a previous radi- patient is taking.
ologic procedure ➤ Review the procedure with the
• Patients who are very obese, who may related to the procedure. Explain to
exceed the weight limit for the equip- the patient that some pain may be
ment experienced during the test, and
Esophagogastroduodenoscopy 619
there may be moments of discom- procedure. Ensure that the patient

fort, but that the throat will be anes- has removed all external metallic
thetized with a spray or swab. objects (jewelry, dentures, etc.) prior
Explain the purpose of the test and to the procedure.
how the procedure is performed. ➤ Have emergency equipment readily
Inform the patient that the procedure available.
is performed in a GI Lab or radiology
department, usually by a health care ➤ Patients are given a gown, robe, and
practitioner and support staff, and foot coverings to wear and instructed
takes approximately 30 to 60 min- to void prior to the procedure.
utes. ➤ Instruct the patient to cooperate fully
➤ Inform the patient that dentures and
eyewear will be removed before the
test.
➤ Inform the patient that he or she will
not be able to speak during the pro-
cedure, but that breathing will not be
affected.
➤ Explain that an intravenous (IV) line lection container with the correspon-
may be started to allow for the infu- ding patient demographics, date, and
sion of a sedative or IV fluids. time of collection.
➤ Sensitivity to cultural and social ➤ Start an IV line and administer
issues, as well as concern for mod- ordered sedation.
esty, is important in providing psy- ➤ Spray or swab the oropharynx with a
chological support before, during and topical local anesthetic.
➤ Provide an emesis basin for the
➤ The patient should fast and refrain increased saliva and encourage the
from drinking liquids for 8 hours prior patient to spit out the saliva because
to the procedure. the gag reflex may be impaired.
➤ Inform the patient that a laxative and ➤ Place the patient on an examination
cleansing enema may be needed the table in the left lateral decubitus posi-
day before the procedure, with tion with the neck slightly flexed for-
cleansing enemas on the morning of ward.
the procedure, depending on the
institution’s policy. ➤ The endoscope is passed through
the mouth with a dental suction
➤ Instruct the patient to remove jew- device in place to drain secretions. A
elry, including watches, credit cards, side-viewing flexible, fiberoptic endo-
and other metallic objects. scope is advanced, and visualization
➤ Obtain and record baseline vital of the GI tract is started.
signs. ➤ Air is insufflated to distend the upper
➤ Make sure a written and informed GI tract, as needed. Biopsy speci-
consent has been signed prior to the mens are obtained and/or endo-
procedure and before administering scopic surgery is performed.
any medications. ➤ Promptly transport the specimens to
Intratest: analysis.
➤ Assess for completion of bowel ➤ At the end of the procedure, excess
preparation according to the institu- air and secretions are aspirated
tion’s procedure. through the scope and the endo-
➤ Ensure that the patient has complied scope is removed.
with dietary, fluids, and medication ➤ The results are recorded manually or
restrictions and pretesting prepara- in a computerized system for recall
tions for at least 6 hours prior to the and postprocedure interpretation by
the appropriate health care practi- bloating, or flatulence is the result of

tioner. air insufflation and is temporary.
➤ Emphasize that any severe pain,
Post-test: fever, difficulty breathing, or expecto-
➤ Do not allow the patient to eat or ration of blood must be immediately
drink until the gag reflex returns; reported to the health care practi-
then allow the patient to eat lightly tioner.
for 12 to 24 hours. ➤ A written report of the examination
➤ Instruct the patient to resume usual will be completed by a health care
activity and diet in 24 hours or as tol- practitioner specializing in this branch
erated after the examination, as of medicine. The report will be sent
directed by the health care practi- to the requesting health care practi-
tioner. tioner. who will discuss the results
➤ Inform the patient that he or she may with the patient.
experience some throat soreness ➤ Reinforce information given by the
and hoarseness. Instruct patient to patient’s health care provider regard-
treat throat discomfort with lozenges ing further testing, treatment, or
and warm gargles when the gag referral to another health care pro-
reflex returns. vider. Answer any questions or
➤ Monitor vital signs and neurologic address any concerns voiced by the
status every 15 minutes for 1 hour, patient or family.
then every 2 hours for 4 hours, and ➤ Depending on the results of this pro-
as ordered by the health care practi- cedure, additional testing may be
tioner. Take temperature every 4 needed to evaluate or monitor pro-
hours for 24 hours. Compare with gression of the disease process and
baseline values. Notify the health determine the need for a change in
care practitioner if temperature is therapy. Evaluate test results in rela-
elevated. Protocols may vary from tion to the patient’s symptoms and
facility to facility. other tests performed.
➤ Observe the patient for indications of
esophageal perforation (i.e., painful Related diagnostic tests:
swallowing with neck movement, ➤ Related diagnostic tests include
substernal pain with respiration, computed tomography of the abdo-
shoulder pain or dyspnea, and men; hepatobiliary scan; hepatobil-
abdominal or back pain, cyanosis, iary ultrasound; kidney, ureter, and
fever). bladder film; and magnetic reso-
➤ Inform the patient that any belching, nance imaging of the abdomen.
ESTRADIOL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: E2.

Estradiol 621

6 m–10 y Less than 15 pg/mL Less than 55 pmol/L
11–15 y
Male Less than 40 pg/mL Less than 147 pmol/L
Female 10–300 pg/mL 37–1100 pmol/L
Adult male 10–50 pg/mL 37–184 pmol/L
Adult female
Early follicular phase 20–150 pg/mL 73–551 pmol/L
Late follicular phase 40–350 pg/mL 147–1285 pmol/L
Midcycle peak 150–750 pg/mL 551–2753 pmol/L
Luteal phase 30–450 pg/mL 110–1652 pmol/L
Postmenopause Less than 20 pg/mL Less than 73 pmol/L
RESULT
DESCRIPTION & RATIONALE: Estro-
gens are hormones secreted in large Increased in:
amounts by the ovaries and during • Adrenal tumors
pregnancy by the placenta. Estradiol is
• Estrogen-producing tumors
also secreted in minute amounts by
the adrenal cortex and the testes. Only • Feminization in children
three types of estrogen are present in • Gynecomastia
the blood in measurable amounts:
• Hepatic cirrhosis
estrone, estradiol, and estriol. Estra-
diol is the most active of the estrogens. • Hyperthyroidism
Estrone (E1) is the immediate precur-
Decreased in:
sor of estradiol (E2). Estriol (E3) is
secreted in large amounts from the • Ovarian failure
placenta during pregnancy from pre- • Primary and secondary hypogonadism
cursors produced by the fetal liver. ■ • Turner’s syndrome
INDICATIONS: CRITICAL VALUES: N/A

• Assist in determining the presence of
gonadal dysfunction. INTERFERING FACTORS:
• Drugs that may increase estradiol levels
• Evaluate menstrual abnormalities, fer- include cimetidine, clomiphene, dehy-
tility problems, and estrogen-produc- droepiandrosterone, diazepam, estro-
ing tumors in women, and testicular or gen/progestin therapy, ketoconazole,
adrenal tumors and feminization disor- mifepristone (some patients with
ders in men. meningiomas and not receiving any
other drugs), nafarelin, nilutamide,
• Monitor menotropins (Pergonal) ther-
phenytoin, tamoxifen, and trolean-
apy. Menotropins is a preparation of
domycin.
follicle-stimulating hormone (FSH)
and luteinizing hormone (LH) used to • Drugs that may decrease estradiol levels
induce ovulation and increase the include aminoglutethimide, chemo-
chance of pregnancy. therapy drugs, cimetidine, danazol,
fadrozole, formestane, goserelin, leupro- imen collection takes approximately

lide, megestrol, mepartricin, mifepris- 5 to 10 minutes. Address concerns
tone (pregnant women with expulsion about pain related to the procedure.
of fetus), nafarelin (women being Explain to the patient that there may
treated for endometriosis), and oral venipuncture.
contraceptives.
• Estradiol is secreted in a biphasic pat- issues, as well as concern for mod-
tern during normal menstruation. esty, is important in providing psy-
Knowledge of the phase of the men- chological support before, during,
strual cycle may assist interpretation of and after the procedure.
estradiol levels. ➤ There are no food, fluid, or medica-
direction.
Procedure ● ● ● ● ● ● ● ● ● ● ●

used to assist in the evaluation of fer-
tility or postmenopausal status.
➤ Obtain a history of the patient’s patient to breathe normally and to
complaints, including a list of known avoid unnecessary movement.
allergens (especially allergies or sen- ➤ Observe standard precautions, and
sitivities to latex), and inform the follow the general guidelines in
appropriate health care practitioner Appendix A. Positively identify the
accordingly. patient, and label the appropriate
endocrine and reproductive systems, demographics, date, and time of col-
as well as phase of menstrual cycle lection. Perform a venipuncture; col-
and results of previously performed lect the specimen in a 5-mL red- or
laboratory tests, surgical procedures, tiger-top tube.
and other diagnostic procedures. For ➤ Remove the needle, and apply a
related laboratory tests, refer to the pressure dressing over the puncture
Endocrine and Reproductive System site.
tables.
➤ Record the date of the last menstrual the laboratory for processing and
period and determine the possibility analysis.
women. ➤ The results are recorded manually or
ceuticals. Note the last time and
dose of medication taken. The Post-test:
and laboratory should be advised if ➤ Observe venipuncture site for bleed-
the patient regularly uses these ing or hematoma formation. Apply
products so that their effects can be paper tape or other adhesive to hold
taken into consideration when pressure bandage in place, or
reviewing results. replace with a plastic bandage.
➤ Review the procedure with the ➤ A written report of the examination
patient. Inform the patient that spec- will be sent to the requesting health
Estrogen and Progesterone Receptor Assays 623
care practitioner, who will discuss already taking in the event that the
the results with the patient. requesting health care practitioner
➤ Reinforce information given by the prescribes a medication.
patient’s health care provider regard- ➤ Depending on the results of this pro-
ing further testing, treatment, or cedure, additional testing may be
referral to another health care performed to evaluate or monitor
provider. Explain to the patient the progression of the disease process
importance of following the medica- and determine the need for a change
tion regimen and instructions regard- in therapy. Evaluate test results in
ing drug interactions. Answer any relation to the patient’s symptoms
questions or address any concerns and other tests performed.
➤ Instruct the patient to be prepared to
provide the pharmacist with a list of ➤ Related laboratory tests include FSH,
other medications he or she is LH, progesterone, and prolactin.
ESTROGEN AND PROGESTERONE

RECEPTOR ASSAYS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Estrogen receptor protein (ERP), progesterone

receptor protein (PRP).
SPECIMEN: Breast tissue.

REFERENCE VALUE: (Method: Cytochemical or immunocytochemical)
Interpretation of results is subjective depending on the intensity of staining
and the number of cells classified as positive. More recently, immunoperoxi-
dase methods employing monoclonal antibodies have been introduced.
These antibodies have greater specificity and are not subject to interference
by exogenous hormones.
Cytochemical Findings Values

Favorable findings Greater than 20% of cell nuclei are stained
Borderline findings 11–20% of cell nuclei are stained
Unfavorable findings Less than 10% of cell nuclei are stained
DESCRIPTION & RATIONALE: Estro- type of breast cancer that may be more
gen and progesterone receptor assays responsive than other types of tumors
are used to identify patients with a to estrogen-deprivation (antiestrogen)
therapy or removal of the ovaries. age, and analysis are important to

achieve accurate results.
Patients with these types of tumors
generally have a better prognosis.
DNA ploidy testing by flow cytome- Nursing Implications and
try may also be performed on suspi- Procedure ● ● ● ● ● ● ● ● ● ● ●
cious tissue. Cancer cells contain

abnormal amounts of DNA. The Pretest:
higher the grade of tumor cells, the
more likely abnormal DNA will be marily used to assist in the prognosis
detected. The ploidy, or number of and in the management of response
chromosome sets in the nucleus, is an to therapy for breast and endometrial
indication of the speed of cell replica- cancer.
tion and tumor growth. ■ ➤ Obtain a history of the patient’s com-
INDICATIONS: allergens (especially allergies or sen-
• Identify patients with breast or other
types of cancer that may respond to accordingly.
hormone or antihormone therapy
• Monitor responsiveness to hormone or endocrine, immune, and reproduc-
antihormone therapy tive systems and results of previ-
RESULT surgical procedures, and other diag-
Positive findings in: tory tests, refer to the Endocrine,
Immune, and Reproductive System
• Hormonal therapy tables.
• Receptor-positive tumors ➤ Record the date of the last menstrual
Negative findings in: of pregnancy in perimenopausal
women.
• Receptor-negative tumors
CRITICAL VALUES: N/A interfere with test results. Ensure
that the patient has not received
antiestrogen therapy within 2 months
INTERFERING FACTORS: of the test.
• Antiestrogen preparations (e.g., tamox-
ifen) ingested 2 months before tissue ➤ Obtain a list of the medications the
sampling will affect test results.
lant therapy, acetylsalicylic acid, herbs,
• Tissue specimens contaminated with nutritional supplements, and nutra-
formalin or failure to freeze the speci- ceuticals, especially those known to
men adequately using liquid nitrogen affect coagulation. It is recommen-
ded that use be discontinued 14 days
or dry ice will falsely decrease results.
before dental or surgical procedures.
• Massive tumor necrosis or tumors with The requesting health care practi-
low cellular composition falsely decrease tioner and laboratory should be
results. advised if the patient regularly uses
• Failure to transport specimen to the can be taken into consideration
laboratory immediately can result in when reviewing results.
degradation of receptor sites. Prompt ➤ Review the procedure with the
and proper specimen processing, stor- patient. Inform the patient that it may
Estrogen and Progesterone Receptor Assays 625
be necessary to shave the site to reduce the risk of nausea and

before the procedure. Instruct that vomiting.
administered prior to the procedure. General:
Address concerns about pain related ➤ Make sure a written and informed
to the procedure. Explain that a seda- consent has been signed prior to the
tive and/or analgesia will be adminis- procedure and before administering
tered to promote relaxation and any medications.
reduce discomfort prior to the percu-
taneous biopsy; a general anesthesia Intratest:
will be administered prior to the
open biopsy. Explain to the patient ➤ Ensure that the patient has complied
that no pain will be experienced dur- with dietary restrictions; assure that
ing the test when general anesthesia food has been restricted for at least
is used, but that any discomfort with 4 to 8 hours prior to the procedure,
a needle biopsy will be minimized depending on the anesthetic chosen
with local anesthetics and systemic for the procedure.
analgesics. Inform the patient that ➤ Have emergency equipment readily
the biopsy is performed under sterile available.
conditions by a health care practi-
tioner specializing in this procedure.
cedure.
The surgical procedure usually takes
about 20 to 30 minutes to complete, ➤ Observe standard precautions, and
and that sutures may be necessary follow the general guidelines in
to close the site. A needle biopsy Appendix A. Positively identify the
usually takes about 15 minutes to patient, and label the appropriate col-
complete. lection containers with the corre-
sponding patient demographics, date
➤ Sensitivity to cultural and social and time of collection, and site loca-
issues, as well as concern for mod- tion, especially left or right breast.
chological support before, during, ➤ Assist the patient to the desired
and after the procedure. position depending on the test site
to be used, and direct the patient to
➤ Explain that an intravenous (IV) line breath normally during the beginning
will be inserted to allow infusion of of the general anesthesic. Instruct
IV fluids, antibiotics, anesthetics, and the patient to cooperate fully and to
analgesics. follow directions. Direct the patient
➤ Ensure that anticoagulant therapy to breathe normally and to avoid
has been withheld for the appropri- unnecessary movement during the
ate amount of days prior to the pro- local anesthetic and the procedure.
cedure. Amount of days to withhold ➤ Record baseline vital signs and con-
medication is dependant on the type tinue to monitor throughout the pro-
of anticoagulant. Notify health care cedure. Protocols may vary from
practitioner if patient anticoagulant facility to facility.
therapy has not been withheld.
local anesthesia, cleanse the site
Open biopsy: with an antiseptic solution, and
➤ Instruct the patient that nothing drape the area with sterile towels.
should be taken by mouth for 6 to 8 Open biopsy:
➤ After administration of general
anesthesia and surgical prep is com-
Needle biopsy:
pleted, an incision is made, suspi-
➤ Instruct the patient that nothing cious area(s) are located, and tissue
should be taken by mouth for at samples are collected. Using needle
least 4 hours prior to the procedure biopsy or resection, suspicious areas
are located and a tissue specimen ing, inflammation, or hematoma for-

weighing at least 200 mg is col- mation.
lected.
Needle biopsy: assessment of the site. Instruct
the patient to report any redness,
➤ Direct the patient to take slow deep edema, bleeding, or pain at the
breaths when the local anesthetic is biopsy site. Instruct the patient to
injected. Protect the site with sterile immediately report chills or fever.
drapes. Instruct the patient to take a Instruct the patient to keep the site
deep breath, exhale forcefully, and clean and change the dressing as
hold the breath while the biopsy nee- needed.
dle is inserted and rotated to obtain a
core of breast tissue. Once the nee- ➤ Assess for nausea and pain. Adminis-
dle is removed, the patient may ter antiemetic and analgesic medica-
breathe. Pressure is applied to the tions as needed and as directed by
site for 3 to 5 minutes, then a sterile the health care practitioner.
pressure dressing is applied. ➤ Administer antibiotic therapy if or-
dered. Remind the patient of the
General: importance of completing the entire
➤ Monitor the patient for complications course of antibiotic therapy, even if
related to the procedure (e.g., aller- signs and symptoms disappear
gic reaction, anaphylaxis). before completion of therapy.
➤ Place tissue samples in a formalin- ➤ A written report of the examination
free specimen container. Label the will be completed by a health care
specimen, indicating site location, practitioner specializing in this branch
and promptly transport the specimen of medicine. The report will be sent
to the laboratory for processing and to the requesting health care practi-
analysis. tioner, who will discuss the results
➤ The results are recorded manually or with the patient.
in a computerized system for recall ➤ Recognize anxiety related to test
and postprocedure interpretation by results, and offer support. Discuss
the appropriate health care practi- the implications of abnormal test
tioner. results on the patient’s lifestyle.
Post-test: regarding the clinical implications of
➤ Instruct the patient to resume preop-
Inform the patient about hormone
erative diet, as directed by the health
therapy, as appropriate based on test
care practitioner.
results. Educate the patient regard-
➤ Monitor vital signs and neurologic ing access to counseling services.
and then every 2 hours for 4 hours, ➤ Reinforce information given by the
and then as ordered by the health patient’s health care provider regard-
care practitioner. Monitor tempera- ing further testing, treatment, or
ture every 4 hours for 24 hours. referral to another health care pro-
Compare with baseline values. vider. Inform the patient of a follow-
Notify the health care practitioner if up appointment for removal of
temperature is elevated. Protocols sutures, if indicated. Instruct and
may vary from facility to facility. educate the patient on how to per-
form monthly breast self-examination
➤ Observe for delayed allergic reac- and emphasize, as appropriate, the
tions, such as rash, urticaria, tachy- importance of having a mammogram
cardia, hyperpnea, hypertension, performed annually. Answer any
palpitations, nausea, or vomiting. questions or address any concerns
➤ Observe the biopsy site for bleed- voiced by the patient or family.
Evoked Brain Potentials 627
➤ Instruct the patient in the use of any performed to evaluate or monitor

ordered medications. Explain the progression of the disease process
importance of adhering to the ther- and determine the need for a change
apy regimen. As appropriate, instruct in therapy. Evaluate test results in
the patient in significant side effects relation to the patient’s symptoms
and systemic reactions associated and other tests performed.
Encourage him or her to review cor- Related laboratory tests:
pharmacist.
breast biopsy, CA 15-3, carcinoem-
➤ Depending on the results of this pro- bryonic antigen, and HER-2/neu
cedure, additional testing may be oncoprotein.
EVOKED BRAIN POTENTIALS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: EP studies, brainstem auditory evoked potentials

(BAEP), brainstem auditory evoked responses (BAER).

CONTRAST: None.
DESCRIPTION & RATIONALE: Evoked cortical (visual and somatosensory) or

brain potentials, also known as evoked midbrain (auditory) sensory area. A
potential (EP) responses, are electro- number of stimuli are given and then
physiologic studies performed to responses are electronically displayed
measure the brain’s electrical responses in waveforms, recorded, and computer
to various visual, auditory, and analyzed. Abnormalities are deter-
somatosensory stimuli. EP studies mined by a delay in time, measured in
help diagnose lesions of the nervous milliseconds, between the stimulus
system by evaluating the integrity of and the response. This is known as
the visual, somatosensory, and audi- increased latency. VER provides infor-
tory nerve pathways. Three response mation about visual pathway function
types are measured: visual evoked to identify lesions of the optic nerves,
response (VER), auditory brainstem optic tracts, and demyelinating dis-
response (ABR), and somatosensory eases such as multiple sclerosis. ABR
evoked response (SER). The stimuli provides information about auditory
activate the nerve tracts that connect pathways to identify hearing loss and
the stimulated (receptor) area with the lesions of the brainstem. SER provides
SER (potentials):
information about the somatosensory
pathways to identify lesions at various • Detect multiple sclerosis and Guillain-
Barré syndrome
levels of the central nervous system
(spinal cord and brain) and peripheral • Detect sensorimotor neuropathies and
nerve disease. EP studies are especially cervical pathology
useful in patients with problems and • Evaluate spinal cord and brain injury
those unable to speak or respond to and function
instructions during the test, because • Monitor sensory potentials to deter-
these studies do not require voluntary mine spinal cord function during a sur-
cooperation or participation in the gical procedure or medical regimen
activity. This allows collection of ob-
jective diagnostic information about ERP (potentials):
visual or auditory disorders affecting • Detect suspected psychosis or dementia
infants and children, and allows dif- • Differentiate between organic brain
ferentiation between organic brain and disorder and cognitive function abnor-
psychological disorders in adults. EP mality
studies are also used to monitor the
progression of or the effectiveness of RESULT
treatment for deteriorating neuro-
Normal Findings:
logic diseases such as multiple scle-
VER and ABR: Normal latency in
rosis. ■
recorded cortical and brainstem
waveforms depending on age,
INDICATIONS sex, and stature
ERP: Normal recognition and
VER (potentials): attention span
• Detect cryptic or past retrobulbar SER: No loss of consciousness or
neuritis presence of weakness
• Detect lesions of the eye or optic nerves
Abnormal Findings:
• Detect neurologic disorders such as • VER (potentials):
multiple sclerosis, Parkinson’s disease,
P100 latencies (extended) confined
and Huntington’s chorea to one eye suggest a lesion
• Evaluate binocularity in infants anterior to the optic chiasm.
• Evaluate optic pathway lesions and Bilateral abnormal P100 latencies
visual cortex defects indicate multiple sclerosis, optic
neuritis, retinopathies,
spinocerebellar degeneration,
ABR (potentials):
sarcoidosis, Parkinson’s disease,
• Detect abnormalities or lesions in the adrenoleukodystrophy,
brainstem or auditory nerve areas Huntington’s chorea, and
• Detect brainstem tumors and acoustic amblyopias.
neuromas • ABR (potentials):
• Screen or evaluate neonates, infants, Normal response at high
children, and adults for auditory prob- intensities; wave V may occur
lems (EP studies may be indicated slightly later. Earlier wave
when a child falls below growth chart distortions suggest cochlear
norms) lesion.
Evoked Brain Potentials 629
Absent or late waves at high rologic system, known or suspected

intensities; increased amplitude neurologic conditions, and trauma to
of wave V suggests retrocochlear the head or spinal cord, as well as
lesion. the results of previously performed
laboratory tests, surgeries, treat-
• SER (potentials): ments, and procedures. For related
Abnormal upper limb latencies diagnostic tests, refer to the
suggest cervical spondylosis or Musculoskeletal System table.
intracerebral lesions. ➤ Obtain a list of the medications the
Abnormal lower limb latencies patient is taking, including herbs,
suggest peripheral nerve root nutritional supplements, and nutra-
disease such as Guillain-Barré ceuticals. The requesting health care
syndrome, multiple sclerosis, practitioner and laboratory should be
transverse myelitis, or traumatic advised if the patient regularly uses
spinal cord injuries. these products so that their effects
INTERFERING FACTORS patient. Inform the patient that the
procedure is painless and harmless.
Factors that may impair the is performed in a special laboratory
results of the examination: by a technologist and takes approxi-
• Inability of the patient to cooperate or mately 30 minutes to 2 hours,
remain still during the procedure depending on the test.
because of age, significant pain, or ➤ Instruct the patient to clean the hair
mental status (note: significant behav- and to refrain from using hair sprays,
ioral problems may limit the ability to creams, or solutions before the test.
complete the test) ➤ There are no food, fluid, or medica-
• Improper placement of electrodes tion restrictions, unless by medical
direction.
• Patient stress, which can affect brain
chemistry, thus making it difficult to consent has been signed prior to the
distinguish whether the results are due procedure and before administering
to the patient’s emotional reaction or to any medications.
organic pathology
• Extremely poor visual acuity, which can Intratest:
hinder accurate determination of VER ➤ Ensure that the patient is able to
• Severe hearing loss, which can interfere relax; report any extreme anxiety or
restlessness.
with accurate determination of ABR
➤ Ensure that hair is clean and free of
hair sprays, creams, or solutions.
➤ Have the patient remove any jewelry
Nursing Implications and or metallic objects above the neck.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: Appendix A.
➤ Inform the patient that this proce-
dure measures electrical activity in Visual evoked potentials:
the nervous system. ➤ Place the patient in a comfortable posi-
➤ Obtain a history of the patient’s neu- tion about 1 m from the stimulation
source. Attach electrodes to the Event-related potentials:

occipital and vertex lobe areas and a
reference electrode to the ear. A ➤ Place the patient in a sitting position
light-emitting stimulation or a check- in a chair in a quiet room. Earphones
erboard pattern is projected on a are placed on the patient’s ears and
screen at a regulated speed. This pro- auditory cues administered. The
cedure is done for each eye (with the patient is asked to push a button
opposite eye covered) as the patient when the tones are recognized.
looks at a dot on the screen without Flashes of light are also used as
any change in the gaze while the visual cues, with the client pushing a
stimuli are delivered. A computer button when cues are noted. Results
interprets the brain’s responses to are compared to normal EP wave-
the stimuli and records them in forms for correct, incorrect, or absent
waveforms. responses.
Post-test:
Auditory evoked potentials:
➤ Place the patient in a comfortable remove the electrodes and clean the
position, and place the electrodes on skin where the electrodes were
the scalp at the vertex lobe area and applied.
on each earlobe. Earphones are
placed on the patient’s ears, and a ➤ A written report of the examination
clicking noise stimulus is delivered will be completed by a health care
into one ear while a continuous practitioner specializing in this branch
tone is delivered to the opposite of medicine. The report will be sent
ear. Responses to the stimuli are to the requesting health care practi-
recorded as waveforms for analysis. tioner, who will discuss the results
with the patient.
Somatosensory evoked ➤ Reinforce information given by the
potentials: patient’s health care provider regard-
➤ Place the patient in a comfortable ral to another health care provider.
position, and place the electrodes at Answer any questions or address
the nerve sites of the wrist, knee, any concerns voiced by the patient or
and ankle and on the scalp at the family.
sensory cortex of the hemisphere on ➤ Depending on the results of this pro-
the opposite side (the electrode that cedure, additional testing may be
picks up the response and delivers it needed to evaluate or monitor pro-
to the recorder). Additional elec- gression of the disease process and
trodes can be positioned at the cer- determine the need for a change in
vical or lumbar vertebrae for upper or therapy. Evaluate test results in rela-
lower limb stimulation. The rate at tion to the patient’s symptoms and
which the electric shock stimulus is other tests performed.
delivered to the nerve electrodes
and travels to the brain is measured, Related diagnostic tests:
computer analyzed, and recorded in
waveforms for analysis. Both sides ➤ Related diagnostic tests include
of the area being examined can be computed tomography of the brain,
tested by switching the electrodes electroencephalography, and mag-
and repeating the procedure. netic resonance imaging of the brain.
Exercise Stress Test 631
EXERCISE STRESS TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Exercise electrocardiogram (ECG, EKG), graded

exercise tolerance test, stress testing, treadmill test.

CONTRAST: None.
DESCRIPTION & RATIONALE: The scans for diagnosing coronary artery

exercise stress test is a noninvasive disease (CAD).
study to measure cardiac function For patients unable to complete the
during physical stress. Exercise elec- test, pharmacologic stress testing can
trocardiography is primarily useful in be done. Medications used to increase
determining the extent of coronary the patient’s heart include vasodilators
artery occlusion by the heart’s ability such as dipyridamole and -agonists
to meet the need for additional oxy- such as dobutamine. ■
gen in response to the stress of exercis-
ing in a safe environment. The patient INDICATIONS:
exercises on a treadmill or pedals a sta- • Detect dysrhythmias during exercising,
tionary bicycle to increase the heart as evidenced by ECG changes
rate to 80% to 90% of maximal heart • Detect peripheral arterial occlusive dis-
rate determined by age and sex, known ease (intermittent claudication), as evi-
as the target heart rate. Every 2 to 3 denced by leg pain or cramping during
minutes the speed and/or grade of the exercising
treadmill is increased to yield an incre- • Determine exercise-induced hyperten-
ment of stress. The patient’s electro- sion
cardiogram (ECG) and blood pressure
are monitored during the test. The test • Evaluate cardiac function after myocar-
proceeds until the patient reaches the dial infarction or cardiac surgery to
determine safe exercise levels for car-
target heart rate or experiences chest
diac rehabilitation as well as work limi-
pain or fatigue. The risks involved in tations
the procedure are possible myocar-
dial infarction (1 in 500) and death • Evaluate effectiveness of medication
(1 in 10,000) in patients experiencing regimens, such as antianginals or
frequent angina episodes before the antiarrhythmics
test. Although useful, this procedure • Evaluate suspected CAD in the pres-
is not as accurate as cardiac nuclear ence of chest pain and other symptoms
• Screen for CAD in the absence of pain • Potassium or calcium imbalance

and other symptoms in patients at risk
• Hypertension, hypoxia, left bundle
branch block, and ventricular hypertro-
RESULT phy
Normal Findings: • Wolff-Parkinson-White syndrome (ano-
• Normal heart rate during physical exer- malous atrioventricular excitation)
cise. Heart rate and systolic blood pres- • Anxiety or panic attack
sure rise in direct proportion to
workload and to metabolic oxygen
demand, which is based on age and
exercise protocol. Maximal heart rate Nursing Implications and
for adults is normally 150 to 200 Procedure ● ● ● ● ● ● ● ● ● ● ●
beats/min.
Pretest:
Abnormal Findings: ➤ Inform the patient that the test
• Activity intolerance related to oxygen assesses the heart’s ability to re-
supply and demand imbalance spond to an increasing workload.
• Bradycardia ➤ Obtain a pertinent history of the
results of previously performed car-
• CAD diac tests and procedures, present
cardiac conditions or abnormalities,
• Chest pain related to ischemia or and therapies received for the car-
inflammation diac conditions. For related diagnos-
• Decreased cardiac output tic tests, refer to the Cardiovascular
System table.
• Dysrhythmias ➤ Obtain a list of medications the pa-
• Hypertension tient is taking, including herbs, nutriti-
onal supplements, and nutraceuticals.
• Peripheral arterial occlusive disease The requesting health care practi-
tioner and laboratory should be
• S-T segment depression of 1 mm (con- advised if the patient regularly uses
sidered a positive test), indicating these products so that their effects
myocardial ischemia can be taken into consideration when
reviewing results.
• Tachycardia
CRITICAL VALUES: N/A tient. Address concerns about pain
related to the procedure. Assure the
patient that the test has very few
INTERFERING FACTORS: The following risks and that exercising can be ter-
factors may impair interpretation of minated if extreme symptoms occur.
examination results because they create Inform the patient that the procedure
an artificial state that makes it difficult is performed in a special department
to determine true physiologic function: by a technician and takes approxi-
• Improper electrode placement
➤ Ask the patient if he or she has had
• High food intake or smoking before any chest pain within the prior 48
testing hours, or has a history of anginal
attacks several times a day; if either
• Drugs such as -blockers, cardiac gly- of these is the case, inform the
cosides, calcium channel blockers, health care practitioner immediately
coronary vasodilators, and barbiturates because the stress test may be too
Exercise Stress Test 633
risky and should be rescheduled in 4 to peddle a bicycle. As the stress is

to 6 weeks. increased, the patient is asked to
➤ Sensitivity to cultural and social report any symptoms, such as chest
issues, as well as concern for mod- or leg pain, dyspnea, or fatigue.
esty, is important in providing psy- ➤ The patient is asked to step onto the
chological support before, during and treadmill and is instructed to use the
after the procedure. handrails to maintain balance.
➤ Record a baseline 12-lead ECG and ➤ The treadmill is turned on to a slow
vital signs, if these recordings were speed, but is increased in speed and
not already obtained or are not avail- elevation to increase the patient’s
able. heart rate. Stress is increased until
➤ The patient should fast and refrain the patient’s predicted target heart
from drinking liquids and smoking for rate is reached.
at least 4 hours prior to the test. ➤ Instruct the patient to report symp-
➤ Advise the patient to wear comfort- toms such as dizziness, sweating,
able shoes and clothing for the exer- breathlessness, or nausea, which
cise. can be normal as speed increases.
➤ Make sure a written and informed The test is terminated if pain or
consent has been signed prior to the fatigue is severe; maximum heart
procedure and before administering rate under stress is attained; signs of
any medications. ischemia are present; maximum
effort has been achieved; or dysp-
Intratest: nea, hypertension (systolic blood
pressure greater than 250 mm Hg),
➤ Ensure that the patient has ab- tachycardia (greater than 200 beats/
stained from food, fluids, and smok- minute minus person’s age), new
ing for at least 4 hours before the dysrhythmias, chest pain that begins
test and that the patient has discon- or worsens, faintness, extreme dizzi-
tinued specific medications that ness, or confusion develops.
can interfere with test results, as
ordered. ➤ After the exercise period, a 3- to 15-
minute rest period is given with the
➤ Have emergency equipment readily patient in a sitting position. During
available. this period, the ECG, blood pres-
➤ An intravenous access may be sure, and heart rate monitoring is
established for emergency use. continued.
➤ Ask the patient to remove clothing ➤ The results are recorded on a paper
from the waist up (give women a strip for postprocedure interpretation
hospital gown that opens in the by the appropriate health care practi-
front). tioner.
Appendix A. Post-test:
➤ Electrodes are placed in appropriate ➤ Remove the electrodes and cleanse
positions on the patient, a blood the skin of any remaining gel or ECG
pressure cuff connected to a moni- electrode adhesive.
toring device is applied, and if the
patient’s oxygen consumption is to ➤ Instruct the patient to contact the
be continuously monitored, the health care practitioner to report any
patient is connected to a machine via anginal pain or other discomforts
a mouthpiece or to a pulse oximeter experienced after the test.
via a finger lead. ➤ Instruct the patient regarding special
➤ The patient is asked to walk on a dietary intake and medication regi-
treadmill (most commonly used) or men, as needed.
➤ Instruct the patient to resume activi- ➤ Depending on the results of this pro-
ties discontinued before the test. cedure, additional testing may be
will be completed by a health care progression of the disease process
practitioner specializing in this branch and determine the need for a change
of medicine. The report will be sent in therapy. Evaluate test results in
to the requesting health care practi- relation to the patient’s symptoms
tioner, who will discuss the results and other tests performed.
with the patient.
➤ Reinforce information given by the Related diagnostic tests:
ing further testing, treatment, or ➤ Related diagnostic tests include elec-
referral to another health care pro- trocardiogram (ECG), myocardial per-
vider. Answer any questions or fusion scan of the heart, and positron
address any concerns voiced by the emission tomography scan of the
patient or family. heart.
FECAL ANALYSIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Stool.
REFERENCE VALUE: (Method: Macroscopic examination, for appearance and
color; microscopic examination, for cell count and presence of meat fibers;
leukocyte esterase, for leukocytes; Clinitest [Bayer Corporation, Pittsburgh,
Pennsylvania] for reducing substances; guaiac, for occult blood; x-ray paper,
for trypsin)
Characteristic Normal Result

Appearance Solid and formed
Color Brown
Epithelial cells Few to moderate
Fecal fat See “Fecal Fat” monograph
Leukocytes (white blood cells) Negative
Meat fibers Negative
Occult blood Negative
Reducing substances Negative
Trypsin 2 to 4
Fecal Analysis 635
RESULT
DESCRIPTION & RATIONALE: Feces
consist mainly of cellulose and other Unusual Appearance:
undigested foodstuffs, bacteria, and • Bloody: Excessive intestinal wall irrita-
water. Other substances normally tion or malignancy
found in feces include epithelial cells • Bulky or frothy: Malabsorption
shed from the gastrointestinal (GI)
• Mucous: Inflammation of intestinal
tract, small amounts of fats, bile pig-
walls
ments in the form of urobilinogen, GI
and pancreatic secretions, electrolytes, • Slender or ribbonlike: Obstruction
and trypsin. Trypsin is a proteolytic
Unusual Color:
enzyme produced in the pancreas. The
average adult excretes 100 to 300 g • Black: Bismuth (antacid) or charcoal
ingestion, iron therapy, upper GI bleed
of fecal material per day, the residue
of approximately 10 L of liquid mate- • Grayish white: Barium ingestion, bile
rial that enters the GI tract each day. duct obstruction
The laboratory analysis of feces • Green: Antibiotics, biliverdin, green
includes macroscopic examination vegetables
(volume, odor, shape, color, consis-
• Red: Beets and food coloring, lower GI
tency, presence of mucus), microscopic bleed, phenazopyridine hydrochloride
examination (leukocytes, epithelial compounds, rifampin
cells, meat fibers), and chemical
tests for specific substances (occult • Yellow: Rhubarb
blood, trypsin, estimation of carbo- Increased:
hydrate). ■ • Carbohydrates/reducing substances:
Malabsorption syndromes
INDICATIONS:
• Assist in diagnosing disorders associ- • Epithelial cells: Inflammatory bowel
ated with GI bleeding or drug therapy disorders
that leads to bleeding • Leukocytes: Bacterial infections of the
• Assist in the diagnosis of pseudomem- intestinal wall, salmonellosis, shigel-
branous enterocolitis after use of losis, and ulcerative colitis
broad-spectrum antibiotic therapy • Meat fibers: Altered protein digestion
• Assist in the diagnosis of suspected • Occult blood: Anal fissure, diverticular
inflammatory bowel disorder disease, esophageal varices, esophagitis,
• Detect altered protein digestion gastritis, hemorrhoids, infectious diar-
rheas, inflammatory bowel disease,
• Detect intestinal parasitic infestation, Mallory-Weiss tears, polyps, tumors,
as indicated by diarrhea of unknown ulcers
cause
Decreased:
• Investigate diarrhea of unknown cause
• Leukocytes: Amebic colitis, cholera,
• Monitor effectiveness of therapy for disorders resulting from toxins, para-
intestinal malabsorption or pancreatic sites, viral diarrhea
insufficiency
• Trypsin: Cystic fibrosis, malabsorption
• Screen for cystic fibrosis syndromes, pancreatic deficiency
CRITICAL VALUES: N/A patient not to contaminate the spec-

imen with urine, water, or toilet tis-
INTERFERING FACTORS: sue. Address concerns about pain
• Drugs that can cause positive results for related to the procedure. Explain to
occult blood include acetylsalicylic
acid, anticoagulants, colchicine, corti-
costeroids, iron preparations, and ➤ Sensitivity to social and cultural
phenylbutazone.
• Ingestion of a diet high in red meat, cer- chological support before, during,
tain vegetables, and bananas can cause and after the procedure.
false-positive results for occult blood. ➤ Instruct the patient not to use laxa-
tives, enemas, or suppositories for 3
• Large doses of vitamin C can cause days before the test.
false-negative occult blood.
➤ Instruct the patient to follow a normal
• Constipated stools may not indicate diet for several days before the test.
any trypsin activity owing to extended
exposure to intestinal bacteria. Intratest:
with medication restrictions; assure
Nursing Implications and laxatives, enemas, or suppositories
Procedure ● ● ● ● ● ● ● ● ● ● ●
have been restricted for at least 3
days prior to the procedure.
intestinal disorders.
➤ Obtain a history of the patient’s com- patient, and label the appropriate col-
plaints, including a list of known lection container with the correspon-
allergens, and inform the appropriate ding patient demographics, date and
health care practitioner accordingly. time of collection, and suspected
➤ Obtain a history of the patient’s gas- cause of enteritis; note any current
trointestinal system and results of or recent antibiotic therapy.
previously performed laboratory ➤ Collect a stool specimen in a half-
tests, surgical procedures, and other pint waterproof container with a
diagnostic procedures. For related tight-fitting lid; if the patient is not
laboratory tests, refer to the Gastro- ambulatory, collect it in a clean, dry
intestinal System table. bedpan. Use a tongue blade to trans-
➤ Obtain a list of medications the fer the specimen to the container,
patient is taking, including herbs, and include any mucoid and bloody
nutritional supplements, and nutra- portions. Collect specimen from the
ceuticals. The requesting health care first, middle, and last portion of the
practitioner and laboratory should be stool. The specimen should be refrig-
advised if the patient regularly uses erated if it will not be transported to
these products so that their effects the laboratory within 4 hours after
can be taken into consideration when collection.
reviewing results. ➤ To collect specimen by rectal swab,
➤ Review the procedure with the insert the swab past the anal sphinc-
patient. Inform the patient of the pro- ter, rotate gently, and withdraw.
cedure for collecting a stool sample, Place the swab in the appropriate
including the importance of good container.
handwashing techniques. The patient ➤ Promptly transport the specimen to
should place the sample in a tightly the laboratory for processing and
covered container. Instruct the analysis.
Fecal Fat 637
➤ The results are recorded manually or ral to another health care provider.
in a computerized system for recall Answer any questions or address
and postprocedure interpretation by any concerns voiced by the patient
the appropriate health care practi- or family.
tioner.
Post-test:
lifestyle. Provide teaching and infor- Related laboratory tests:
mation regarding the clinical impli- ➤ Related laboratory tests include 1-
cations of the test results, as antitrypsin/phenotyping, sweat chlo-
appropriate. ride, D-xylose tolerance, fecal fat,
➤ Reinforce information given by the gliadin antibody, intestinal biopsy,
patient’s health care provider regard- lactose tolerance, ova and parasites,
ing further testing, treatment, or refer- and stool culture.
FECAL FAT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Stool fat, fecal fat stain.

SPECIMEN: Stool (80 mL) aliquot from an unpreserved and homogenized
24- to 72-hour timed collection. Random specimens may also be submitted.
REFERENCE VALUE: (Method: Stain with Sudan black or oil red O.
Treatment with ethanol identifies neutral fats; treatment with acetic acid
identifies fatty acids.)
Random, Semiquantitative
Neutral fat Less than 50 fat globules/hpf

Fatty acids Less than 100 fat globules/hpf
Age (diet) 72-hour, Quantitative
Infant (breast milk) Less than 1 g/24 h

0–6 y Less than 2 g/24 h
Adult 2–7 g/24 h; less than 20% of total solids
Adult (fat-free) Less than 4 g/24 h
hpf high-power field.

• Abetalipoprotein deficiency
DESCRIPTION & RATIONALE: Fecal
fat primarily consists of triglycerides
(neutral fats), fatty acids, and fatty • Amyloidosis
acid salts. Through microscopic exam- • Bile salt deficiency
ination, the number and size of fat
droplets can be determined as well as • Carcinoid syndrome
the type of fat present. Excretion of • Celiac disease
greater than 7 g of fecal fat in a 24-
hour period is abnormal but nonspe-
cific for disease. Increases in excretion • Cystic fibrosis
of neutral fats are associated with pan- • Diabetes
creatic exocrine insufficiency, whereas
• Enteritis
decreases are related to small bowel
disease. An increase in triglycerides • Malnutrition
indicates that insufficient pancreatic • Multiple sclerosis
enzymes are available to convert the
triglycerides into fatty acids. Patients • Pancreatic insufficiency or obstruction
with malabsorption conditions have • Peptic ulcer disease
normal amounts of triglycerides but
• Pernicious anemia
an increase in total fecal fat because
the fats are not absorbed through the • Progressive systemic sclerosis
intestine. Malabsorption disorders • Thyrotoxicosis
(e.g., cystic fibrosis) cause blockage of
the pancreatic ducts by mucus, which • Tropical sprue
prevents the enzymes from reaching • Viral hepatitis
the duodenum and results in lack of • Whipple’s disease
fat digestion. Without digestion, the
fats cannot be absorbed, and steator- • Zollinger-Ellison syndrome
rhea results. The appearance and odor
Decreased in: N/A
of stool from patients with steatorrhea
is typically foamy, greasy, soft, and
foul-smelling. The semiquantitative
test is used to screen for the presence INTERFERING FACTORS:
of fecal fat. The quantitative method, • Cimetidine has been associated with
which requires a 72-hour stool collec- decreased fecal fat in some patients
tion, measures the amount of fat pres- with cystic fibrosis who are also receiv-
ent in grams. ■ ing pancreatic enzyme therapy.
INDICATIONS: • Some drugs cause steatorrhea as a result
• Assist in the diagnosis of malabsorption of mucosal damage. These include
or pancreatic insufficiency, as indicated colchicine, kanamycin, lincomycin,
by elevated fat levels methotrexate, and neomycin. Other
drugs that can cause an increase
• Monitor the effectiveness of therapy infecal fat include aminosalicylic
RESULT acid, bisacodyl and phenolphthalein
(observed in laxative abusers), and
Increased in: cholestyramine (in high doses).
Fecal Fat 639
• Use of suppositories, oily lubricants, or can be taken into consideration

mineral oil in the perianal area for 3 when reviewing results.
days before the test can falsely increase ➤ Review the procedure with the
neutral fats. patient. Stress the importance of col-
lecting all stools for the quantitative
• Use of herbals with laxative effects, test, including diarrhea, over the
including cascara, psyllium, and senna, timed specimen-collection period.
for 3 days before the test can falsely Inform the patient not to urinate in
increase neutral fats. the stool-collection container and not
to put toilet paper in the container.
• Barium interferes with test results. Address concerns about pain related
• Failure to collect all stools may reflect to the procedure. Explain to the
patient that there should be no dis-
falsely decreased results. comfort during the procedure.
• Ingestion of a diet too high or low in ➤ Sensitivity to social and cultural
fats may alter the results. issues, as well as concern for mod-
➤ Instruct the patient not to use laxa-
Procedure ● ● ● ● ● ● ● ● ● ● ●
tives, enemas, or suppositories for 3
days before the test.
Pretest:
➤ Inform the patient that the test is by medical direction.
➤ Instruct the patient to ingest a diet
malabsorption syndromes.
containing 50 to 150 g of fat for at
➤ Obtain a history of the patient’s com- least 3 days before beginning speci-
plaints that indicate a gastrointestinal men collection. This approach does
(GI) disorder, diarrhea related to GI not work well with children; instruct
dysfunction, pain related to tissue the caregiver to record the child’s
inflammation or irritation, alteration dietary intake to provide a basis from
in diet resulting from an inability to which an estimate of fat intake can
digest certain foods, or fluid volume be made.
deficit related to active loss. Obtain a
history of known allergens and Intratest:
practitioner accordingly. ➤ Ensure that the patient has complied
➤ Obtain a history of the patient’s GI with dietary and other pretesting
and respiratory systems, and results preparations prior to the procedure.
of previously performed laboratory ➤ Instruct the patient to cooperate fully
tests, surgical procedures, and other and to follow directions.
diagnostic procedures. For related ➤ Observe standard precautions, and
laboratory tests, refer to the Gastro- follow the general guidelines in
intestinal and Respiratory System Appendix A. Positively identify the
tables. patient, and label the appropriate
➤ Note any recent procedures that can collection container with the corre-
interfere with test results. sponding patient demographics,
➤ Obtain a list of the medications the date, and the start and stop times of
patient is taking, including herbs, collection.
nutritional supplements, and nutra- ➤ Obtain the appropriate-sized speci-
ceuticals. The requesting health care men container, toilet-mounted col-
practitioner and laboratory should be lection container to aid in specimen
advised if the patient regularly uses collection, and plastic bag for speci-
these products so that their effects men transport. A large, clean, pre-
weighed container should be used abnormal test results on the

for the timed test. A smaller, clean patient’s lifestyle. Instruct the patient
container can be used for the collec- with abnormal values on the impor-
tion of the random sample. tance of fluid intake and proper diet
➤ For the quantitative procedure, specific to his or her condition.
instruct the patient to collect each Provide teaching and information
stool and place it in the 500-mL con- regarding the clinical implications of
tainer during the timed collection the test results, as appropriate.
period. Keep the container refriger- Educate the patient regarding access
ated in the plastic bag throughout to counseling services.
the entire collection period. ➤ Reinforce information given by the
➤ Promptly transport the specimen to patient’s health care provider regard-
the laboratory for processing and ing further testing, treatment, or
analysis. referral to another health care
➤ The results are recorded manually or address any concerns voiced by the
in a computerized system for recall patient or family.
the appropriate health care practi- ➤ Depending on the results of this pro-
tioner. cedure, additional testing may be
➤ Instruct the patient to resume usual in therapy. Evaluate test results in
diet and medication, as directed by relation to the patient’s symptoms
the health care practitioner. and other tests performed.
care practitioner, who will discuss ➤ Related laboratory tests include 1-
the results with the patient. antitrypsin/phenotyping, complete
➤ Recognize anxiety related to test blood count, D-xylose tolerance test,
results. Discuss the implications of fecal analysis, and sweat chloride.
FERRITIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Ferritin 641
SI Units
Conventional (Conventional
Age Units Units 1)
Newborn 25–200 ng/mL 25–200 g/L
1 mo 200–600 ng/mL 200–600 g/L
2–5 mo 50–200 ng/mL 50–200 g/L
6 mo–15 y 7–140 ng/mL 7–140 g/L
Adult
Men 20–250 ng/mL 20–250 g/L
Women younger than 40 y 10–120 ng/mL 10–120 g/L
Women 40 y and older 12–263 ng/mL 12–263 g/L
RESULT
DESCRIPTION & RATIONALE: Ferritin,
a protein manufactured in the liver, Increased in:
spleen, and bone marrow, consists of a • Alcoholism (active abusers)
protein shell, apoferritin, and an iron
• Breast cancer
core. The amount of ferritin in the cir-
culation is usually proportional to the • Fasting
amount of stored iron (ferritin and • Hemochromatosis
hemosiderin) in body tissues. Levels • Hemolytic anemia
vary according to age and gender, but
they are not affected by exogenous • Hemosiderosis
iron intake or subject to diurnal varia- • Hepatocellular disease (acute or chronic)
tions. Compared to iron and total • Hodgkin’s disease
iron-binding capacity, ferritin is a
more sensitive and specific test for • Hyperthyroidism
diagnosing iron-deficiency anemia. • Infection (acute or chronic)
Iron-deficiency anemia in adults is • Inflammatory diseases
indicated at ferritin levels less than 10
ng/mL; hemochromatosis or hemo- • Leukemias
siderosis is indicated at levels greater • Oral or parenteral administration of
than 400 ng/mL. ■ iron
• Thalassemia
INDICATIONS:
• Assist in the diagnosis of iron-deficiency Decreased in:
anemia • Hemodialysis
• Assist in the differential diagnosis of • Iron-deficiency anemia
microcytic, hypochromic anemias
• Monitor hematologic responses during
pregnancy, when serum iron is usually INTERFERING FACTORS:
decreased and ferritin may be decreased • Drugs that may increase ferritin levels
include ethanol, ferric polymaltose,
• Support diagnosis of hemochromatosis
iron, and oral contraceptives.
or other disorders of iron metabolism
and storage • Drugs that may decrease ferritin levels
include erythropoietin, methimazole, be taken to avoid the use of equip-

propylthiouracil, and thiamazole. ment containing latex.
• Recent transfusion can elevate serum ➤ Instruct the patient to cooperate

fully and to follow directions. Direct
ferritin. the patient to breathe normally
and to avoid unnecessary move-
ment.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: patient, and label the appropriate
➤ Inform the patient that the test is tubes with the corresponding patient
used to assist in the diagnosis of demographics, date, and time of col-
hypochromic, microcytic anemias. lection. Perform a venipuncture; col-
tiger-top tube.
allergens (especially allergies or sen- ➤ Remove the needle, and apply a pres-
sitivities to latex), and inform the sure dressing over the puncture site.
➤ Obtain a history of the patient’s analysis.
hematopoietic system as well as
tioner.
interfere with test results. Post-test:
ceuticals. The requesting health care pressure bandage in place, or replace
practitioner and laboratory should be with a plastic bandage.
➤ Nutritional considerations: Nutri-
tional therapy may be indicated for
patients with decreased ferritin val-
ues because this may indicate cor-
➤ Review the procedure with the responding iron deficiency. Instruct
patient. Inform the patient that spec- these patients in the dietary inclu-
imen collection takes approximately sion of iron-rich foods and in the
5 to 10 minutes. Address concerns administration of iron supplements,
about pain related to the procedure. including side effects, as appro-
Explain to the patient that there may priate.
➤ There are no food, fluid, or medica- care practitioner, who will discuss
tion restrictions, unless by medical the results with the patient.
direction.
Intratest:
➤ If the patient has a history of severe referral to another health care pro-
allergic reaction to latex, care should vider. Answer any questions or
Fetal Fibronectin 643

patient or family.
➤ Related laboratory tests include bone
➤ Depending on the results of this pro- marrow biopsy, complete blood
cedure, additional testing may be count, erythropoietin, hematocrit,
performed to evaluate or monitor hemoglobin, iron/total iron-binding
progression of the disease process capacity, liver biopsy, platelet count,
and determine the need for a change red blood cell count, red blood cell
in therapy. Evaluate test results in indices, red blood cell morphology
relation to the patient’s symptoms and inclusions, and white blood cell
and other tests performed. count and differential.
FETAL FIBRONECTIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: fFN.
SPECIMEN: Swab of vaginal secretions.
Negative in: N/A

DESCRIPTION & RATIONALE: Fibro-
nectin is a protein found in the vagi- CRITICAL VALUES: N/A
nal secretions of pregnant women. It
is first secreted early in pregnancy and INTERFERING FACTORS: If signs and
is believed to help implantation of the symptoms persist in light of negative test
results, repeat testing may be necessary.
fertilized egg to the uterus. Fibronectin
is not detectable again until 22 to 34
weeks of gestation; if it is detected in Nursing Implications and
vaginal secretions at this gestational Procedure ● ● ● ● ● ● ● ● ● ● ●
age, delivery may happen prematurely.

The test is a useful marker for impend- Pretest:
ing membrane rupture within 7 to 14
days if the level rises to greater than used to assess the risk of preterm
0.05 g/mL. ■ delivery.
INDICATIONS: Investigate signs of pre- plaints, including a list of known
mature labor allergens (especially allergies or sen-
RESULT appropriate health care practitioner
accordingly.
Positive in: Premature labor ➤ Obtain a history of the patient’s
reproductive system and results of be taken to avoid the use of equip-

previously performed laboratory ment containing latex.
tests, surgical procedures, and other ➤ Instruct the patient to cooperate fully
diagnostic procedures. For related and to follow directions. Direct the
laboratory tests, refer to the Repro- patient to breathe normally and to
ductive System table. avoid unnecessary movement.
➤ Ensure that the patient knows the ➤ Observe standard precautions, and
symptoms of premature labor, which follow the general guidelines in
include uterine contractions (with or Appendix A. Positively identify the
without pain) lasting 20 seconds or patient, and label the appropriate col-
longer or increasing in frequency, lection container with the correspon-
menstrual-like cramping (intermittent ding patient demographics, date, and
or continuous), pelvic pressure, time of collection.
lower back pain that does not dissi-
➤ Position the patient on the gyneco-
pate with a change in position, per-
logic examination table with the feet
sistent diarrhea, intestinal cramps,
up in stirrups. Drape the patient’s
changes in vaginal discharge, or a
legs to provide privacy and to reduce
feeling that something is wrong.
chilling. Collect a small amount of
➤ The health care practitioner should vaginal secretion using a special
be informed if contractions occur swab from a fetal fibronectin kit.
more frequently than 4 times per
hour.
➤ Obtain a list of the medications the analysis.
tioner.
Post-test:
➤ Review the procedure with the ➤ A written report of the examination
patient. Inform the patient that spec- will be sent to the requesting health
imen collection takes approximately care practitioner, who will discuss
5 to 10 minutes and will be per- the results with the patient.
formed by a health care practitioner ➤ Recognize anxiety related to test
specializing in this branch of medi- results. Discuss the implications of
cine. Address concerns about pain abnormal test results on the patient’s
related to the procedure. Explain to lifestyle. Provide teaching and infor-
the patient that there should be min- mation regarding the clinical impli-
imal to no discomfort during the pro- cations of the test results, as
cedure. appropriate. Educate the patient
➤ Sensitivity to social and cultural regarding access to counseling
issues, as well as concern for mod- services.
esty, is important in providing psy- ➤ Reinforce information given by the
chological support before, during, patient’s health care provider regard-
and after the procedure. ing further testing, treatment, or
➤ There are no food, fluid, or medica- referral to another health care
tion restrictions, unless by medical provider. Explain the possible causes
direction. and increased risks associated with
premature labor and delivery. Rein-
Intratest: force education on signs and symp-
toms of labor, as appropriate. Inform
➤ If the patient has a history of severe the patient that hospitalization or
allergic reaction to latex, care should more frequent prenatal checks may
1-Fetoprotein 645
be ordered. Other therapies may progression of the disease process

also be administered, such as antibi- and determine the need for a change
otics, corticosteroids, and intravenous in therapy. Evaluate test results in
tocolytics. Instruct the patient in the relation to the patient’s symptoms
importance of completing the entire and other tests performed.
course of antibiotic therapy, if ordered,
even if no symptoms are present. Related laboratory tests:
Answer any questions or address any
amniotic fluid analysis, chorionic
family.
villus biopsy, chromosome analy-
➤ Depending on the results of this pro- sis, estradiol, 1-fetoprotein, human
cedure, additional testing may be chorionic gonadotropin, and lecithin/
performed to evaluate or monitor sphingomyelin ratio.
1-FETOPROTEIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: AFP.
SPECIMEN: Serum (1 mL for tumor marker in men and nonpregnant
women; 3 mL for maternal triple-marker testing), collected in a red- or
tiger-top tube. For maternal triple-marker testing, include human chorionic
gonadotropin and free estriol measurement.
REFERENCE VALUE: (Method: Immunoassay for tumor marker, radioim-

munoassay for maternal triple-marker testing)
Tumor Marker, Men and Women
AFP
Fetus, first-trimester peak 200–400 mg/dL
Cord blood Less than 5 mg/dL
AFP in White Black Hispanic Asian

Maternal AFP AFP AFP AFP
Serum (Median) (Median) (Median) (Median)
Low risk Less than Less than Less than Less than
2 MoM 2 MoM 2 MoM 2 MoM

AFP in White Black Hispanic Asian

Maternal AFP AFP AFP AFP
Serum (Median) (Median) (Median) (Median)
Gestational
Age (wk)
14 19.9 ng/mL 23.2 ng/mL 18.3 ng/mL 22.4 ng/mL
MoM = multiples of the median.
HCG and Estriol

in Maternal Serum HCG Free Estriol
Gestational Age (wk) Median Value Median Value
14 41.5 IU/mL 0.5 ng/mL
15 36.0 IU/mL 0.7 ng/mL
16 31.0 IU/mL 0.9 ng/mL
17 27.0 IU/mL 1.1 ng/mL
18 24.0 IU/mL 1.4 ng/mL
19 21.0 IU/mL 1.8 ng/mL
20 18.0 IU/mL 2.3 ng/mL
21 16.0 IU/mL 2.8 ng/mL
22 14.0 IU/mL 3.6 ng/mL
Results vary widely from laboratory to laboratory and method to method.

HCG = human chorionic gonadotropin.
DESCRIPTION & RATIONALE: 1- investigation into fetal well-being by

Fetoprotein (AFP) is a glycoprotein ultrasound or amniocentesis. Human
produced in the fetal liver, gastroin- chorionic gonadotropin (HCG), a
testinal tract, and yolk sac. AFP is the hormone secreted by the placenta,
major serum protein produced for 10 stimulates secretion of progesterone
weeks in early fetal life. (See “Amniotic by the corpus luteum. (The use of
Fluid Analysis” monograph for meas- HCG as a triple marker is also dis-
urement of AFP levels in amniotic cussed in the monograph titled
fluid.) After 10 weeks of gestation, “Human Chorionic Gonadotropin.”)
levels of fetal AFP can be detected in During intrauterine development, the
maternal blood, with peak levels normal fetus and placenta produce
occurring at 16 to 18 weeks. Elevated estriol, a portion of which passes
maternal levels of AFP on two tests into maternal circulation. Decreased
taken 1 week apart suggest further estriol levels are an independent indi-
1-Fetoprotein 647
cator of neural tube defects. The inci- The MoM should also be corrected for
maternal insulin requirement (achieved
dence of neural tube defects is about 1
by dividing MoM by 1.1 for diabetic
in 1000 births. African American patients and by 0.8 for
The presence of AFP in excessive diabetic patients of other races) and mul-
amounts is abnormal in adults. AFP tiple fetuses (multiply by 2.13 for twins).
measurements are used as a tumor Some laboratories also provide additional
marker to assist in the diagnosis of statistical information regarding Down’s
cancer. ■ syndrome risk.
INDICATIONS: Increased in:

• Assist in the diagnosis of primary hepa- • Pregnant women:
tocellular carcinoma or metastatic Congenital nephrosis
lesions involving the liver, as indicated Fetal abdominal wall defects
by highly elevated levels (30% to 50%
Fetal distress
of Americans with liver cancer do not
have elevated AFP levels) Fetal neural tube defects (e.g.,
anencephaly, spina bifida,
• Investigate suspected hepatitis or cir- myelomeningocele)
rhosis, indicated by slightly to moder- Low birth weight
ately elevated levels Multiple pregnancy
• Monitor response to treatment for Polycystic kidneys
hepatic carcinoma, with successful treat- Underestimation of gestational age
ment indicated by an immediate
decrease in levels • Men or nonpregnant women:
Cirrhosis
• Monitor for recurrence of hepatic carci-
Hepatic carcinoma
noma, with elevated levels occurring 1
to 6 months before the patient becomes Hepatitis
symptomatic Metastatic lesions involving the liver
• Investigate suspected intrauterine fetal Decreased in:

death, as indicated by elevated levels • Pregnant women:
• Routine prenatal screening at 13 to 16 Down’s syndrome (trisomy 21)
weeks of pregnancy for fetal neural Edwards’ syndrome (trisomy 18)
tube defects and other disorders, as Fetal demise (undetected over a
indicated by elevated levels in maternal lengthy period of time)
serum and amniotic fluid Hydatidiform moles
• Support diagnosis of embryonal gonadal Overestimation of gestational age
teratoblastoma, hepatoblastoma, and Pseudopregnancy
testicular or ovarian carcinomas Spontaneous abortion
RESULT: Maternal serum AFP test results CRITICAL VALUES: N/A
report actual values and multiples of the
median (MoM) by gestational age (in
weeks). MoM are calculated by dividing
• Drugs that may decrease AFP levels
the patient’s AFP by the midpoint (or
in pregnant women include aceta-
median) of values expected for a large
minophen, acetylsalicylic acid, and
population of unaffected women at the
phenacetin.
same gestational age in weeks. MoM
should be corrected for maternal weight. • Recent radioactive scans or radiation
within 1 week before the test can inter- patient is taking, including herbs,
fere with test results when radioim- nutritional supplements, and nutra-
munoassay is the test method. ceuticals. The requesting health care
• Multiple fetuses can cause increased advised if the patient is regularly
levels. using these products so that their
• Gestational age must be between 15 tion when reviewing results.
and 22 weeks for initial and follow-up ➤ Review the procedure with the
testing. The most common cause of an patient. Inform the patient that spec-
abnormal MoM is inaccurate estima- imen collection takes approximately
tion of gestational age (defined as 5 to 10 minutes. Address concerns
weeks from the first day of the last about pain related to the procedure.
menstrual period). Explain to the patient that there may
• Maternal AFP levels vary by race. venipuncture.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Make sure a written and informed
Pretest: procedure and before administering
any medications.
marily used to screen for neural tube Intratest:
defects.
plaints and known or suspected
malignancy. Obtain a list of known
sitivities to latex, and inform the ➤ Instruct the patient to cooperate fully
appropriate health care practitioner and to follow directions. Direct the
accordingly. patient to breathe normally and to
immune and reproductive systems, ➤ Observe standard precautions, and
gestational age, and results of previ- follow the general guidelines in
ously performed laboratory tests, Appendix A. Positively identify the
surgical procedures, and other diag- patient, and label the appropriate
nostic procedures. For related labo- tubes with the corresponding patient
ratory tests, refer to the Immune and demographics, date, and time of col-
Reproductive System tables. lection. Perform a venipuncture; col-
➤ Note any recent procedures that can tube.
➤ The sample may be collected directly
➤ Provide required information to labo- from the cord using a syringe and
ratory for triple-marker testing, includ- transferred to a red-top tube.
ing maternal birth date, weight, age,
race, calculated gestational age, ges- ➤ Remove the needle, and apply a pres-
tational age by ultrasound, gesta- sure dressing over the puncture site.
tional date by physical examination, ➤ Promptly transport the specimen to
first day of last menstrual period, esti- the laboratory for processing and
mated date of delivery, and whether analysis.
the patient has insulin-dependent ➤ The results are recorded manually or
(type 1) diabetes. in a computerized system for recall
1-Fetoprotein 649
the appropriate health care practi- options (termination of pregnancy or

tioner. adoption). It is also important to dis-
cuss feelings the mother and father
Post-test: may experience (e.g., guilt, depres-
sion, anger) if fetal abnormalities are
➤ Observe venipuncture site for bleed- detected. Educate the patient regard-
ing or hematoma formation. Apply ing access to counseling services.
pressure bandage in place, or replace ➤ In patients with carcinoma, recog-
with a plastic bandage. nize anxiety related to test results,
and offer support. Discuss the impli-
➤ Nutritional considerations: Hyper- cations of abnormal test results on
homocysteinemia resulting from the patient’s lifestyle. Provide teach-
folate deficiency in pregnant women ing and information regarding the
is believed to increase the risk of neu- clinical implications of the test results,
ral tube defects. Elevated levels of as appropriate. Educate the patient
homocysteine are thought to chemi- regarding access to counseling serv-
cally damage the exposed neural tis- ices, as appropriate.
sue of the developing fetus. As
appropriate, instruct pregnant women ➤ Reinforce information given by the
to eat foods rich in folate, such as patient’s health care provider regard-
liver, salmon, eggs, asparagus, green ing further testing, treatment, or refer-
leafy vegetables, broccoli, sweet ral to another health care provider.
potatoes, beans, and whole wheat. Answer any questions or address any
➤ A written report of the examination family.
performed to evaluate or monitor pro-
➤ Social and cultural considerations: In gression of the disease process and
pregnant patients, recognize anxiety determine the need for a change in
related to test results, and encourage therapy. Inform the pregnant patient
the family to seek counseling if that an ultrasound may be performed
concerned with pregnancy termina- and AFP levels in amniotic fluid may
tion or to seek genetic counseling be analyzed if maternal blood levels
if a chromosomal abnormality is are elevated in two samples obtained
determined. Discuss the implications 1 week apart. Evaluate test results in
of abnormal test results on the relation to the patient’s symptoms
patient’s lifestyle. Provide teaching and other tests performed.
implications of the test results, as Related laboratory tests:
appropriate. Decisions regarding
elective abortion should take place in ➤ Related laboratory tests include
the presence of both parents. Provide amniotic fluid analysis, chorionic vil-
a nonjudgmental, nonthreatening lus biopsy, carcinoembryonic anti-
atmosphere for discussing the risks gen, estradiol, fetal fibronectin, folic
and difficulties of delivering and rais- acid, hexosamidase, homocysteine,
ing a developmentally challenged human chorionic gonadotropin, and
infant, as well as exploring other lecithin/sphingomyelin ratio.
FIBRIN DEGRADATION PRODUCTS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Fibrin split products, fibrin breakdown products,

FDP, FSP, FBP.
SPECIMEN: Plasma (1 mL) collected in special blue-top tube containing

thrombin and a protease inhibitor.
REFERENCE VALUE: (Method: Latex agglutination)

Less than 10 g/mL Less than 10 mg/dL
• Evaluate response to therapy with fibri-

DESCRIPTION & RATIONALE: This nolytic drugs
coagulation test evaluates fibrin split
• Monitor the effects on hemostasis of
products or fibrin/fibrinogen degrada- trauma, extensive surgery, obstetric
tion products that interfere with nor- complications, and disorders such as
mal coagulation and formation of the liver or renal disease
hemostatic platelet plug. After a fibrin
clot has formed, the fibrinolytic sys- RESULT
tem prevents excessive clotting. In the
fibrinolytic system, plasmin digests Increased in:
fibrin. Fibrinogen also can be degraded • DIC
if there is a disproportion among plas-
• Excessive bleeding
min, fibrin, and fibrinogen. Seven
substances labeled A, B, C, D, E, X, • Liver disease
and Y result from this degradation,
which can indicate abnormal coagula-
tion. Under normal conditions, the • Obstetric complications, such as pre-
liver and reticuloendothelial system eclampsia, abruptio placentae, intra-
remove fibrin split products from the uterine fetal death
circulation. ■ • Post–cardiothoracic surgery period
INDICATIONS: • Pulmonary embolism
• Assist in the diagnosis of suspected dis- • Renal disease
seminated intravascular coagulation
(DIC) • Renal transplant rejection
Fibrin Degradation Products 651
CRITICAL VALUES: ➤ Obtain a list of medications the

patient takes, including anticoagulant
Greater than 40 g/mL. therapy, acetylsalicylic acid, herbs,
Note and immediately report to the nutritional supplements, and nutra-
health care practitioner any critically ceuticals, especially those known to
increased values and related symptoms. affect coagulation. It is recommended
that use of these products be dis-
INTERFERING FACTORS: continued 14 days before dental or
• Traumatic venipunctures and excessive surgical procedures. The requesting
agitation of the sample can alter test health care practitioner and labora-
results. tory should be advised if the patient
regularly uses these products so that
• Drugs that may increase fibrin degrada- their effects can be taken into con-
tion product levels include heparin and sideration when reviewing results.
fibrinolytic drugs such as streptokinase ➤ Review the procedure with the
and urokinase. patient. Inform the patient that spec-
• The presence of rheumatoid factor may imen collection takes approximately
falsely elevate results with some test kits. 5 to 10 minutes. Address concerns
• The test should not be ordered on Explain to the patient that there may
patients receiving heparin therapy. be some discomfort during the
venipuncture.
Nursing Implications and issues, as well as concern for mod-
Procedure ● ● ● ● ● ● ● ● ● ● ● esty, is important in providing psy-
Pretest: and after the procedure.
➤ Inform the patient that the test is ➤ There are no food, fluid, or medica-
used to evaluate conditions associ- tion restrictions, unless by medical
ated with abnormal fibrinolytic and direction.
fibrinogenolytic activity, such as DIC,
deep vein thrombosis, and pulmonary Intratest:
embolism. ➤ If the patient has a history of severe
➤ Obtain a history of the patient’s com- allergic reaction to latex, care should
plaints, including a list of known be taken to avoid the use of equip-
allergens (especially allergies or sen- ment containing latex.
accordingly.
➤ Obtain a history of the patient’s car- avoid unnecessary movement.
diovascular and hematopoietic sys-
tems, any bleeding disorders, and ➤ Observe standard precautions, and
results of previously performed labo- follow the general guidelines in
ratory tests (especially bleeding time, Appendix A. Positively identify the
clotting time, complete blood count, patient, and label the appropriate
D-dimer, partial thromboplastin time, tubes with the corresponding patient
platelets, and prothrombin time), sur- demographics, date, and time of col-
gical procedures, and other diagnos- lection. Perform a venipuncture; col-
tic procedures. For related laboratory lect the specimen in a special
tests, refer to the Cardiovascular and blue-top tube.
Hematopoietic System tables. ➤ Remove the needle, and apply a pres-
➤ Note any recent procedures that can sure dressing over the puncture site.
interfere with test results. ➤ Promptly transport the specimen to
the laboratory for processing and ➤ A written report of the examination

analysis. will be sent to the requesting health
➤ The results are recorded manually or care practitioner, who will discuss
in a computerized system for recall the results with the patient.
the appropriate health care practitioner. patient’s health care provider regard-
Post-test: ral to another health care provider.
or family.
pressure bandage in place, or replace ➤ Depending on the results of this pro-
with a plastic bandage. cedure, additional testing may be
➤ Instruct the patient to report bleeding performed to evaluate or monitor
from skin or mucous membranes, progression of the disease process
ecchymosis, petechiae, hematuria and determine the need for a change
and occult blood. in therapy. Evaluate test results in
➤ Inform the patient with increased and other tests performed.
levels of fibrin degradation products
of the importance of taking precau- Related laboratory tests:
tions against bruising and bleeding,
including the use of a soft bristle tooth- ➤ Related laboratory tests include acti-
brush, use of an electric razor, avoid- vated partial thromboplastin time,
ance of constipation, avoidance of aspartate alanino aminotransbiliru-
acetylsalicylic acid and similar prod- bin, BUN creatinine, complete blood
ucts, and avoidance of intramuscular count, D-dimer, fibrinogen, plasmino-
injections. gen, and platelet count.
FIBRINOGEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Factor I.
SPECIMEN: Plasma (1 mL) collected in blue-top (sodium citrate) tube.
REFERENCE VALUE: (Method: Photo-optical clot detection)
Newborn 125–300 mg/dL 1.25–3.00 g/L
Adult 200–400 mg/dL 2.00–4.00 g/L
Fibrinogen 653
CRITICAL VALUE:
DESCRIPTION & RATIONALE: Fib- Less than 80 mg/dL.
rinogen (factor I) is synthesized in the Note and immediately report to the
liver. In the common final pathway of health care practitioner any critically
the coagulation sequence, thrombin decreased values and related symptoms.
converts fibrinogen to fibrin, which Signs and symptoms of microvascular
then clots blood as it combines with thrombosis include cyanosis, ischemic tis-
platelets. In normal, healthy individu- sue necrosis, hemorrhagic necrosis,
als, the serum should contain no tachypnea, dyspnea, pulmonary emboli,
residual fibrinogen after clotting has venous distention, abdominal pain, and
oliguria. Possible interventions include
occurred. ■
identification and treatment of the under-
lying cause, support through administra-
INDICATIONS: tion of required blood products (platelets,
• Assist in the diagnosis of suspected dis-
cryoprecipitate, or fresh frozen plasma),
seminated intravascular coagulation
and administration of heparin.
(DIC), as indicated by decreased fib-
rinogen levels
• Evaluate congenital or acquired dysfib- • Drugs that may increase fibrinogen
rinogenemias levels include acetylsalicylic acid, nore-
• Monitor hemostasis in disorders associ- thandrolone, oral contraceptives, oxan-
ated with low fibrinogen levels or ele- drolone, and oxymetholone.
vated levels that can predispose patients • Drugs that may decrease fibrinogen
to excessive thrombosis levels include anabolic steroids, asparag-
inase, bezafibrate, danazol, dextran,
RESULT fenofibrate, fish oils, gemfibrozil, lovas-
tatin, pentoxifylline, phosphorus, and
Increased in: ticlopidine.
• Acute myocardial infarction
• Transfusions of whole blood, plasma,
• Cancer or fractions within 4 weeks of the test
• Eclampsia invalidate results.
• Hodgkin’s disease • Placement of tourniquet for longer
• Inflammation sis and changes in the concentration of
• Multiple myeloma plasma proteins to be measured. Platelet
activation may also occur under these
• Nephrotic syndrome conditions, causing erroneous results.
• Pregnancy
• Vascular injury during phlebotomy can
• Tissue necrosis activate platelets and coagulation fac-
tors, causing erroneous results.
Decreased in:
• Hemolyzed specimens must be rejected
• Congenital fibrinogen deficiency (rare) because hemolysis is an indication of
• DIC platelet and coagulation factor activa-
tion.
• Dysfibrinogenemia
• Incompletely filled tubes contaminated
• Liver disease (severe)
with heparin or clotted specimens must
• Primary fibrinolysis be rejected.
• Icteric or lipemic specimens interfere Intratest:

with optical testing methods, produc-
ing erroneous results. ➤ If the patient has a history of severe
• Traumatic venipuncture and excessive be taken to avoid the use of equip-
agitation of the sample can alter test ment containing latex.
results. ➤ Instruct the patient to cooperate fully
used to evaluate fibrinolytic activity demographics, date, and time of
as well as identify congenital defi- collection. Perform a venipuncture;
ciency and DIC. collect the specimen in a 5-mL blue-
➤ Obtain a history of the patient’s com- top tube. Fill the tube completely.
plaints, including a list of known Important note: Two different con-
allergens (especially allergies or sen- centrations of sodium citrate preser-
sitivities to latex), and inform the vative are currently added to blue-top
appropriate health care practitioner tubes for coagulation studies: 3.2%
accordingly. and 3.8%. The Clinical and Labo-
ratory Standards Institute/CLSI (for-
➤ Obtain a history of the patient’s merly the National Committee for
hematopoietic and hepatobiliary sys- Clinical Laboratory Standards/NCCLS)
tems, as well as results of previously guideline for sodium citrate is 3.2%.
performed laboratory tests, surgical Laboratories establish reference
procedures, and other diagnostic pro- ranges for coagulation testing based
cedures. For related laboratory tests, on numerous factors, including
refer to the Hematopoietic and Hepa- sodium citrate concentration, test
tobiliary System tables. equipment, and test reagents. It is
➤ Note any recent procedures that can important to inquire from the labora-
interfere with test results. tory which concentration it recom-
➤ Obtain a list of medications the mends, because each concentration
patient is taking, including herbs, will have its own specific reference
nutritional supplements, and nutra- range.
ceuticals. The requesting health care ➤ When multiple specimens are
practitioner and laboratory should be drawn, the blue-top tube should be
advised if the patient regularly takes collected after sterile (i.e., blood cul-
these products so that their effects ture) and nonadditive red-top tubes.
can be taken into consideration when When coagulation testing is the only
reviewing results. work to be done, an extra red-top
➤ Review the procedure with the tube should be collected before the
patient. Inform the patient that spec- blue-top tube to avoid contaminating
imen collection takes approximately the specimen with tissue thrombo-
5 to 10 minutes. Address concerns plastin, which can falsely decrease
about pain related to the procedure. values.
Explain to the patient that there may ➤ Remove the needle, and apply a
be some discomfort during the pressure dressing over the puncture
venipuncture. site.
➤ There are no food, fluid, or medica- ➤ Promptly transport the specimen to
tion restrictions, unless by medical the laboratory for processing and
direction. analysis. The CLSI recommenda-
Fluorescein Angiography 655
tion for processed and unprocessed will be sent to the requesting health
specimens stored in unopened tubes care practitioner, who will discuss
is that testing should be completed the results with the patient.
within 1 to 4 hours of collection. ➤ Reinforce information given by the
➤ The results are recorded manually or patient’s health care provider regard-
in a computerized system for recall ing further testing, treatment, or refer-
and postprocedure interpretation by ral to another health care provider.
the appropriate health care practi- Answer any questions or address any
tioner. concerns voiced by the patient or
family.
➤ Observe venipuncture site for bleed- performed to evaluate or monitor
ing or hematoma formation. Apply progression of the disease process
paper tape or other adhesive to hold and determine the need for a change
pressure bandage in place, or replace in therapy. Evaluate test results in
with a plastic bandage. relation to the patient’s symptoms
➤ Instruct the patient to report bruis- and other tests performed.
ing, petechiae, and bleeding from
mucous membranes, hematuria and
occult blood. Related laboratory tests:
➤ Inform the patient with a decreased ➤ Related laboratory tests include acti-
fibrinogen level of the importance of vated partial thromboplastin time,
taking precautions against bruising alanine aminotransferase, albumin,
and bleeding, including the use of a alkaline phosphatase, aspartate
soft bristle toothbrush, use of an aminotransferase, bilirubin, clot
electric razor, avoidance of constipa- retraction, D-dimer, erythrocyte sedi-
tion, avoidance of acetylsalicylic acid mentation rate, fibrin degradation
and similar products, and avoidance products, -glutamyl transpeptidase,
of intramuscular injections. liver biopsy, plasminogen, and pro-
➤ A written report of the examination thrombin time.
FLUORESCEIN ANGIOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: FA.
CONTRAST: Fluorescein dye.
DESCRIPTION & RATIONALE: This trast medium known as sodium fluo-

test involves the color radiographic roscein. A special fundus camera is
examination of the retinal vasculature used that allows for images to be taken
following a rapid injection of a con- in sequence and manipulated by a
computer to provide views of abnor- aneurysms, or obstructions caused by

stenosis and resulting in collateral
malities of the retinal vessels during
circulation
filling and emptying of the dye. The
camera allows only light waves at 490 Abnormal Findings:
nm in the blue range to strike the fun- • Aneurysm
dus of the eye. When the fluorescein
dye is injected into the eye, the blue • Arteriovenous shunts
light excites the dye molecules to a • Diabetic retinopathy
higher state of activity and causes
• Macular degeneration
them to emit a greenish-yellow fluo-
resence that is recorded. ■ • Neovascularization
• Obstructive disorders of the arteries or
INDICATIONS: veins that lead to collateral circulation
• Detect arterial or venous occlusion evi-
denced by the reduced, delayed, or
absent flow of the contrast medium CRITICAL VALUES: N/A
through the vessels or possible vessel
leakage of the medium INTERFERING FACTORS:
• Detect possible vascular disorders This procedure is
affecting visual acuity contraindicated for:
• Detect presence of microaneurysms • Patients with a past history of hyper-
caused by hypertensive retinopathy sensitivity to radiographic dyes
• Detect the presence of tumors, retinal • Patients with narrow-angle glaucoma
edema, or inflammation, as evidenced if pupil dilation is performed as dila-
by abnormal patterns of degree of fluo- tion can initiate a severe and sight-
rescence threatening open-angle attack
• Diagnose diabetic retinopathy • Patients with allergies to mydriatics if
• Diagnose past reduced flow or patency pupil dilation using mydriatics is per-
of the vascular circulation of the retina, formed
as evidenced by neovascularization
• Diagnose presence of macular degener- results of the examination:
ation and any other degeneration and • Inability of the patient to cooperate or
any associated hemorrhaging remain still during the test because of
• Observe ocular effects resulting from age, significant pain, or mental status
the long-term use of high-risk medica- may interfere with the test results.
tions • Presence of cataracts may interfere with
fundal view.
RESULT
• Ineffective dilation of the pupils may
Normal Findings: impair clear imaging.
• No leakage of dye from retinal blood • Allergic reaction to radiographic dye,
vessels including nausea and vomiting.
• Normal retina and retinal and choroidal • Failure to follow medication restric-
vessels tions before the procedure may cause
• No evidence of vascular abnormali- the procedure to be canceled or
ties, such as hemorrhage, retinopathy, repeated.
Fluorescein Angiography 657
cause facial flushing or nausea and

Nursing Implications and vomiting. Inform the patient that a
Procedure ● ● ● ● ● ● ● ● ● ● ● technician, optometrist, or health care
practitioner performs the test, in a
Pretest: quiet, darkened room, and that to
dilate and evaluate both eyes, the
➤ Inform the patient that the test test can take up 60 minutes.
detects possible vascular disorders
of the eye. ➤ Explain that an intravenous (IV) line
➤ Obtain a history of the patient’s com- dye.
allergens, especially allergies or sen- ➤ There are no food or fluid restric-
sitivities to radiographic dyes, shell- tions, unless by medical direction.
fish, and bee venom. ➤ The patient should avoid eye medica-
➤ Obtain a history of the patient’s known tions (particularly mydriatic eye drops
or suspected vision loss, changes in if the patient has glaucoma) for at
visual acuity, including type and cause; least 1 day prior to the test.
use of glasses or contact lenses; eye ➤ Ensure that the patient understands
conditions with treatment regimens; that he or she must refrain from driv-
eye surgery; and other tests and pro- ing until the pupils return to normal
cedures to assess and diagnose (about 4 hours) after the test and has
visual deficit. made arrangements to have some-
➤ Obtain a history of results of previ- one else be responsible for trans-
ously performed laboratory tests, portation after the test.
surgical procedures, and other diag- ➤ Make sure a written and informed
nostic procedures. consent has been signed prior to the
➤ Obtain a list of the medications the procedure and before administering
patient is taking, including herbs, any medications.
ceuticals. The requesting health care Intratest:
practitioner should be advised if the ➤ Ensure that the patient has complied
patient regularly uses these products with medication restrictions; assure
so that their effects can be taken that eye medications, especially
into consideration when reviewing mydriatics, have been withheld for at
results. least 1 day prior to the test.
➤ Instruct the patient to remove con- ➤ Have emergency equipment readily
tact lenses or glasses, as appropri- available.
ate. Instruct the patient regarding
the importance of keeping the eyes ➤ Instruct the patient to cooperate fully
open for the test. and to follow directions. Ask the
patient to remain still during the pro-
➤ Review the procedure with the cedure because movement produces
patient. Explain that the patient will unreliable results.
be requested to fixate the eyes dur-
ing the procedure. Address concerns ➤ Seat the patient in a chair that faces
about pain related to the procedure. the camera. Instruct the patient to
Explain to the patient that mydriatics, look at directed target while the eyes
if used, may cause blurred vision and are examined.
sensitivity to light. There may also be ➤ If dilation is to be performed, admin-
a brief stinging sensation when the ister the ordered mydriatic to each
drop is put in the eye. Explain to the eye and repeat in 5 to 15 minutes.
patient that some discomfort may be Drops are placed in the eye with the
experienced during the insertion of patient looking up and the solution
the intermittent infusion device. directed at the six o’clock position of
Inform the patient that, when fluo- the sclera (white of the eye) near the
resecein dye is injected, it may limbus (grey, semitransparent area
of the eyeball where the cornea and ➤ A written report of the examination
sclera meet). The dropper bottle will be completed by a health care
should not touch the eyelashes. practitioner specializing in this branch
➤ Insert an intermittent infusion device, of medicine. The report will be sent
as ordered, for subsequent injection to the requesting health care practi-
of the contrast media or emergency tioner, who will discuss the results
medications. with the patient.
➤ After the eyedrops are administered
results, and be supportive of impaired
but before the dye is injected, color
activity related to vision loss or per-
photographs are taken.
ceived loss of driving privileges.
➤ Ask the patient to place the chin in Discuss the implications of abnormal
the chin rest and gently press the test results on the patient’s lifestyle.
forehead against the support bar. Provide teaching and information
Ask the patient to open his or her regarding the clinical implications of
eyes wide and look at the desired the test results, as appropriate.
target.
➤ Fluorescein dye is then injected into patient’s health care provider regard-
the brachial vein using the intermit- ing further testing, treatment, or
tent infusion device, and a rapid referral to another health care pro-
sequence of photographs are taken vider. Inform the patient that visual
and repeated after the dye has acuity and resposnses to light may
reached the retinal vascular system. change. Suggest that the patient
Follow-up photographs are taken in wear dark glasses after the test until
20 to 30 minutes. the pupils return to normal size.
➤ At the conclusion of the proce- Inform the patient that yellow discol-
dure, the IV needle is removed, and oration of the skin and urine from the
an adhesive strip is applied to the radiographic dye is normally present
site. for up to 2 days. Answer any ques-
➤ Observe for hypersensitive reaction by the patient or family.
to the dye. The patient may become
nauseous and vomit. ➤ Depending on the results of this pro-
➤ The results are recorded on devel- performed to evaluate or monitor
oped color film or electronically on progression of the disease process
computerized equipment for recall and determine the need for a change
and postprocedure interpretation by in therapy. Evaluate test results in
the appropriate health care practi- relation to the patient’s symptoms
tioner. and other tests performed.
Post-test: Related diagnotic tests:

➤ Instruct the patient to resume usual ➤ Related diagnostic tests include fun-
medications, as directed by the dus photography, gonioscopy, and
health care practitioner. visual field testing.
Folate 659
FOLATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Folic acid.

SI Units
Newborn–1 y 5–21 ng/mL 11–48 nmol/L
Adult Greater than 2.5 ng/mL Greater than 5.7 nmol/L
• Monitor the effects of prolonged par-

DESCRIPTION & RATIONALE: Folate, enteral nutrition
a water-soluble vitamin, is produced • Monitor response to disorders that may
by bacteria in the intestines and stored lead to folate deficiency or decreased
in small amounts in the liver. Dietary absorption and storage
folate is absorbed through the intes-
tinal mucosa and stored in the liver. RESULT
Folate is necessary for normal red
blood cell and white blood cell func- Increased in:
tion, DNA replication, and cell divi- • Blind loop syndrome
sion. Folate levels are often measured
• Distal small bowel disease
in association with serum vitamin B12
determinations. Hyperhomocystine- • Excessive dietary intake of folate or
mia resulting from folate deficiency folate supplements
in pregnant women is believed to • Pernicious anemia
increase the risk of neural tube defects.
• Vitamin B12 deficiency
Elevated levels of homocysteine are
thought to cause chemical damage to Decreased in:
the exposed neural tissue of the devel- • Chronic alcoholism
oping fetus. ■
INDICATIONS: • Exfoliative dermatitis
• Assist in the diagnosis of megaloblastic
anemia resulting from deficient folate • Hemolytic anemias
intake or increased folate requirements,
• Infantile hyperthyroidism
such as in pregnancy and hemolytic
anemia • Liver disease
• Malnutrition tems, as well as results of previously

• Megaloblastic anemia procedures, and other diagnostic
• Myelofibrosis procedures. For related laboratory
• Neoplasms and Hematopoietic System tables.
• Pregnancy ➤ Note any recent procedures that can
• Regional enteritis ➤ Obtain a list of medications the
• Scurvy patient is taking, including herbs,
• Sideroblastic anemias ceuticals. The requesting health care
• Sprue advised if the patient regularly uses
• Ulcerative colitis these products so that their effects
• Whipple’s disease when reviewing results.
CRITICAL VALUES: N/A patient. Inform the patient that spec-
INTERFERING FACTORS: 5 to 10 minutes. Address concerns
• Drugs that may decrease folate levels in- about pain related to the procedure.
clude aminopterin, ampicillin, antacids, Explain to the patient that there may
anticonvulsants, barbiturates, chloram- be some discomfort during the
venipuncture.
phenicol, chloroguanide, erythromycin,
ethanol, glutethimide, lincomycin, ➤ There are no food, fluid, or medica-
metformin, methotrexate, nitrofurans, tion restrictions, unless by medical
oral contraceptives, penicillin, pentami- direction.
dine, phenytoin, pyrimethamine, tetra-
cycline, and triamterene. Intratest:
• Recent radioactive scans or radiation ➤ If the patient has a history of severe
within 1 week before the test can inter- allergic reaction to latex, care should
fere with test results when radioim- be taken to avoid the use of equip-
munoassay is the test method. ment containing latex.
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to detect folate deficiency and tubes with the corresponding patient
to monitor folate therapy. demographics, date, and time of col-
plaints, including a list of known lect the specimen in a 5-mL red- or
allergens (especially allergies or sen- tiger-top tube. Protect the specimen
sitivities to latex), and inform the from light.
appropriate health care practitioner ➤ Remove the needle, and apply a
accordingly. pressure dressing over the puncture
➤ Obtain a history of the patient’s gas- site.
trointestinal and hematopoietic sys- ➤ Promptly transport the specimen to
Follicle-Stimulating Hormone 661
the laboratory for processing and will be sent to the requesting health
analysis. care practitioner, who will discuss
➤ The results are recorded manually or the results with the patient.
in a computerized system for recall ➤ Reinforce information given by the
and postprocedure interpretation by patient’s health care provider regard-
the appropriate health care practi- ing further testing, treatment, or refer-
tioner. ral to another health care provider.
Post-test: concerns voiced by the patient or
family.
ing or hematoma formation. Apply ➤ Depending on the results of this pro-
paper tape or other adhesive to cedure, additional testing may be
hold pressure bandage in place, or performed to evaluate or monitor
replace with a plastic bandage. progression of the disease process
➤ Nutritional considerations: Instruct in therapy. Evaluate test results in
the folate-deficient patient (espe- relation to the patient’s symptoms
cially pregnant women), as appropri- and other tests performed.
ate, to eat foods rich in folate, such
as liver, salmon, eggs, asparagus,
green leafy vegetables, broccoli, Related laboratory tests:
sweet potatoes, beans, and whole ➤ Related laboratory tests include
wheat. complete blood count, homocys-
➤ A written report of the examination teine, and vitamin B12.
FOLLICLE-STIMULATING HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Follitropin, FSH.

SI Units
Status Conventional Units (Conventional Units 1)
Prepuberty Less than 10 mIU/mL Less than 10 IU/L
Men 1.4–15.5 mIU/mL 1.4–15.5 IU/L
Women
Follicular phase 1.4–9.9 mIU/mL 1.4–9.9 IU/L
Ovulatory peak 6.2–17.2 mIU/mL 6.2–17.2 IU/L
Luteal phase 1.1–9.2 mIU/mL 1.1–9.2 IU/L
Postmenopause 19–100 mIU/mL 19–100 IU/L
• Gonadal failure
DESCRIPTION & RATIONALE: Follicle-
stimulating hormone (FSH) is pro- • Gonadotropin-secreting pituitary tumors
duced and stored in the anterior • Klinefelter’s syndrome
portion of the pituitary gland. In
• Menopause
women, FSH promotes maturation of
the graafian (germinal) follicle, caus- • Orchitis
ing estrogen secretion and allowing
• Precocious puberty in children
the ovum to mature. In men, FSH
partially controls spermatogenesis, but • Primary hypogonadism
the presence of testosterone is also • Reifenstein’s syndrome
necessary. Gonadotropin-releasing hor-
mone secretion is stimulated by a • Turner’s syndrome
decrease in estrogen and testosterone
Decreased in:
levels. Gonadotropin-releasing hor-
mone secretion stimulates FSH secre- • Anorexia nervosa
tion. FSH production is inhibited by • Anterior pituitary hypofunction
an increase in estrogen and testosterone
• Hemochromatosis
levels. FSH production is pulsatile,
episodic, and cyclic, and is subject to • Hyperprolactinemia
diurnal variation. Serial measurement • Hypothalamic disorders
is often required. ■
• Polycystic ovary disease
INDICATIONS: • Pregnancy
• Assist in distinguishing between pri-
mary and secondary (pituitary or hypo- • Sickle cell anemia
thalamic) gonadal failure
• Define menstrual cycle phases as a part CRITICAL VALUES: N/A
of infertility testing
• Evaluate ambiguous sexual differentia- • Drugs that may increase FSH levels
tion in infants include cimetidine, clomiphene, digi-
• Evaluate early sexual development in talis, gonadotropin-releasing horm-
girls younger than age 9 or boys younger one, ketoconazole, levodopa, nafarelin,
than age 10 (precocious puberty associ- naloxone, nilutamide, oxcarbazepine,
ated with elevated levels) and pravastatin.
• Evaluate failure of sexual maturation in • Drugs that may decrease FSH levels
adolescence include anabolic steroids, anticonvul-
• Evaluate testicular dysfunction sants, buserelin, estrogens, corticotropin-
releasing hormone, goserelin, mege-
• Investigate impotence, gynecomastia, strol, mestranol, oral contraceptives,
and menstrual disturbances phenothiazine, pimozide, pravastatin,
progesterone, stanozolol, tamoxifen,
RESULT toremifene, and valproic acid.
Increased in: • In menstruating women, values vary in

relation to the phase of the menstrual
• Alcoholism
cycle. Values are higher in post-
• Castration menopausal women.
Follicle-Stimulating Hormone 663

Pretest: follow the general guidelines in Ap-
pendix A. Positively identify the pa-
used to distinguish primary causes
of gonadal failure from secondary
graphics, date, and time of collec-
causes, evaluate menstrual distur-
tion. Perform a venipuncture; collect
bances, and assist in infertility evalu-
the specimen in a 5-mL red- or tiger-
ations.
top tube.
site.
analysis.
endocrine and reproductive systems, ➤ The results are recorded manually or
as well as phase of menstrual cycle in a computerized system for recall
and results of previously performed and postprocedure interpretation by
laboratory tests, surgical procedures, the appropriate health care practi-
and other diagnostic procedures. For tioner.
Endocrine and Reproductive System Post-test:
tables. ➤ Observe venipuncture site for bleed-
nutritional supplements, and nutra- pressure bandage in place, or replace
ceuticals. The requesting health care with a plastic bandage.
these products so that their effects care practitioner, who will discuss the
can be taken into consideration when results with the patient.
reviewing results.
➤ Review the procedure with the Recognize anxiety related to test
patient. Inform the patient that spec- results and provide a supportive,
imen collection takes approximately nonjudgmental environment when
5 to 10 minutes. Address concerns assisting a patient through the
about pain related to the procedure. process of fertility testing. Discuss
Explain to the patient that there may the implications of abnormal test re-
be some discomfort during the sults on the patient’s lifestyle. Provide
venipuncture. teaching and information regarding
➤ There are no food, fluid, or medica- the clinical implications of the test
tion restrictions, unless by medical results, as appropriate. Educate the
direction. patient and partner regarding access
to counseling services, as appro-
Intratest: priate.
➤ If the patient has a history of severe patient’s health care provider regard-
allergic reaction to latex, care should ing further testing, treatment, or refer-
be taken to avoid the use of equip- ral to another health care provider.
ment containing latex. Inform the patient that multiple spec-
➤ Instruct the patient to cooperate fully imens may be required. Answer any
questions or address any concerns relation to the patient’s symptoms

voiced by the patient or family. and other tests performed.
and determine the need for a change estradiol, luteinizing hormone, pro-
in therapy. Evaluate test results in lactin, and testosterone.
FRUCTOSAMINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Glycated albumin.

Status Conventional Units Units 0.01)
Normal 174–286 mol/L 1.74–2.86 mmol/L
Diabetic
Controlled 210–421 mol/L 2.10–4.21 mmol/L
Uncontrolled 268–870 mol/L 2.68–8.70 mmol/L
INDICATIONS: Evaluate diabetic control

DESCRIPTION & RATIONALE: Fructo-
samine is the result of a covalent link- RESULT
age between glucose and albumin or
other proteins. Similar to glycated Increased in: Diabetic patients with
hemoglobin, fructosamine can be used poor glucose control
to monitor long-term control of glu-
cose in diabetics. It has a shorter half- Decreased in: Severe
hypoproteinemia
life than glycated hemoglobin and is
thought to be more sensitive to short-
term fluctuations in glucose concen-
trations. Some glycated hemoglobin INTERFERING FACTORS:
methods are affected by hemoglobin • Drugs that may increase fructosamine
variants. Fructosamine is not subject levels include bendroflumethiazide and
to this interference. ■ captopril.
Fructosamine 665
• Drugs that may decrease fructosamine be taken to avoid the use of equip-
levels include ascorbic acid, pyridoxine, ment containing latex.
and terazosin. ➤ Instruct the patient to cooperate fully
• Decreased albumin levels may result in patient to breathe normally and to
falsely decreased fructosamine levels. avoid unnecessary movement.
Nursing Implications and Appendix A. Positively identify the pa-
Procedure ● ● ● ● ● ● ● ● ● ● ●
graphics, date, and time of collec-
Pretest:
tion. Perform a venipuncture; collect
➤ Inform the patient that the test is the specimen in a 5-mL red- or tiger-
used to evaluate diabetic control. top tube.
➤ Obtain a history of the patient’s com- ➤ Remove the needle, and apply a pres-
plaints, especially related to diabetic sure dressing over the puncture site.
control. Obtain a list of known aller- ➤ Promptly transport the specimen to
gens, especially allergies or sensi- the laboratory for processing and
tivities to latex, and inform the analysis.
appropriate health care practitioner ➤ The results are recorded manually or
accordingly. in a computerized system for recall
➤ Obtain a history of the patient’s en- and postprocedure interpretation by
docrine and gastrointestinal systems, the appropriate health care practi-
as well as results of previously per- tioner.
procedures, and other diagnostic Post-test:
tests, refer to the Endocrine and
Gastrointestinal System tables.
➤ Obtain a list of medications the pressure bandage in place, or replace
patient is taking, including herbs, with a plastic bandage.
nutritional supplements, and nutra- ➤ Nutritional considerations: Abnormal
ceuticals. The requesting health care fructosamine levels may be associ-
practitioner and laboratory should be ated with conditions resulting from
advised if the patient regularly uses poor glucose control. Instruct the
these products so that their effects diabetic patient, as appropriate, in
can be taken into consideration when nutritional management of the dis-
reviewing results. ease. Patients who adhere to dietary
➤ Review the procedure with the recommendations report a better
patient. Inform the patient that spec- general feeling of health, better
imen collection takes approximately weight management, greater control
5 to 10 minutes. Address concerns of glucose and lipid values, and
about pain related to the procedure. improved use of insulin. There is no
Explain to the patient that there “diabetic diet”; however, many meal-
may be some discomfort during the planning approaches with nutritional
venipuncture. goals are endorsed by the American
➤ There are no food, fluid, or medica- Dietetic Association. The nutritional
tion restrictions, unless by medical needs of each diabetic patient must
direction. be determined individually with the
appropriate health care profession-
als, particularly professionals trained
Intratest: in nutrition.
➤ If the patient has a history of severe ➤ Instruct the patient and caregiver to
allergic reaction to latex, care should report signs and symptoms of hypo-
glycemia (weakness, confusion, Diabetes Association (http://www.

diaphoresis, rapid pulse) or hyper- diabetes.org).
glycemia (thirst, polyuria, hunger, ➤ Reinforce information given by the
lethargy). patient’s health care provider regard-
➤ A written report of the examination ing further testing, treatment, or refer-
will be sent to the requesting health ral to another health care provider.
care practitioner, who will discuss Answer any questions or address any
the results with the patient. concerns voiced by the patient or
➤ Recognize anxiety related to test re- family.
sults, and be supportive of impaired ➤ Depending on the results of this pro-
activity related to perceived loss of cedure, additional testing may be
independence and fear of shortened performed to evaluate or monitor
life expectancy. Discuss the implica- progression of the disease process
tions of abnormal test results on the and determine the need for a change
patient’s lifestyle. Provide teaching in therapy. Evaluate test results in
and information regarding the clinical relation to the patient’s symptoms
implications of the test results, as and other tests performed.
appropriate. Emphasize, as appropri-
ate, that good control of glucose lev- Related laboratory tests:
els delays the onset and slows the
progression of diabetic retinopathy, ➤ Related laboratory tests include cor-
nephropathy, and neuropathy. Educate tisol, C-peptide, glucose, glucose
the patient regarding access to coun- tolerance test, glycated hemoglo-
seling services. Provide contact infor- bin A1C, insulin, insulin antibodies,
mation, if desired, for the American ketones, and microalbumin.
FUNDUS PHOTOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
CONTRAST: N/A.
INDICATIONS:
DESCRIPTION & RATIONALE: This • Detect the presence of choroidal nevus
test involves the photographic exami-
nation of the structures of the eye to • Detect various types and stages of glau-
coma
document the condition of the eye,
detect abnormalities, and assist in fol- • Document the presence of diabetic
lowing the progress of treatment. ■ retinopathy
Fundus Photography 667
• Document the presence of macular • Failure to follow medication restrictions

degeneration and any other degenera- before the procedure may cause the pro-
tion and any associated hemorrhaging cedure to be canceled or repeated.
• Observe ocular effects resulting from
the long-term use of high-risk medica-
tions Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
RESULT
Pretest:
Normal Findings:
• Normal optic nerve and vessels detects possible vascular or other
• No evidence of other ocular abnormal- structural abnormalities of the eye.
ities ➤ Obtain a history of the patient’s com-
Abnormal Findings: allergens, especially mydratics if dila-
• Aneurysm tion is to be performed.
• Choroidal nevus ➤ Obtain a history of the patient’s
known or suspected vision loss,
• Diabetic retinopathy changes in visual acuity, including
• Macular degeneration type and cause; use of glasses or
contact lenses; eye conditions with
• Obstructive disorders of the arteries or treatment regimens; eye surgery;
veins that lead to collateral circulation and other tests and procedures to
assess and diagnose visual deficit.
CRITICAL VALUES: N/A ➤ Obtain a history of results of previ-
INTERFERING FACTORS: surgical procedures, and other diag-
nostic procedures. For related diag-
This procedure is nostic tests, refer to the table of tests
contraindicated for: associated with the Ocular System.
• Patients with narrow-angle glaucoma if
pupil dilation is performed as dilation patient is taking, including herbs,
can initiate a severe and sight-threaten- nutritional supplements, and nutra-
ing open-angle attack ceuticals. The requesting health care
practitioner should be advised if the
• Patients with allergies to mydriatics if
pupil dilation using mydriatics is per- so that their effects can be taken into
formed consideration when reviewing results.
Factors that may impair the ➤ Instruct the patient to remove con-
results of the examination: tact lenses or glasses, as appropri-
• Inability of the patient to cooperate or ate. Instruct the patient regarding
the importance of keeping the eyes
remain still during the test because of open for the test.
age, significant pain, or mental status
may interfere with the test results. ➤ Review the procedure with the pa-
tient. Explain that the patient will be
• Presence of cataracts may interfere with requested to fixate the eyes during
fundal view. the procedure. Address concerns
• Ineffective dilation of the pupils may about pain related to the procedure.
impair clear imaging. Explain to the patient that mydriatics,
if used, may cause blurred vision and
• Rubbing or squeezing the eyes may sensitivity to light. There may also be
affect results. a brief stinging sensation when the
drop is put in the eye but that no dis- ➤ The results are recorded on devel-
comfort will be experienced during oped photographic film or electroni-
the examination. Inform the patient cally on computerized equipment for
that a technician, optometrist, or recall and postprocedure interpreta-
health care practitioner performs the tion by the appropriate health care
test, in a quiet, darkened room, and practitioner.
that to dilate and evaluate both eyes,
the test can take up 60 minutes.
Post-test:
➤ There are no food or fluid restric-
tions, unless by medical direction. ➤ Instruct the patient to resume usual
medications, as directed by the health
➤ The patient should avoid eye medica-
care practitioner.
tions (particularly mydriatic eye drops
if the patient has glaucoma) for at ➤ A written report of the examination
least 1 day prior to the test. will be completed by a health care
➤ Ensure that the patient understands practitioner specializing in this branch
that he or she must refrain from driv- of medicine. The report will be sent
ing until the pupils return to normal to the requesting health care practi-
(about 4 hours) after the test and has tioner, who will discuss the results
made arrangements to have some- with the patient.
one else be responsible for trans- ➤ Recognize anxiety related to test
portation after the test. results, and be supportive of impaired
activity related to vision loss or per-
Intratest: ceived loss of driving privileges Dis-
cuss the implications of abnormal
➤ Ensure that the patient has complied test results on the patient’s lifestyle.
with medication restrictions; assure Provide teaching and information
that eye medications, especially regarding the clinical implications of
mydriatics, have been restricted for the test results, as appropriate.
at least 1 day prior to the test.
and to follow directions. Ask the pa- ing further testing, treatment, or refer-
tient to remain still during the proce- ral to another health care provider.
dure because movement produces Inform the patient that visual acuity
unreliable results. and responses to light may change.
➤ Seat the patient in a chair that faces Suggest that the patient wear dark
the camera. Instruct the patient to glasses after the test until the pupils
look at directed target while the eyes return to normal size. Answer any
are examined. questions or address any concerns
➤ If dilation is to be performed, admin- voiced by the patient or family.
ister the ordered mydriatic to each ➤ Depending on the results of this pro-
eye and repeat in 5 to 15 minutes. cedure, additional testing may be
Drops are placed in the eye with the performed to evaluate or monitor pro-
patient looking up and the solution gression of the disease process and
directed at the six o’clock position of determine the need for a change in
the sclera (white of the eye) near the therapy. Evaluate test results in rela-
limbus (grey, semitransparent area tion to the patient’s symptoms and
of the eyeball where the cornea and other tests performed.
sclera meet). The dropper bottle
should not touch the eyelashes.
➤ Ask the patient to place the chin in the
chin rest and gently press the fore- ➤ Related diagnostic tests include fluo-
head against the support bar. Ask the rescein angiography, gonioscopy,
patient to open his or her eyes wide intraocular pressure, refraction, slit-
and look at desired target while a lamp biomicroscopy, and visual field
sequence of photographs are taken. testing.
Gallium Scan 669
GALLIUM SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gallium scan, tumor; gallium scan, abscess; gallium

scan, fever of undetermined origin.
AREA OF APPLICATION: Whole body.
CONTRAST: Intravenous radioactive gallium-67 citrate.
DESCRIPTION & RATIONALE: Gallium netic resonance imaging, and ultra-

imaging is a nuclear medicine study sonography. ■
that assists in diagnosing neoplasm
and inflammation activity. Gallium, INDICATIONS:
which has 90% sensitivity for inflam- • Aid in the diagnosis of infectious or
matory disease, is readily distributed inflammatory diseases
throughout plasma and body tissues. • Evaluate lymphomas
Gallium imaging is sensitive in detect-
ing abscesses, pneumonia, pyelone- • Evaluate recurrent lymphomas or
tumors after radiation therapy or
phritis, active sarcoidosis, and active
chemotherapy
tuberculosis. In immunocompromised
patients, such as patients with acquired • Perform as a screening examination for
immunodeficiency syndrome, gallium fever of undetermined origin
imaging can detect complications
such as Pneumocystis jiroveci (formerly RESULT
carinii) pneumonitis. Gallium imag-
Normal Findings:
ing is useful but less commonly per-
formed in the diagnosis and staging of • Normal distribution of gallium. Some
localization of the radionuclide within
some neoplasms, including Hodgkin’s
the liver, spleen, bone, nasopharynx,
disease, lymphoma, melanoma, and lacrimal glands, breast, and bowel is
leukemia. Imaging can be performed expected.
6 to 72 hours after gallium injection.
A gamma camera detects the radiation Abnormal Findings:
emitted from the injected radioactive • Abscess
material, and a representative image of
the distribution of the radioactive • Infection
material is obtained. The nonspeci- • Inflammation
ficity of gallium imaging requires cor-
• Lymphoma
relation with other diagnostic studies,
such as computed tomography, mag- • Tumor
CRITICAL VALUES: N/A • Risks associated with radiologic overex-

posure can result from frequent x-ray
INTERFERING FACTORS: procedures. Personnel in the room with
This procedure is contraindicated lead apron, stand behind a shield, or
for: leave the area while the examination is
• Patients who are pregnant or suspected being done. Badges that reveal the level
of being pregnant, unless the potential of exposure to radiation should be
benefits of the procedure far outweigh worn by persons working in the area
the risks to the fetus and mother where the examination is being done.
Factors that may impair clear Nursing Implications and

imaging: Procedure ● ● ● ● ● ● ● ● ● ● ●

or remain still during the procedure be- Pretest:
cause of age, significant pain, or mental ➤ Inform the patient that the test
status detects inflammation, infection, or
• Improper adjustment of the radio- tumor.
graphic equipment to accommodate ➤ Obtain a history of the patient’s com-
obese or thin patients, which can cause plaints and symptoms, including a
overexposure or underexposure and a list of known allergens.
poor-quality study ➤ Obtain a history of results of pre-
• Metallic objects within the examina- cedures, surgical procedures, and
tion field (e.g., jewelry, body rings), laboratory tests For related diagnos-
which may inhibit organ visualization tic tests, refer to the Musculoskele-
and can produce unclear images tal, Respiratory, and Immune System
tables.
• Patients who are very obese, who may ➤ Record the date of the last menstrual
exceed the weight limit for the equip- period and determine the possibil-
ment ity of pregnancy in perimenopausal
women.
which may produce poor visualization medications.
• Performance of other nuclear scans patient. Explain to the patient that
within the preceding 24 to 48 hours some pain may be experienced dur-
• Administration of certain medications moments of discomfort. Explain the
(e.g., gastrin, cholecystokinin), which purpose of the test and how the pro-
may interfere with gastric emptying cedure is performed. Inform the
Other considerations: formed in a nuclear medicine depart-
ment, usually by a technologist and
• Improper injection of the radionuclide support staff, and takes approxi-
may allow the tracer to seep deep into mately 30 to 60 minutes. Delayed
the muscle tissue, producing erroneous images are needed 72 hours after
hot spots. the initial injection. Inform the
patient that the technologist will
• Consultation with a health care practi- inject gallium in an arm vein and ask
tioner should occur before the procedure the patient to return later for the
for radiation safety concerns regarding imaging procedure, at which time
younger patients or patients who are lac- the patient will be placed in a supine
tating. position on a flat table.
Gallium Scan 671
➤ Sensitivity to cultural and social imaging is complete, as directed by

issues, as well as concern for mod- the health care practitioner.
esty, is important in providing psy- ➤ Advise the patient to drink increased
chological support before, during, amounts of fluids for several days to
and after the procedure. eliminate the radionuclide from the
➤ There are no food, fluid, or medica- body, unless contraindicated. Tell the
tion restrictions, unless by medical patient the radionuclide is eliminated
direction. from the body within 48 to 72 hours.
➤ Instruct the patient to remove den- ➤ Inform the patient to flush the toilet
tures, jewelry (including watches), immediately after each voiding fol-
hairpins, credit cards, and other me- lowing the procedure, and to wash
tallic objects. hands meticulously with soap and
➤ Make sure a written and informed water after each voiding for 72 hours
consent has been signed prior to the after the procedure.
procedure and before administering ➤ Tell all caregivers to wear gloves
any medications. when discarding urine for 48 hours
Intratest: hands with soap and water before
removing gloves. Then wash un-
➤ Ensure that the patient has removed gloved hands after removing the
jewelry, dentures, all external metal- gloves.
lic objects, and the like prior to the
procedure. ➤ Instruct the patient in the care and
assessment of the injection site.
➤ Patients are given a gown, robe, and Observe the site for bleeding, hema-
foot coverings to wear and instructed toma formation, and inflammation.
➤ Instruct the patient to cooperate fully will be completed by a health care
and to follow directions. Instruct the practitioner specializing in this branch
patient to lie still during the proce- of medicine. The report will be sent
dure because movement produces to the requesting health care practi-
unclear images. tioner, who will discuss the results
➤ Observe standard precautions, and with the patient.
follow the general guidelines in ➤ Reinforce information given by the
Appendix A. patient’s health care provider regard-
➤ Administer sedative to a child or to ing further testing, treatment, or refer-
an uncooperative adult, as ordered. ral to another health care provider.
➤ The radionuclide is administered Answer any questions or address
intravenously. Delayed views may be any concerns voiced by the patient
taken at 6, 24, 48, and 72 hours after or family.
the injection. ➤ Depending on the results of this pro-
➤ If an abdominal abscess or infection cedure, additional testing may be
is suspected, laxatives or enemas needed to evaluate or monitor pro-
may be ordered before delayed gression of the disease process and
imaging at 48 or 72 hours after the determine the need for a change in
injection. therapy. Evaluate test results in rela-
the appropriate health care practi- Related diagnostic tests:
tioner.
Post-test: chest x-ray; computed tomography
of the thorax, abdomen, and pelvis;
➤ Instruct the patient to resume usual and magnetic resonance imaging of
diet, medication, and activity, after the chest and abdomen.
GASTRIC ACID STIMULATION TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Gastric fluid collected in eight plastic tubes at 15-minute intervals.
REFERENCE VALUE: (Method: Volume measurement and pH by ion-selective
electrode)
Basal acid output (BAO) Male: 0–10.5 mmol/h

Female: 0–5.6 mmol/h
Peak acid output (PAO) Male: 12–60 mmol/h
Female: 8–40 mmol/h
Peak response time Pentagastrin, intramuscular: 15–45 min
Pentagastrin, subcutaneous: 10–30 min
BAO/PAO ratio Less than 0.20
DESCRIPTION & RATIONALE: The and PAO are compared as a ratio,

gastric acid stimulation test is per- which is normally less than 0.20. ■
formed to determine the response to
substances administered to induce INDICATIONS:
increased gastric acid production. • Detect duodenal ulcer
Pentagastrin is the usual drug of • Detect gastric carcinoma
choice to induce gastric secretion
• Detect pernicious anemia
because it has no major side effects.
The samples obtained from gastric • Detect Zollinger-Ellison syndrome
acid stimulation tests are examined for • Evaluate effectiveness of vagotomy in
volume, pH, and amount of acid the treatment of peptic ulcer disease
secreted. First, basal acid output
(BAO) is determined by averaging the RESULT
results of gastric samples collected
before the administration of a gastric Increased:
stimulant. Then a gastric stimulant is • BAO
administered and peak acid output Basophilic leukemia
(PAO) is determined by adding Duodenal ulcer
together the gastric acid output of the G-cell hyperplasia
highest two consecutive 15-minute Recurring peptic ulcer
stimulation samples. Finally, BAO Retained antrum syndrome
Gastric Acid Stimulation Test 673
Systemic mastocytosis • Failure to follow dietary restrictions

Vagal hyperfunction may result in stimulation of gastric
Zollinger-Ellison syndrome secretions.
• PAO • Failure to follow dietary restrictions
Duodenal ulcer before the procedure may cause the
Zollinger-Ellison syndrome
• Exposure to the sight, smell, or thought
Decreased: of food immediately before and during
• BAO the test may result in stimulation of
Gastric ulcer gastric secretions.
• PAO
Chronic gastritis Nursing Implications and
Gastric cancers Procedure ● ● ● ● ● ● ● ● ● ● ●
Gastric polyps
Gastric ulcer Pretest:
Myxedema ➤ Inform the patient that the test is
Pernicious anemia used to asist in the differential dag-
nosis of gastrointestinal disorders.
CRITICAL VALUES: N/A ➤ Obtain a history of the patient’s com-
• Drugs that may increase gastric volume appropriate health care practitioner
include atropine, diazepam, ganglionic accordingly.
blocking agents, and insulin.
• Drugs and substances that may increase trointestinal system, as well as
gastric pH include caffeine, calcium results of previously performed labo-
salts, corticotropin, ethanol, rauwolfia, ratory tests, surgical procedures,
reserpine, and tolazoline. and other diagnostic procedures. For
• Drugs and substances that may decrease Gastrointestinal System table.
gastric pH include atropine, cimeti- ➤ Obtain a list of the medications the
dine, diazepam, famotidine, ganglionic patient is taking, including herbs,
blocking agents, glucagon, nizatidine, nutritional supplements, and nutra-
omeprazole, oxmetidine, propranolol, ceuticals. The requesting health care
prostaglandin F2a, ranitidine, and practitioner and laboratory should be
secretin. advised if the patient regularly uses
• Gastric intubation is contraindicated in can be taken into consideration
patients with esophageal varices, diver- when reviewing results.
ticula, stenosis, malignant neoplasm of ➤ Review the procedure with the
the esophagus, aortic aneurysm, severe patient. Inform the patient that spec-
gastric hemorrhage, and congenital imen collection takes approximately
heart failure. 60 to 120 minutes. Address concerns
• The use of histamine diphosphate is Explain that some discomfort is
contraindicated in patients with a his- experienced from insertion of the
tory of asthma, paroxysmal hyper- nasogastric tube.
tension, urticaria, or other allergic ➤ Sensitivity to social and cultural is-
conditions. sues, as well as concern for modesty,
is important in providing psychologi- patient, and label the appropriate col-

cal support before, during, and after lection containers with the corre-
the procedure. sponding patient demographics,
➤ Drugs and substances that may alter date, and time of collection.
gastric secretions (e.g., alcohol, his- ➤ A cold lubricated gastric (Levine)
tamine, nicotine, adrenocorticotropic tube is inserted orally. Alternatively,
steroids, insulin, para-sympathetic if the patient has a hyperactive gag
agents, belladonna alkaloids, anti- reflex, the tube can be inserted
cholinergic drugs, histamine receptor nasally. The tube must have a radio-
antagonists) should be restricted by paque tip.
medical direction for 72 hours before ➤ Fluoroscopy or x-ray is used to con-
the test. firm proper position of the tube
➤ Instruct the patient to fast from food before the start of the test.
after the evening meal the night ➤ Using a constant but gentle suction,
before the test, and not to drink gastric contents are collected. Do not
water for 1 hour before the test. The use specimens obtained from the
patient should be instructed to first 15 to 30 minutes of suctioning.
refrain from chewing gum or smok-
ing for at least 12 hours before the ➤ The gastric stimulant is administered,
test. and the peak basal specimens are
collected over a 60-minute period as
four 15-minute specimens. Number
the specimen tubes in the order in
which they were collected.
any medications.
Intratest: the laboratory for processing and
analysis.
➤ Ensure that the patient has complied ➤ The results are recorded manually or
with dietary restrictions and other in a computerized system for recall
pretesting preparations; assure that and postprocedure interpretation by
food has been restricted for at least the appropriate health care practi-
12 hours prior to the procedure. tioner.
allergic reaction to latex, care should Post-test:
ment containing latex. ➤ Instruct the patient to resume usual
diet and medication, as directed by
➤ Ensure that the patient does not
have a history of asthma, paroxysmal
hypertension, urticaria, or other aller- ➤ Monitor vital signs and neurologic
gic conditions if histamine diphos- status every 15 minutes for 1 hour,
phate is being considered for use in then every 2 hours for 4 hours, and
the test. then as ordered by the health care
practitioner for evaluation. Protocols
➤ Record baseline vital signs.
➤ If the patient is wearing dentures,
remove them. ➤ Instruct the patient to report any
chest pain, upper abdominal pain,
➤ Have the patient sit, or help the pain on swallowing, difficulty breath-
patient recline on the left side. ing, or expectoration of blood. Report
➤ Instruct the patient to cooperate fully these to the health care practitioner
and to follow directions. Direct the immediately.
patient to breathe normally and to ➤ Monitor for side effects of drugs
avoid unnecessary movement. administered to induce gastric secre-
➤ Observe standard precautions, and tion (e.g., flushing, headache, nasal
follow the general guidelines in stuffiness, dizziness, faintness, nau-
Appendix A. Positively identify the sea).
Gastric Emptying Scan 675
➤ A written report of the examination apy regimen. As appropriate, instruct

will be sent to the requesting health the patient in significant side effects
care practitioner, who will discuss and systemic reactions associated
the results with the patient. with the prescribed medication.
pharmacist.
abnormal test results on the pa-
tient’s lifestyle. Provide teaching and ➤ Depending on the results of this pro-
information regarding the clinical cedure, additional testing may be
implications of the test results, as performed to evaluate or monitor
appropriate. progression of the disease process
ral to another health care provider.
concerns voiced by the patient or Related laboratory tests:
family.
➤ Related laboratory tests include com-
➤ Instruct the patient in the use of any plete blood count, folate, gastrin,
ordered medications. Explain the Helicobacter pylori antibody, intrinsic
importance of adhering to the ther- factor antibodies, and vitamin B12.
GASTRIC EMPTYING SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gastric emptying quantitation, gastric emptying

scintigraphy.
AREA OF APPLICATION: Esophagus, stomach, small bowel.

CONTRAST: Oral radioactive technetium-99m sulfur colloid.
DESCRIPTION & RATIONALE: A gas- dromes, and assessment of medical and

tric emptying scan quantifies gastric surgical treatments for diseases known
emptying physiology. The procedure to affect gastric motility. A radionu-
is indicated for patients with gastric clide is administered, and the clear-
motility symptoms, including diabetic ance of solids and liquids may be
gastroparesis, anorexia nervosa, gastric evaluated. The images are recorded
outlet obstruction syndromes, post- electronically, showing the gastric
vagotomy and postgastrectomy syn- emptying function over time. ■
INDICATIONS: Factors that may

• Investigate the cause of rapid or slow impair clear imaging:
rate of gastric emptying • Inability of the patient to cooperate or
remain still during the procedure because
• Measure gastric emptying rate of age, significant pain, or mental status
RESULT • Improper adjustment of the radi-
Normal Findings: obese or thin patients, which can cause
• Mean time emptying of liquid phase: a poor-quality study
30 minutes (range, 11 to 49 minutes) • Metallic objects within the examina-
• Mean time emptying of solid phase: 40 tion field (e.g., jewelry, body rings),
minutes (range, 28 to 80 minutes) which may inhibit organ visualization
• No delay in gastric emptying rate
• Decreased rate: • Patients who are very obese, who may
Dumping syndrome exceed the weight limit for the equip-
Duodenal ulcer ment
Malabsorption syndromes • Incorrect positioning of the patient,
Zollinger-Ellison syndrome which may produce poor visualization
• Increased rate: of the area to be examined
Amyloidosis • Performance of other nuclear scans
Anorexia nervosa within the preceding 24 to 48 hours
Diabetes • Administration of certain medications
Gastric outlet obstruction (e.g., gastrin, cholecystokinin), which
Gastric ulcer may interfere with gastric emptying
Gastroenteritis
Gastroesophageal reflux
Hypokalemia, hypomagnesemia
Post–gastric surgery period procedure to be canceled or repeated.
Postoperative ileus
Post–radiation therapy period
• Consultation with a health care practi-
tioner should occur before the proce-
Scleroderma dure for radiation safety concerns
CRITICAL VALUES: N/A who are lactating.
INTERFERING FACTORS: • Risks associated with radiologic overex-
This procedure is
contraindicated for: procedures. Personnel in the room with
being done. Badges that reveal the level
of exposure to radiation should be
• Patients with esophageal motor disor- worn by persons working in the area
ders or swallowing difficulties where the examination is being done.
Gastric Emptying Scan 677
hairpins, credit cards, and other me-

Nursing Implications and tallic objects.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest:
➤ Inform the patient that the procedure with dietary and fluids restrictions
assesses gastric emptying. and pretesting preparations. Ensure
➤ Obtain a history of the patient’s com- that the patient has removed all
plaints and symptoms, including a external metallic objects (jewelry,
list of known allergens, especially to dentures, etc.) prior to the procedure.
eggs. ➤ Patients are given a gown, robe, and
➤ Obtain a history of the patient’s foot coverings to wear and instructed
gastrointestinal system, as well as to void prior to the procedure.
results of previously performed diag- ➤ Obtain and record baseline vital signs.
nostic procedures, surgical proce- ➤ Instruct the patient to cooperate fully
dures, and laboratory tests. For related and to follow directions. Instruct the
diagnostic tests, refer to the Gastroin- patient to lie still during the proce-
testinal System table. dure because movement produces
➤ Record the date of the last menstrual unclear images.
period and determine the possibility ➤ Observe standard precautions, and
of pregnancy in perimenopausal follow the general guidelines in
women. Appendix A.
➤ Obtain a list of the patient’s current ➤ Administer sedative to a child or to
medications. an uncooperative adult, as ordered.
➤ Review the procedure with the ➤ Place the patient in an upright posi-
patient. Address concerns about pain tion in front of the gamma camera.
➤ Ask the patient to take the radionu-
clide orally, combined with eggs or
as a liquid.
there may be moments of discom-
fort. Explain the purpose of the test ➤ Images are recorded over a period of
and how the procedure is per- time (30 to 60 minutes) and evalu-
formed. Reassure the patient that ated with regard to the amount of
the radionuclide poses no radioactive time the stomach takes to empty its
hazard and rarely produces side contents.
effects. Inform the patient that the ➤ The results are recorded on film or in
procedure is performed in a nuclear a computerized system for recall and
medicine department, usually by a postprocedure interpretation by the
technologist and support staff, and appropriate health care practitioner.
takes approximately 30 to 120 min-
utes. Inform the patient that the tech-
nologist will place him or her in an
Post-test:
upright position in front of the ➤ Instruct the patient to resume usual
gamma camera (scanner). diet, medication, and activity, as
➤ Sensitivity to cultural and social directed by the health care practi-
issues, as well as concern for mod- tioner.
esty, is important in providing psy- ➤ Monitor vital signs every 15 minutes
chological support before, during and for 1 hour, then every 2 hours for 4
after the procedure. hours, and then as ordered by the
➤ Restrict food and fluids for 6 to 8 health care practitioner. Compare
hours before the scan. with baseline values. Protocols may
➤ Instruct the patient to remove den- vary from facility to facility.
tures, jewelry (including watches), ➤ Advise the patient to drink increased
amounts of fluids for 24 to 48 hours practitioner, who will discuss the

to eliminate the radionuclide from results with the patient.
the body, unless contraindicated. Tell ➤ Reinforce information given by the
the patient that radionuclide is elimi- patient’s health care provider regard-
nated from the body within 6 to 24 ing further testing, treatment, or refer-
hours. ral to another health care provider.
➤ Inform the patient to flush the toilet Answer any questions or address
immediately after each voiding fol- any concerns voiced by the patient
lowing the procedure, and to wash or family.
hands meticulously with soap and ➤ Depending on the results of this pro-
water after each voiding for 24 hours cedure, additional testing may be
after the procedure. needed to evaluate or monitor pro-
➤ Tell all caregivers to wear gloves gression of the disease process and
when discarding urine for 24 hours determine the need for a change in
after the procedure. Wash gloved therapy. Evaluate test results in rela-
hands with soap and water before tion to the patient’s symptoms and
removing gloves. Then wash hands other tests performed.
after removing the gloves.
will be completed by a health care ➤ Related diagnostic tests include
practitioner specializing in this computed tomography of the abdo-
branch of medicine. The report will men, and upper gastrointestinal and
be sent to the requesting health care small bowel series.
GASTRIN AND GASTRIN

STIMULATION TEST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Infant 120–183 pg/mL 120–183 ng/L
Child Less than 10–125 Less than 10–125 ng/L
pg/mL
Adult
Up to 60 y 25–90 pg/mL 25–90 ng/L
60 y and older Less than 100 pg/mL Less than 100 ng/L
Gastrin and Gastrin Stimulation Test 679
Stimulation Tests
Gastrin stimulation test No response or slight

with calcium or secretin increase over baseline
• Retained antrum
DESCRIPTION & RATIONALE: Gastrin
is a hormone secreted by the stomach • Zollinger-Ellison syndrome
and duodenum in response to vagal
Decreased in:
stimulation; the presence of food, alco-
• Hypothyroidism
hol, or calcium in the stomach; and
the alkalinity of gastric secretions. After • Vagotomy
its absorption into the circulation,
gastrin returns to the stomach and acts CRITICAL VALUES: N/A
as a stimulant for acid, insulin, pepsin, INTERFERING FACTORS:
and intrinsic factor secretion. Gastrin • Drugs and substances that may increase
stimulation tests can be performed gastrin levels include amino acids,
after a test meal or intravenous infu- catecholamines, cimetidine, insulin,
sion of calcium or secretin. ■ morphine, omeprazole, pantoprazole,
sufotidine, terbutaline, calcium prod-
ucts, and coffee.
INDICATIONS:
• Assist in the diagnosis of gastric carci- • Drugs that may decrease gastrin levels
noma, pernicious anemia, or G-cell include atropine, enprostil, glucagon,
hyperplasia secretin, streptozocin, and tolbu-
tamide.
• Assist in the diagnosis of Zollinger-
Ellison syndrome • In some cases, protein ingestion ele-
vates serum gastrin levels.
ulcers from other gastrointestinal pep-
tic disorders
RESULT
• Failure to follow dietary and medica-
Increased in: tion restrictions before the procedure
may cause the procedure to be canceled
• Chronic gastritis
or repeated.
• Chronic renal failure
• Gastric and duodenal ulcers
• Gastric carcinoma Procedure ● ● ● ● ● ● ● ● ● ● ●
• G-cell hyperplasia
Pretest:
• Hyperparathyroidism
• Pernicious anemia used to assist in the diagnosis of
Zollinger-Ellison syndrome and gas-
• Pyloric obstruction trinoma.
➤ Obtain a history of the patient’s com- ➤ If the patient has a history of severe
plaints, including a list of known allergic reaction to latex, care should
allergens (especially allergies or sen- be taken to avoid the use of equip-
sitivities to latex), and inform the ment containing latex.
appropriate health care practitioner ➤ Instruct the patient to cooperate fully
accordingly. and to follow directions. Direct the
➤ Obtain a history of the patient’s patient to breathe normally and to
endocrine and gastrointestinal sys- avoid unnecessary movement.
tems, as well as results of previ- ➤ Administer gastrin stimulators as
ously performed laboratory tests, appropriate.
surgical procedures, and other
diagnostic procedures. For related ➤ Observe standard precautions, and
laboratory tests, refer to the Endo- follow the general guidelines in Ap-
crine and Gastrointestinal System pendix A. Positively identify the pa-
tables. tient, and label the appropriate tubes
with the corresponding patient
➤ Note any recent procedures that can demographics, date, and time of col-
interfere with test results. lection. Perform a venipuncture; col-
➤ Obtain a list of medications the lect the specimen in a 5-mL red- or
patient is taking, including herbs, tiger-top tube.
nutritional supplements, and nutra- ➤ Remove the needle, and apply a
ceuticals. The requesting health care pressure dressing over the puncture
practitioner and laboratory should be site.
analysis.
patient. Inform the patient that spec- and postprocedure interpretation by
imen collection takes approximately the appropriate health care practi-
5 to 10 minutes. Address concerns tioner.
Post-test:
venipuncture. ➤ Observe venipuncture site for bleed-
➤ Instruct the patient to fast for 12 ing or hematoma formation. Apply
hours before the test. paper tape or other adhesive to hold
➤ Instruct the patient to withhold med- with a plastic bandage.
ications and alcohol for 12 to 24
hours, as ordered by the health care ➤ Instruct the patient to resume usual
practitioner. diet and medications, as directed by
by medical direction. ➤ Nutritional considerations: Nutritional
support with calcium, iron, and vita-
min B12 supplementation may be
Intratest: ordered, as appropriate.
➤ Ensure that the patient has com- ➤ A written report of the examination
plied with dietary and medication will be sent to the requesting health
restrictions and other pretesting care practitioner, who will discuss
preparations; assure that food and the results with the patient.
medications have been withheld for ➤ Reinforce information given by the
at least 12 hours prior to the proce- patient’s health care provider regard-
dure. ing further testing, treatment, or refer-
Gastroesophageal Reflux Scan 681
ral to another health care provider. in therapy. Evaluate test results in

or family.
cedure, additional testing may be ➤ Related laboratory tests include com-
performed to evaluate or monitor plete blood count, folate, gastric acid
progression of the disease process stimulation, glucose, Helicobacter
and determine the need for a change pylori antibody, and vitamin B12.
GASTROESOPHAGEAL REFLUX SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Aspiration scan, GER scan, GERD scan.

AREA OF APPLICATION: Esophagus and stomach.
CONTRAST: Oral radioactive technetium-99m sulfur colloid.
DESCRIPTION & RATIONALE: The Computer calculation determines the

gastroesophageal reflux (GER) scan amount of reflux into the esophagus
assesses gastric reflux across the eso- at each of these abdominal pressures
phageal sphincter. Symptoms of GER as recorded on the images. For aspira-
include heartburn, regurgitation, tion scans, images are taken over the
vomiting, dysphagia, and a bitter taste lungs to detect tracheoesophageal aspi-
in the mouth. This procedure may be ration of the radionuclide.
used to evaluate the medical or surgi- In infants, the study distinguishes
cal treatment of patients with GER between vomiting and reflux. Reflux
and to detect aspiration of gastric con- occurs predominantly in infants
tents into the lungs. A radionuclide younger than age 2, who are mainly
such as technetium-99m sulfur colloid on a milk diet. This procedure is indi-
is ingested orally in orange juice. cated when an infant has symptoms
Scanning studies are done immediately such as failure to thrive, feeding prob-
to assess the amount of liquid that has lems, and episodes of wheezing with
reached the stomach. An abdominal chest infection. The radionuclide is
binder is applied and then tightened added to the infant’s milk, images are
gradually to obtain images at increas- obtained of the gastric and esophageal
ing degrees of abdominal pressure: 0, area, and the images are evaluated
20, 40, 60, 80, and 100 mm Hg. visually and by computer. ■
INDICATIONS: • Incorrect positioning of the patient,

• Aid in the diagnosis of GER in patients which may produce poor visualization
with unexplained nausea and vomiting of the area to be examined
• Distinguish between vomiting and • Retained barium from a previous radi-
reflux in infants with failure to thrive, ologic procedure
feeding problems, and wheezing com- • Other nuclear scans done within the
bined with chest infection previous 24 to 48 hours
RESULT • Metallic objects within the examina-
Normal Findings: which may inhibit organ visualization
• Reflux less than or equal to 4% across and can produce unclear images
the esophageal sphincter
Abnormal Findings: • Consultation with a health care practi-
• Reflux of greater than 4% at any pres- tioner should occur before the proce-
sure level dure for radiation safety concerns
• Pulmonary aspiration who are lactating.
CRITICAL VALUES: N/A • Risks associated with radiologic overex-
INTERFERING FACTORS: procedures. Personnel in the room with
This procedure is lead apron, stand behind a shield, or
contraindicated for: leave the area while the examination is
• Patients who are pregnant or suspected being done. Badges that reveal the level
of being pregnant, unless the potential of exposure to radiation should be
benefits of the procedure far outweigh worn by persons working in the area
the risks to the fetus and mother where the examination is being done.
• Patients with hiatal hernia, esophageal

motor disorders, or swallowing difficul- Nursing Implications and
ties
Procedure ● ● ● ● ● ● ● ● ● ● ●
Factors that may Pretest:

• Inability of the patient to cooperate or ➤ Inform the patient that the procedure
remain still during the procedure be- evaluates gastric reflux.
cause of age, significant pain, or mental ➤ Obtain a history of the patient’s com-
status plaints and symptoms, including a
• Improper adjustment of the radi- ➤ Obtain a history of the patient’s gas-
ographic equipment to accommodate trointestinal system, signs and symp-
obese or thin patients, which can cause toms of gastroesophageal reflux, and
overexposure or underexposure and a results of previously performed diag-
poor-quality study nostic procedures, surgical proce-
dures, and laboratory tests. For
• Patients who are very obese, who may related diagnostic tests, refer to the
exceed the weight limit for the equip- Gastrointestinal and Musculoskeletal
ment System tables.
Gastroesophageal Reflux Scan 683
➤ Record the date of the last menstrual Intratest:

of pregnancy in perimenopausal ➤ Ensure the patient has removed all
women. external metallic objects (jewelry,
➤ Note any recent procedures that can dentures, etc.) prior to the procedure.
interfere with test results; including ➤ Have emergency equipment readily
examinations using iodine-based con- available.
trast medium or barium.
➤ Obtain a list of the medications allergic reactions to any substance or
the patient is taking, including anti- drug, administer ordered prophylac-
coagulant therapy, acetylsalicylic tic steroids or antihistamines before
acid, herbs, nutritional supplements, the procedure. Use nonionic contrast
and nutraceuticals, especially those medium for the procedure.
known to affect coagulation (see
Appendix F). It is recommended that
use be discontinued 14 days before
surgical procedures. The requesting
health care practitioner and labora- ➤ Record baseline vital signs and
tory should be advised if the patient assess neurologic status. Protocols
regularly uses these products so that may vary from facility to facility.
their effects can be taken into con- ➤ Instruct the patient to cooperate fully
sideration when reviewing results. and to follow directions. Instruct the
➤ Review the procedure with the patient to remain still throughout the
patient. Address concerns about pain procedure because movement pro-
related to the procedure. Explain to duces unreliable results.
the patient that some pain may be ➤ Observe standard precautions, and
experienced during the test, or there follow the general guidelines in
may be moments of discomfort. Appendix A.
Explain that the radioactive colloid is
ingested orally in either orange juice ➤ Establish an intravenous fluid line for
or milk. Reassure the patient that the the injection of emergency drugs
radionuclide poses no radioactive and of sedatives.
hazard and rarely produces side ➤ Administer an antianxiety agent, as
effects. Inform the patient that the ordered, if the patient has claustro-
procedure is performed in a special phobia. Administer a sedative to a
department, usually in a radiology child or to an uncooperative adult, as
department, by a healthcare practi- ordered.
tioner and support staff and takes ➤ Place the patient in a supine position
approximately 30 to 60 minutes. on a flat table with foam wedges,
➤ Sensitivity to social and cultural which help maintain position and
issues, as well as concern for mod- immobilization. Images are recorded
esty, is important in providing psy- to confirm swallowing of the liquid
chological support before, during and and emptying into the stomach.
after the procedure. ➤ The abdominal binder is applied, and
➤ Fasting before the scan is not scans are taken as the binder is tight-
required; the patient may be encour- ened at various pressures, as
aged to eat a full meal before the described previously.
procedure. ➤ If reflux occurs at lower pressures,
➤ Instruct the patient to remove den- an additional 30 mL of water may be
tures, jewelry (including watches), given to clear the esophagus.
hairpins, credit cards, and other ➤ Wear gloves during the radionuclide
metallic objects in the area to be administration and while handling
examined. the patient’s urine.
➤ Instruct the patient to take slow, must have a nuclear scan, she should
deep breaths if nausea occurs during not breast-feed the infant until the
the procedure. Monitor and adminis- radionuclide has been eliminated.
ter an antiemetic agent if ordered. This could take as long as 3 days.
Ready an emesis basin for use. She should be instructed to express
the milk and discard it during the 3-
➤ Monitor the patient for complica- day period to prevent cessation of
tions related to the procedure (e.g., milk production.
chospasm). ➤ Nutritional considerations: A low-fat,
low-cholesterol, and low-sodium diet
➤ The results are recorded on film or in should be consumed to reduce cur-
a computerized system for recall and rent disease processes. High fat con-
postprocedure interpretation by the sumption increases the amount of
appropriate health care practitioner. bile acids in the colon and should be
avoided.
Post-test: ➤ No other radionuclide tests should
➤ Monitor vital signs and neurologic this procedure.
then every 2 hours for 4 hours, and ➤ A written report of the examination
then as ordered by the health care will be completed by a health care
practitioner. Compare with baseline practitioner specializing in this branch
values. Protocols may vary from faci- of medicine. The report will be sent
lity to facility. to the requesting health care practi-
➤ Observe for delayed allergic reac- with the patient.
cardia, hyperpnea, hypertension, ➤ Recognize anxiety related to test
palpitations, nausea, or vomiting. results, and be supportive of per-
ceived loss of independent function.
➤ Instruct the patient to immediately Discuss the implications of abnormal
report symptoms such as fast heart test results on the patient’s lifestyle.
rate, difficulty breathing, skin rash, Provide teaching and information
itching, or decreased urinary output. regarding the clinical implications of
➤ Instruct the patient to drink increased the test results, as appropriate.
amounts of fluids for 24 to 48 hours ➤ Reinforce information given by the
to eliminate the radionuclide from patient’s health care provider regard-
the body, unless contraindicated. Tell ing further testing, treatment, or refer-
the patient that radionuclide is elimi- ral to another health care provider.
nated from the body within 6 to 24 Answer any questions or address
hours. any concerns voiced by the patient
➤ Instruct the patient to flush the toilet or family.
immediately after each voiding fol-
lowing the procedure, and to wash
hands meticulously with soap and
water after each voiding for 24 hours
➤ Instruct all caregivers to wear gloves and systemic reactions associated
when discarding urine for 24 hours with the prescribed medication.
after the procedure. Wash gloved Encourage him or her to review cor-
hands with soap and water before responding literature provided by a
removing gloves. Then wash hands pharmacist.
after the gloves are removed.
➤ If a woman who is breast-feeding cedure, additional testing may be
Gastrointestinal Blood Loss Scan 685

determine the need for a change in ➤ Related diagnostic tests include com-
therapy. Evaluate test results in rela- puted tomography of the abdomen,
tion to the patient’s symptoms and gastric emptying scan, and upper gas-
other tests performed. trointestinal and small bowel series.
GASTROINTESTINAL BLOOD
LOSS SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gastrointestinal bleed localization study, GI bleed

scintigraphy, lower GI blood loss scan, GI scintigram.

CONTRAST: Intravenous radioactive technetium-99m–labeled red blood cells.
DESCRIPTION & RATIONALE: Gastro- the site of active bleeding. This proce-
intestinal (GI) blood loss scan is a dure is valuable for the detection and
nuclear medicine study that assists in localization of recent non-GI intra-
detecting and localizing active GI abdominal hemorrhage. Images may
tract bleeding (2 or 3 mL/min) for the be taken over an extended period to
purpose of better directing endoscopic show intermittent bleeding. ■
or angiographic studies. This proce-
dure can detect bleeding if the rate is INDICATIONS: Diagnose unexplained
greater than 0.5 mL/min, but it is not abdominal pain and GI bleeding
specific for site localization or cause of
bleeding. Endoscopy is the procedure
RESULT
of choice for diagnosing upper GI Normal Findings:
bleeding. After injection of technetium- • Normal distribution of radionuclide in
99m–labeled red blood cells, immedi- the large vessels with no extravascular
ate and delayed images of various views activity
of the abdomen are obtained. The
Abnormal Findings:
radionuclide remains in the circula-
tion long enough to extravasate and • Angiodysplasia
accumulate within the bowel lumen at • Aortoduodenal fistula
• Diverticulosis Other considerations:

• GI bleeding • The examination detects only active or
intermittent bleeding.
• Inflammatory bowel disease
• The procedure is of little value in
• Polyps patients with chronic anemia or slowly
decreasing hematocrit.
• Tumor
• The scan is less accurate for localization
• Ulcer of bleeding sites in the upper GI tract.
CRITICAL VALUES: N/A • Improper injection of the radionuclide
allows the tracer to seep deep into the
INTERFERING FACTORS: muscle tissue, producing erroneous hot
spots.
This procedure is • The test is not specific and does not
contraindicated for: indicate the exact pathologic condition
• Patients who are pregnant or suspected causing the bleeding, and may miss
of being pregnant, unless the potential small sites of bleeding (less than 0.5
benefits of the procedure far outweigh mL/min) caused by diverticular disease
the risks to the fetus and mother or angiodysplasia.
• Physiologically unstable patients may
Factors that may
impair clear imaging: be unable to be scanned over long peri-
ods or may need to go to surgery before
the procedure is complete.
because of age, significant pain, or men- • Consultation with a health care practi-
tal status tioner should occur before the procedure
for radiation safety concerns regarding
• Retained barium from a previous radi- younger patients or patients who are lac-
ologic procedure tating.
• Metallic objects within the examina- • Risks associated with radiographic
tion field (e.g., jewelry, body rings), overexposure can result from frequent
which may inhibit organ visualization x-ray procedures. Personnel in the room
and can produce unclear images with the patient should wear a protec-
• Improper adjustment of the radi- tive lead apron, stand behind a shield,
ographic equipment to accommodate or leave the area while the examination
obese or thin patients, which can cause is being done. Personnel working in the
overexposure or underexposure and a area where the examination is being
poor-quality study done should wear badges that reveal
ment Nursing Implications and
• Incorrect positioning of the patient, Procedure ● ● ● ● ● ● ● ● ● ● ●

of the area to be examined Pretest:
evaluates GI bleeding.
previous 24 to 48 hours
• Inaccurate timing of imaging after the plaints and symptoms, including a
radionuclide injection list of known allergens.
Gastrointestinal Blood Loss Scan 687
➤ Obtain a history of the patient’s gas- issues, as well as concern for mod-
trointestinal system, including signs esty, is important in providing psy-
and symptoms of GI bleeding, pain, chological support before, during and
intussusception, volvulus, or divertic- after the procedure.
ulitis, as well as results of previously ➤ Fasting before the scan is not
performed diagnostic procedures, needed, unless otherwise indicated.
surgical procedures, and laboratory
tests. For related diagnostic tests, ➤ Instruct the patient to remove den-
refer to the Gastrointestinal and tures, jewelry, including watches,
Hematopoietic System tables. hairpins, credit cards, and other
metallic objects in the area to be
➤ Note any recent procedures that can examined.
interfere with test results; including
examinations using iodine-based ➤ Make sure a written and informed
contrast medium or barium. consent has been signed prior to the
Intratest:
women.
➤ Obtain a list of the medications the ➤ Ensure that the patient has removed
patient is taking, including antico- all external metallic objects (jewelry,
agulant therapy, acetylsalicylic acid, dentures, etc.) prior to the proce-
herbs, nutritional supplements, and dure.
nutraceuticals, especially those ➤ Have emergency equipment readily
known to affect coagulation (see available.
Appendix F). It is recommended that
health care practitioner and labora-
tory should be advised if the patient
regularly uses these products so that
their effects can be taken into con-
sideration when reviewing results. ➤ Patients are given a gown, robe, and
➤ Review the procedure with the foot coverings to wear and instructed
patient. Address concerns about pain to void prior to the procedure.
related to the procedure. Explain to ➤ Record baseline vital signs and as-
the patient that some pain may be sess neurologic status. Protocols
experienced during the test, or there may vary from facility to facility.
may be moments of discomfort. ➤ Instruct the patient to cooperate fully
Reassure the patient that the radio- and to follow directions. Instruct the
nuclide poses no radioactive hazard patient to remain still throughout the
and rarely produces side effects. procedure because movement pro-
Inform the patient that the procedure duces unreliable results.
is performed in a special depart-
ment, usually in a radiology depart- ➤ Observe standard precautions, and
ment, by a health care practitioner follow the general guidelines in
and support staff, and takes approxi- Appendix A.
mately 60 minutes to complete, with ➤ Establish IV fluid line for the injection
additional images taken periodically of emergency drugs, radionuclide,
over 24 hours. and sedatives.
➤ Explain that an intravenous (IV) line ➤ Administer an antianxiety agent, as
may be inserted to allow infusion of ordered, if the patient has claustro-
IV fluids, contrast medium, dye, or phobia. Administer a sedative to a
sedatives. Usually normal saline is child or to an uncooperative adult, as
infused. ordered.
➤ Sensitivity to social and cultural ➤ Place the patient in a supine position
on a flat table with foam wedges to needed, to reduce discomfort or

help maintain position and immobi- edema.
lization. The radionuclide is adminis- ➤ Instruct the patient to drink in-
tered intravenously, and the abdomen creased amounts of fluids for 24 to
is scanned immediately for 1 minute 48 hours to eliminate the radionu-
to screen for vascular lesions that clide from the body, unless con-
cause bleeding. Images are taken traindicated. Tell the patient that
every 5 minutes for the next 60 min- radionuclide is eliminated from the
utes in the anterior, oblique, and lat- body within 6 to 24 hours.
eral views, and a postvoid anterior
view is taken. ➤ Instruct the patient to flush the toilet
immediately after each voiding fol-
➤ Wear gloves during the radionuclide lowing the procedure, and to wash
injection and while handling the hands meticulously with soap and
patient’s urine. water after each voiding for 24 hours
➤ Instruct the patient to take slow, after the procedure.
deep breaths if nausea occurs during ➤ Instruct all caregivers to wear gloves
the procedure. Monitor and adminis- when discarding urine for 24 hours
ter an antiemetic agent if ordered. after the procedure. Wash gloved
Ready an emesis basin for use. hands with soap and water before
➤ Monitor the patient for complica- removing gloves. Then wash hands
tions related to the procedure (e.g., after the gloves are removed.
allergic reaction, anaphylaxis, bron- ➤ If a woman who is breast-feeding
chospasm). must have a nuclear scan, she
➤ The needle or catheter is removed, should not breast-feed the infant
and a pressure dressing is applied until the radionuclide has been elimi-
over the puncture site. nated. This could take as long as 3
➤ The results are recorded on film or in days. She should be instructed to
a computerized system for recall and express the milk and discard it dur-
postprocedure interpretation by the ing the 3-day period to prevent ces-
appropriate health care practitioner. sation of milk production.
Post-test: low-cholesterol, and low-sodium diet
should be consumed to reduce cur-
➤ Monitor vital signs and neurologic rent disease processes. High fat con-
status every 15 minutes for 1 hour, sumption increases the amount of
then every 2 hours for 4 hours, and bile acids in the colon and should be
then as ordered by the health care avoided.
practitioner. Compare with baseline
values. Protocols may vary from ➤ No other radionuclide tests should
facility to facility. be scheduled for 24 to 48 hours after
this procedure.
tions, such as rash, urticaria, tachy- ➤ A written report of the examination
cardia, hyperpnea, hypertension, will be completed by a health care
palpitations, nausea, or vomiting. practitioner specializing in this
➤ Advise the patient to immediately be sent to the requesting health care
report symptoms such as fast heart practitioner, who will discuss the
rate, difficulty breathing, skin rash, results with the patient.
itching, or decreased urinary output.
➤ Observe the needle/catheter inser- results, and be supportive of per-
tion site for bleeding, inflammation, ceived loss of independent function.
or hematoma formation. Discuss the implications of abnormal
➤ Instruct the patient to apply cold test results on the patient’s lifestyle.
compresses to the puncture site, as Provide teaching and information
Glucagon 689
regarding the clinical implications of responding literature provided by a

the test results, as appropriate. pharmacist.
➤ Reinforce information given by the ➤ Depending on the results of this
ing further testing, treatment, or re- needed to evaluate or monitor pro-
ferral to another health care provider. gression of the disease process and
Answer any questions or address determine the need for a change in
any concerns voiced by the patient therapy. Evaluate test results in rela-
or family. tion to the patient’s symptoms and
ordered medications. Explain the Related diagnostic tests:
apy regimen. As appropriate, instruct ➤ Related diagnostic tests include
the patient in significant side effects angiography of the abdomen, com-
and systemic reactions associated puted tomography of the abdomen,
with the prescribed medication. and magnetic resonance imaging of
Encourage him or her to review cor- the abdomen.
GLUCAGON
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Plasma (1 mL) collected in chilled, lavender-top

(EDTA) tube. Specimen should be transported tightly capped
and in an ice slurry.
SI Units
Cord blood 0–215 pg/mL 0–215 ng/L
1–3 d 0–1750 pg/mL 0–1750 ng/L
4–14 y 0–148 pg/mL 0–148 ng/L
Adult 20–100 pg/mL 20–100 ng/L

DESCRIPTION & RATIONALE: Gluca- renal failure or renal transplant rejec-
gon is a hormone secreted by the tion
alpha cells of the islets of Langerhans
in the pancreas in response to hypo- RESULT
glycemia. This hormone acts prima-
Increased in:
rily on the liver to promote glucose
• Acromegaly
production and to control glucose
storage. The coordinated release of • Acute pancreatitis
insulin, glucagon, and somatostatin • Burns
ensures an adequate fuel supply while
• Cirrhosis
maintaining stable blood glucose.
Patients with glucagonoma have val- • Cushing’s syndrome
ues greater than 500 ng/L. Values • Diabetes (uncontrolled)
greater than 1000 ng/L are diagnostic
• Glucagonoma
for this condition. Glucagonoma
causes three different syndromes: • Hyperlipoproteinemia types III and IV
1. Syndrome 1: A characteristic • Hypoglycemia
skin rash, diabetes or impaired • Infections
glucose tolerance, weight loss,
anemia, and venous thrombosis • Kidney transplant rejection
2. Syndrome 2: Severe diabetes • Renal failure
3. Syndrome 3: Multiple endocrine
neoplasia • Stress
A dramatic increase in glucagon • Trauma
occurring soon after renal transplant Decreased in:
may indicate organ rejection. In the • Chronic pancreatitis
case of kidney transplant rejection,
glucagon levels increase several days • Cystic fibrosis
before an increase in creatinine • Postpancreatectomy period
levels.
Glucagon deficiency can be con- CRITICAL VALUES: N/A
firmed by measuring glucagon levels
before and after intravenous infusion INTERFERING FACTORS:
• Drugs that may increase glucagon lev-
of 0.5 g arginine/kg. Glucagon defi-
els include amino acids (e.g., arginine),
ciency is confirmed when levels fail to cholecystokinin, danazol, gastrin, glu-
rise 30 to 60 minutes after infusion. cocorticoids, insulin, and nifedipine.
Newborn infants of diabetic mothers
have impaired glucagon secretion, • Drugs that may decrease glucagon lev-
els include atenolol, pindolol, propra-
which may play a role in their hypo-
nolol, secretin, and verapamil.
glycemia. ■
INDICATIONS: within 1 week before the test can inter-
• Assist in confirming glucagon defi- fere with test results when radioim-
ciency munoassay is the test method.
• Assist in the diagnosis of suspected • Failure to follow dietary restrictions
glucagonoma (alpha islet-cell neoplas- before the procedure may cause the
tic tumor) procedure to be canceled or repeated.
Glucagon 691

Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Ensure that the patient has complied
Pretest: food has been restricted for at least
12 hours prior to the procedure.
glucagonoma.
➤ Obtain a history of the patient’s com- ment containing latex.
accordingly.
endocrine system as well as results Appendix A. Positively identify the
of previously performed laboratory patient, and label the appropriate
tests, surgical procedures, and other tubes with the corresponding patient
diagnostic procedures. For related demographics, date, and time of col-
laboratory tests, refer to the Endo- lection. Perform a venipuncture; col-
crine System table. lect the specimen in a chilled 5-mL
➤ Note any recent procedures that can lavender-top tube. The sample should
interfere with test results. be placed in an ice slurry immedi-
ately after collection. Information on
the specimen label can be protected
from water in the ice slurry if the
specimen is first placed in a protec-
tive plastic bag.
advised if the patient regularly uses ➤ Remove the needle, and apply a
these products so that their effects pressure dressing over the puncture
can be taken into consideration site.
when reviewing results. ➤ Promptly transport the specimen to
patient. Inform the patient that spec- analysis.
imen collection takes approximately ➤ The results are recorded manually or
5 to 10 minutes. Address concerns in a computerized system for recall
about pain related to the procedure. and postprocedure interpretation by
Explain to the patient that there may the appropriate health care practi-
be some discomfort during the tioner.
venipuncture.
➤ Instruct the patient to fast for at least Post-test:
12 hours before specimen collection ➤ Observe venipuncture site for bleed-
for baseline values. Diabetic patients ing or hematoma formation. Apply
should be in good glycemic control paper tape or other adhesive to hold
before testing. pressure bandage in place, or replace
➤ There are no fluid or medication with a plastic bandage.
restrictions unless by medical direc- ➤ Instruct the patient to resume usual
tion. diet, as directed by the health care
➤ Prepare an ice slurry in a cup or plas- practitioner.
tic bag to have ready for immediate ➤ Nutritional considerations: Instruct
transport of the specimen to the lab- the diabetic patient, as appropriate,
oratory. Prechill the lavender-top tube in nutritional management of the dis-
in the ice slurry. ease. Patients who adhere to dietary
recommendations report a better gen- the test results, as appropriate.

eral feeling of health, better weight Emphasize, as appropriate, that good
management, greater control of glu- glycemic control delays the onset
cose and lipid values, and improved and slows the progression of dia-
use of insulin. There is no “diabetic betic retinopathy, nephropathy, and
diet”; however, many meal-planning neuropathy. Educate the patient re-
approaches with nutritional goals are garding access to counseling serv-
endorsed by the American Dietetic ices. Provide contact information, if
Association. The nutritional needs of desired, for the American Diabetes
each diabetic patient must be deter- Association (http://www.diabetes.
mined individually with the appro- org).
priate health care professionals, ➤ Reinforce information given by the
particularly professionals trained in patient’s health care provider regard-
nutrition. ing further testing, treatment, or refer-
➤ Increased glucagon levels may be ral to another health care provider.
associated with diabetes. Instruct the Answer any questions or address
patient and caregiver to report signs any concerns voiced by the patient
and symptoms of hypoglycemia or family.
(weakness, confusion, diaphoresis, ➤ Depending on the results of this pro-
rapid pulse) or hyperglycemia (thirst, cedure, additional testing may be
polyuria, hunger, lethargy). performed to evaluate or monitor
results, and be supportive of per-
ceived loss of independence and fear Related laboratory tests:
of shortened life expectancy. Discuss
the implications of abnormal test ➤ Related laboratory tests include glu-
results on the patient’s lifestyle. cose, glucose tolerance tests, gly-
Provide teaching and information cated hemoglobin A1C, insulin, insulin
regarding the clinical implications of antibodies, and microalbumin.
GLUCOSE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Blood sugar, fasting blood sugar (FBS), postpran-

dial glucose, 2-hour PC.

(1 mL) collected in gray-top (sodium fluoride) or green-top (heparin) tube is
also acceptable.

Glucose 693
SI Units
Fasting
Cord blood 45–96 mg/dL 2.5–5.3 mmol/L

Premature infant 20–60 mg/dL 1.1–3.3 mmol/L
Neonate 30–60 mg/dL 1.7–3.3 mmol/L
Newborn 1 d 40–60 mg/dL 2.2–3.3 mmol/L
Newborn 2 d–2 y 50–80 mg/dL 2.8–4.4 mmol/L
Child 60–100 mg/dL 3.3–5.6 mmol/L
Adult 65–99 mg/dL 3.6–5.5 mmol/L
Prediabetes or 100–125 mg/dL 5.6–6.9 mmol/L
Impaired Fasting
Glucose
2-Hour Postprandial
2-h Postprandial Less than 105 mg/dL Less than 5.8 mmol/L
DESCRIPTION & RATIONALE: Glucose, • Symptoms of diabetes (e.g., polyuria,

a simple six-carbon sugar (monosac- polydipsia, unexplained weight loss)
charide), enters the diet as part of the in addition to a random glucose
sugars sucrose, lactose, and maltose level greater than 200 mg/dL
and as the major constituent of the • Fasting blood glucose greater than
complex polysaccharide called dietary 126 mg/dL, after a minimum of an
starch. The body acquires most of its 8-hour fast
energy from the oxidative metabolism • Glucose level greater than 200 mg/
of glucose. Excess glucose is stored in dL 2 hours after glucose challenge
the liver or in muscle tissue as glycogen. with standardized 75-mg load ■
Diabetes is a group of diseases char-
acterized by hyperglycemia or elevated INDICATIONS:
glucose levels. Hyperglycemia results • Assist in the diagnosis of insulinoma
from a defect in insulin secretion • Determine insulin requirements
(type 1 diabetes), a defect in insulin • Evaluate disorders of carbohydrate
action, or a combination of defects in metabolism
secretion and action (type 2 diabetes).
• Identify hypoglycemia
The chronic hyperglycemia of dia-
betes may result over time in damage, • Screen for diabetes
dysfunction, and eventually failure of
the eyes, kidneys, nerves, heart, and
RESULT
blood vessels. The American Diabetes Increased in:
Association’s criteria for diagnosing • Acromegaly, gigantism
diabetes include any combination of
• Acute stress reaction
the following findings or confirma-
tion of any of the individual findings • Cerebrovascular accident
by repetition on a subsequent day: • Cushing’s syndrome
• Diabetes CRITICAL VALUES:

• Glucagonoma Less than 40 mg/dL
• Hemochromatosis Greater than 400 mg/dL
• Liver disease (severe) health care practitioner any critically
• Myocardial infarction increased or decreased values and related
symptoms.
• Pancreatic adenoma Symptoms of decreased glucose levels
• Pancreatitis (acute and chronic) include headache, confusion, hunger, irri-
tability, nervousness, restlessness, sweat-
• Pancreatitis due to mumps ing, and weakness. Possible interventions
• Pheochromocytoma include oral or intravenous (IV) adminis-
• Renal disease (severe) tration of glucose, IV or intramuscular
injection of glucagon, and continuous
• Shock, trauma glucose monitoring.
• Somatostatinoma Symptoms of elevated glucose levels
include abdominal pain, fatigue, muscle
• Strenuous exercise cramps, nausea, vomiting, polyuria, and
• Syndrome X (metabolic syndrome) thirst. Possible interventions include sub-
cutaneous or IV injection of insulin with
• Thyrotoxicosis continuous glucose monitoring.
• Vitamin B1 deficiency
Decreased in: • Drugs that may increase glucose lev-
• Acute alcohol ingestion els include acetazolamide, alanine,
• Addison’s disease albuterol, anesthetic agents, antipyrine,
atenolol, betamethasone, cefotaxime,
• Ectopic insulin production from chlorpromazine, chlorprothixene, cloni-
tumors (adrenal carcinoma, carcinoma dine, clorexolone, corticotropin, corti-
of the stomach, fibrosarcoma) sone, cyclic AMP, cyclopropane,
• Excess insulin by injection dexamethasone, dextroamphetamine,
diapamide, epinephrine, enflurane,
• Galactosemia
ethacrynic acid, ether, fludrocortisone,
• Glucagon deficiency fluoxymesterone, furosemide, glucagon,
• Glycogen storage diseases glucocorticoids, homoharringtonine,
hydrochlorothiazide, hydroxydione, iso-
• Hereditary fructose intolerance niazid, maltose, meperidine, mepred-
• Hypopituitarism nisone, methyclothiazide, metolazone,
niacin, nifedipine, nortriptyline, octre-
• Hypothyroidism
otide, oral contraceptives, oxyphenbu-
• Insulinoma tazone, pancreozymin, phenelzine,
• Malabsorption syndromes phenylbutazone, piperacetazine, poly-
thiazide, prednisone, quinethazone,
• Maple syrup urine disease reserpine, rifampin, ritodrine, salbuta-
• Poisoning resulting in severe liver dis- mol, secretin, somatostatin, thiazides,
ease thyroid hormone, and triamcinolone.
• Postgastrectomy • Drugs that may decrease glucose levels
include acarbose, acetylsalicylic acid,
• Starvation
acipimox, alanine, allopurinol, anti-
• von Gierke disease mony compounds, arsenicals, ascorbic
Glucose 695
acid, benzene, buformin, cannabis, sitivities to latex), and inform the

captopril, carbutamide, chloroform, appropriate health care practitioner
clofibrate, dexfenfluramine, enalapril, accordingly.
enprostil, erythromycin, fenfluramine, ➤ Obtain a history of the patient’s
gemfibrozil, glibornuride, glyburide, endocrine system as well as results
guanethidine, niceritrol, nitrazepam, of previously performed laboratory
oral contraceptives, oxandrolone, oxy- tests, surgical procedures, and other
metholone, phentolamine, phospho-
laboratory tests, refer to the Endo-
rus, promethazine, ramipril, rotenone, crine System table.
sulfonylureas, thiocarlide, tolbutamide,
tromethamine, and verapamil. ➤ Obtain a list of medications the
• Elevated urea levels and uremia can nutritional supplements, nutraceuti-
lead to falsely elevated glucose levels. cals, insulin, and any other substances
used to regulate glucose levels. The
• Extremely elevated white blood cell requesting health care practitioner
counts can lead to falsely decreased glu- and laboratory should be advised if
cose values. the patient regularly uses these
• Failure to follow dietary restrictions products so that their effects can be
taken into consideration when re-
before the fasting test can lead to falsely viewing results.
elevated glucose values.
• Administration of insulin or oral hypo- patient. Inform the patient that spec-
glycemic agents within 8 hours of a imen collection takes approximately
fasting blood glucose can lead to falsely 5 to 10 minutes. Address concerns
decreased values. about pain related to the procedure.
• Specimens should never be collected be some discomfort during the
above an intravenous (IV) line because venipuncture.
of the potential for dilution when the
➤ For the fasting glucose test, the
specimen and the IV solution combine patient should fast for at least 12
in the collection container, falsely hours before specimen collection.
decreasing the result. There is also the
potential of contaminating the sample restrictions, unless by medical direc-
with the substance of interest, if it is tion.
present in the IV solution, falsely
➤ The patient should follow the instruc-
increasing the result.
tions given for 2-hour postprandial
• Failure to follow dietary restrictions glucose test. Some health care prac-
before the procedure may cause the titioners may order administration
procedure to be canceled or repeated. of a standard glucose solution,
whereas others may instruct the
patient to eat a meal with a known
Nursing Implications and carbohydrate composition.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest:
➤ Inform the patient that the test is with dietary restrictions and other
used to to assist in the diagnosis of pretesting preparations; assure that
diabetes and to evaluate disorders of food has been restricted for at least
carbohydrate metabolism. 12 hours prior to the fasting proce-
➤ Obtain a history of the patient’s com- dure.
plaints, including a list of known ➤ If the patient has a history of severe
allergens (especially allergies or sen- allergic reaction to latex, care should
be taken to avoid the use of equip- particularly professionals trained in

ment containing latex. nutrition.
➤ Instruct the patient to cooperate fully ➤ Instruct the patient and caregiver to
and to follow directions. Direct the report signs and symptoms of hypo-
patient to breathe normally and to glycemia (weakness, confusion,
avoid unnecessary movement. diaphoresis, rapid pulse) or hyper-
➤ Observe standard precautions, and glycemia (thirst, polyuria, hunger,
follow the general guidelines in lethargy).
Appendix A. Positively identify the ➤ A written report of the examination
patient, and label the appropriate will be sent to the requesting health
tubes with the corresponding patient care practitioner, who will discuss
demographics, date, and time of col- the results with the patient.
lect the specimen in a 5-mL gray-top
tube.
ceived loss of independence and
➤ Remove the needle, and apply a fear of shortened life expectancy.
pressure dressing over the puncture Discuss the implications of abnormal
site. test results on the patient’s lifestyle.
➤ Promptly transport the specimen to Provide teaching and information
the laboratory for processing and regarding the clinical implications of
analysis. the test results, as appropriate.
Emphasize, as appropriate, that good
glycemic control delays the onset
of and slows the progression of dia-
betic retinopathy, nephropathy, and
neuropathy. Educate the patient
tioner.
regarding access to counseling serv-
Post-test: ices. Provide contact information, if
desired, for the American Diabetes
➤ Observe venipuncture site for bleed- Association (http://www.diabetes.
ing or hematoma formation. Apply org).
paper tape or other adhesive to hold ➤ Reinforce information given by the
pressure bandage in place, or replace patient’s health care provider regard-
with a plastic bandage. ing further testing, treatment, or refer-
➤ Instruct the patient to resume usual ral to another health care provider.
diet, as directed by the health care Answer any questions or address
practitioner. any concerns voiced by the patient
➤ Nutritional considerations: Increased or family.
glucose levels may be associated ➤ Depending on the results of this pro-
with diabetes. Instruct the diabetic cedure, additional testing may be
patient, as appropriate, in nutritional performed to evaluate or monitor
management of the disease. Pa- progression of the disease process
tients who adhere to dietary recom- and determine the need for a change
mendations report a better general in therapy. Evaluate test results in
feeling of health, better weight man- relation to the patient’s symptoms
agement, greater control of glucose and other tests performed.
and lipid values, and improved use of
insulin. There is no “diabetic diet”; Related laboratory tests:
however, many meal-planning ap-
proaches with nutritional goals are ➤ Related laboratory tests include
endorsed by the American Dietetic blood urea nitrogen, C-peptide, crea-
Association. The nutritional needs of tinine, fructosamine, glucose toler-
each diabetic patient must be deter- ance tests, glycated hemoglobin A1C,
mined individually with the appro- insulin, insulin antibodies, ketones,
priate health care professionals, and microalbumin.
Glucose-6-Phosphate Dehydrogenase 697
GLUCOSE-6-PHOSPHATE
DEHYDROGENASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: G6PD.
(ethylenediaminetetra-acetic acid [EDTA]) tube.
REFERENCE VALUE: (Method: Fluorescent) Qualitative assay—enzyme activ-
ity detected; quantitative assay—the following table reflects enzyme activity
in units per gram of hemoglobin and in units per milliliter of erythrocytes:

Newborn 7.8–14.4 U/g hemoglobin 0.5–0.93 MU/mol hemoglobin
Adult 5.5–9.3 U/g hemoglobin 0.35–0.60 MU/mol hemoglobin
Newborn 2.65–4.90 U/mL erythrocytes 2.65–4.90 kU/L erythrocytes
Adult 1.87–3.16 U/mL erythrocytes 1.87–3.16 kU/L erythrocytes
DESCRIPTION & RATIONALE: Glucose- common in Greeks, Italians, Turks,

6-phosphate dehydrogenase (G6PD) North Africans, Spaniards, Portuguese,
is a red blood cell enzyme. It is and Ashkenazic Jews. G6PD Mahidol
involved in the hexose monophos- is common in Southeast Asians (22%
phate shunt, and its function is to of males). ■
protect hemoglobin from oxidation.
G6PD deficiency is an inherited X- INDICATIONS:
linked abnormality; approximately • Assist in identifying the cause of
20% of female carriers are heterozy- hemolytic anemia resulting from
drug sensitivity, metabolic disorder, or
gous. This deficiency results in hemol-
infection
ysis of varying degrees and acuity
depending on the severity of the • Assist in identifying the cause of
abnormality. There are three G6PD hemolytic anemia resulting from
enzyme deficiency
variants of high frequency in different
ethnic groups. G6PD A– is more com- RESULT
mon in African-Americans (10% of
males). G6PD Mediterranean is espe- Increased in:
cially common in Iraqis, Kurds, • Hepatic coma
Sephardic Jews, and Lebanese and less • Hyperthyroidism
• Idiopathic thrombocytopenic purpura can be taken into consideration

• Pernicious anemia patient. Inform the patient that spec-
• Viral hepatitis imen collection takes approximately
Decreased in: about pain related to the procedure.
• Congenital nonspherocytic anemia Explain to the patient that there may
• G6PD deficiency venipuncture.
• Nonimmunologic hemolytic disease of ➤ There are no food, fluid, or medica-
the newborn tion restrictions, unless by medical
direction.
Intratest:
• Sulfates may decrease G6PD levels. allergic reaction to latex, care should
• G6PD levels are increased in reticulo- be taken to avoid the use of equip-
cytes; the test results may be falsely pos- ment containing latex.
itive when a patient is in a period of ➤ Instruct the patient to cooperate fully
acute hemolysis. G6PD levels can also and to follow directions. Direct the
be affected by the presence of large patient to breathe normally and to
numbers of platelets and white blood avoid unnecessary movement.
cells, which also contain significant ➤ Observe standard precautions, and
amounts of the enzyme. follow the general guidelines in
Nursing Implications and tubes with the corresponding pa-
Procedure ● ● ● ● ● ● ● ● ● ● ● tient demographics, date, and time
of collection. Perform a venipunc-
Pretest: ture; collect the specimen in a 5-mL
lavender-top tube.
➤ Remove the needle, and apply a pres-
used to identify an enzyme defi-
sure dressing over the puncture site.
ciency that can result in red blood
cell hemolysis. ➤ Promptly transport the specimen to
analysis.
allergens (especially allergies or sen- ➤ The results are recorded manually or
sitivities to latex), and inform the in a computerized system for recall
appropriate health care practitioner and postprocedure interpretation by
accordingly. the appropriate health care practi-
tioner.
hematopoietic system as well as Post-test:
ratory tests, surgical procedures, ➤ Observe venipuncture site for bleed-
and other diagnostic procedures. For ing or hematoma formation. Apply
related laboratory tests, refer to the paper tape or other adhesive to hold
Hematopoietic System table. pressure bandage in place, or re-
➤ Obtain a list of medications the place with a plastic bandage.
patient is taking, including herbs, ➤ Nutritional considerations: Educate
nutritional supplements, and nutra- the patient with G6PD deficiency, as
ceuticals. The requesting health care appropriate, to avoid certain foods,
practitioner and laboratory should be vitamins, and drugs that may precip-
advised if the patient regularly uses itate an acute episode of intravascu-
these products so that their effects lar hemolysis, including fava beans,
Glucose Tolerance Tests 699
ascorbic acid (large doses), acetanilid, ➤ Depending on the results of this pro-
antimalarials, furazolidone, isobutyl cedure, additional testing may be
nitrate, methylene blue, nalidixic acid, performed to evaluate or monitor
naphthalene, niridazole, nitrofurantoin, progression of the disease process
phenazopyridine, phenylhydrazine, and determine the need for a change
primaquine, sulfacetamide, sulfame- in therapy. Evaluate test results in
thoxazole, sulfanilamide, sulfapyri- relation to the patient’s symptoms
dine, thiazolesulfone, toluidine blue, and other tests performed.
trinitrotoluene, and urate oxidase.
care practitioner, who will discuss ➤ Related laboratory tests include biliru-
the results with the patient. bin, complete blood count (including
➤ Reinforce information given by the examination of peripheral smear for
patient’s health care provider regard- red blood cell abnormalities and the
ing further testing, treatment, or refer- presence of Heinz bodies), Ham’s test,
ral to another health care provider. haptoglobin, hemosiderin, osmotic
Answer any questions or address fragility, reticulocyte count, urinalysis
any concerns voiced by the patient (for hemoglobin and urobilinogen),
or family. and vitamin B12.
GLUCOSE TOLERANCE TESTS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Standard oral tolerance test, standard gestational

screen, standard gestational tolerance test, GTT.
SPECIMEN: Plasma (1 mL) collected in gray-top (sodium fluoride) tube.

Serum (1 mL) collected in a red- or tiger-top tube or plasma collected in a
green-top (heparin) tube is also acceptable. It is important to use the same
type of collection container throughout the entire test.
Standard Oral
Tolerance
Fasting sample Less than 126 mg/dL Less than 7.0 mmol/L
2-h sample Less than 200 mg/dL Less than 11.1 mmol/L
Prediabetes or 140–199 mg/dL 7.8–11.0 mmol/L
Impaired Glucose
Tolerance
Standard Gestational Less than 141 mg/dL Less than 7.8 mmol/L
Screen

Standard Gestational
Tolerance
Fasting sample 75–104 mg/dL 4.2–5.8 mmol/L
1-h sample 75–180 mg/dL 4.2–10.0 mmol/L
Plasma glucose values are reported to be 10%–20% higher than serum values.
DESCRIPTION & RATIONALE: The • Fasting blood glucose greater

glucose tolerance test (GTT) meas- than 126 mg/dL, after a
ures glucose levels after administration minimum of an 8-hour fast
of an oral or intravenous carbohydrate • Glucose level greater than
challenge. Patients with diabetes are 200 mg/dL 2 hours after glucose
challenge with standardized
unable to metabolize glucose at a nor- 75-mg load ■
mal rate. The oral GTT is used for
individuals who are able to eat and
INDICATIONS:
who are not known to have problems • Evaluate abnormal fasting or postpran-
with gastrointestinal malabsorption. dial blood glucose levels that do not
The intravenous GTT is used for clearly indicate diabetes
individuals who are unable to tolerate
• Evaluate glucose metabolism in women
oral glucose. of childbearing age, especially women
Diabetes is a group of diseases char- who are pregnant and have (1) a history
acterized by hyperglycemia or elevated of previous fetal loss or birth of infants
glucose levels. Hyperglycemia results weighing 9 pounds or more, and/or (2)
from a defect in insulin secretion (type a family history of diabetes
1 diabetes), a defect in insulin action, • Identify abnormal renal tubular func-
or a combination of dysfunction secretion if glycosuria occurs without hyper-
tion and action (type 2 diabetes). The glycemia
chronic hyperglycemia of diabetes over • Identify impaired glucose metabolism
time results in damage, dysfunction, without overt diabetes
and eventually failure of the eyes, kid-
• Support the diagnosis of hyperthy-
neys, nerves, heart, and blood vessels.
roidism and alcoholic liver disease,
The American Diabetes Association’s which are characterized by a sharp rise
criteria for diagnosing diabetes include in blood glucose followed by a decline
any combination of the following to subnormal levels
findings or confirmation of any of the
individual findings by repetition on a
RESULT
subsequent day:
Tolerance increased in:
• Symptoms of diabetes (e.g.,
polyuria, polydipsia, and • Decreased absorption of glucose:
unexplained weight loss) in Adrenal insufficiency (Addison’s
addition to a random glucose disease, hypopituitarism)
level greater than 200 mg/dL Hypothyroidism
Intestinal diseases, such as celiac cutaneous or IV injection of insulin with

disease and tropical sprue continuous glucose monitoring.
Whipple’s disease
• Increased insulin secretion: INTERFERING FACTORS:
Pancreatic islet cell tumor • Drugs and substances that may increase
GTT values include acetylsalicylic acid,
atenolol, bendroflumethiazide, clofi-
Tolerance impaired in: brate, fenfluramine, fluoxymesterone,
• Increased absorption of glucose: glyburide, guanethidine, lisinopril,
Excessive intake of glucose methandrostenolone, metoprolol, nan-
Gastrectomy drolone, niceritrol, nifedipine, nitren-
Gastroenterostomy dipine, norethisterone, phenformin,
Hyperthyroidism phenobarbital, prazosin, terazosin, and
caffeine.
Vagotomy
• Drugs and substances that may
• Decreased usage of glucose:
decrease GTT values include acebu-
Central nervous system lesions tolol, beclomethasone, bendroflume-
Cushing’s syndrome thiazide, betamethasone, calcitonin,
Diabetes catecholamines, chlorothiazide, chlor-
Hemochromatosis promazine, chlorthalidone, cimeti-
Hyperlipidemia dine, corticotropin, cortisone, danazol,
deflazacort, dexamethasone, diapam-
• Decreased glycogenesis: ide, diethylstilbestrol, ethacrynic acid,
Hyperthyroidism fludrocortisone, furosemide, glucagon,
Infections glucocorticosteroids, heroin, hydro-
Liver disease (severe) chlorothiazide, mephenytoin, mestra-
nol, methadone, methandrostenolone,
Pheochromocytoma
methylprednisolone, muzolimine, nia-
Pregnancy cin, nifedipine, norethindrone, norethy
Stress nodrel, oral contraceptives, parametha-
von Gierke disease sone, perphenazine, phenolphthalein,
phenothiazine, phenytoin, pindolol,
CRITICAL VALUES: prednisolone, prednisone, propranolol,
Less than 40 mg/dL quinethazone, thiazides, triamcinolone,
Greater than 400 mg/dL triamterene, and verapamil.
Note and immediately report to the • The test should be performed on
health care practitioner any critically ambulatory patients. Impaired physical
increased or decreased values and related activity can lead to falsely increased
symptoms. values.
Symptoms of decreased glucose levels
include headache, confusion, hunger, irri- • Excessive physical activity before or
tability, nervousness, restlessness, sweat- during the test can lead to falsely
ing, and weakness. Possible interventions decreased values.
include oral or intravenous (IV) admin-
• Failure of the patient to ingest a diet
istration of glucose, IV or intramuscular
with sufficient carbohydrate content
(e.g., 150 g/day) for at least 3 days
glucose monitoring.
before the test can result in falsely
Symptoms of elevated glucose levels
decreased values.
include abdominal pain, fatigue, muscle
cramps, nausea, vomiting, polyuria, and • Smoking before or during the test can
thirst. Possible interventions include sub- lead to falsely increased values.
• The patient should not be under recent to 12 hours before the standard oral
or current physiologic stress during the and standard gestational GTTs.
test. If the patient has had recent sur- ➤ There are no fluid or medication
gery (less than 2 weeks previously), an restrictions, unless by medical direc-
infectious disease, or a major illness tion.
(e.g., myocardial infarction), the test
should be delayed or rescheduled. Intratest:
• Failure to follow dietary restrictions ➤ Ensure that the patient has complied
with dietary and activity restrictions
as well as other pretesting prepara-
procedure to be canceled or repeated. tions; assure that food has been
restricted for at least 8 to 12 hours
prior to the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ● allergic reaction to latex, care should
➤ Inform the patient that the test is ➤ Instruct the patient to cooperate fully
used to assist in the diagnosis of dia- and to follow directions. Direct the
betes. patient to breathe normally and to
plaints, including a list of known ➤ Observe standard precautions, and
allergens (especially allergies or sen- follow the general guidelines in
sitivities to latex), and inform the Appendix A. Positively identify the
appropriate health care practitioner patient, and label the appropriate
accordingly. tubes with the corresponding patient
➤ Obtain a history of the patient’s lection. Perform a venipuncture;
endocrine system as well as results collect the specimen in a 5-mL gray-
of previously performed laboratory top tube.
diagnostic procedures. For related ➤ Remove the needle, and apply a
laboratory tests, refer to the Endo- pressure dressing over the punc-
crine System table. ture site.
➤ Obtain a list of medications the ➤ Promptly transport the specimen
patient is taking, including herbs, to the laboratory for processing
nutritional supplements, and nutra- and analysis. Do not wait until all
ceuticals. The requesting health care specimens have been collected to
practitioner and laboratory should be transport.
advised if the patient regularly uses ➤ The results are recorded manually
these products so that their effects or in a computerized system for
can be taken into consideration recall and postprocedure interpreta-
when reviewing results. tion by the appropriate health care
➤ Review the procedure with the practitioner.
patient. Inform the patient that spec- Standard oral GTT:
5 to 10 minutes. Inform the patient ➤ The standard oral GTT takes 2 hours.
that multiple specimens may be A fasting blood glucose is deter-
required. Address concerns about mined before administration of an
pain related to the procedure. Ex- oral glucose load. If the fasting blood
plain to the patient that there may glucose is less than 126 mg/dL, the
be some discomfort during the veni- patient is given an oral glucose load.
puncture. ➤ An oral glucose load should not be
➤ The patient should fast for at least 8 administered before the value of the
fasting specimen has been received. ➤ An oral glucose load should not be
If the fasting blood glucose is greater administered before the value of the
than 126 mg/dL, the standard glu- fasting specimen has been received.
cose load is not administered and If the fasting blood glucose is greater
the test is canceled. The laboratory than 126 mg/dL, the glucola is not
will follow its protocol as far as noti- administered and the test is can-
fying the patient of his or her glucose celed (see previous explanation).
level and the reason why the test ➤ The glucose load should be con-
was canceled. The requesting health sumed within 5 minutes, and time
care practitioner will then be issued 0 begins as soon as the patient
a report indicating the glucose level begins to ingest the glucose load.
and the cancellation of the test. A Subsequent specimens are collected
fasting glucose greater than 126 at 1, 2, and 3 hours, concluding the
mg/dL indicates diabetes; therefore, test. The test is discontinued if the
the glucola would never be adminis- patient vomits before all specimens
tered before allowing the requesting have been collected.
health care practitioner to evaluate
the clinical situation. Post-test:
➤ Adults receive 75 g and children ➤ Observe venipuncture site for bleed-
receive 1.75 g/kg ideal weight, not to ing or hematoma formation. Apply
exceed 75 g. The glucose load paper tape or other adhesive to hold
should be consumed within 5 min- pressure bandage in place, or
utes, and time 0 begins as soon as replace with a plastic bandage.
the patient begins to ingest the glu-
cose load. A second specimen is col- ➤ Instruct the patient to resume usual
lected at 2 hours, concluding the diet and activity, as directed by the
test. The test is discontinued if the health care practitioner.
patient vomits before the second ➤ Nutritional considerations: Increased
specimen has been collected. glucose levels may be associated
with diabetes. Instruct the diabe-
Standard gestational screen: tic patient, as appropriate, in nutri-
tional management of the disease.
➤ The standard gestational screen is Patients who adhere to dietary rec-
performed on pregnant women. If ommendations report a better gen-
results from the screen are abnor- eral feeling of health, better weight
mal, a full gestational GTT is per- management, greater control of glu-
formed. The gestational screen does cose and lipid values, and improved
not require a fast. The patient is use of insulin. There is no “diabetic
given a 50-g oral glucose load. The diet”; however, many meal-planning
glucose load should be consumed approaches with nutritional goals are
within 5 minutes, and time 0 begins endorsed by the American Dietetic
as soon as the patient begins to Association. The nutritional needs
ingest the glucose load. One hour of each diabetic patient need to be
after ingestion, a specimen is col- determined individually with the
lected. The test is discontinued if the appropriate health care profession-
patient vomits before the 1-hour als, particularly professionals trained
specimen has been collected. in nutrition.
➤ Impaired glucose tolerance may
Standard gestational GTT: be associated with diabetes. Instruct
➤ The standard gestational GTT takes the patient and caregiver to report
3 hours. A fasting blood glucose is signs and symptoms of hypo-
determined before administration of glycemia (weakness, confusion,
a 100-g oral glucose load. If the fast- diaphoresis, rapid pulse) or hyper-
ing blood glucose is less than 126 glycemia (thirst, polyuria, hunger,
mg/dL, the patient is given an oral lethargy).
glucose load. ➤ A written report of the examination
will be sent to the requesting health patient’s health care provider regard-
care practitioner, who will discuss ing further testing, treatment, or
the results with the patient. referral to another health care pro-
➤ Recognize anxiety related to test vider. Answer any questions or
results, and be supportive of per- address any concerns voiced by the
ceived loss of independence and fear patient or family.
of shortened life expectancy. Discuss ➤ Depending on the results of this pro-
the implications of abnormal test cedure, additional testing may be
results on the patient’s lifestyle. performed to evaluate or monitor
Provide teaching and information progression of the disease process
regarding the clinical implications and determine the need for a change
of the test results, as appropriate. in therapy. Evaluate test results in
Emphasize, as appropriate, that good relation to the patient’s symptoms
glycemic control delays the onset and other tests performed.
of and slows the progression of dia-
betic retinopathy, nephropathy, and
neuropathy. Educate the patient Related laboratory tests:
regarding access to counseling serv- ➤ Related laboratory tests include blood
ices. Provide contact information, if urea nitrogen, C-peptide, cholesterol
desired, for the American Diabetes (total and HDL), creatinine, fructosa-
Association (http://www.diabetes. mine, glucose, glycated hemoglobin
org). A1C, insulin, insulin antibodies, keto-
➤ Reinforce information given by the nes, microalbumin, and triglycerides.
-GLUTAMYLTRANSFERASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Serum -glutamyltransferase, -glutamyl transpep-

tidase, GGT, SGGT.

mL) collected in green-top (heparin) tube is also acceptable.
Conventional &
Sex SI Units
DESCRIPTION & RATIONALE: -
Glutamyltransferase (GGT) assists
Male 1–94 U/L with the reabsorption of amino acids
Female 1–70 U/L
and peptides from the glomerular
-Glutamyltransferase 705
filtrate and intestinal lumen. disulfiram, methyldopa, oral contra-

Hepatobiliary, renal tubular, and pan- ceptives, phenothiazines, rifampin, and
streptokinase.
creatic tissues contain large amounts
of GGT. Other sources include the • Drugs that may decrease GGT levels
prostate gland, brain, and heart. GGT include bezafibrate, cefotaxime, clofi-
is elevated in all types of liver disease brate, fenofibrate, and ursodiol.
and is more responsive to biliary
obstruction, cholangitis, or cholecysti-
tis than any of the other enzymes used Nursing Implications and
as markers for liver disease. ■ Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
INDICATIONS:
• Assist in the diagnosis of obstructive ➤ Inform the patient that the test is
jaundice in neonates used to assess liver function.
• Detect the presence of liver disease plaints, including a list of known
• Evaluate and monitor patients with allergens (especially allergies or sen-
known or suspected alcohol abuse (lev- sitivities to latex), and inform the
els rise after ingestion of small amounts appropriate health care practitioner
accordingly.
of alcohol)
RESULT hepatobiliary system as well as re-
sults of previously performed labora-
tory tests, surgical procedures, and
Increased in: other diagnostic procedures. For
• Cirrhosis related laboratory tests, refer to the
Hepatobiliary System table.
• Diabetes with hypertension
➤ Obtain a history of intravenous drug
• Hepatitis use, alcohol use, high-risk sexual ac-
tivity, and occupational exposure.
• Hepatobiliary tract disorders
• Hepatocellular carcinoma patient is taking, including herbs,
• Hyperthyroidism ceuticals. The requesting health care
• Obstructive liver disease practitioner and laboratory should be
• Pancreatitis these products so that their effects
• Renal transplantation when reviewing results.
• Significant alcohol ingestion ➤ Review the procedure with the
Decreased in: imen collection takes approximately
• Hypothyroidism 5 to 10 minutes. Address concerns
venipuncture.
INTERFERING FACTORS: ➤ Sensitivity to social and cultural
• Drugs that may increase GGT issues, as well as concern for mod-
levels include acetaminophen, esty, is important in providing psy-
aminoglutethimide, anticonvulsants, chological support before, during,
barbiturates, captopril, clotiazepam, and after the procedure.
➤ There are no food, fluid, or medica- moderate-fat diet with a high fluid
tion restrictions, unless by medical intake is often recommended for
direction. patients with hepatitis. Treatment of
cirrhosis is different because a low-
Intratest: protein diet may be in order if the
patient’s liver has lost the ability to
➤ If the patient has a history of severe process the end products of pro-
allergic reaction to latex, care should tein metabolism. A diet of soft foods
be taken to avoid the use of equip- also may be required if esophageal
ment containing latex. varices have developed. Ammonia
➤ Instruct the patient to cooperate fully levels may be used to determine
and to follow directions. Direct the whether protein should be added to
patient to breathe normally and to or reduced from the diet. The patient
avoid unnecessary movement. should be encouraged to eat simple
➤ Observe standard precautions, and carbohydrates and emulsified fats
follow the general guidelines in (as in homogenized milk or eggs), as
Appendix A. Positively identify the opposed to complex carbohydrates
patient, and label the appropriate (e.g., starch, fiber, and glycogen [ani-
tubes with the corresponding patient mal carbohydrates]) and complex
demographics, date, and time of col- fats, which would require additional
lection. Perform a venipuncture; bile to emulsify them so that they
collect the specimen in a 5-mL red- can be used. The cirrhotic patient
or tiger-top tube. should also be carefully observed for
the development of ascites, in which
➤ Remove the needle, and apply a case fluid and electrolyte balance
pressure dressing over the punc- requires strict attention. The alco-
ture site. holic patient should be encouraged
➤ Promptly transport the specimen to to avoid alcohol and to seek appro-
the laboratory for processing and priate counseling for substance
analysis. abuse.
➤ The results are recorded manually ➤ A written report of the examination
or in a computerized system for will be sent to the requesting health
recall and postprocedure interpreta- care practitioner, who will discuss
tion by the appropriate health care the results with the patient.
practitioner.
results, and be supportive of im-
Post-test:
paired activity related to lack of neu-
➤ Observe venipuncture site for bleed- romuscular control, perceived loss of
ing or hematoma formation. Apply independence, and fear of shortened
paper tape or other adhesive to life expectancy. Discuss the implica-
hold pressure bandage in place, or tions of abnormal test results on the
replace with a plastic bandage. patient’s lifestyle. Provide teaching
➤ Nutritional considerations: Increased
GGT levels may be associated with
liver disease. Dietary recommenda-
regarding access to counseling serv-
tions may be indicated and vary
ices.
depending on the condition and its
severity. Currently, there are no spe- ➤ Reinforce information given by the
cific medications that can be given to patient’s health care provider regard-
cure hepatitis, but elimination of ing further testing, treatment, or
alcohol ingestion and a diet opti- referral to another health care pro-
mized for convalescence are com- vider. Answer any questions or
monly included in the treatment address any concerns voiced by the
plan. A high-calorie, high-protein, patient or family.
Glycated Hemoglobin A1C 707

be performed to evaluate or moni- ➤ Related laboratory tests include ala-
tor progression of the disease nine aminotransferase, alkaline phos-
process and determine the need for phatase and isoenzymes, ammonia,
a change in therapy. Evaluate test aspartate aminotransferase, bilirubin,
results in relation to the patient’s electrolytes, hepatitis A antibody,
symptoms and other tests per- hepatitis B antigen and antibody, and
formed. hepatitis C antibody.
GLYCATED HEMOGLOBIN A1C

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Hemoglobin A1C, A1C.

(ethylenediaminetetra-acetic acid [EDTA]) tube.
REFERENCE VALUE: (Method: Chromatography)
Total A1 4.0–7.0% (type 1 diabetes), a defect in insulin

A1C 4.0–5.5% action, or a combination of dysfunc-
Values vary widely by method.
tion secretion and action (type 2 dia-
betes). The chronic hyperglycemia of
diabetes over time results in damage,
DESCRIPTION & RATIONALE: Gly- dysfunction, and eventually failure of
cosylated or glycated hemoglobin is a the eyes, kidneys, nerves, heart, and
term used to describe the combina- blood vessels. Hemoglobin A1C levels
tion of glucose and hemoglobin into a are not age dependent and are not
ketamine; the rate at which this occurs affected by exercise, diabetic medica-
is proportional to glucose concentrations, or nonfasting state before speci-
tion. The average life span of a red men collection. ■
blood cell is approximately 120 days;
measurement of glycated hemoglobin INDICATIONS: Assess long-term glucose
is a way to monitor long-term diabetic control in diabetics
management.
RESULT
Diabetes is a group of diseases char-
acterized by hyperglycemia or elevated Increased in:
glucose levels. Hyperglycemia results • Diabetes (poorly controlled or uncon-
from a defect in insulin secretion trolled)
Decreased in: ➤ Obtain a list of medications the

• Chronic blood loss patient is taking, including herbs,
• Chronic renal failure ceuticals. The requesting health care
• Conditions that decrease red blood cell advised if the patient regularly uses
life span these products so that their effects
• Hemolytic anemia when reviewing results.
• Pregnancy ➤ Review the procedure with the
CRITICAL VALUES: N/A 5 to 10 minutes. Address concerns
INTERFERING FACTORS: Explain to the patient that there may
• Drugs that may increase glycated be some discomfort during the
hemoglobin A1C values include hydro- venipuncture.
chlorothiazide, indapamide, insulin, ➤ There are no food, fluid, or medica-
morphine, propranolol, and sulfony- tion restrictions, unless by medical
lureas. direction.
• Drugs that may decrease glycated Intratest:

hemoglobin A1C values include carba-
mate, galactose, and metformin.
• Conditions involving abnormal hemo- be taken to avoid the use of equip-
globins (hemoglobinopathies) affect ment containing latex.
the reliability of glycated hemoglobin ➤ Instruct the patient to cooperate fully
A1C values, causing (1) falsely increased and to follow directions. Direct the
values, (2) falsely decreased values, or patient to breathe normally and to
(3) discrepancies in either direction
depending on the method. ➤ Observe standard precautions, and
Nursing Implications and tubes with the corresponding patient
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: lect the specimen in a 5-mL lavender
top tube.
➤ Inform the patient that the test is ➤ Remove the needle, and apply a
used to assess long-term glycemic pressure dressing over the puncture
control (past 3 months). site.
➤ Obtain a history of the patient’s com- ➤ Promptly transport the specimen to
plaints, including a list of known the laboratory for processing and
allergens (especially allergies or sen- analysis.
sitivities to latex), and inform the ap-
propriate health care practitioner ➤ The results are recorded manually
accordingly. or in a computerized system for re-
call and postprocedure interpretation
➤ Obtain a history of the patient’s by the appropriate health care practi-
endocrine system as well as results tioner.
tests, surgical procedures, and other Post-test:
laboratory tests, refer to the Endo- ➤ Observe venipuncture site for bleed-
crine System table. ing or hematoma formation. Apply
Gonioscopy 709
paper tape or other adhesive to hold ➤ Discuss the implications of abnormal

pressure bandage in place, or test results on the patient’s lifestyle.
replace with a plastic bandage. Provide teaching and information
➤ Nutritional considerations: Increased the test results, as appropriate.
glycated hemoglobin A1C levels may Emphasize, as appropriate, that good
be associated with diabetes. Instruct glycemic control delays the onset
the diabetic patient, as appropriate, of and slows the progression of
in nutritional management of the dis- diabetic retinopathy, nephropathy,
ease. Patients who adhere to dietary and neuropathy. Educate the patient
recommendations report a better regarding access to counseling
general feeling of health, better services. Provide contact informa-
weight management, greater control tion, if desired, for the American
of glucose and lipid values, and Diabetes Association (http://www.
improved use of insulin. There is no diabetes.org).
“diabetic diet”; however, many ➤ Reinforce information given by
meal-planning approaches with nutri- the patient’s health care provider
tional goals are endorsed by the regarding further testing, treatment,
American Dietetic Association. The or referral to another health care
nutritional needs of each diabetic provider. Answer any questions or
patient must be determined individu- address any concerns voiced by the
ally with the appropriate health care patient or family.
professionals, particularly profession-
als trained in nutrition. ➤ Depending on the results of this pro-
➤ Instruct the patient and caregiver to performed to evaluate or monitor
report signs and symptoms of hypo- progression of the disease process
glycemia (weakness, confusion, and determine the need for a change
diaphoresis, rapid pulse) or hyper- in therapy. Evaluate test results in
glycemia (thirst, polyuria, hunger, relation to the patient’s symptoms
lethargy). and other tests performed.
care practitioner, who will discuss ➤ Related laboratory tests include C-
the results with the patient. peptide, cholesterol (total and HDL),
➤ Recognize anxiety related to test fructosamine, glucose, glucose toler-
results, and be supportive of per- ance tests, insulin, insulin antibodies,
ceived loss of independence and ketones, microalbumin, and triglyc-
fear of shortened life expectancy. erides.
GONIOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
CONTRAST: N/A.
DESCRIPTION & RATIONALE: gonioscopy is performed with a

Gonioscopy is a technique that is used gonioscope containing a dome-shaped
for examination of the anterior cham- contact lens known as a gonioprism.
ber structures of the eye; the trabecu- The gonioprism eliminates internally
lar meshwork and the anatomic reflected light, allowing direct visuali-
relationship of the trabecular mesh- zation of the angle. Interpretation of
work to the iris. The trabecular mesh- visual examination is usually docu-
work is the drainage system of the eye, mented in a color hand-drawn dia-
and gonioscopy is performed to deter- gram. Scheie’s classification is used to
mine if it is suspected that the standardize definition of angles based
drainage angle may be damaged, on appearance by gonioscopy. Shaffer’s
blocked, or clogged. Gonioscopy in classification is based on the angular
combination with biomicroscopy is width of the angle recess. ■
considered to be the most thorough
basis to confirm a diagnosis of glau- INDICATIONS:
coma and to differentiate between • Assessment of peripheral anterior
synechiae (PAS)
open-angle and angle-closure glau-
coma. The angle structures of the • Conditions affecting the ciliary body
anterior chamber are normally not • Degenerative conditions of the anterior
visible because light entering the eye chamber
through the cornea is reflected back
• Evaluation of glaucoma (confirmation
into the anterior chamber. Placement
of normal structures and estimation of
of a special contact lens (goniolens) angle width)
over the cornea allows reflected light
to pass back through the cornea and • Growth or tumor in the angle
onto a reflective mirror in the contact • Hyperpigmentation
lens. It is in this way that the angle
• Post-trauma evaluation for angle
structures can be visualized. There are recession
two types of gonioscopy; indirect and
direct. The more commonly used • Suspected neovascularization of the
indirect technique employs a mirrored angle
goniolens and biomicroscope. Direct • Uveitis
RESULT
Scheie’s Classification Based on Visible Angle Structures

Classification Appearance
Wide Open All angle structures seen
Grade I Narrow Difficult to see over the iris root
Grade II Narrow Ciliary band obscured
Grade III Narrow Posterior trabeculum hazy
Grade IV Narrow Only Schwalbe’s line visible
Gonioscopy 711
Shaffer’s Classification Based on Angle Width

Classification Appearance
Wide Open (20–45) Closure improbable
Moderately Narrow (10–20) Closure possible
Extremely Narrow (less than 10) Closure possible
Partially/Totally Closed Closure present
Normal Findings: ➤ Obtain a history of the patient’s com-

• Normal appearance of anterior cham- plaints, including a list of known
ber structures and wide, unblocked, allergens.
normal angle ➤ Obtain a history of the patient’s
known or suspected vision loss,
Abnormal Findings: changes in visual acuity, including
type and cause; use of glasses or
• Corneal endothelial disorders (Fuchs contact lenses; eye conditions with
endothelial dystrophy, iridocorneal treatment regimens; eye surgery;
endothelial syndrome) and other tests and procedures to
• Glaucoma assess and diagnose visual deficit.
• Lens disorders (cataract, displaced lens) ously performed laboratory tests,
• Malignant ocular neoplasm in angle surgical procedures, and other diag-
nostic procedures. For related diag-
• Neovascularization in angle nostic tests, refer to the table of
• Ocular hemorrhage tests associated with the Ocular
System.
• PAS
• Schwartz syndrome patient is taking, including herbs,
• Trauma ceuticals. The requesting health care
• Tumors practitioner should be advised if the
• Uveitis so that their effects can be taken
CRITICAL VALUES: N/A results.
➤ Instruct the patient to remove con-
INTERFERING FACTORS: tact lenses or glasses, as appropri-
• Inability of the patient to cooperate or ate. Instruct the patient regarding
remain still during the test because of the importance of keeping the eyes
age, significant pain, or mental status open for the test.
may interfere with the test results. ➤ Review the procedure with the
patient. Explain that the patient will
Nursing Implications and ing the procedure. Address concerns
Procedure ● ● ● ● ● ● ● ● ● ● ●
Explain to the patient that no pain
Pretest: will be experienced during the test,
but there may be moments of dis-
➤ Inform the patient that the procedure comfort. Explain to the patient that
detects abnormailities in the struc- some discomfort may be experi-
tures of the anterior chamber of the enced after the test when the numb-
eye. ness wears off from anesthetic
drops adminstered prior to the test. Post-test:

Tell the patient that the test is per-
formed by a health care practitioner ➤ A written report of the examina-
or optometrist and takes about 5 tion will be completed by a health
minutes to complete. care practitioner specializing in this
➤ There are no food, fluid, or medica- branch of medicine. The report will
tion restrictions, unless by medical be sent to the requesting health care
direction. practitioner, who will discuss the
Intratest: ➤ Recognize anxiety related to test
results, and be supportive of
➤ Instruct the patient to cooperate fully impaired activity related to vision
and to follow directions. Ask the loss or perceived loss of driving
patient to remain still during the pro- privileges. Discuss the implications
cedure because movement proof abnormal test results on the
duces unreliable results. patient’s lifestyle. Provide teaching
➤ Seat the patient comfortably. Instill and information regarding the clinical
ordered topical anesthetic in each implications of the test results, as
eye, as ordered, and allow time for it appropriate.
to work. Topical anesthetic drops are ➤ Reinforce information given by
placed in the eye with the patient the patient’s health care provider
looking up and the solution directed regarding further testing, treatment,
at the six o’clock position of the or referral to another health care
sclera (white of the eye) near the lim- provider. Answer any questions or
bus (grey, semitransparent area of address any concerns voiced by the
the eyeball where the cornea and patient or family.
sclera meet). The dropper bottle
should not touch the eyelashes. ➤ Depending on the results of this pro-
➤ Ask the patient to place the chin in performed to evaluate or monitor
the chin rest and gently press the progression of the disease process
forehead against the support bar. and determine the need for a change
Ask the patient to open his or her in therapy. Evaluate test results in
eyes wide and look at desired target. relation to the patient’s symptoms
Explain that the health care practi- and other tests performed.
tioner or optometrist will place a lens
on the eye while a narrow beam of
light is focused on the eye. Related diagnostic tests:
➤ The results are recorded manually ➤ Related diagnostic tests include fun-
for recall and postprocedure interpre- dus photography, pachymetry, slit-
tation by the appropriate health care lamp biomicroscopy, and visual field
practitioner. testing.
GRAM STAIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Gram Stain 713
SPECIMEN: Blood, biopsy specimen, or body fluid as collected for culture.

REFERENCE VALUE: N/A.
DESCRIPTION & RATIONALE: Gram field, regardless of the number of

stain is a technique commonly used to polymorphonuclear white blood cells,
identify bacterial organisms based on indicates contamination of the speci-
their specific staining characteristics. men with saliva, and the specimen
The method involves smearing a small should be rejected for subsequent cul-
amount of specimen on a slide, and ture. The occasional presence of bac-
then exposing it to gentian or crystal teria in an unspun urine Gram stain
violet, iodine, alcohol, and safranin suggests a correlating colony count of
O. Gram-positive bacteria retain the 10,000 bacteria/mL. The presence of
gentian or crystal violet and iodine bacteria in most fields is clinically sig-
stain complex after a decolorization nificant and suggests greater than
step and appear purple-blue in color. 100,000 bacteria/mL of urine. ■
Gram-negative bacteria do not retain
INDICATIONS:
the stain after decolorization but can • Provide a rapid determination of the
pick up the pink color of the safranin acceptability of the specimen for fur-
O counterstain. Gram stain results ther analysis
should be correlated with culture • Provide rapid, presumptive informa-
results to interpret the significance of tion about the type of potential
isolated organisms. A sputum Gram pathogen present in the specimen (i.e.,
stain showing greater than 25 squa- gram-positive bacteria, gram-negative
mous epithelial cells per low-power bacteria, or yeast)
RESULT
Acid Fast
or Partial
Gram Positive Gram Negative Acid Fast
Actinomadura Acinetobacter Helicobacter Xanthomonas Nocardia
Actinomyces Aeromonas Klebsiella Yersinia Mycobacterium
Bacillus Alcaligenes Legionella
Clostridium Bacteroides Leptospira
Corynebacterium Bordetella Moraxella
Enterococcus Borrelia Neisseria
Erysipelothrix Brucella Pasteurella
Lactobacillus Campylobacter Plesiomonas
Listeria Citrobacter Porphyromonas
Micrococcus Chlamydia Prevotella
Mycobacterium
(gram variable) Enterobacter Proteus
Peptostreptococcus Escherichia Pseudomonas

Acid Fast
or Partial
Gram Positive Gram Negative Acid Fast
Propionibacterium Flavobacter Rickettsia
Rhodococcus Francisella Salmonella
Staphylococcus Fusobacterium Serratia
Streptococcus Gardnerella Shigella
Haemophilus Vibrio
Note: Treponema species are classified as gram-negative spirochetes, but they are most
often visualized using dark-field or silver staining techniques.
CRITICAL VALUES: ceuticals. The requesting health care

Note and immediately report to the practitioner and laboratory should be
health care practitioner any positive
results in blood, cerebrospinal fluid, or can be taken into consideration
any body cavity fluid, along with related when reviewing results.
symptoms.
patient. Inform the patient that
INTERFERING FACTORS: Very young, the time it takes to collect a proper
very old, or dead cultures may react specimen varies according to the
atypically to the Gram stain technique. patient’s level of cooperation as well
as the specimen collection site.
Nursing Implications and patient that there may be some dis-
Procedure ● ● ● ● ● ● ● ● ● ● ●
comfort during the procedure.
Pretest:
➤ Inform the patient that the test is esty, is important in providing psy-
used to assist in identifying the pres- chological support before, during,
ence of pathogenic organisms. and after the procedure.
➤ Obtain a history of the patient’s ➤ There are no food, fluid, or medi-
complaints, including a list of known cation restrictions, unless by medical
accordingly.
➤ Obtain a history of the patient’s gas- and to follow directions.
trointestinal, genitourinary, immune,
reproductive, and respiratory sys- ➤ Observe standard precautions, and
tems, as well as results of previously follow the general guidelines in
performed laboratory tests, surgical Appendix A. Positively identify the
procedures, and other diagnostic patient, and label the appropriate col-
procedures. For related laboratory lection container with the correspon-
tests, refer to the Gastrointestinal, ding patient demographics, date, and
Genitourinary, Immune, Reproduc- time of collection.
tive, and Respiratory System tables. ➤ Specific collection instructions are
➤ Obtain a list of medications the found in the associated culture
patient is taking, including herbs, monographs.
nutritional supplements, and nutra- ➤ Promptly transport the specimen to
Group A Streptococcal Screen 715
the laboratory for processing and implications of the test results, as

analysis. appropriate.
➤ The results are recorded manually ➤ Reinforce information given by the
or in a computerized system for patient’s health care provider regard-
recall and postprocedure interpreta- ing further testing, treatment, or
tion by the appropriate health care referral to another health care pro-
practitioner. vider. Answer any questions or
Post-test: patient or family.
➤ Administer antibiotics as ordered, procedure, additional testing may be
and instruct the patient in the impor- performed to evaluate or monitor
tance of completing the entire progression of the disease process
course of antibiotic therapy even if and determine the need for a change
no symptoms are present. in therapy. Evaluate test results in
results. Discuss the implications of ➤ Related laboratory tests include bac-
abnormal test results on the pa- terial and viral cultures, cerebrospinal
tient’s lifestyle. Provide teaching and fluid analysis, complete blood count,
information regarding the clinical and urinalysis.
GROUP A STREPTOCOCCAL SCREEN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Strep screen, rapid strep screen, direct strep screen.

SPECIMEN: Throat swab (two swabs should be submitted so that a culture
can be performed if the screen is negative).
REFERENCE VALUE: (Method: Enzyme immunoassay or latex agglutination)

Negative.
DESCRIPTION & RATIONALE: Rheu- duration of the infection and seque-

matic fever is a possible sequela to an lae. The onset of strep throat is sud-
untreated streptococcal infection. den and includes symptoms such as
Early diagnosis and treatment appear chills, headache, sore throat, malaise,
to lessen the seriousness of symptoms and exudative gray-white patches on
during the acute phase and overall the tonsils or pharynx. The group
A streptococcal screen should not Nursing Implications and

be ordered unless the results would be Procedure ● ● ● ● ● ● ● ● ● ● ●
available within 1 to 2 hours of speci-

men collection to make rapid, effec- Pretest:
tive therapeutic decisions. A positive ➤ Inform the patient that the test is
result can be a reliable basis for the used to detect group A streptococcal
initiation of therapy. A negative result infection.
is presumptive for infection and ➤ Obtain a history of the patient’s
should be backed up by culture re- complaints, including a list of known
sults. In general, specimens showing allergens (especially allergies or sen-
growth of less than 10 colonies on cul- appropriate health care practitioner
ture yield negative results by the rapid accordingly.
screening method. Evidence of group ➤ Obtain a history of the patient’s
A streptococci disappears rapidly after immune and respiratory systems,
the initiation of antibiotic therapy. A as well as results of previously
performed laboratory tests, surgi-
nucleic acid probe method has also
cal procedures, and other diagnostic
been developed for rapid detection of procedures. For related laboratory
group A streptococci. ■ tests, refer to the Immune and Res-
INDICATIONS: Assist in the rapid deter- ➤ Obtain a history of prior antibiotic
mination of the presence of group A therapy.
streptococci ➤ Obtain a list of medications the
Positive findings in: advised if the patient regularly uses
• Rheumatic fever these products so that their effects
• Scarlet fever when reviewing results.
➤ Before specimen collection, verify
• Strep throat with the laboratory whether wet
• Streptococcal glomerulonephritis or dry swabs are preferred for
collection.
• Tonsillitis ➤ Review the procedure with the
CRITICAL VALUES: N/A imen collection takes approximately
INTERFERING FACTORS: Explain to the patient that there may
• Polyester swabs are favored over cotton be some discomfort during the
for best chance of detection. swabbing procedure.
• Sensitivity of the method varies from ➤ There are no food, fluid, or medica-
manufacturer to manufacturer.
direction.
• Adequate specimen collection in chil-
dren may be difficult to achieve, which Intratest:
explains the higher percentage of false- ➤ Instruct the patient to cooperate fully
negative results in this age group. and to follow directions. Direct the
Growth Hormone, Stimulation and Suppression Tests 717
patient to breathe normally and to course of antibiotic therapy even if

avoid unnecessary movement. no symptoms are present.
➤ Observe standard precautions, and ➤ A written report of the examination
follow the general guidelines in will be sent to the requesting health
Appendix A. Positively identify the care practitioner, who will discuss
patient, and label the appropriate the results with the patient.
specimen container with the corre- ➤ Reinforce information given by the
sponding patient demographics, patient’s health care provider regard-
date, and time of collection. Vigorous ing further testing, treatment, or
swabbing of both tonsillar pillars and referral to another health care pro-
the posterior throat enhances the vider. Answer any questions or
probability of streptococcal antigen address any concerns voiced by the
detection. patient or family.
➤ Promptly transport the specimen to ➤ Depending on the results of this
the laboratory for processing and procedure, additional testing may
analysis. be performed to evaluate or monitor
➤ The results are recorded manually progression of the disease process
or in a computerized system for and determine the need for a change
recall and postprocedure interpreta- in therapy. Evaluate test results in
tion by the appropriate health care relation to the patient’s symptoms
practitioner. and other tests performed.

➤ Administer antibiotics as ordered, ➤ Related laboratory tests include
and emphasize to the patient the complete blood count, Gram stain,
importance of completing the entire and relevant cultures.
GROWTH HORMONE, STIMULATION

AND SUPPRESSION TESTS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Somatotropic hormone, somatotropin, GH, hGH.

Growth Hormone
SI Units
Cord blood 8–40 ng/mL 8–40 g/L
1d 5–50 ng/mL 5–50 g/L
1 wk 5–25 ng/mL 5–25 g/L
Child 2–10 ng/mL 2–10 g/L
Adult
Male 0–5 ng/mL 0–5 g/L
Female 0–10 ng/mL 0–10 g/L
Male older 0–10 ng/mL 0–10 g/L
than 60 y
Female older 0–14 ng/mL 0–14 g/L
than 60 y
Stimulation Tests
Rise above Greater than 5 ng/mL Greater than 5 g/L
baseline
Peak response Greater than 10 ng/mL Greater than 10 g/L
Suppression Tests
0–2 ng/mL 0–2 g/L
dren with decreased GH levels, indica-

DESCRIPTION & RATIONALE: Human tive of a pituitary cause
growth hormone (GH) is secreted in • Assist in establishing a diagnosis of
episodic bursts by the anterior pitu- gigantism in children with GH in-
itary gland; the highest level is usually creased levels, indicative of a pituitary
secreted during deep sleep. GH plays cause
an integral role in growth from birth • Detect suspected disorder associated
to puberty. GH promotes skeletal with decreased GH
growth by stimulating hepatic pro- • Monitor response to treatment of
duction of proteins; it also affects lipid growth retardation
and glucose metabolism. Random lev-
els are rarely useful because secretion RESULT
of GH is episodic and pulsatile. Increased in:
Stimulation tests with arginine, glu- • Acromegaly
cagon, insulin, or L-dopa, as well as • Anorexia nervosa
suppression tests with glucose, pro- • Cirrhosis
vide useful information. ■
• Diabetes (uncontrolled)
INDICATIONS: • Ectopic GH secretion (neoplasms of
• Assist in the diagnosis of acromegaly in stomach, lung)
adults • Exercise
• Assist in establishing a diagnosis of • Gigantism (pituitary)
dwarfism or growth retardation in chil- • Hyperpituitarism
Growth Hormone, Stimulation and Suppression Tests 719
• Laron dwarfism appropriate health care practitioner

accordingly.
• Malnutrition
• Renal failure endocrine system as well as results
• Stress of previously performed laboratory
Decreased in: laboratory tests, refer to the Endo-
• Adrenocortical hyperfunction crine System table.
• Dwarfism (pituitary) ➤ Record pertinent information related
to diet, sleep pattern, and activity at
• Hypopituitarism the time of the test.
CRITICAL VALUES: N/A interfere with test results.
INTERFERING FACTORS: patient is taking, including herbs,
• Drugs that may increase GH levels nutritional supplements, and nutra-
include alanine, anabolic steroids, ceuticals. The requesting health care
angiotensin II, apomorphine, arginine, practitioner and laboratory should be
clonidine, corticotropin, cyclic AMP, advised if the patient regularly uses
desipramine, dexamethasone, dopa- these products that so their effects
mine, fenfluramine, galanin, glucagon, can be taken into consideration
GH-releasing hormone, hydrazine, when reviewing results.
levodopa, methamphetamine, methyl- ➤ Review the procedure with the
dopa, metoclopramide, midazolam, patient. The patient should have bed
niacin, oral contraceptives, phenytoin, rest for 1 hour before each sample is
propranolol, and vasopressin. obtained. Inform the patient that
multiple specimens may be required.
• Drugs that may decrease GH levels Inform the patient that specimen
include corticosteroids, corticotropin, collection takes approximately 5 to
hydrocortisone, octreotide, and piren- 10 minutes. Address concerns about
zepine. pain related to the procedure.
• Recent radioactive scans or radiation be some discomfort during the
within 1 week before the test can inter- venipuncture.
➤ The patient should fast and avoid
munoassay is the test method. strenuous exercise for 12 hours
• Failure to follow dietary and activity before specimen collection.
restrictions before the procedure may ➤ There are no fluid or medication
cause the procedure to be canceled or restrictions, unless by medical direc-
repeated. tion.
Intratest:
Nursing Implications and ➤ Ensure that the patient has complied
Procedure ● ● ● ● ● ● ● ● ● ● ●
with dietary and activity restrictions;
assure that food and strenuous activ-
Pretest: ity have been restricted for at least
➤ Inform the patient that the test is 12 hours prior to the procedure.
used to assess pituitary function. ➤ If the patient has a history of severe
➤ Obtain a history of the patient’s com- allergic reaction to latex, care should
plaints, including a list of known be taken to avoid the use of equip-
allergens (especially allergies or sen- ment containing latex.
sitivities to latex), and inform the ➤ Instruct the patient to cooperate fully
and to follow directions. Direct the paper tape or other adhesive to hold
patient to breathe normally and to pressure bandage in place, or
avoid unnecessary movement. replace with a plastic bandage.
➤ Observe standard precautions, and ➤ Instruct the patient to resume usual
follow the general guidelines in diet, fluids, medications, or activ-
Appendix A. Positively identify the ity, as directed by the health care
patient, and label the appropriate practitioner.
lect the specimen in a 5-mL red- or care practitioner, who will discuss
tiger-top tube. Test samples may be the results with the patient.
requested at baseline and 10-, 20-, ➤ Reinforce information given by the
30-, 45-, and 60-minute intervals patient’s health care provider regard-
after stimulation and at baseline and ing further testing, treatment, or
30-, 60-, 90-, and 120-minute inter- referral to another health care pro-
vals after suppression. vider. Answer any questions or
➤ Remove the needle, and apply a address any concerns voiced by the
pressure dressing over the punc- patient or family.
ture site.
➤ Promptly transport the specimen to procedure, additional testing may
the laboratory for processing and be performed to evaluate or moni-
analysis. tor progression of the disease pro-
➤ The results are recorded manually cess and determine the need for a
or in a computerized system for change in therapy. Evaluate test
recall and postprocedure interpreta- results in relation to the patient’s
tion by the appropriate health care symptoms and other tests per-
practitioner. formed.

➤ Observe venipuncture site for bleed- ➤ A related laboratory test is adreno-
ing or hematoma formation. Apply corticotropic hormone.
HAM’S TEST FOR PAROXYSMAL

NOCTURNAL HEMOGLOBINURIA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Acid hemolysis test for PNH.

SPECIMEN: Whole blood (5 mL) collected in lavender-top
(EDTA) top tube and serum (3 mL) collected in red-top tube.
REFERENCE VALUE: (Method: Acidified hemolysis) No hemolysis seen.

Ham’s Test for Paroxysmal Nocturnal Hemoglobinuria 721
Decreased in: N/A

DESCRIPTION & RATIONALE: Parox-
ysmal nocturnal hemoglobinuria CRITICAL VALUES: N/A
(PNH) is a condition in which the
patient experiences nocturnal hemo- INTERFERING FACTORS:
globinuria, chronic hemolytic anemia, • False-positives may occur in the pres-
diminished or absent generation of ence of other disorders, such as aplastic
new red blood cells (RBCs), and a ten- anemia, HEMPAS, hereditary or ac-
dency to thrombose. It is caused by an quired spherocytosis, leukemia, and
acquired defect in hematopoietic stem myeloproliferative syndromes. False-
cells. In patients with PNH, erythro- positives may also occur with aged
RBCs. The sugar water test is negative
cytes have an increased sensitivity to
in HEMPAS.
complement and will lyse when mixed
with acidified serum containing com- • False-negatives can occur if the patient’s
plement. The patient’s RBCs are also serum sample contains a low level of
mixed with fresh normal serum that is complement.
ABO compatible with the patient’s
cells. Some of the control serum is
acidified, and some is heated to inacti- Nursing Implications and
vate the complement. The result is Procedure ● ● ● ● ● ● ● ● ● ● ●
positive if 10% to 50% cell lysis

occurs in the samples mixed with Pretest:
patient and control acidified serum. ➤ Inform the patient that the test is
No hemolysis should occur in the used to assist in the diagnosis of
heated control serum. The sugar water PNH.
test can also be performed to investi- ➤ Obtain a history of the patient’s
gate the presence of PNH. Platelet and complaints, including a list of known
granulocyte membranes are affected as sitivities to latex), and inform the
well, but RBC hemolysis in a positive appropriate health care practitioner
test is clear evidence of PNH. ■ accordingly.
INDICATIONS: hematopoietic system, as well as
• Evaluate hemolytic anemia, especially results of previously performed labo-
with hemosiderinuria ratory tests, surgical procedures,
• Evaluate suspected congenital dysery- related laboratory tests, refer to the
thropoietic anemia, type II (also known Hematopoietic System table.
as HEMPAS [hereditary erythroblastic
multinuclearity with positive acidified patient is taking, including herbs,
serum test]) nutritional supplements, and nutra-
• Evaluate suspected PNH ceuticals. The requesting health care
RESULT these products so that their effects
Increased in:
• Congenital dyserythropoietic anemia,
type II ➤ Review the procedure with the
• Paroxysmal nocturnal hemoglobinuria imen collection takes approximately
5 to 10 minutes. Address concerns tion by the appropriate health care

about pain related to the procedure. practitioner.
be some discomfort during the Post-test:
venipuncture.
➤ There are no food, fluid, or medica- ing or hematoma formation. Apply
tion restrictions, unless by medical paper tape or other adhesive to
direction. hold pressure bandage in place, or
ment containing latex. ➤ Reinforce information given by
➤ Observe standard precautions, and patient or family.
pendix A. Positively identify the
lect the specimen in a 5-mL lavender
and a 5-mL red-top tube.
pressure dressing over the punc- Related laboratory tests:
ture site.
➤ Promptly transport the specimen to bone marrow biopsy, complete blood
the laboratory for processing and count, direct Coombs’ test, glucose-
analysis. 6-phosphate dehydrogenase, hapto-
➤ The results are recorded manually globin, hematocrit, hemoglobin,
or in a computerized system for hemosiderin, leukocyte alkaline
recall and postprocedure interpreta- phosphatase, and osmotic fragility.
HAPTOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Hapto, HP, Hp.

Haptoglobin 723
SI Units
Newborn 5–48 mg/dL 0.05–0.48 g/L
6 mo–16 y 25–138 mg/dL 0.25–1.38 g/L
Adult 15–200 mg/dL 0.15–2.00 g/L
such as ulcerative colitis, arthritis, and

DESCRIPTION & RATIONALE: Hapto- pyelonephritis
globin is an 2-globulin produced in
• Neoplasms
the liver. It binds with the free hemo-
globin released when red blood cells • Steroid therapy
(RBCs) are lysed. If left unchecked,
Decreased in:
free hemoglobin in the plasma can
cause renal damage; haptoglobin pre- • Autoimmune hemolysis
vents it from accumulating. In condi- • Hemolysis due to drug reaction
tions such as hemolytic anemia, so • Hemolysis due to mechanical destruc-
many hemolyzed RBCs are available tion (e.g., artificial heart valves, contact
for binding that the liver cannot com- sports, subacute bacterial endocarditis)
pensate by producing additional hap- • Hemolysis due to RBC membrane or
toglobin fast enough, resulting in low metabolic defects
serum levels. ■
• Hemolysis due to transfusion reaction
INDICATIONS: • Hypersplenism
• Assist in the investigation of suspected • Ineffective hematopoiesis due to condi-
transfusion reaction tions such as folate deficiency or hemo-
• Evaluate known or suspected chronic globinopathies
liver disease, as indicated by decreased • Liver disease
levels
• Evaluate known or suspected disorders
characterized by excessive RBC hemol-
ysis, as indicated by decreased levels
• Drugs that may increase haptoglo-
• Evaluate known or suspected disorders bin levels include anabolic steroids,
involving a diffuse inflammatory pro- danazol, ethylestrenol, fluoxymes-
cess or tissue destruction, as indicated terone, methandrostenolone, norethan-
by elevated levels drolone, oxandrolone, oxymetholone,
and stanozolol.
RESULT • Drugs that may decrease haptoglobin
levels include acetanilid, aminosalicy-
Increased in: lic acid, chlorpromazine, dapsone, dex-
• Biliary obstruction tran, diphenhydramine, furadaltone,
• Disorders involving tissue destruction, furazolidone, isoniazid, nitrofurantoin,
such as cancers, burns, and acute norethindrone, oral contraceptives,
myocardial infarction quinidine, resorcinol, stibophen, tam-
oxifen, thiazolsulfone, and tripelen-
• Infection or inflammatory diseases, namine.

marily used to investigate hemolytic
states.
➤ Obtain a history of the patient’s demographics, date, and time of col-
complaints, including a list of known lection. Perform a venipuncture; col-
allergens (especially allergies or sen- lect the specimen in a 5-mL red-top
sitivities to latex), and inform the tube.
accordingly.
➤ Obtain a history of the patient’s site.
hematopoietic, hepatobiliary, and
➤ Promptly transport the specimen
immune systems, as well as results
to the laboratory for processing and
analysis.
tests, surgical procedures, and
other diagnostic procedures. For ➤ The results are recorded manually or
related laboratory tests, refer to the in a computerized system for recall
Hematopoietic, Hepatobiliary, and and postprocedure interpretation by
Immune System tables. the appropriate health care practi-
tioner.
practitioner and laboratory should be ➤ Observe venipuncture site for bleed-
these products so that their effects paper tape or other adhesive to
can be taken into consideration hold pressure bandage in place, or
when reviewing results. replace with a plastic bandage.
➤ Review the procedure with the ➤ Instruct the patient to immediately

patient. Inform the patient that spec- report symptoms of hemolysis, in-
imen collection takes approximately cluding chills, fever, flushing, back
5 to 10 minutes. Address concerns pain, and fast heartbeat, to the
about pain related to the procedure. health care practitioner.
Explain to the patient that there ➤ A written report of the examination
may be some discomfort during the will be sent to the requesting health
tion restrictions, unless by medical ➤ Reinforce information given by the
Intratest: vider. Answer any questions or
patient or family.
be taken to avoid the use of equip- ➤ Depending on the results of this
ment containing latex. procedure, additional testing may be
Helicobacter Pylori Antibody 725
performed to evaluate or monitor Related laboratory tests:

and determine the need for a change ➤ Related laboratory tests include
in therapy. Evaluate test results in bilirubin, blood group and type, direct
relation to the patient’s symptoms Coombs’ test, indirect Coombs’ test,
and other tests performed. and Ham’s test.
HELICOBACTER PYLORI ANTIBODY

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: H. pylori.
SPECIMEN: Serum (1 mL) collected in a plain red-top tube.
REFERENCE VALUE: (Method: Enzyme-linked immunosorbent assay
[ELISA]) Negative.
• Assist in establishing a diagnosis of gas-

DESCRIPTION & RATIONALE: There tritis, gastric carcinoma, or peptic or
is a strong association between duodenal ulcer
Helicobacter pylori infection and gas-
tric cancer, duodenal and gastric ulcer, RESULT
and chronic gastritis. Immunoglobu-
lin G (IgG) antibodies can be detected Positive findings in:
for up to 1 year after treatment. The • H. pylori infection
presence of H. pylori can also be • H. pylori colonization
demonstrated by a positive urea
breath test, positive stool culture, or Negative findings in: N/A
positive endoscopic biopsy. Patients
with symptoms and evidence of H.
pylori infection are considered to be
infected with the organism; patients INTERFERING FACTORS: N/A
who demonstrate evidence of H. pylori
but are without symptoms are said to
be colonized. ■ Nursing Implications and
• Assist in differentiating between H.

pylori infection and nonsteroidal anti- Pretest:
inflammatory drug use as the cause of ➤ Inform the patient that the test is
gastritis or peptic or duodenal ulcer used to assist in the diagnosis of H.
pylori infection in patients with duo- tubes with the corresponding patient
denal and gastric disease. demographics, date, and time of col-
➤ Obtain a history of the patient’s com- lection. Perform a venipuncture;
appropriate health care practitioner pressure dressing over the punc-
accordingly. ture site.
➤ Obtain a history of the patient’s gas- ➤ Promptly transport the specimen to
trointestinal and immune systems, the laboratory for processing and
as well as results of previously per- analysis.
formed laboratory tests, surgical ➤ The results are recorded manually
procedures, and other diagnostic or in a computerized system for
procedures. For related laboratory recall and postprocedure interpreta-
tests, refer to the Gastrointestinal tion by the appropriate health care
and Immune System tables. practitioner.
patient is taking, including herbs, Post-test:
ceuticals. The requesting health care ➤ Observe venipuncture site for bleed-
practitioner and laboratory should be ing or hematoma formation. Apply
advised if the patient regularly uses paper tape or other adhesive to hold
these products so that their effects pressure bandage in place, or re-
can be taken into consideration place with a plastic bandage.
when reviewing results. ➤ A written report of the examination
➤ Review the procedure with the will be sent to the requesting health
patient. Inform the patient that spec- care practitioner, who will discuss
imen collection takes approximately the results with the patient.
5 to 10 minutes. Address concerns ➤ Reinforce information given by the
about pain related to the procedure. patient’s health care provider regard-
Explain to the patient that there may ing further testing, treatment, or
be some discomfort during the referral to another health care pro-
venipuncture. vider. Inform the patient that a posi-
➤ There are no food, fluid, or medica- tive test result constitutes an
tion restrictions, unless by medical independent risk factor for gastric
direction. cancer. Answer any questions or ad-
Intratest: patient or family.
➤ If the patient has a history of severe ➤ Depending on the results of this
allergic reaction to latex, care should procedure, additional testing may be
be taken to avoid the use of equip- performed to evaluate or monitor
ment containing latex. progression of the disease process
➤ Instruct the patient to cooperate fully in therapy. Evaluate test results in
and to follow directions. Direct the relation to the patient’s symptoms
patient to breathe normally and to and other tests performed.
➤ Observe standard precautions, and Related laboratory tests:
Appendix A. Positively identify the ➤ Related laboratory tests include gas-
patient, and label the appropriate tric acid stimulation and gastrin.
Hematocrit 727
HEMATOCRIT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Packed cell volume (PCV), Hct.

SPECIMEN: Whole blood from one full lavender-top (EDTA) tube,
Microtainer, or capillary. Whole blood from a green-top (lithium or
sodium heparin) tube may also be submitted.
REFERENCE VALUE: (Method: Automated, computerized, multichannel

analyzers)
SI Unit (Volume Fraction,

Age Conventional Units (%) Conventional Units 0.01)
Cord blood 47–57 0.47–0.57
1d 51–65 0.51–0.65
2 wk 47–57 0.47–0.57
1 mo 38–52 0.38–0.52
6 mo 35–41 0.35–0.41
1y 37–41 0.37–0.41
10 y 36–42 0.36–0.42
Adult
Male 43–49 0.43–0.49
Female 38–44 0.38–0.44
DESCRIPTION & RATIONALE: Blood concentration is elevated, may in-

consists of a fluid portion (plasma) crease the Hct level.
and a solid portion that includes red Hct level is included in the com-
blood cells (RBCs), white blood cells, plete blood count (CBC) and is
and platelets. The hematocrit, or generally tested together with hemo-
packed cell volume, is the percentage globin (Hgb). These levels parallel
of RBCs in a volume of whole blood. each other and are the best determi-
For example, a hematocrit (Hct) of nant of the degree of anemia or poly-
45% means that a 100-mL sample of cythemia. Polycythemia is a term used
blood contains 45 mL of packed in conjunction with conditions result-
RBCs. Although the Hct depends pri- ing from an abnormal increase in
marily on the number of RBCs, the Hgb, Hct, and RBC count. Anemia is
average size of the RBCs plays a role. a term associated with conditions
Conditions that cause the RBCs to resulting from an abnormal decrease
swell, such as when the serum sodium in Hgb, Hct, and RBC count. Results
of the Hgb, Hct, and RBC count • Monitor response to drugs or chemo-
therapy, and evaluate undesired reac-
should be evaluated simultaneously
tions to drugs that may cause blood
because the same underlying condi- dyscrasias
tions affect this triad of tests similarly.
The RBC count multiplied by 3 • Provide screening as part of a CBC
should approximate the Hgb concen- count in a general physical examina-
tration. The Hct should be within tion, especially upon admission to a
health care facility or before surgery
three times the Hgb if the RBC pop-
ulation is normal in size and shape. RESULT
The Hct plus 6 should approximate
the first two figures of the RBC count Increased in:
within 3 (e.g., Hct is 40%; there- • Burns
fore 40 6 46, and the RBC count
should be 4.3 to 4.9). There are some
cultural variations in Hgb and Hct • COPD
(H&H) values. After the first decade • Dehydration
of life, the mean Hgb in African
Americans is 0.5 to 1.0 g lower than • Erythrocytosis
in whites. Mexican Americans and • Hemoconcentration
Asian Americans have higher H&H • High altitudes
values than whites. ■
• Polycythemia
INDICATIONS: • Shock
• Detect hematologic disorder, neo-
plasm, or immunologic abnormality Decreased in:
• Anemia
• Determine the presence of hereditary
hematologic abnormality • Blood loss (acute and chronic)
• Evaluate known or suspected anemia • Bone marrow hyperplasia
and related treatment, in combination • Chronic disease
with Hgb
• Hemolytic disorders
• Monitor blood loss and response to
blood replacement, in combination • Hemorrhage (acute and chronic)
with Hgb • Fluid retention
• Monitor the effects of physical or emo- • Nutritional deficit
tional stress on the patient
• Pregnancy
• Monitor fluid imbalances or their
treatment • Splenomegaly
• Monitor hematologic status during CRITICAL VALUES:
pregnancy, in combination with Hgb Less than 18%
• Monitor the progression of nonhema- Greater than 54%
tologic disorders such as chronic Note and immediately report to the
obstructive pulmonary disease, malab- health care practitioner any critically
sorption syndromes, cancer, and renal increased or decreased values and related
disease symptoms.
Hematocrit 729
• Low Hct leads to anemia. Anemia can decreased pulse pressure and volume,
be caused by blood loss, decreased loss of skin turgor, dry mucous mem-
blood cell production, increased blood branes, headaches, hepatomegaly, low
cell destruction, and hemodilution. central venous pressure, orthostatic
Causes of blood loss include menstrual hypotension, pruritis (especially after a
excess or frequency, gastrointestinal hot bath), splenomegaly, tachycardia,
bleeding, inflammatory bowel disease, thirst, tinnitus, vertigo, and weakness.
and hematuria. Decreased blood cell Treatment of polycythemia depends on
production can be caused by folic acid the cause. Possible interventions for
deficiency, vitamin B12 deficiency, hemoconcentration due to dehydration
iron deficiency, and chronic disease. include intravenous fluids and discon-
Increased blood cell destruction can be tinuance of diuretics if they are believed
caused by a hemolytic reaction, chemi- to be contributing to critically elevated
cal reaction, medication reaction, and Hct. Polycythemia due to decreased
sickle cell disease. Hemodilution can be oxygen states can be treated by removal
caused by congestive heart failure, renal of the offending substance, such as
failure, polydipsia, and overhydra- smoke or carbon monoxide. Treatment
tion. Symptoms of anemia (due to includes oxygen therapy in cases of
these causes) include anxiety, dyspnea, smoke inhalation, carbon monoxide
edema, hypertension, hypotension, poisioning, and desaturating chronic
hypoxia, jugular venous distention, lung disease. Symptoms of poly-
fatigue, pallor, rales, restlessness, and cythemic overload crisis include signs
weakness. Treatment of anemia depends of thrombosis, pain and redness in the
on the cause. extremities, facial flushing, and irri-
tability. Possible interventions for
• High Hct leads to polycythemia.
hemoconcentration due to poly-
Polycythemia can be caused by dehy-
cythemia include therapeutic phle-
dration, decreased oxygen levels in the
botomy and intravenous fluids.
body, and an overproduction of RBCs
by the bone marrow. Dehydration
from diuretic use, vomiting, diarrhea,
excessive sweating, severe burns, or • Drugs and substances that may cause a
decreased fluid intake decreases the decrease in Hct include those that
plasma component of whole blood, induce hemolysis due to drug sensitiv-
thereby increasing the ratio of RBCs to ity or enzyme deficiency, such as
plasma, and leads to a higher than nor- acetaminophen, aminopyrine, aminos-
mal Hct. Causes of decreased oxygen alicylic acid, amphetamine, anticonvul-
include smoking, exposure to carbon sants, antimalarials, antipyretics,
monoxide, high altitude, and chronic antipyrine, arsenicals, benzene, busul-
lung disease, which leads to a mild fan, carbenicillin, cephalothin,
hemoconcentration of blood in the chemotherapy drugs, chlorate, chloro-
body to carry more oxygen to the quine, chlorothiazide, chlorpromazine,
body’s tissues. An overproduction of colchicine, corticosteroids, dapsone,
RBCs by the bone marrow leads to dimercaprol, diphenhydramine, dipy-
polycythemia vera, which is a rare rone, glucosulfone, glycerin, gold,
chronic myeloproliferative disorder hydroflumethiazide, indomethacin,
that leads to a severe hemocon- mephytoin, methyldopa, nalidixic
centration of blood. Severe hemocon- acid, neomycin, niridazole, nitroben-
centration can lead to thrombosis zene, nitrofurantoin, novobiocin, peni-
(spontaneous blood clotting). Symp- cillin, phenacemide, phenazopyridine,
toms of hemoconcentration include phenothiazines, and pipobroman
(intended effect for polycythemia); Hct levels because of swelling of the

and those that result in anemia, such erythrocytes.
as miconazole, penicillamine, phenyl-
hydrazine, primaquine, probenecid,
pyrazolones, pyrimethamine, quinines, Nursing Implications and
streptomycin, sulfamethizole, sulfame- Procedure ● ● ● ● ● ● ● ● ● ● ●
thoxypyridazine, sulfisoxazole, suramin,

thioridazine, tolbutamide, trimetha- Pretest:
dione, and tripelennamine.
➤ Inform the patient that the test
• Some drugs may also affect Hct values is used to evaluate anemia, poly-
by increasing or decreasing the RBC cythemia, and hydration status and
count (see monograph titled “Red to monitor therapy.
Blood Cell Count”). ➤ Obtain a history of the patient’s com-
• The results of RBC counts may vary
depending on the patient’s position: sitivities to latex), and inform the
Hct can decrease when the patient is appropriate health care practitioner
recumbent as a result of hemodilution accordingly.
and can increase when the patient rises ➤ Obtain a history of the patient’s car-
as a result of hemoconcentration. diovascular, gastrointestinal, hema-
• Leaving the tourniquet in place for topoietic, hepatobiliary, immune,
longer than 60 seconds can falsely musculoskeletal, and respiratory sys-
increase Hct levels by 2% to 5%. performed laboratory tests, surgical
• Traumatic venipuncture and hemoly- procedures, and other diagnostic
sis may result in falsely decreased Hct procedures. For related labora-
values. tory tests, refer to the Cardiovascu-
lar, Gastrointestinal, Hematopoietic,
• Failure to fill the tube sufficiently (i.e., Hepatobiliary, Immune, Muscu-
tube less than three-quarters full) may loskeletal, and Respiratory System
yield inadequate sample volume for tables.
automated analyzers and may be a rea- ➤ Note any recent procedures that can
son for specimen rejection. interfere with test results.
• Clotted or hemolized specimens must ➤ Obtain a list of the medications

the patient is taking, including herbs,
be rejected for analysis. nutritional supplements, and nutra-
• Care should be taken in evaluating the ceuticals. The requesting health care
Hct during the first few hours after practitioner and laboratory should be
transfusion or acute blood loss because advised if the patient regularly uses
these products so their that effects
the value may appear to be normal can be taken into consideration
and may not be a reliable indicator of when reviewing results.
anemia.
• Abnormalities in the RBC size (macro- patient. Inform the patient that spec-
cytes, microcytes) or shape (sphero- imen collection takes approximately
cytes, sickle cells) may alter Hct values, 5 to 10 minutes. Address concerns
as in diseases and conditions including about pain related to the procedure.
sickle cell anemia, hereditary spherocy-
tosis, and iron deficiency. venipuncture.
• Elevated blood glucose or serum ➤ Sensitivity to social and cultural
sodium levels may produce elevated issues, as well as concern for mod-
Hematocrit 731
esty, is important in providing psy- ➤ The results are recorded manually

chological support before, during, or in a computerized system for
and after the procedure. recall and postprocedure interpreta-
➤ There are no food, fluid, or medication by the appropriate health care
tion restrictions, unless by medical practitioner.
direction.
Post-test:
Intratest:
allergic reaction to latex, care should paper tape or other adhesive to
be taken to avoid the use of equip- hold pressure bandage in place, or
ment containing latex. replace with a plastic bandage.
➤ Instruct the patient to cooperate ➤ Nutritional considerations: Nutritional
fully and to follow directions. Direct therapy may be indicated for patients
the patient to breathe normally with decreased Hct. Iron deficiency
and to avoid unnecessary move- is the most common nutrient defi-
ment. ciency in the United States. Patients
at risk (e.g., children, pregnant wom-
➤ Observe standard precautions, and en and women of childbearing age,
follow the general guidelines in low-income populations) should be
Appendix A. Positively identify the instructed to include foods that are
patient, and label the appropriate high in iron in their diet, such as
tubes with the corresponding patient meats (especially liver), eggs, grains,
demographics, date, and time of green leafy vegetables, and multivit-
collection. Perform a venipunc- amins with iron. Iron absorption is
ture; collect the specimen in a 5-mL affected by numerous factors (see
lavender-top (EDTA) tube. An EDTA monograph titled “Iron”).
Microtainer sample may be obtained
from infants, children, and adults for ➤ A written report of the examination
whom venipuncture may not be fea- will be sent to the requesting health
sible. The specimen should be mixed care practitioner, who will discuss
gently by inverting the tube 10 times. the results with the patient.
The specimen should be analyzed ➤ Reinforce information given by the
within 6 hours when stored at room patient’s health care provider regard-
temperature or within 24 hours if ing further testing, treatment, or re-
stored at refrigerated temperature. If ferral to another health care provider.
it is anticipated the specimen will not Answer any questions or address
be analyzed within 4 to 6 hours, two any concerns voiced by the patient
blood smears should be made or family.
immediately after the venipuncture
and submitted with the blood sam- ➤ Depending on the results of this pro-
ple. Smears made from specimens cedure, additional testing may be
older than 6 hours will contain an performed to evaluate or monitor
unacceptable number of mislead- progression of the disease process
ing artifactual abnormalities of the and determine the need for a change
RBCs, such as echinocytes and in therapy. Evaluate test results in
spherocytes, as well as necrobiotic relation to the patient’s symptoms
white blood cells. and other tests performed.
pressure dressing over the punc- Related laboratory tests:
ture site. ➤ Related laboratory tests include CBC,
➤ Promptly transport the specimen to erythropoietin, ferritin, iron/total iron-
the laboratory for processing and binding capacity, peripheral blood
analysis. smear, and reticulocyte count.
HEMOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Hgb.
SPECIMEN: Whole blood from one full lavender-top (EDTA) tube,
Microtainer, or capillary. Whole blood from a green-top (lithium or
sodium heparin) tube may also be submitted.
SI Units
Cord blood 13.5–20.5 g/dL 135–205 mmol/L
2 wk 13.4–19.8 g/dL 134–198 mmol/L
1 mo 10.7–17.1 g/dL 107–171 mmol/L
6 mo 11.1–14.4 g/dL 111–144 mmol/L
1y 11.3–14.1 g/dL 113–141 mmol/L
9–14 y 12.0–14.4 g/dL 120–144 mmol/L
Adult
Male 13.2–17.3 g/dL 132–173 mmol/L
Female 11.7–15.5 g/dL 117–155 mmol/L
Older adult
(65–74 y)
Male 12.6–17.4 g/dL 126–174 mmol/L
Female 11.7–16.1 g/dL 117–161 mmol/L
DESCRIPTION & RATIONALE: Hemo- high affinity for O2. The affinity of
globin (Hgb) is the main intracellular Hgb molecules for O2 is influenced by
protein of erythrocytes. It carries oxy- 2,3-diphosphoglycerate (2,3-DPG), a
gen (O2) to and removes carbon diox- substance produced by anaerobic gly-
ide (CO2) from red blood cells colysis to generate energy for the
(RBCs). It also serves as a buffer to RBCs. When Hgb binds with 2,3-
maintain acid-base balance in the DPG, O2 affinity decreases. The abil-
extracellular fluid. Each Hgb mole- ity of Hgb to bind and release O2 can
cule consists of heme and globulin. be graphically represented by an oxy-
Copper is a cofactor necessary for the hemoglobin dissociation curve. The
enzymatic incorporation of iron mol- term shift to the left is used to describe
ecules into heme. Heme contains iron an increase in the affinity of Hgb for
and porphyrin molecules that have a O2. Conditions that can cause this
Hemoglobin 733
leftward shift include decreased body tions affect this triad of tests similarly.
temperature, decreased 2,3-DPG, The RBC count multiplied by 3
decreased CO2 concentration, and should approximate the Hgb concen-
increased pH. Conversely, a shift to the tration. The Hct should be within
right represents a decrease in the affin- three times the Hgb if the RBC pop-
ity of Hgb for O2. Conditions that ulation is normal in size and shape.
can cause a rightward shift include The Hct plus 6 should approximate
increased body temperature, increased the first two figures of the RBC count
2,3-DPG levels, increased CO2 con- within 3 (e.g., Hct is 40%; therefore
centration, and decreased pH. 40 6 46, and the RBC count
Hgb levels are a direct reflection of should be 4.6 or in the range of 4.3 to
the O2-combining capacity of the 4.9). There are some cultural varia-
blood. It is the combination of heme tions in Hgb and Hct (H&H) values.
and O2 that gives blood its characteris- After the first decade of life, the mean
tic red color. RBC counts parallel the Hgb in African Americans is 0.5 to
O2-combining capacity of Hgb, but 1.0 g lower than in whites. Mexican
because some RBCs contain more Hgb Americans and Asian Americans have
than other cells, the relationship is not higher Hgb and H&H values than
directly proportional. As CO2 diffuses whites. ■
into RBCs, an enzyme called carbonic
anhydrase converts the CO2 into INDICATIONS:
bicarbonate and hydrogen ions. Hgb • Detect hematologic disorder, neo-
that is not bound to O2 combines with plasm, or immunologic abnormality
the free hydrogen ions, increasing pH. • Determine the presence of hereditary
As this binding is occurring, bicarbon- hematologic abnormality
ate is leaving the RBC in exchange for
• Evaluate known or suspected anemia
chloride ions. (For additional informa- and related treatment, in combination
tion about the relationship between with Hct
the respiratory and renal components
of this buffer system, see monograph • Monitor blood loss and response to
titled “Blood Gases.”) blood replacement, in combination
with Hct
Hgb is included in the complete
blood count (CBC) and generally per- • Monitor the effects of physical or emo-
formed with a hematocrit (Hct). tional stress on the patient
These levels parallel each other and • Monitor fluid imbalances or their
are frequently used to evaluate ane- treatment
mia. Polycythemia is a term used in
conjunction with conditions resulting • Monitor hematologic status during
from an abnormal increase in Hgb, pregnancy, in combination with Hct
Hct, and RBC count. Anemia is a • Monitor the progression of nonhemato-
term associated with conditions logic disorders, such as chronic obstruc-
resulting from an abnormal decrease tive pulmonary disease (COPD),
in Hgb, Hct, and RBC count. Results malabsorption syndromes, cancer, and
of the Hgb, Hct, and RBC count renal disease
should be evaluated simultaneously • Monitor response to drugs or
because the same underlying condi- chemotherapy, and evaluate undesired
reactions to drugs that may cause blood increased or decreased values and related
dyscrasias symptoms.
• Provide screening as part of a CBC in a • Low Hgb leads to anemia. Anemia can
general physical examination, especially be caused by blood loss, decreased
upon admission to a health care facility blood cell production, increased blood
or before surgery cell destruction, and hemodilution.
Causes of blood loss include menstrual
RESULT excess or frequency, gastrointestinal
bleeding, inflammatory bowel disease,
Increased in: and hematuria. Decreased blood cell
• Burns production can be caused by folic acid
deficiency, vitamin B12 deficiency, iron
• Congestive heart failure deficiency, and chronic disease.
• COPD Increased blood cell destruction can be
caused by a hemolytic reaction, chemi-
• Dehydration cal reaction, medication reaction, and
• Erythrocytosis sickle cell disease. Hemodilution can be
caused by congestive heart failure, renal
• Hemoconcentration failure, polydipsia, and overhydration.
• High altitudes Symptoms of anemia (due to these
causes) include anxiety, dyspnea,
• Polycythemia vera edema, hypertension, hypotension,
hypoxia, jugular venous distention,
Decreased in: fatigue, pallor, rales, restlessness, and
• Anemias weakness. Treatment of anemia
• Carcinoma depends on the cause.
• Fluid retention • High Hgb leads to polycythemia.
Polycythemia can be caused by dehydra-
• Hemoglobinopathies tion, decreased oxygen levels in the
• Hemolytic disorders body, and an overproduction of RBCs
by the bone marrow. Dehydration from
• Hemorrhage (acute and chronic) diuretic use, vomiting, diarrhea, exces-
• Hodgkin’s disease sive sweating, severe burns, or decreased
fluid intake decreases the plasma com-
• Incompatible blood transfusion ponent of whole blood, thereby increas-
• Intravenous overload ing the ratio of RBCs to plasma and
leads to a higher than normal Hgb.
• Leukemia Causes of decreased oxygen include
• Lymphomas smoking, exposure to carbon monox-
ide, high altitude, and chronic lung
• Nutritional deficit disease, which leads to a mild hemocon-
• Pregnancy centration of blood in the body to carry
more oxygen to the body’s tissues. An
• Splenomegaly overproduction of RBCs by the bone
marrow leads to polycythemia vera,
CRITICAL VALUES: which is a rare chronic myeloprolifera-
Less than 6.0 g/dL tive disorder that leads to a severe
Greater than 18.0 g/dL hemoconcentration of blood. Severe
Note and immediately report to the hemoconcentration can lead to throm-
health care practitioner any critically bosis (spontaneous blood clotting).
Hemoglobin 735
Symptoms of hemoconcentration anemia, such as miconazole, penicil-

include decreased pulse pressure and lamine, phenylhydrazine, primaquine,
volume, loss of skin turgor, dry mucous probenecid, pyrazolones, pyrimetha-
membranes, headaches, hepatomegaly, mine, quinines, streptomycin, sul-
low central venous pressure, orthostatic famethizole, sulfamethoxypyridazine,
hypotension, pruritis (especially after a sulfisoxazole, suramin, thioridazine,
hot bath), splenomegaly, tachycardia, tolbutamide, trimethadione, and tripe-
thirst, tinnitus, vertigo, and weakness. lennamine.
Treatment of polycythemia depends on
• Some drugs may also affect Hgb values
the cause. Possible interventions for
by increasing or decreasing the RBC
hemoconcentration due to dehydration
count (see monograph titled “Red
include intravenous fluids and discon-
Blood Cell Count”).
tinuance of diuretics if they are believed
to be contributing to critically elevated • The results of RBC counts may vary
Hgb. Polycythemia due to decreased depending on the patient’s position:
oxygen states can be treated by removal Hgb can decrease when the patient is
of the offending substance, such as recumbent as a result of hemodilution
smoke or carbon monoxide. Treatment and can increase when the patient rises
includes oxygen therapy in cases of as a result of hemoconcentration.
smoke inhalation, carbon monoxide
poisioning, and desaturating chronic • Use of the neutraceutical liver extract
lung disease. Symptoms of poly- is strongly contraindicated in iron-
cythemic overload crisis include signs of storage disorders, such as hemochro-
thrombosis, pain and redness in extrem- matosis, because it is rich in heme (the
ities, facial flushing, and irritability. iron-containing pigment in Hgb).
Possible interventions for hemoconcen- • A severe copper deficiency may result
tration due to polycythemia include in decreased Hgb levels.
therapeutic phlebotomy and intra-
venous fluids. • Cold agglutinins may falsely increase
the mean corpuscular Hgb concentra-
INTERFERING FACTORS: tion (MCHC) and decrease the RBC
• Drugs and substances that may cause count, affecting Hgb values. This can
a decrease in Hgb levels include those be corrected by warming the blood or
that induce hemolysis due to drug sen- replacing the plasma with warmed
sitivity or enzyme deficiency, such as saline and repeating the analysis.
acetaminophen, aminopyrine, aminos- • Leaving the tourniquet in place for
alicylic acid, amphetamine, anticonvul- longer than 60 seconds can falsely
sants, antimalarials, antipyretics, increase Hgb levels by 2% to 5%.
antipyrine, arsenicals, benzene, busul-
fan, carbenicillin, cephalothin, chemo- • Failure to fill the tube sufficiently (i.e.,
therapy drugs, chlorate, chloroquine, tube less than three-quarters full) may
chlorothiazide, chlorpromazine, colchi- yield inadequate sample volume for
cine, corticosteroids, dapsone, dimer- automated analyzers and may be a rea-
caprol, diphenhydramine, dipyrone, son for specimen rejection.
glucosulfone, glycerin, gold, hydro- • Clotted or hemolized specimens must
flumethiazide, indomethacin, mephey- be rejected for analysis.
toin, methyldopa, nalidixic acid,
neomycin, niridazole, nitrobenzene, • Care should be taken in evaluating the
nitrofurantoin, novobiocin, penicillin, Hgb during the first few hours after
phenacemide, phenazopyridine, and transfusion or acute blood loss because
phenothiazines; and those that result in the value may appear to be normal.
• Abnormalities in the RBC size (macro- advised if the patient regularly uses
cytes, microcytes) or shape (sphero- these products so that their effects
cytes, sickle cells) may alter Hgb values, can be taken into consideration
as in diseases and conditions including when reviewing results.
sickle cell anemia, hereditary spherocy- ➤ Review the procedure with the
tosis, and iron deficiency. patient. Inform the patient that spec-
• Lipemia will falsely increase the Hgb 5 to 10 minutes. Address concerns
measurement, also affecting the mean about pain related to the procedure.
corpuscular volume (MCV) and Explain to the patient that there may
MCHC. This can be corrected by be some discomfort during the
venipuncture.
replacing the plasma with saline,
repeating the measurement, and manu- ➤ Sensitivity to social and cultural
ally correcting the Hgb, MCH, and issues, as well as concern for mod-
MCHC using specific mathematical esty, is important in providing psy-
formulas. and after the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest:
➤ Inform the patient that the test is allergic reaction to latex, care should
used to evaluate anemia, poly- be taken to avoid the use of equip-
cythemia, and hydration status and ment containing latex.
to monitor therapy. ➤ Instruct the patient to cooperate fully
➤ Obtain a history of the patient’s com- and to follow directions. Direct the
plaints, including a list of known patient to breathe normally and to
allergens (especially allergies or sen- avoid unnecessary movement.
sitivities to latex), and inform the ➤ Observe standard precautions, and
➤ Obtain a history of the patient’s car- patient, and label the appropriate
diovascular, gastrointestinal, hema- tubes with the corresponding patient
topoietic, hepatobiliary, immune, demographics, date, and time of col-
musculoskeletal, and respiratory lection. Perform a venipuncture; col-
systems, as well as results of previ- lect the specimen in a 5-mL
ously performed laboratory tests, lavender-top (EDTA) tube. An EDTA
surgical procedures, and other diag- Microtainer sample may be obtained
nostic procedures. For related from infants, children, and adults for
laboratory tests, refer to the Cardio- whom venipuncture may not be fea-
vascular, Gastrointestinal, Hema- sible. The specimen should be mixed
topoietic, Hepatobiliary, Immune, gently by inverting the tube 10 times.
Musculoskeletal, and Respiratory The specimen should be analyzed
System tables. within 6 hours when stored at room
temperature or within 24 hours if
stored at refrigerated temperature. If
it is anticipated the specimen will not
➤ Obtain a list of the medications the be analyzed within 4 to 6 hours, two
patient is taking, including herbs, blood smears should be made
nutritional supplements, and nutra- immediately after the venipuncture
ceuticals. The requesting health care and submitted with the blood sam-
practitioner and laboratory should be ple. Smears made from specimens
Hemoglobin Electrophoresis 737
older than 6 hours will contain an be instructed to include foods that are
unacceptable number of misleading high in iron in their diet, such as
artifactual abnormalities of the meats (especially liver), eggs, grains,
RBCs, such as echinocytes and green leafy vegetables, and multivita-
spherocytes, as well as necrobiotic mins with iron. Iron absorption is
white blood cells. affected by numerous factors (see
➤ Remove the needle, and apply a monograph titled “Iron”).
pressure dressing over the puncture ➤ A written report of the examination
site. will be sent to the requesting health
➤ Promptly transport the specimen to care practitioner, who will discuss
the laboratory for processing and the results with the patient.
analysis. ➤ Reinforce information given by the
➤ The results are recorded manually patient’s health care provider regard-
or in a computerized system for ing further testing, treatment, or
recall and postprocedure interpreta- referral to another health care
tion by the appropriate health care provider. Answer any questions or
practitioner. address any concerns voiced by the
patient or family.
➤ Observe venipuncture site for bleed- cedure, additional testing may be
ing or hematoma formation. Apply performed to evaluate or monitor
paper tape or other adhesive to hold progression of the disease process
pressure bandage in place, or and determine the need for a change
replace with a plastic bandage. in therapy. Evaluate test results in
➤ Nutritional considerations: Nutritional and other tests performed.
therapy may be indicated for patients
with decreased Hgb. Iron deficiency Related laboratory tests:
is the most common nutrient defi-
ciency in the United States. Patients ➤ Related laboratory tests include CBC,
at risk (e.g., children, pregnant erythropoietin, ferritin, iron/total iron-
women and women of childbearing binding capacity, peripheral blood
age, low-income populations) should smear, and reticulocyte count.
HEMOGLOBIN ELECTROPHORESIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Whole blood (1 mL) collected in a lavender-top (EDTA) tube.
REFERENCE VALUE: (Method: Electrophoresis)
Hgb A
Adult Greater than 95%
Hgb A2
Adult 1.5–3.7%
Hgb F
Newborns and infants
1 d–3 wk 70–77%
6–9 wk 42–64%
3–4 mo 7–39%
6 mo 3–7%
8–11 mo 0.6–2.6%
Adult Less than 2%
Megaloblastic anemia
DESCRIPTION & RATIONALE: Hemo- Thalassemias
globin (Hgb) electrophoresis is a sepa-
• Hgb F:
ration process used to identify normal
Acquired aplastic anemia
and abnormal forms of Hgb. Hgb A is
Hereditary persistence of fetal Hgb
the main form of Hgb in the normal
Hyperthyroidism
adult. Hgb F is the main form of Hgb
in the fetus, the remainder being com- Leakage of fetal blood into
maternal circulation
posed of Hgb A1 and A2. Small
Leukemia (acute or chronic)
amounts of Hgb F are normal in the
Myeloproliferative disorders
adult. Hgb D, E, H, S, and C result
from abnormal amino acid substitu- Sickle cell disease
tions during the formation of Hgb and Thalassemias
are inherited hemoglobinopathies. ■ • -Chain substitutions:
Hgb C (second most common
INDICATIONS: variant in the United States, it
• Assist in the diagnosis of Hgb C disease has a higher prevalence among
• Assist in the diagnosis of thalassemia, African Americans):
especially in patients with a family his- • Hgb C disease
tory positive for the disorder Hgb D (rare hemoglobinopathy that
• Differentiate among thalassemia types may also be found in
combination with Hgb S or
• Evaluate hemolytic anemia of un- thalassemia):
known cause
• Splenomegaly without other significant
• Evaluate a positive sickle cell screening
clinical implications
test to differentiate sickle cell trait from
sickle cell disease Hgb E (second most common
hemoglobinopathy in the world,
occurs with the highest
RESULT frequency in Southeast Asians
Increased: and African-Americans):
• Hgb A2: • Thalassemia-like condition
Hemoglobin Electrophoresis 739
Hgb S (most common variant in the sitivities to latex), and inform the
United States, occurs with a appropriate health care practitioner
frequency of about 8% among accordingly.
African Americans): ➤ Obtain a history of the patient’s
• Sickle cell trait or disease
• -Chain substitutions: ratory tests, surgical procedures,
Hgb H:
• -Thalassemias Hematopoietic System table.
Bart’s Hgb: ➤ Note any recent procedures that can
• -Thalassemias
• Hgb Bart’s hydrops fetalis syndrome patient is taking, including herbs,
Decreased: ceuticals. The requesting health care
• Hgb A2: advised if the patient is regularly
Erythroleukemia: using these products so that their
• Hgb H disease
• Iron-deficiency anemia (untreated) ➤ Review the procedure with the
• Sideroblastic anemia patient. Inform the patient that spec-
CRITICAL VALUES: N/A about pain related to the procedure.
INTERFERING FACTORS: be some discomfort during the
• High altitude and dehydration may venipuncture.
increase values. ➤ Sensitivity to social and cultural
• Iron deficiency may decrease Hgb A2,
C, and S. chological support before, during,
• In patients less than 3 months of age, and after the procedure.
false-negative results for Hgb S occur in ➤ There are no food, fluid, or medica-
coincidental polycythemia. tion restrictions, unless by medical
direction.
• Red blood cell transfusion within 4
months of test can mask abnormal Hgb
levels. Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: and to follow directions. Direct the
used to identify hemoglobin variants ➤ Observe standard precautions, and
and diagnose thalassemias. follow the general guidelines in
➤ Obtain a history of the patient’s com- Appendix A. Positively identify the
plaints, including a list of known patient, and label the appropriate
allergens (especially allergies or sen- tubes with the corresponding patient
demographics, date, and time of care practitioner, who will discuss

collection. Perform a venipunc- the results with the patient.
ture; collect the specimen in a 5-mL ➤ Reinforce information given by the
lavender-top tube. patient’s health care provider regard-
➤ Remove the needle, and apply a pres- ing further testing, treatment, or
sure dressing over the puncture site. referral to another health care
➤ Promptly transport the specimen to provider. Answer any questions or
the laboratory for processing and address any concerns voiced by the
analysis. patient or family.
➤ The results are recorded manually ➤ Depending on the results of this
or in a computerized system for procedure, additional testing may be
recall and postprocedure interpreta- performed to evaluate or monitor
Post-test: and other tests performed.
ing or hematoma formation. Apply Related laboratory tests:
paper tape or other adhesive to hold ➤ Related laboratory tests include
pressure bandage in place, or blood gases, complete blood count
replace with a plastic bandage. (including evaluation of blood smear
➤ A written report of the examination for RBC morphology), methemoglo-
will be sent to the requesting health bin, and sickle cell screen.
HEMOSIDERIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Hemosiderin stain, Pappenheimer body stain, iron

stain.
SPECIMEN: Urine (5 mL) from a random first morning sample, collected in

a clean plastic collection container.
REFERENCE VALUE: (Method: Microscopic examination of Prussian

blue–stained specimen) None seen.
DESCRIPTION & RATIONALE: Hemo- examination of urine sediment.

siderin stain is used to indicate the Granules of hemosiderin stain blue
presence of iron storage granules when potassium ferrocyanide is added
called hemosiderin by microscopic to the sample. Hemosiderin is nor-
Hemosiderin 741
mally found in the liver, spleen, and Nursing Implications and

bone marrow, but not in the urine. Procedure ● ● ● ● ● ● ● ● ● ● ●
Under normal conditions, hemo-

siderin is absorbed by the renal Pretest:
tubules; however, in extensive hemol- ➤ Inform the patient that the test is
ysis, renal tubule damage, or an iron used to indicate recent intravascular
metabolism disorder, hemosiderin fil- hemolysis and to assist in the diag-
ters its way into the urine. The Prus- nosis of unexplained anemia.
sian blue stain may also be used to ➤ Obtain a history of the patient’s com-
identify siderocytes (iron-containing plaints, including a list of known
allergens, and inform the appropriate
red blood cells [RBCs]) in peripheral health care practitioner accordingly.
blood. The presence of siderocytes in
circulating RBCs is abnormal. ■ hematopoietic and genitourinary sys-
tems, especially a history of hemo-
INDICATIONS: lytic anemia, as well as results of
• Assist in the diagnosis of hemochro- previously performed laboratory
matosis (tissue damage caused by iron tests, surgical procedures, and
toxicity) other diagnostic procedures. For
• Detect excessive RBC hemolysis within Hematopoietic and Genitourinary
the systemic circulation System tables.
• Evaluate renal tubule dysfunction patient is taking, including herbs,
Increased in: advised if the patient regularly uses
• Burns these products so that their effects
• Cold hemagglutinin disease when reviewing results.
• Hemochromatosis ➤ Review the procedure with the
• Hemolytic transfusion reactions imen collection takes approximately
• Mechanical trauma to RBCs about pain related to the procedure.
• Megaloblastic anemia Explain to the patient that there
should be no discomfort during the
• Microangiopathic hemolytic anemia procedure.
• Paroxysmal nocturnal hemoglobinuria ➤ Sensitivity to social and cultural
• Pernicious anemia esty, is important in providing psy-
• Sickle cell anemia and after the procedure.
• Thalassemia major ➤ There are no food, fluid, or medica-
Decreased in: N/A direction.
CRITICAL VALUES: N/A Intratest:

INTERFERING FACTORS: N/A allergic reaction to latex, care should
be taken to avoid the use of equip- ➤ The results are recorded manually
ment containing latex. or in a computerized system for
➤ Instruct the patient to cooperate fully recall and postprocedure interpreta-
and to follow directions. tion by the appropriate health care
practitioner.
Appendix A. Positively identify the Post-test:
time of collection.
Clean-catch specimen: ➤ Recognize anxiety related to test
➤ Instruct the male patient to (1) thor- results. Discuss the implications of
oughly wash his hands, (2) cleanse abnormal test results on the
the meatus, (3) void a small amount patient’s lifestyle. Provide teaching
into the toilet, and (4) void directly and information regarding the clinical
into the specimen container. implications of the test results, as
➤ Instruct the female patient to (1) appropriate.
thoroughly wash her hands; (2) ➤ Reinforce information given by the
cleanse the labia from front to back; patient’s health care provider regard-
(3) while keeping the labia separated, ing further testing, treatment, or
void a small amount into the toilet; referral to another health care
and (4) without interrupting the urine provider. Answer any questions or
stream, void directly into the speci- address any concerns voiced by the
men container. patient or family.
Indwelling catheter: ➤ Depending on the results of this pro-

➤ Put on gloves. Empty drainage tube performed to evaluate or monitor
of urine. It may be necessary to progression of the disease process
clamp off the catheter for 15 to 30 and determine the need for a change
minutes before specimen collection. in therapy. Evaluate test results in
Cleanse specimen port with antisep- relation to the patient’s symptoms
tic swab, and then aspirate 5 mL of and other tests performed.
urine with a 21- to 25-gauge needle
and syringe. Transfer urine to a col-
lection container. Related laboratory tests:
General: bone marrow studies, complete
➤ Promptly transport the specimen to blood count, ferritin, iron/total iron-
the laboratory for processing and binding capacity, kidney biopsy, lead,
analysis. and RBC morphology.
Hepatitis A Antibody 743
HEPATITIS A ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HAV serology.

REFERENCE VALUE: (Method: Enzyme immunoassay) Negative.
residential facilities or correctional

DESCRIPTION & RATIONALE: The facilities
hepatitis A virus is classified as a picor-
• Screen individuals with suspected HAV
navirus. Its primary mode of transmis- infection
sion is by the fecal-oral route under
conditions of poor personal hygiene or
inadequate sanitation. The incubation
RESULT
period is about 28 days, with a range of Positive findings in:
15 to 50 days. Onset is usually abrupt, • Individuals with current hepatitis A
with the acute disease lasting about 1 infection
week. Therapy is supportive, and there
is no development of chronic or carrier • Individuals with past hepatitis A
infection
states. Assays for total (immunoglobu-
lin G and immunoglobulin M [IgM])
hepatitis A antibody and IgM-specific
hepatitis A antibody assist in differen- INTERFERING FACTORS: N/A
tiating recent infection from prior
exposure. If results from the IgM-
specific or from both assays are posi- Nursing Implications and
tive, recent infection is suspected. If Procedure ● ● ● ● ● ● ● ● ● ● ●
the IgM-specific test results are nega-

tive and the total antibody test results Pretest:
are positive, past infection is indicated. ➤ Inform the patient that the test is
The clinically significant assay—IgM- used to test blood for the pres-
specific antibody—is often the only ence of antibodies that would indi-
test requested. Jaundice occurs in 70% cate past or current hepatitis A
infection.
to 80% of adult cases of HAV infection
and in 70% of pediatric cases. ■ ➤ Obtain a history of the patient’s com-
INDICATIONS: sitivities to latex), and inform the
• Screen individuals at high risk of appropriate health care practitioner
exposure, such as those in long-term accordingly.
➤ Obtain a history of the patient’s the laboratory for processing and

hepatobiliary and immune systems analysis.
and results of previously performed ➤ The results are recorded manually
laboratory tests, surgical proce- or in a computerized system for
dures, and other diagnostic proce- recall and postprocedure interpreta-
dures. For related laboratory tests, tion by the appropriate health care
refer to the Hepatobiliary and practitioner.
Immune System tables.
➤ Obtain a list of the medications the Post-test:
practitioner and laboratory should be paper tape or other adhesive to
advised if the patient regularly uses hold pressure bandage in place, or
when reviewing results. ➤ Nutritional considerations: Dietary
recommendations may be indicated
➤ Review the procedure with the and will vary depending on the type
patient. Inform the patient that spec- and severity of the condition. Elimi-
imen collection takes approximately nation of alcohol ingestion and a
5 to 10 minutes. Address concerns diet optimized for convalescence are
about pain related to the procedure. commonly included in the treat-
Explain to the patient that there may ment plan.
direction.
Intratest: Recognize anxiety related to test
results, and offer support. Discuss
➤ If the patient has a history of severe the implications of abnormal test
allergic reaction to latex, care should results on the patient’s lifestyle.
be taken to avoid the use of equip- Provide teaching and information
ment containing latex. regarding the clinical implications of
Counsel the patient, as appropriate,
regarding risk of transmission and
proper prophylaxis. Immune globulin
can be given before exposure (in the
➤ Observe standard precautions, and case of individuals who may be trav-
follow the general guidelines in eling to a location where the disease
Appendix A. Positively identify the is endemic) or after exposure, during
patient, and label the appropriate the incubation period. Prophylaxis is
tubes with the corresponding patient most effective when administered 2
demographics, date, and time of col- weeks after exposure.
collect the specimen in a 5-mL red- ➤ Reinforce information given by the
or tiger-top tube. patient’s health care provider regard-
➤ Remove the needle, and apply a referral to another health care
pressure dressing over the puncture provider. Answer any questions or
site. address any concerns voiced by the
➤ Promptly transport the specimen to patient or family.
Hepatitis B Antigen and Antibody 745

progression of the disease process alanine aminotransferase, alkaline
and determine the need for a change phosphatase, aspartate aminotrans-
in therapy. Evaluate test results in ferase, bilirubin, -glutamyltranspep-
relation to the patient’s symptoms tidase, and hepatitis B and C
and other tests performed. antigens and antibodies.
HEPATITIS B ANTIGEN
AND ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: HBeAg, HBeAb, HBcAb, HBsAb, HBsAg.

DESCRIPTION & RATIONALE: The cedes symptoms. At about the time

hepatitis B virus (HBV) is classified as liver enzymes fall back to normal
a double-stranded DNA retrovirus of levels, the HBsAg titer has fallen to
the Hepadnaviridae family. Its pri- nondetectable levels. If the HBsAg re-
mary modes of transmission are par- mains detectable after 6 months, the
enteral, perinatal, and sexual contact. patient will likely become a chronic
Serologic profiles vary with different carrier who can transmit the virus.
scenarios (i.e., asymptomatic infec- Hepatitis Be antigen (HBeAg) appears
tion, acute/resolved infection, coin- in the serum 10 to 12 weeks after
fection, and chronic carrier state). The exposure. HBeAg can be found in the
formation and detectability of mark- serum of patients with acute or
ers is also dose dependent. The fol- chronic HBV infection and is a sign of
lowing description refers to HBV active viral replication and infectivity.
infection that becomes resolved. The Levels of hepatitis Be antibody
incubation period is generally 6 to 16 (HBeAb) appear about 14 weeks after
weeks. The hepatitis B surface antigen exposure, suggesting resolution of the
(HBsAg) is the first marker to appear infection and reduction of the
after infection. It is detectable 8 to 12 patient’s ability to transmit the dis-
weeks after exposure and often pre- ease. The more quickly HBeAg disap-
pears, the shorter the acute phase blood- or plasma-derived products,

allied health care workers, and public
of the infection. Immunoglobulin
service employees who come in contact
M–specific hepatitis B core antibody with blood and blood products.
(HBcAb) appears 6 to 14 weeks after
exposure to HBsAg and continues to RESULT
be detectable either until the infection
is resolved or over the life span in Positive findings in:
patients who are in a chronic carrier • Patients currently infected with HBV
state. In some cases, HBcAb may be • Patients with a past HBV infection
the only detectable marker; hence its
lone appearance has sometimes been CRITICAL VALUES: N/A
referred to as the core window. HBcAb
INTERFERING FACTORS: Drugs that may
is not an indicator of recovery decrease HBeAb and HBsAb include
or immunity; however, it does indi- interferon.
cate current or previous infection.
Hepatitis B surface antibody (HBsAb)
appears 2 to 16 weeks after HBsAg Nursing Implications and
disappears. Appearance of HBsAb Procedure ● ● ● ● ● ● ● ● ● ● ●
represents clinical recovery and Pretest:

immunity to the virus.
Onset of HBV infection is usually used to identify and confirm hepati-
insidious. Most children and half of tis B infection.
infected adults are asymptomatic. ➤ Obtain a history of the patient’s com-
During the acute phase of infection, plaints, including a list of known
symptoms range from mild to severe. allergens (especially allergies or sen-
Chronicity decreases with age. HBsAg sitivities to latex), and inform the
and HBcAb tests are used to screen accordingly.
donated blood before transfusion. ➤ Obtain a history of the patient’s
HBsAg testing is often part of the hepatobiliary and immune systems,
routine prenatal screen. ■ as well as results of previously
procedures, and other diagnos-
INDICATIONS: tic procedures. For related laboratory
• Detect exposure to HBV tests, refer to the Hepatobiliary and
• Detect possible carrier status Immune System tables.
➤ Obtain a history of intravenous drug
• Screen donated blood before transfu- use, high-risk sexual activity, or occu-
sion pational exposure.
• Screen for individuals at high risk ➤ Obtain a list of the medications
of exposure, such as hemodialy- the patient is taking, including
sis patients, persons with multiple sex herbs, nutritional supplements, and
partners, persons with a history of nutraceuticals. The requesting health
other sexually transmitted diseases, should be advised if the patient is
intravenous drug abusers, infants born regularly using these products so
to infected mothers, individuals resid- that their effects can be taken into
ing in long-term residential facilities or consideration when reviewing re-
correctional facilities, recipients of sults.
Hepatitis B Antigen and Antibody 747
➤ Review the procedure with the ➤ Nutritional considerations: Dietary

patient. Inform the patient that spec- recommendations may be indicated
imen collection takes approximately and will vary depending on the
5 to 10 minutes. Address concerns type and severity of the condition.
about pain related to the procedure. Elimination of alcohol ingestion, and
Explain to the patient that there may a diet optimized for convalescence
be some discomfort during the are commonly included in the treat-
venipuncture. ment plan. A high-calorie, high-
➤ Sensitivity to social and cultural protein, moderate-fat diet with a high
issues, as well as concern for mod- fluid intake is often recommended
esty, is important in providing psy- for patients with hepatitis.
chological support before, during, ➤ A written report of the examination
and after the procedure. will be sent to the requesting health
direction. ➤ Cultural and social considerations:
Recognize anxiety related to test
Intratest: results, and be supportive of
➤ If the patient has a history of severe impaired activity related to lack of
allergic reaction to latex, care should neuromuscular control, perceived
be taken to avoid the use of equip- loss of independence, and fear of
ment containing latex. shortened life expectancy. Discuss
➤ Instruct the patient to cooperate fully results on the patient’s lifestyle.
and to follow directions. Direct the Provide teaching and information
patient to breathe normally and to regarding the clinical implications of
avoid unnecessary movement. the test results, as appropriate.
➤ Observe standard precautions, and Educate the patient regarding access
follow the general guidelines in to counseling services. Counsel the
Appendix A. Positively identify the patient, as appropriate, regarding risk
patient, and label the appropriate of transmission and proper prophy-
tubes with the corresponding patient laxis. Hepatitis B immune globulin
demographics, date, and time of col- (HBIG) vaccination should be given
lection. Perform a venipuncture; immediately after situations in which
collect the specimen in a 5-mL red- there is a potential for HBV exposure
or tiger-top tube. (e.g., accidental needle stick, peri-
➤ Remove the needle, and apply a pres- natal period, sexual contact) for tem-
sure dressing over the puncture site. porary, passive protection. Some
studies have indicated that interferon
➤ Promptly transport the specimen to alfa may be useful in the treatment
the laboratory for processing and of chronic hepatitis B.
analysis.
➤ Counsel the patient and significant
contacts, as appropriate, that HBIG
immunization is available and has in
fact become a requirement in many
places as part of childhood immu-
practitioner.
nization and employee health pro-
Post-test: grams. Parents may choose to sign a
waiver preventing their newborns
➤ Observe venipuncture site for bleed- from receiving the vaccine; they may
ing or hematoma formation. Apply choose not to vaccinate on the basis
paper tape or other adhesive to of philosophical, religious, or medical
hold pressure bandage in place, or reasons. Vaccination regulations vary
replace with a plastic bandage. from state to state.
➤ Inform the patient that positive find- provider. Answer any questions or
ings must be reported to local health address any concerns voiced by the
department officials, who will ques- patient or family.
tion him or her regarding sexual ➤ Depending on the results of this pro-
partners. cedure, additional testing may be
➤ Offer support, as appropriate, to performed to evaluate or monitor
patients who may be the victims of progression of the disease process
rape or other forms of sexual assault, and determine the need for a change
including children and elderly individ- in therapy. Evaluate test results in
uals. Educate the patient regard- relation to the patient’s symptoms
ing access to counseling services. and other tests performed.
Provide a nonjudgmental, nonthreat-
ening atmosphere for a discussion
during which the risks of sexually Related laboratory tests:
transmitted diseases are explained. It ➤ Related laboratory tests include ala-
is also important to discuss the prob- nine aminotransferase, alkaline phos-
lems that the patient may experience phatase, aspartate aminotransferase,
(e.g., guilt, depression, anger). bilirubin, culture anal and chlamydia
➤ Reinforce information given by group antibody, -glutamyltranspepti-
the patient’s health care provider dase, hepatitis C serology, human
regarding further testing, treatment, immunodeficiency virus serology,
or referral to another health care liver biopsy, and syphilis serology.
HEPATITIS C ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: HCV serology, hepatitis non-A/non-B.

REFERENCE VALUE: (Method: Enzyme immunoassay, branched chain DNA
[bDNA], polymerase chain reaction [PCR], recombinant immunoblot assay
[RIBA]) Negative.
DESCRIPTION & RATIONALE: The and sexual contact. The virus is

hepatitis C virus (HCV) causes the thought to be a flavivirus and contains
majority of blood-borne non-A, non- a single-stranded RNA core. The
B hepatitis cases. Its primary modes of incubation period varies widely, from
transmission are parenteral, perinatal, 2 to 52 weeks. Onset is insidious, and
Hepatitis C Antibody 749
the risk of chronic liver disease after INTERFERING FACTORS: Drugs that may
infection is high. On average, anti- decrease hepatitis C antibody levels
bodies to hepatitis C are detectable in include interferon.
approximately 45% of infected indi-
viduals within 6 weeks of infection. Nursing Implications and
The remaining 55% produce antibod- Procedure ● ● ● ● ● ● ● ● ● ● ●
ies within the next 6 to 12 months.

Once infected with HCV, 50% of Pretest:
patients will become chronic carriers. ➤ Inform the patient that the test is
Infected individuals and carriers have used to identify and confirm hepati-
a high frequency of chronic liver dis- tis C infection.
eases such as cirrhosis and chronic ➤ Obtain a history of the patient’s com-
active hepatitis, and they have a plaints, including a list of known
higher risk of developing hepatocellu- sitivities to latex), and inform the
lar cancer. The transmission of hep- appropriate health care practitioner
atitis C by blood transfusion has accordingly.
decreased dramatically since it became ➤ Obtain a history of the patient’s
part of the routine screening panel for hepatobiliary and immune systems,
blood donors. The possibility of pre- as well as results of previously per-
natal transmission exists, especially in
the presence of human immunodefi- procedures. For related laboratory
ciency virus (HIV) coinfection. There- tests, refer to the Hepatobiliary and
fore, this test is often included in Immune System tables.
prenatal testing packages. ■ ➤ Obtain a history of intravenous drug
use, high-risk sexual activity, or occu-
pational exposure.
INDICATIONS:
• Assist in the diagnosis of non-A, non-B
viral hepatitis infection nutritional supplements, and nutra-
• Monitor patients suspected of HCV ceuticals. The requesting health care
infection but who have not yet pro-
duced antibody using these products so that their
• Screen donated blood before trans- effects can be taken into considera-
fusion
RESULT imen collection takes approximately
Positive findings in: about pain related to the procedure.
• Patients currently infected with HCV Explain to the patient that there
may be some discomfort during the
• Patients with a past HCV infection venipuncture.
Negative findings in: N/A issues, as well as concern for mod-
CRITICAL VALUES: N/A and after the procedure.
➤ There are no food, fluid, or medica- the treatment plan. A high-calorie,

tion restrictions, unless by medical high-protein, moderate-fat diet with
direction. a high fluid intake is often recom-
mended for patients with hepatitis.
➤ If the patient has a history of severe care practitioner, who will discuss
allergic reaction to latex, care should the results with the patient.
ment containing latex. ➤ Cultural and social considerations:
Recognize anxiety related to test
➤ Instruct the patient to cooperate fully results, and be supportive of
and to follow directions. Direct the impaired activity related to lack of
patient to breathe normally and to neuromuscular control, perceived
avoid unnecessary movement. loss of independence, and fear of
➤ Observe standard precautions, and shortened life expectancy. Discuss
follow the general guidelines in the implications of abnormal test
Appendix A. Positively identify the results on the patient’s lifestyle.
patient, and label the appropriate Provide teaching and information
tubes with the corresponding patient regarding the clinical implications of
demographics, date, and time of col- the test results, as appropriate.
lection. Perform a venipuncture; Educate the patient regarding access
collect the specimen in a 5-mL red- to counseling services. Counsel the
or tiger-top tube. patient, as appropriate, regarding
the risk of transmission and pro-
➤ Remove the needle, and apply a pres- per prophylaxis. Interferon alfa was
sure dressing over the punc-ture site. approved in 1991 by the U.S. Food
➤ Promptly transport the specimen to and Drug Administration for use as a
the laboratory for processing and therapeutic agent in the treatment of
analysis. chronic HCV infection.
➤ The results are recorded manually ➤ Inform the patient that positive find-
or in a computerized system for ings must be reported to local health
recall and postprocedure inter- department officials, who will ques-
pretation by the appropriate health tion him or her regarding sexual
care practitioner. partners.
➤ Offer support, as appropriate, to
Post-test: patients who may be the victims of
rape or other forms of sexual assault,
➤ Observe venipuncture site for bleed- including children and elderly individ-
ing or hematoma formation. Apply uals. Educate the patient regard-
paper tape or other adhesive to hold ing access to counseling services.
pressure bandage in place, or replace Provide a nonjudgmental, nonthreat-
with a plastic bandage. ening atmosphere for a discussion
➤ Nutritional considerations: Dietary during which the risks of sexually
recommendations may be indicated transmitted diseases are explained. It
and will vary depending on the type is also important to discuss the prob-
and severity of the condition. lems that the patient may experience
Currently, for example, there are no (e.g., guilt, depression, anger).
specific medications that can be ➤ Reinforce information given by the
given to cure hepatitis; however, bed patient’s health care provider regard-
rest, elimination of alcohol inges- ing further testing, treatment, or
tion, and a diet optimized for conva- referral to another health care pro-
lescence are commonly included in vider. Answer any questions or
Hepatitis D Antibody 751
address any concerns voiced by the Related laboratory tests

patient or family.
➤ Depending on the results of this ➤ Related laboratory tests include ala-
procedure, additional testing may be nine aminotransferase, alkaline phos-
performed to evaluate or monitor phatase, aspartate aminotransferase,
progression of the disease process bilirubin, culture anal and chlamydia
and determine the need for a change group antibody, -glutamyltranspe-
in therapy. Evaluate test results in ptidase, hepatitis B serology, HIV
relation to the patient’s symptoms serology, liver biopsy, and syphilis
and other tests performed. serology.
HEPATITIS D ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Delta hepatitis.

REFERENCE VALUE: (Method: Enzyme immunoassay, EIA) Negative.
DESCRIPTION & RATIONALE: Symp- (see monograph titled “Hepatitis B

toms of hepatitis D virus (HDV) Antigen and Antibody.”) ■
infection are similar but often more
severe than those of hepatitis B virus INDICATIONS: Establish the presence of
(HBV) infection. As with HBV, the coinfection or superinfection in patients
primary modes of HDV transmission with HBV (clinical course of superinfec-
tion is more severe)
are parenteral, perinatal, and sexual
contact. The virus contains a single- RESULT
stranded RNA core. In order to repli-
cate, it requires the presence of the Positive findings in:
hepatitis B outer coat. Therefore, • Individuals currently infected with
HDV infection can only occur with HDV
hepatitis B coinfection or superinfec-
• Individuals with a past HDV infection
tion. Onset is abrupt, after an incuba-
tion period of 3 to 13 weeks. Because CRITICAL VALUES: N/A
of its dependence on HBV, prevention
can be accomplished by using the INTERFERING FACTORS: Drugs that may
same pre-exposure and postexposure decrease hepatitis D antibody levels
protective measures used for HBV include interferon.

Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ If the patient has a history of severe
Pretest: be taken to avoid the use of equip-
used to test blood for the presence and to follow directions. Direct the
of antibodies that would indicate patient to breathe normally and to
past or current hepatitis D infection. avoid unnecessary movement.
plaints, including a list of known follow the general guidelines in Ap-
allergens (especially allergies or pendix A. Positively identify the
sensitivities to latex), and inform the patient, and label the appropriate
➤ Obtain a history of the patient’s lection. Perform a venipuncture;
hepatobiliary and immune systems collect the specimen in a 5-mL red-
and results of previously performed or tiger-top tube.
laboratory tests, surgical procedures, ➤ Remove the needle, and apply a pres-
and other diagnostic procedures. For sure dressing over the puncture site.
Hepatobiliary and Immune System
tables.
analysis.
➤ Obtain a history of intravenous drug ➤ The results are recorded manually
use, high-risk sexual activity, or occu- or in a computerized system for re-
pational exposure. call and postprocedure interpretation
➤ Obtain a list of the medications by the appropriate health care practi-
should be advised if the patient is reg-
ularly using these products so that
their effects can be taken into consid-
eration when reviewing results.
➤ Review the procedure with the pa- ➤ Nutritional considerations: Dietary
tient. Inform the patient that speci- recommendations may be indicated
men collection takes approximately and will vary depending on the type
5 to 10 minutes. Address concerns and severity of the condition. Elim-
about pain related to the procedure. ination of alcohol ingestion, and a diet
Explain to the patient that there may optimized for convalescence are
be some discomfort during the commonly included in the treatment
venipuncture. plan. A high-calorie, high-protein,
➤ Sensitivity to social and cultural moderate-fat diet with a high fluid
issues, as well as concern for mod- intake is often recommended for
esty, is important in providing patients with hepatitis.
psychological support before, during, ➤ A written report of the examination
and after the procedure. will be sent to the requesting health
➤ There are no food, fluid, or medi- care practitioner, who will discuss
cation restrictions, unless by medical the results with the patient.
direction. ➤ Cultural and social considerations:
Hepatobiliary Scan 753
Recognize anxiety related to test choose not to vaccinate on the basis

results, and and be supportive of of philosophical, religious, or medical
impaired activity related to lack of reasons. Vaccination regulations vary
neuromuscular control, perceived from state to state.
loss of independence, and fear of ➤ Reinforce information given by the
shortened life expectancy. Discuss patient’s health care provider regard-
the implications of abnormal test ing further testing, treatment, or
results on the patient’s lifestyle. referral to another health care pro-
Provide teaching and information vider. Answer any questions or
regarding the clinical implications address any concerns voiced by the
of the test results, as appropriate. patient or family.
to counseling services. Counsel the ➤ Depending on the results of this pro-
patient, as appropriate, regarding the cedure, additional testing may be
risk of transmission and proper pro- performed to evaluate or monitor
phylaxis. Hepatitis B immune globulin progression of the disease process
(HBIG) vaccination should be given and determine the need for a change
immediately after situations in which in therapy. Evaluate test results in
there is a potential for HBV exposure relation to the patient’s symptoms
(e.g., accidental needle stick, perina- and other tests performed.
tal period, sexual contact) for tempo-
rary, passive protection. Related laboratory tests:
➤ Counsel the patient and significant ➤ Related laboratory tests include ala-
contacts, as appropriate, that HBIG nine aminotransferase, alkaline phos-
immunization is available and has in phatase, aspartate aminotransferase,
fact become a requirement in many bilirubin, culture anal and chlamydia
places as part of childhood immu- group antibody, -glutamyltranspe-
nization and employee health pro- ptidase, hepatitis B and C antibodies/
grams. Parents may choose to sign a antigens human immunodeficiency
waiver preventing their newborns virus serology, liver biopsy, and
from receiving the vaccine; they may syphilis serology.
HEPATOBILIARY SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Hepatobiliary imaging, biliary tract radionuclide

scan, hepatobiliary scintigraphy, gallbladder scan, cholescintigraphy, HIDA
(a technetium-99m disopropyl analogue) scan.
AREA OF APPLICATION: Bile ducts.

CONTRAST: Intravenous contrast medium (aminodiacetic acid compounds),
usually combined with technetium-99m.
• Postoperatively evaluate gastric surgical

DESCRIPTION & RATIONALE: The procedures and abdominal trauma
hepatobiliary scan is a nuclear medi-
cine study of the hepatobiliary excre- RESULT
tion system. It is primarily used to
Normal Findings:
determine the patency of the cystic
• Normal shape, size, and function of the
and common bile ducts, but it can gallbladder with patent cystic and com-
also be used to determine overall mon bile ducts
hepatic function, gallbladder func-
tion, presence of gallstones (indi- Abnormal Findings:
rectly), and sphincter of Oddi • Acalculous cholecystitis
dysfunction. Technetium (Tc-99m) • Acute cholecystitis
HIDA (tribromoethyl, an aminodi-
acetic acid) is injected intravenously • Chronic cholecystitis
(IV) and excreted into the bile duct • Common bile duct obstruction sec-
system. A gamma camera detects the ondary to gallstones, tumor, or stricture
radiation emitted from the injected • Congenital biliary atresia or chole-
contrast medium, and a representative dochal cyst
image of the duct system is obtained. • Postoperative biliary leak, fistula, or
The results are correlated with other obstruction
diagnostic studies, such as IV cholan-
• Trauma-induced bile leak or cyst
giography, computed tomography
(CT) scan of the gallbladder, and CRITICAL VALUES: N/A
ultrasonography. Gallbladder empty-
ing or ejection fraction can be deter- INTERFERING FACTORS:
mined by administering a fatty meal
or cholecystokinin to the patient. This This procedure is
procedure can be used before and after
surgery to determine the extent of bile
reflux. ■ benefits of the procedure far outweigh
INDICATIONS:
• Aid in the diagnosis of acute and Factors that may
chronic cholecystitis impair clear imaging:
• Aid in the diagnosis of suspected gall- remain still during the procedure
bladder disorders, such as inflamma- because of age, significant pain, or
tion, perforation, or calculi mental status
• Assess enterogastric reflux • Improper adjustment of the radi-
• Assess obstructive jaundice when done
in combination with radiography or
ultrasonography
poor-quality study
• Determine common duct obstruction
caused by tumors or choledocholithiasis • Patients who are very obese, who
• Evaluate biliary enteric bypass patency equipment
Hepatobiliary Scan 755
• Incorrect positioning of the patient, done should wear badges that reveal
which may produce poor visualization their level of exposure to radiation.
ologic procedure Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●

tion field (e.g., jewelry, body rings), Pretest:
and can produce unclear images ➤ Inform the patient that the procedure
detects inflammation or obstruc-
• Bilirubin levels greater than or equal to tion of the gallbladder or bile duct
30 mg/dL, depending on the radionu- system.
clide used, which may decrease hepatic ➤ Obtain a history of the patient’s com-
uptake plaints and symptoms, including a
previous 24 to 48 hours ➤ Obtain a history of results of previ-
• Fasting for more than 24 hours before dures, surgical procedures, and
the procedure, total parenteral nutri- laboratory tests. For related diagnos-
tion, and alcoholism tic tests, refer to the Hepatobiliary
System table.
• Ingestion of food or liquids within 2 to
4 hours before the scan ➤ Record the date of the last menstrual
period and determine the possibi-
lity of pregnancy in perimenopausal
women.
medications.
• Improper injection of the radionuclide patient. Address concerns about pain
that allows the tracer to seep deep into related to the procedure. Explain to
the muscle tissue can produce erro- the patient that some pain may be
neous hot spots. experienced during the test, and
• Inaccurate timing of imaging after the fort. Explain the purpose of the test
radionuclide injection can affect the and how the procedure is performed.
results. Inform the patient that the procedure
is performed in a nuclear medicine
• Consultation with a health care practi- department, usually by a technologist
tioner should occur before the procedure and support staff, and usually takes
for radiation safety concerns regarding approximately 60 to 90 minutes.
younger patients or patients who are lac- Inform the patient that the technolo-
tating. gist will place him or her in a supine
position on a flat table for the injec-
• Risks associated with radiologic overex- tion of contrast medium. Delayed
posure can result from frequent x-ray images are needed up to 24 hours
procedures. Personnel in the room after the initial injection. The patient
with the patient should wear a protec- may leave the department and return
tive lead apron, stand behind a shield, later to undergo delayed imaging.
or leave the area while the examination ➤ Sensitivity to cultural and social
is being done. Personnel working in the issues, as well as concern for mod-
area where the examination is being esty, is important in providing psy-
chological support before, during, the sphincter of Oddi, forcing the

and after the procedure. radionuclide into the gallbladder, if
➤ Restrict food and fluids for 4 to 6 the organ is not visualized within 1
hours before the scan. hour of injection of the radionuclide.
Imaging is then done 20 to 50 min-
➤ Instruct the patient to remove den- utes later to determine delayed
tures, jewelry (including watches), visualization or nonvisualization of
hairpins, credit cards, and other the gallbladder.
metallic objects.
➤ If gallbladder function or bile reflux is
being assessed, the patient will be
given a fatty meal or cholecystokinin
60 minutes after the injection.
any medications.
➤ Wear gloves during the radionuclide
Intratest: administration and while handling
the patient’s urine.
➤ Ensure that the patient fasted for 4
to 6 hours before the scan, unless ➤ The results are recorded on film or in
otherwise indicated. a computerized system for recall and
postprocedure interpretation by the
➤ Ask patient to remove jewelry, appropriate health care practitioner.
including watches, and any other
metallic objects. Post-test:
and foot coverings to wear and ➤ Instruct the patient to resume usual
instructed to void prior to the proce- diet, medications, and activity, after
dure. imaging is complete, as directed by
and to follow directions. Instruct the ➤ Advise patient to drink increased
patient to lie still during the proce- amounts of fluids for 24 to 48 hours
dure because movement produces to eliminate the radionuclide from
unclear images. the body, unless contraindicated. Tell
the patient that radionuclide is elimi-
nated from the body within 6 to
24 hours.
Appendix A.
➤ Administer sedative to a child or to ➤ Inform the patient to immediately
an uncooperative adult, as ordered. flush the toilet after each voiding
after the procedure, and to meticu-
➤ Place the patient in a supine position lously wash hands with soap and
on a flat table with foam wedges water after each voiding for 24 hours
to help maintain position and immo- after the procedure.
bilization.
➤ Tell all caregivers to wear gloves
➤ IV radionuclide is administered, and
when discarding urine for 24 hours
the upper-right quadrant of the
abdomen is scanned immediately,
hands with soap and water before
with images then taken every 5 min-
removing gloves. Then wash un-
utes for the first 30 minutes and
gloved hands after the gloves are
every 10 minutes for the next 30
removed.
minutes. Delayed views are taken in
2, 4, and 24 hours if the gallbladder ➤ Instruct the patient in the care and
cannot be visualized, in order to dif- assessment of the injection site.
ferentiate acute from chronic chole- Observe for bleeding, hematoma for-
cystitis or to detect the degree of mation, and inflammation.
obstruction. ➤ A written report of the examina-
➤ IV morphine may be administered tion will be completed by a health
during the study to initiate spasms of care practitioner specializing in this
HER-2/Neu Oncoprotein 757
branch of medicine. The report will needed to evaluate or monitor pro-

be sent to the requesting health care gression of the disease process and
practitioner, who will discuss the determine the need for a change in
results with the patient. therapy. Evaluate test results in rela-
➤ Reinforce information given by the tion to the patient’s symptoms and
patient’s health care provider regard- other tests performed.
referral to another health care Related diagnostic tests:
provider. Answer any questions or ➤ Related diagnostic tests include
address any concerns voiced by the computed tomography of the abdo-
patient or family. men, magnetic resonance imaging
➤ Depending on the results of this proof the abdomen, and ultrasound of
cedure, additional testing may be the liver and bile ducts.
HER-2/NEU ONCOPROTEIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: c-erb-B2.
SPECIMEN: Breast tissue or cells.
REFERENCE VALUE: (Method: Immunocytochemical) Negative.
DESCRIPTION & RATIONALE: Breast rapid tumor progression, increased

cancer is the most common newly rate of recurrence, poor response to
diagnosed cancer in American women. standard therapies, and a lower sur-
It is the second leading cause of can- vival rate.
cer-related death. The presence of The specimen is collected by fine-
abnormal amounts of a protein called needle or open biopsy. The tissue sam-
human epidermal growth factor recep- ple is treated with a material that
tor 2 (HER-2/neu oncoprotein) is binds to HER-2/neu oncoprotein. A
helpful in establishing histologic evi- dye is added to the tissue sample; areas
dence of metastatic breast cancer. of tissue that have large amounts of
Overexpression of this protein results HER-2/neu oncoprotein are indicated
from an acquired genetic mutation by high-intensity color on the tissue
and occurs in 25% to 30% of patients sample. ■
with metastatic breast cancer. Metasta-
tic breast cancer patients with high INDICATIONS: Evidence of breast lesion
levels of HER-2/neu oncoprotein by palpation, mammography, or ultra-
have a poor prognosis: They have sound
RESULT may be necessary to shave the site

before the procedure. Instruct that
Positive findings in: Breast cancer
CRITICAL VALUES: N/A to the procedure. Explain that a
administered to promote relaxation
INTERFERING FACTORS: N/A and reduce discomfort prior to the
anesthesia will be administered prior
Nursing Implications and to the open biopsy. Explain to the
Procedure ● ● ● ● ● ● ● ● ● ● ●
patient that no pain will be experi-
Pretest: anesthesia is used, but that any dis-
➤ Inform the patient that the test is pri- minimized with local anesthetics and
marily used to assist in the prognosis systemic analgesics. Inform the
and in the management of response patient that the biopsy is performed
to therapy for breast cancer. under sterile conditions by a health
➤ Obtain a history of the patient’s com- care practitioner specializing in this
plaints, including a list of known procedure. The surgical procedure
allergens (especially allergies or sen- usually takes about 20 to 30 minutes
sitivities to latex), and inform the to complete, and that sutures may
appropriate health care practitioner be necessary to close the site. A
accordingly. needle biopsy usually takes about 15
minutes to complete.
immune and reproductive systems ➤ Sensitivity to cultural and social
and results of previously performed issues, as well as concern for mod-
laboratory tests, surgical procedures, esty, is important in providing psy-
and other diagnostic procedures. For chological support before, during and
related laboratory tests, refer to the after the procedure.
Immune and Reproductive System ➤ Explain that an intravenous (IV) line
tables. will be inserted to allow infusion of
➤ Record the date of the last menstrual IV fluids, antibiotics, anesthetics, and
period and determine the possibil- analgesics.
ity of pregnancy in perimenopausal ➤ Ensure that anticoagulant therapy
women. has been withheld for the appropri-
➤ Obtain a list of the medications ate amount of days prior to the pro-
the patient is taking, including anti- cedure. Amount of days to withhold
coagulant therapy, acetylsalicylic medication is dependant on the type
acid, herbs, nutritional supplements, of anticoagulant. Notify health care
and nutraceuticals, especially those practitioner if patient anticoagulant
known to affect coagulation. It is rec- therapy has not been withheld.
Open biopsy:
cedures. The requesting health care ➤ Instruct the patient that nothing
practitioner and laboratory should be should be taken by mouth for 6 to 8
advised if the patient regularly uses hours prior to a general anesthetic.
can be taken into consideration Needle biopsy:
when reviewing results. ➤ Instruct the patient that nothing
➤ Review the procedure with the should be taken by mouth for at
patient. Inform the patient that it least 4 hours prior to the procedure
HER-2/Neu Oncoprotein 759
to reduce the risk of nausea and cious area(s) are located, and tissue
vomiting. samples are collected.
General: Needle biopsy:

➤ Make sure a written and informed ➤ Direct the patient to take slow deep
consent has been signed prior to the breaths when the local anesthetic is
procedure and before administering injected. Protect the site with sterile
any medications. drapes. Instruct the patient to take a
deep breath, exhale forcefully, and
Intratest: hold the breath while the biopsy nee-
➤ Ensure that the patient has complied dle is inserted and rotated to obtain
with dietary restrictions; assure that a core of breast tissue. Once the
food has been restricted for at least needle is removed, the patient may
4 to 8 hours prior to the procedure, breathe. Pressure is applied to the
depending on the anesthetic chosen site for 3 to 5 minutes, then a sterile
for the procedure. pressure dressing is applied.
General:
available.
➤ Have the patient void before the pro- ➤ Monitor the patient for complications
cedure. related to the procedure (e.g., aller-
follow the general guidelines in ➤ Apply a sterile dressing to the site.
Appendix A. Positively identify the ➤ Place tissue samples in properly
patient, and label the appropriate col- labeled specimen container contain-
lection containers with the corre- ing formalin solution, and promptly
sponding patient demographics, transport the specimen to the labo-
date and time of collection, and ratory for processing and analysis.
site location, especially left or right
breast. ➤ The results are recorded manually
➤ Assist the patient to the desired recall and postprocedure interpreta-
position depending on the test site tion by the appropriate health care
to be used, and direct the patient to practitioner.
breath normally during the beginning
of the general anesthesia. Instruct
the patient to cooperate fully and to Post-test:
follow directions. Direct the patient ➤ Instruct the patient to resume preop-
to breathe normally and to avoid erative diet, as directed by the health
unnecessary movement during the care practitioner.
local anesthetic and the procedure.
➤ Monitor vital signs every 15 minutes
➤ Record baseline vital signs and con-
for 1 hour, and then every 2 hours for
tinue to monitor throughout the
4 hours, and then as ordered by the
procedure. Protocols may vary from
health care practitioner. Monitor
temperature every 4 hours for 24
➤ After the administration of general hours. Compare with baseline val-
or local anesthesia, cleanse the site ues. Notify the health care practi-
with an antiseptic solution, and tioner if temperature is elevated.
drape the area with sterile towels. Protocols may vary from facility to
facility.
Open biopsy:
➤ After administration of general tions, such as rash, urticaria, tachy-
anesthesia and surgical prep is com- cardia, hyperpnea, hypertension,
pleted, an incision is made, suspi- palpitations, nausea, or vomiting.
➤ Observe the biopsy site for bleed- results. Educate the patient regard-
ing, inflammation, or hematoma ing access to counseling services.
formation. ➤ Reinforce information given by the
➤ Instruct the patient in the care and patient’s health care provider regard-
assessment of the site. Instruct ing further testing, treatment, or
the patient to report any redness, referral to another health care
edema, bleeding, or pain at the provider. Inform the patient of a
biopsy site. Instruct the patient to follow-up appointment for removal of
immediately report chills or fever. sutures, if indicated. Instruct and
Instruct the patient to keep the site educate the patient on how to per-
clean and change the dressing as form monthly breast self-examina-
needed. tion and emphasize, as appropriate,
the importance of having a mammo-
➤ Assess for nausea and pain. gram performed annually. Answer
Administer antiemetic and analge- any questions or address any con-
sic medications as needed and cerns voiced by the patient or family.
as directed by the health care
practitioner. ➤ Instruct the patient in the use of any
➤ Administer antibiotic therapy if importance of adhering to the ther-
ordered. Remind the patient of the apy regimen. As appropriate, instruct
importance of completing the entire the patient in significant side effects
course of antibiotic therapy, even if and systemic reactions associated
signs and symptoms disappear with the prescribed medication.
before completion of therapy. Encourage him or her to review cor-
➤ A written report of the examina- responding literature provided by a
tion will be completed by a health pharmacist.
care practitioner specializing in this ➤ Depending on the results of this
branch of medicine. The report will procedure, additional testing may be
be sent to the requesting health care performed to evaluate or monitor
practitioner, who will discuss the progression of the disease process
results with the patient. and determine the need for a change
results, and offer support. Discuss relation to the patient’s symptoms
the implications of abnormal test and other tests performed.
results on the patient’s lifestyle
regarding the clinical implications of ➤ Related laboratory tests include
the test results, as appropriate. breast biopsy, CA 15-3, carcinoem-
Inform the patient about hormone bryonic antigen, and estrogen and
therapy, as appropriate based on test progesterone receptors.
HEXOSAMINIDASE A AND B
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Hexosaminidase A and B 761
SPECIMEN: Serum (3 mL) collected in a red-top tube. After the specimen is

collected, it must be brought immediately to the laboratory. The specimen
must be allowed to clot for 1 to 1.5 hours in the refrigerator. The serum
should be removed and frozen immediately.
REFERENCE VALUE: (Method: Fluorometry)
Total Conventional SI Units (Conventional

Hexosaminidase Units Units 0.0167)
Noncarrier 589–955 nmol/h/mL 9.83–15.95 U/L
Heterozygote 465–675 nmol/h/mL 3.30–5.39 U/L
Tay-Sachs Greater than Greater than
homozygote 1027 nmol/h/mL 17.15 U/L

Hexosaminidase A Units Units 0.0167)
Tay-Sachs 0 nmol/h/mL 0 U/L
homozygote

Hexosaminidase B Units Units 0.0167)
Tay-Sachs Greater than Greater than
homozygote 305 nmol/h/mL 5.09 U/L
DESCRIPTION & RATIONALE: Hex- This enzyme deficiency is most

osaminidase is a lysosomal enzyme. common among Ashkenazic Jews.
There are three predominant isoen- Patients who are homozygous for this
zymes: hexosaminidase A, B, and S. trait have no hexosaminidase A and
Deficiency results in the accumulation have greatly elevated levels of hex-
of complex sphingolipids and ganglio- osaminidase B; signs and symptoms
sides in the brain. There are more include red spot in the retina, blind-
than 70 lysozymal enzyme disorders. ness, and muscular weakness. Tay-
Testing for hexosaminidase A is done Sachs disease results in early death,
to determine the presence of Tay- usually by age 3 or 4 years. ■
Sachs disease, a genetic autosomal
recessive condition characterized by INDICATIONS:
early and progressive retardation of • Assist in the diagnosis of Tay-Sachs
physical and mental development. disease
• Identify carriers with hexosaminidase appropriate health care practitioner

deficiency accordingly.
RESULT reproductive system and results of
Increased in: tests, surgical procedures, and other
• Total laboratory tests, refer to the
Gastric cancer Reproductive System table.
Hepatic disease ➤ Obtain a list of the medications the
Myeloma patient is taking, including herbs,
Myocardial infarction nutritional supplements, and nutra-
Pregnancy practitioner and laboratory should be
Symptomatic porphyria advised if the patient regularly uses
Vascular complications of diabetes these products so that their effects
• Hexosaminidase A when reviewing results.
Diabetes ➤ Review the procedure with the
Pregnancy patient. Inform the patient that spec-
• Hexosaminidase B 5 to 10 minutes. Address concerns
Tay-Sachs disease about pain related to the procedure.
Decreased in: be some discomfort during the
venipuncture.
• Total
Sandhoff’s disease
• Hexosaminidase A esty, is important in providing psy-
Tay-Sachs disease chological support before, during,
• Hexosaminidase B ➤ There are no food, fluid, or medica-
Sandhoff’s disease tion restrictions, unless by medical
direction.
Intratest:
INTERFERING FACTORS: Drugs that may ➤ If the patient has a history of severe
increase hexosaminidase levels include allergic reaction to latex, care should
ethanol, isoniazid, oral contraceptives, be taken to avoid the use of equip-
and rifampin. ment containing latex.
Nursing Implications and the patient to breathe normally
Procedure ● ● ● ● ● ● ● ● ● ● ● and to avoid unnecessary move-
ment.
used to identify carrier status for Tay- patient, and label the appropriate
Sachs disease. tubes with the corresponding patient
Holter Monitor 763
➤ Remove the needle, and apply a Encourage the family to seek genetic
pressure dressing over the puncture counseling if results are abnormal. It
site. is also important to discuss feelings
➤ Promptly transport the specimen the mother and father may experi-
to the laboratory for processing and ence (e.g., guilt, depression, anger) if
analysis. abnormalities are detected. Educate
seling services. Provide contact infor-
mation, if desired, for the National Tay
Sachs and Allied Diseases Associa-
tion (http://www.ntsad.org).
practitioner.
Post-test: patient’s health care provider regard-
➤ Observe venipuncture site for bleed- referral to another health care
ing or hematoma formation. Apply provider. Answer any questions or
paper tape or other adhesive to hold address any concerns voiced by the
pressure bandage in place, or patient or family.
➤ A written report of the examination procedure, additional testing may be
results, and be supportive fear of relation to the patient’s symptoms
shortened life expectancy. Discuss and other tests performed.
results on the patient’s lifestyle. Related laboratory tests:
regarding the clinical implications of ➤ A related laboratory test is chromo-
the test results, as appropriate. some analysis.
HOLTER MONITOR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Holter electrocardiography, ambulatory monitoring,

ambulatory electrocardiography, event recorder.

CONTRAST: None.
DESCRIPTION & RATIONALE: The study includes the use of a portable

Holter monitor records electrical car- device worn around the waist or over
diac activity on a continuous basis for the shoulder that records cardiac elec-
24 to 48 hours. This noninvasive trical impulses on a magnetic tape.
The recorder has a clock that allows tachyarrhythmias, conduction defects,

and bradycardia
accurate time markings on the tape.
The patient is asked to keep a log or • Cardiomyopathy
diary of daily activities and to record • Hypoxic or ischemic changes
any occurrence of cardiac symptoms.
When the client pushes a button indi- • Mitral valve abnormality
cating that symptoms (e.g., pain, pal- • Palpitations
pitations, dyspnea, syncope) have
occurred, an event marker is placed on CRITICAL VALUES: N/A
the tape for later comparison with the
cardiac activity recordings and the INTERFERING FACTORS:
daily activity log. Some recorders
allow the data to be transferred to the results of the examination:
physician’s office by telephone, where • Improper placement of the electrodes
the tape is interpreted by a computer or movement of the electrodes
to detect any significantly abnormal
variations in the recorded waveform • Failure of the patient to maintain a
daily log of symptoms or to push the
patterns. ■
button to produce a mark on the strip
when experiencing a symptom
INDICATIONS:
• Detect arrhythmias that occur during
normal daily activities, and correlate Nursing Implications and
them with symptoms experienced by Procedure ● ● ● ● ● ● ● ● ● ● ●
the patient
• Evaluate activity intolerance related to Pretest:
oxygen supply and demand imbalance ➤ Inform the patient that the procedure
evaluates how the heart responds to
• Evaluate chest pain, dizziness, syncope, normal activity or to a medication
and palpitations regimen.
• Evaluate the effectiveness of antiar- ➤ Obtain a history of the patient’s car-
rhythmic medications for dosage diovascular system, cardiac disease,
adjustment, if needed and present cardiovascular status,
as well as results of previously
• Evaluate pacemaker function performed laboratory tests, surgi-
• Monitor for ischemia and arrhythmias procedures. For related diagnostic
after myocardial infarction or cardiac tests, refer to the Cardiovascular
surgery before changing rehabilitation System table.
and other therapy regimens ➤ Obtain a list of the medications the
RESULT nutritional supplements, and nutra-
Normal Findings:
• Normal sinus rhythm these products so that their effects
Abnormal Findings: when reviewing results.
• Arrhythmias such as premature ventric- ➤ Review the procedure with the
ular contractions, bradyarrhythmias, patient. Address concerns about
Holter Monitor 765
pain related to the procedure. oughly with alcohol and rub until red
Explain that no electricity is delivered in color.
to the body during this procedure ➤ Apply electropaste to the skin sites
and that no discomfort is experi- to provide conduction between the
enced during monitoring. Inform the skin and electrodes, or apply disk
patient that the electrocardiography electrodes that are prelubricated and
(ECG) recorder is worn for 24 to 48 disposable.
hours, at which time the patient is to
return to the laboratory with an activ- ➤ Apply two electrodes on the
ity log to have the monitor and strip manubrium (negative electrodes),
removed for interpretation. one in the V1 position (fourth inter-
costal space at the border of the right
➤ Advise the patient to avoid contact sternum), and one at the V5 position
with electrical devices that can affect (level of the fifth intercostal space at
the strip tracings (e.g., shavers, the midclavicular line, horizontally
toothbrush, massager, blanket) and and at the left axillary line). A ground
to avoid showers and tub bathing. electrode is also placed and secured
➤ Instruct the patient to perform nor- to the skin of the chest or abdomen.
mal activities, such as walking, ➤ After checking to ensure that the
sleeping, climbing stairs, sexual electrodes are secure, attach the
activity, bowel or urinary elimina- electrode cable to the monitor and
tion, cigarette smoking, emotional the lead wires to the electrodes.
upsets, and medications, and to
record them in an activity log. ➤ Check the monitor for paper supply
and battery, insert the tape, and turn
➤ Instruct the patient to wear loose- on the recorder. Tape all wires to the
fitting clothing over the electrodes chest, and place the belt or shoulder
and not to disturb or disconnect the strap in the proper position.
electrodes or wires.
➤ Instruct the patient regarding record-
ing and pressing the button upon
Post-test:
experiencing pain or discomfort. ➤ Gently remove the tape and other
➤ Advise the patient to report a light items securing the electrodes to the
signal on the monitor, which indi- patient.
cates equipment malfunction or that ➤ Advise the patient to immediately
an electrode has come off. report symptoms such as fast heart
➤ Sensitivity to cultural and social rate or difficulty breathing.
issues, as well as concern for mod- ➤ Compare the activity log and tape
esty, is important in providing psy- recordings for changes during the
chological support before, during and monitoring period.
Intratest: will be completed by a health care
practitioner specializing in this
➤ Patients are given a gown, robe, and branch of medicine. The report will
foot coverings to wear and instructed be sent to the requesting health care
to void prior to the procedure. practitioner, who will discuss the
➤ Instruct the patient to cooperate fully results with the patient.
and to follow directions. ➤ Recognize anxiety related to test
➤ Observe standard precautions, and results, and be supportive of per-
follow the general guidelines in ceived loss of independence and
Appendix A. fear of shortened life expectancy.
➤ Place the patient in a supine position. test results on the patient’s lifestyle.
➤ Expose the chest. Shave excessive Provide teaching and information
hair at the skin sites; cleanse thor- regarding the clinical implications of
the test results, as appropriate. therapy. Evaluate test results in rela-

Educate the patient regarding access tion to the patient’s symptoms and
to counseling services. other tests performed.
gression of the disease process and echocardiography and electrocar-
determine the need for a change in diogram.
HOMOCYSTEINE AND
METHYLMALONIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Serum (4 mL) collected in a red- or tiger-top tube if methyl-
malonic acid and homocysteine are to be measured together. Alternatively,
plasma collected in a lavender-top (EDTA) tube may be acceptable for the
homocysteine measurement. The laboratory should be consulted before spec-
imen collection because specimen type may be method dependent. Care
must be taken to use the same type of collection container if serial measure-
ments are to be taken.
REFERENCE VALUE: (Method: Chromatography) Homocysteine: 8 to 20

mol/L; methylmalonic acid: 80 to 560 mol/L.
DESCRIPTION & RATIONALE: Homo- ies from dilating, increasing the risk
cysteine is an amino acid formed from of plaque formation; cause platelet
methionine. Normally homocysteine aggregation; and cause smooth muscle
is rapidly remetabolized in a biochem- cells lining the arterial wall to multi-
ical pathway that requires vitamin B12 ply, promoting atherosclerosis.
and folate, preventing the buildup of Approximately one-third of patients
homocysteine in the blood. Excess with hyperhomocystinuria have nor-
levels damage the endothelial lining of mal fasting levels. Patients with a het-
blood vessels; change coagulation fac- erozygous biochemical enzyme defect
tor levels, increasing the risk of blood in cystathionine B synthase or with a
clot formation; prevent smaller arter- nutritional deficiency in vitamin B6
Homocysteine and Methylmalonic Acid 767
can be identified through the admin- CRITICAL VALUES: N/A

istration of a methionine challenge or
loading test. Specimens are collected INTERFERING FACTORS:
• Drugs that may increase plasma homo-
while fasting and 2 hours later. An
cysteine levels include anticonvulsants,
increase in homocysteine after 2 hours cycloserine, hydralazine, isoniazid,
is indicative of hyperhomocystinuria. methotrexate, penicillamine, phenel-
In patients with vitamin B12 defi- zine, and theophylline.
ciency, elevated levels of methyl-
• Specimens should be kept at a refriger-
malonic acid and homocysteine
ated temperature and delivered imme-
develop fairly early in the course of diately to the laboratory for processing.
the disease. Unlike vitamin B12 levels,
homocysteine levels will remain ele-
vated for at least 24 hours after the Nursing Implications and
start of vitamin therapy. This may be Procedure ● ● ● ● ● ● ● ● ● ● ●
useful if vitamin therapy is inadver-

tently begun before specimen collec- Pretest:
tion. Patients with folate deficiency, ➤ Inform the patient that the test is
for the most part, will only develop used to screen for risk of cardiovas-
elevated homocysteine levels. Hyper- cular disease and stroke.
homocystinemia due to folate defi- ➤ Obtain a history of the patient’s
ciency in pregnant women is believed complaints, including a list of known
to increase the risk of neural tube sitivities to latex), and inform the
defects. Elevated levels of homocys- appropriate health care practitioner
teine are thought to chemically dam- accordingly.
age the exposed neural tissue of the ➤ Obtain a history of the patient’s car-
developing fetus. ■ diovascular and hematopoietic sys-
INDICATIONS: performed laboratory tests, surgical
• Evaluate inherited enzyme deficiencies
that result in homocystinuria tests, refer to the Cardiovascular and
• Evaluate the risk for cardiovascular dis- Hematopoietic System tables.
ease ➤ Obtain a list of the medications the
• Evaluate the risk for venous thrombosis nutritional supplements, and nutra-
RESULT practitioner and laboratory should be
Increased in: these products so that their effects
• Chronic renal failure can be taken into consideration
• Coronary artery disease ➤ Review the procedure with the
• Folic acid deficiency patient. Inform the patient that spec-
• Homocystinuria 5 to 10 minutes. Address concerns
• Vitamin B12 deficiency Explain to the patient that there may
Decreased in: N/A venipuncture.
➤ There are no food, fluid, or medica- weight. The American Heart

tion restrictions, unless by medical Association has Step 1 and Step 2
direction. diets that may be helpful in achieving
a goal of lowering total cholesterol
Intratest: and triglyceride levels. The Step 1
diet emphasizes a reduction in foods
➤ If the patient has a history of severe high in saturated fats and cholesterol.
allergic reaction to latex, care should Red meats, eggs, and dairy products
be taken to avoid the use of equip- are the major sources of saturated
ment containing latex. fats and cholesterol. If triglycerides
➤ Instruct the patient to cooperate fully are also elevated, patients should be
and to follow directions. Direct the advised to eliminate or reduce alco-
patient to breathe normally and to hol and simple carbohydrates from
avoid unnecessary movement. their diet. The Step 2 diet recom-
➤ Observe standard precautions, and mends stricter reductions.
follow the general guidelines in ➤ Nutritional considerations: Diets rich
Appendix A. Positively identify the in fruits, grains, and cereals, in addi-
patient, and label the appropriate tion to a multivitamin containing B12
tubes with the corresponding patient and folate, may be recommended for
demographics, date, and time of col- patients with elevated homocysteine
lection. Perform a venipuncture; col- levels. Processed and refined foods
lect the specimen for combined should be kept to a minimum.
methylmalonic acid and homocys- ➤ A written report of the examination
teine studies in two 5-mL red- or will be sent to the requesting health
tiger-top tubes. If only homocysteine care practitioner, who will discuss
is to be measured, a 5-mL lavender- the results with the patient.
top tube is acceptable.
➤ Remove the needle, and apply a pres- results, and be supportive of fear of
sure dressing over the puncture site. shortened life expectancy. Discuss
➤ Promptly transport the specimen to the implications of abnormal test
the laboratory for processing and results on the patient’s lifestyle.
➤ The results are recorded manually regarding the clinical implications of
or in a computerized system for the test results, as appropriate.
recall and postprocedure interpreta- Educate the patient regarding access
tion by the appropriate health care to counseling services. Provide
practitioner. contact information, if desired, for
the American Heart Association
(http://www.americanheart.org).
Post-test:
pressure bandage in place, or provider. Answer any questions or
➤ Nutritional considerations: Increased patient or family.
homocysteine levels may be associ- ➤ Depending on the results of this
ated with atherosclerosis and coro- procedure, additional testing may be
nary artery disease. Nutritional performed to evaluate or monitor
therapy is recommended for individu- progression of the disease process
als identified to be at high risk for and determine the need for a change
developing coronary artery disease. in therapy. Evaluate test results in
If overweight, these patients should relation to the patient’s symptoms
be encouraged to achieve a normal and other tests performed.
Homovanillic Acid 769
Related laboratory tests: complete blood count, C-reactive

protein, creatine kinase and isoen-
➤ Related laboratory tests include zymes, folate, glucose, glycated
antiarrhythmic drugs, apolipoprotein hemoglobin, ketones, lactate dehy-
A, apolipoprotein B, aspartate amino- drogenase and isoenzymes, lipopro-
transferase, atrial natriuretic pep- tein electrophoresis, magnesium,
tide, blood gases, B-type natriuretic myoglobin, pericardial fluid, potas-
peptide, calcium (blood and ionized), sium, triglycerides, troponin, and
cholesterol (total, HDL, and LDL), vitamin B12.
HOMOVANILLIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HVA.
SPECIMEN: Urine (10 mL) from a timed specimen collected in a clean
plastic collection container with 6N HCl as a preservative.
REFERENCE VALUE: (Method: Chromatography)

Homovanillic acid
3–6 y 1.4–4.3 mg/24 h 8–24 mol/24 h
7–10 y 2.1–4.7 mg/24 h 12–26 mol/24 h
11–16 y 2.4–8.7 mg/24 h 13–48 mol/24 h
Adult 1.4–8.8 mg/24 h 8–48 mol/24 h
Vanillylmandelic Acid
3–6 y 1.0–2.6 mg/24 h 5–13 mol/24 h
7–10 y 2.0–3.2 mg/24 h 10–16 mol/24 h
11–16 y 2.3–5.2 mg/24 h 12–26 mol/24 h
Adult 1.4–6.5 mg/24 h 7–33 mol/24 h
DESCRIPTION & RATIONALE: Homo- metabolite of epinephrine and norep-

vanillic acid (HVA) is the main inephrine. Both of these tests should
terminal metabolite of dopamine. be evaluated together for the diagnosis
Vanillylmandelic acid is a major of neuroblastoma. Excretion may
toma, pheochromocytoma, and gan-

be intermittent; therefore, a 24-hour
glioblastoma and to monitor therapy.
specimen is preferred. Creatinine is
usually measured simultaneously to plaints, including a list of known
ensure adequate collection and to cal- allergens (especially allergies or sen-
culate an excretion ratio of metabolite sitivities to latex), and inform the
to creatinine. ■ appropriate health care practitioner
accordingly.
INDICATIONS: ➤ Obtain a history of the patient’s
• Assist in the diagnosis of pheochromo- endocrine system, as well as results
cytoma, neuroblastoma, and gan- of previously performed laboratory
glioblastoma tests, surgical procedures, and other
• Monitor the course of therapy laboratory tests, refer to the
Endocrine System table.
RESULT ➤ Obtain a list of the medications the
Increased in: nutritional supplements, and nutra-
• Ganglioblastoma ceuticals. The requesting health care
• Neuroblastoma advised if the patient regularly uses
• Pheochromocytoma can be taken into consideration
• Riley-Day syndrome when reviewing results.
Decreased in: patient. Provide a nonmetallic urinal,
• Schizotypal personality disorders device. Address concerns about pain
CRITICAL VALUES: N/A the patient that there should be no
INTERFERING FACTORS: ➤ Usually a 24-hour time frame for
• Drugs that may increase HVA levels urine collection is ordered. Inform
include acetylsalicylic acid, disulfiram, the patient that all urine must be
levodopa, pyridoxine, and reserpine. saved during that 24-hour period.
Instruct the patient not to void
• Drugs that may decrease HVA levels directly into the laboratory collection
include moclobemide. container. Instruct the patient to
avoid defecating in the collection
• All urine voided for the timed collec-
device and to keep toilet tissue out
tion period must be included in the of the collection device to prevent
collection or else falsely decreased val- contamination of the specimen.
ues may be obtained. Compare output Place a sign in the bathroom to
records with volume collected to verify remind the patient to save all urine.
that all voids were included in the ➤ Instruct the patient to void all urine
collection. into the collection device and then to
pour the urine into the laboratory col-
lection container. Alternatively, the
Nursing Implications and specimen can be left in the collection
Procedure ● ● ● ● ● ● ● ● ● ● ●
tion container.
Pretest:
➤ Inform the patient that the test issues, as well as concern for mod-
is used to diagnose neuroblas- esty, is important in providing psy-
Homovanillic Acid 771
chological support before, during, replace the tubing and container sys-
and after the procedure. tem at the start of the collection
➤ If possible, and with medical direc- time. Keep the container system on
tion, patients should withhold acetyl- ice during the collection period, or
salicylic acid, disulfiram, pyridoxine, empty the urine into a larger con-
and reserpine for 2 days before spec- tainer periodically during the collec-
imen collection. Levodopa should be tion period; monitor to ensure
withheld for 2 weeks before speci- continued drainage, and conclude
men collection. the test the next morning at the
same hour the collection was begun.
➤ There are no food or fluid restric-
tions, unless by medical direction. ➤ At the conclusion of the test, com-
urinary output record for the collec-
Intratest: tion; if the specimen contains less
➤ Ensure that the patient has complied than what was recorded as output,
with medication restrictions; assure some urine may have been dis-
that specified medications, with carded, invalidating the test.
medical direction, have been ➤ Include on the collection container’s
restricted for at least 2 days prior to label the amount of urine, test start
the procedure. and stop times, and ingestion of any
➤ If the patient has a history of severe foods or medications that can affect
allergic reaction to latex, care should test results.
be taken to avoid the use of equip- ➤ Promptly transport the specimen to
ment containing latex. the laboratory for processing and
➤ Instruct the patient to cooperate fully analysis.
and to follow directions. ➤ The results are recorded manually
➤ Observe standard precautions, and or in a computerized system for
follow the general guidelines in recall and postprocedure interpreta-
Appendix A. Positively identify the tion by the appropriate health care
patient, and label the appropriate practitioner.
demographics, date, and time of Post-test:
collection.
Timed specimen: medications, as directed by the
container, toilet-mounted collection ➤ A written report of the examination
device, and plastic bag (for transport will be sent to the requesting health
of the specimen container). The care practitioner, who will discuss
specimen must be refrigerated or the results with the patient.
kept on ice throughout the entire col- ➤ Recognize anxiety related to test
lection period. If an indwelling uri- results. Discuss the implications
nary catheter is in place, the of abnormal test results on the
drainage bag must be kept on ice. patient’s lifestyle. Provide teaching
➤ Begin the test between 6 a.m. and 8 and information regarding the clinical
a.m., if possible. Collect first voiding implications of the test results, as
and discard. Record the time the appropriate. Educate the patient
specimen was discarded as the regarding access to counseling
beginning of the timed collection services.
period. The next morning, ask the ➤ Reinforce information given by the
patient to void at the same time the patient’s health care provider regard-
collection was started and add this ing further testing, treatment, or
last voiding to the container. referral to another health care pro-
➤ If an indwelling catheter is in place, vider. Answer any questions or

progression of the disease process carcinoembryonic antigen, catecho-
and determine the need for a change lamines (blood and urine), metane-
in therapy. Evaluate test results in phrines, and vanillylmandelic acid.
HUMAN CHORIONIC GONADOTROPIN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Chorionic gonadotropin, pregnancy test, HCG,

hCG, -HCG, -subunit HCG.

Conventional Units Units 1)
Males and nonpregnant Less than 5 mIU/mL Less than 5 IU/L
females
Pregnant females by
week of gestation:
Less than 1 wk 5–50 mIU/mL 5–50 IU/L
2 wk 50–500 mIU/mL 50–500 IU/L
3 wk 100–10,000 mIU/mL 100–10,000 IU/L
4 wk 1,000–30,000 mIU/mL 1,000–30,000 IU/L
5 wk 3,500–115,000 mIU/mL 3,500–115,000 IU/L
6–8 wk 12,000–270,000 mIU/mL 12,000–270,000 IU/L
12 wk 15,000–220,000 mIU/mL 15,000–220,000 IU/L
DESCRIPTION & RATIONALE: Human tion of the fertilized ovum. It stimu-

chorionic gonadotropin (HCG) is a lates secretion of progesterone by the
hormone secreted by the placenta corpus luteum. HCG levels peak at 8
beginning 8 to 10 days after concep- to 12 weeks of gestation and then fall
tion, which coincides with implanta- to less than 10% of first trimester
Human Chorionic Gonadotropin 773
levels by the end of pregnancy. By • Prenatally detect neural tube defects

and trisomy 21 (Down syndrome)
postpartum week 2, levels are unde-
tectable. HCG levels increase at a RESULT
slower rate in ectopic pregnancy and
spontaneous abortion than in normal Increased in:
pregnancy; a low rate of change • Choriocarcinoma
between serial specimens is predictive
of a nonviable fetus. As assays improve • Ectopic HCG-producing tumors
in sensitivity over time, ectopic preg- (stomach, lung, colon, pancreas, liver,
breast)
nancies are increasingly being identi-
fied before rupture. HCG is used • Erythroblastosis fetalis
along with estriol and 1-fetoprotein
• Germ cell tumors (ovary and testes)
in prenatal screening for neural tube
defects. These prenatal measurements • Hydatidiform mole
are also known as triple markers. Serial • Islet cell tumors
measurements are needed for an accu-
rate estimate of gestational stage and • Multiple gestation pregnancy
determination of fetal viability. Triple • Pregnancy
marker testing has also been used to
screen for trisomy 21 (Down syn- Decreased in:
drome). (To compare HCG to other • Ectopic pregnancy
tests in the triple marker screening
• Incomplete abortion
procedure, see monograph titled “1-
Fetoprotein.”) HCG is also produced • Intrauterine fetal demise
by some germ cell tumors. Most assays
• Spontaneous abortion
measure both the intact and free -
HCG subunit, but if HCG is to be • Threatened abortion
used as a tumor marker, the assay must
be capable of detecting both intact CRITICAL VALUES: N/A
and free -HCG. ■
• Drugs that may decrease HCG levels
INDICATIONS: include epostane and mifepristone.
HCG-producing tumors, such as chori- • Results may vary widely depending on
ocarcinoma, germ cell tumors of the the sensitivity and specificity of the
ovary and testes, or hydatidiform moles assay. Performance of the test too early
in pregnancy may cause false-negative
• Confirm pregnancy, assist in the diag-
results. HCG is composed of an and
nosis of suspected ectopic pregnancy, or
a subunit. The structure of the sub-
determine threatened or incomplete
unit is essentially identical to the sub-
abortion
unit of follicle-stimulating hormone,
• Determine adequacy of hormonal lev- luteinizing hormone, and thyroid-
els to maintain pregnancy stimulating hormone. The structure of
the subunit differentiates HCG from
• Monitor effects of surgery or chemo-
the other hormones. False-positive
therapy
results can therefore be obtained if the
• Monitor ovulation induction treatment HCG assay does not detect subunit.

Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient, as appropriate, avoid unnecessary movement.
that the test is used to verify preg- ➤ Observe standard precautions, and
nancy, screen for neural tube defects, follow the general guidelines in
or detect HCG-secreting tumors. Appendix A. Positively identify the
appropriate health care practitioner lect the specimen in a 5-mL red- or
accordingly. tiger-top tube.
➤ Obtain a history of the patient’s ➤ Remove the needle, and apply a pres-
endocrine, immune, and reproduc- sure dressing over the puncture site.
tive systems and results of previ- ➤ Promptly transport the specimen to
ously performed laboratory tests, the laboratory for processing and
surgical procedures, and other diag- analysis.
nostic procedures. For related labo- ➤ The results are recorded manually
ratory tests, refer to the Endocrine, or in a computerized system for
Immune, and Reproductive System recall and postprocedure interpreta-
tables. tion by the appropriate health care
➤ Record the date of the last menstrual practitioner.
ity of pregnancy in perimenopausal Post-test:
women.
ceuticals. The requesting health care pressure bandage in place, or re-
practitioner and laboratory should be place with a plastic bandage.
➤ Review the procedure with the ➤ Social and cultural considerations:
patient. Inform the patient that spec- Recognize anxiety related to abnor-
imen collection takes approximately mal test results, and encourage the
5 to 10 minutes. Address concerns family to seek counseling if con-
about pain related to the procedure. cerned with pregnancy termination or
Explain to the patient that there may to seek genetic counseling if a chro-
be some discomfort during the mosomal abnormality is determined.
venipuncture. Provide teaching and information
➤ There are no food, fluid, or medica- regarding the clinical implications of
tion restrictions, unless by medical the test results, as appropriate.
direction. Decisions regarding elective abortion
should take place in the presence of
Intratest: both parents. Provide a nonjudgmen-
➤ If the patient has a history of severe discussing the risks and difficulties of
allergic reaction to latex, care should delivering and raising a developmen-
Human Immunodeficiency Virus Type 1 and Type 2 Antibodies 775
tally challenged infant, as well as regarding access to counseling serv-

exploring other options (termination ices, as appropriate.
of pregnancy or adoption). It is also ➤ Reinforce information given by the
important to discuss feelings the patient’s health care provider regard-
mother and father may experience ing further testing, treatment, or
(e.g., guilt, depression, anger) if fetal referral to another health care pro-
abnormalities are detected. vider. Answer any questions or
➤ Social and cultural considerations: address any concerns voiced by the
Offer support, as appropriate, to patient or family.
patients who may be the victims of ➤ Depending on the results of this pro-
rape or sexual assault. Educate the cedure, additional testing may be
patient regarding access to counsel- performed to evaluate or monitor the
ing services. Provide a nonjudgmen- patient’s condition and determine
tal, nonthreatening atmosphere for the need for a change in therapy.
a discussion during which risks of Evaluate test results in relation to
sexually transmitted diseases are the patient’s symptoms and other
explained. It is also important to dis- tests performed.
cuss problems the victim of sexual
assault may experience (e.g., guilt,
depression, anger) if there is possi- Related laboratory tests:
bility of pregnancy related to the ➤ Related laboratory tests include
assault. Chlamydia group antibody, chorionic
➤ Social and cultural considerations: In villus biopsy, chromosome analysis,
patients with carcinoma, recognize cytomegalovirus antibody, estradiol,
anxiety related to test results and fetal fibronectin, 1-fetoprotein,
offer support. Provide teaching and hemwatocrit, hemoglobin, proges-
information regarding the clinical terone, rubella antibody, rubeola anti-
implications of abnormal test results, body, syphilis serology, toxoplasma
as appropriate. Educate the patient antibody, and white blood cell count.
HUMAN IMMUNODEFICIENCY VIRUS

TYPE 1 AND TYPE 2 ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HIV-1/HIV-2.

• Nonreactive HIV test results occur dur-

DESCRIPTION & RATIONALE: Human ing the acute stage of the disease, when
immunodeficiency virus (HIV) is the the virus is present but antibodies have
etiologic agent of acquired immunod- not sufficiently developed to be de-
eficiency syndrome (AIDS) and is tected. It may take up to 6 months for
transmitted through bodily secretions, the test to become positive. During this
especially by blood or sexual contact. stage, the test for HIV antigen may not
confirm an HIV infection.
The virus preferentially binds to the
T4 helper lymphocytes and replicates • Test kits for HIV are very sensitive. As
within the cells. Current assays detect a result, nonspecific reactions may
several viral proteins. Positive results occur, leading to a false-positive result.
should be confirmed by Western
blot assay. This test is routinely rec-
ommended as part of a prenatal Nursing Implications and
workup and is required for evaluating Procedure ● ● ● ● ● ● ● ● ● ● ●
donated blood units before release for

transfusion. ■ Pretest:
INDICATIONS: used to test blood for the presence
• Evaluate donated blood units before of antibodies to human inmmunode-
transfusion ficiency virus.
• Perform as part of prenatal screening
• Screen organ transplant donors allergens (especially allergies or sen-
• Test individuals who have documented appropriate health care practitioner
and significant exposure to other accordingly.
infected individuals ➤ Obtain a history of the patient’s
• Test exposed high-risk individuals for immune and reproductive systems,
detection of antibody (e.g., persons a history of high-risk behaviors, and
with multiple sex partners, persons
with a history of other sexually trans- and other diagnostic procedures. For
mitted diseases, intravenous drug users, related laboratory tests, refer to the
infants born to infected mothers, allied Immune and Reproductive System
health care workers, public service tables.
employees who have contact with ➤ Obtain a list of the medications the
blood and blood products) patient is taking, including herbs,
Positive findings in: HIV-1 or HIV- advised if the patient regularly uses
2 infection these products so that their effects
CRITICAL VALUES: N/A ➤ Review the procedure with the
INTERFERING FACTORS: imen collection takes approximately
• Drugs that may decrease HIV antibody 5 to 10 minutes. Address concerns
levels include didanosine, dideoxycyti- about pain related to the procedure.
dine, zalcitabine, and zidovudine. Explain to the patient that there may
Human Immunodeficiency Virus Type 1 and Type 2 Antibodies 777
be some discomfort during the of antibody does not guarantee ab-

venipuncture. sence of infection, because the virus
➤ There are no food, fluid, or medica- may be latent or may not have pro-
tion restrictions, unless by medical duced detectable antibody at the
direction. time of testing.
➤ Make sure a written and informed ➤ Social and cultural considerations:
consent has been signed prior to the Recognize anxiety related to test
procedure and before administering results, and be supportive of
any medications. impaired activity related to weak-
ness, perceived loss of independ-
ence, and fear of shortened life
Intratest: expectancy. Discuss the implications
➤ If the patient has a history of severe patient’s lifestyle. Provide teaching
allergic reaction to latex, care should and information regarding the clinical
be taken to avoid the use of equip- implications of the test results, as
ment containing latex. appropriate. Educate the patient
➤ Instruct the patient to cooperate fully regarding access to counseling serv-
and to follow directions. Direct the ices. Provide contact information, if
patient to breathe normally and to desired, for AIDS information pro-
avoid unnecessary movement. vided by the National Institutes of
➤ Observe standard precautions, and Health (http://www.aidsinfo.nih.gov).
follow the general guidelines in ➤ Social and cultural considerations:
Appendix A. Positively identify the Counsel the patient, as appropriate,
patient, and label the appropriate regarding risk of transmission and
tubes with the corresponding patient proper prophylaxis, and reinforce the
demographics, date, and time of col- importance of strict adherence to
lection. Perform a venipuncture; the treatment regimen.
top tube. ➤ Social and cultural considerations:
Inform patients that positive findings
➤ Remove the needle, and apply a pres- must be reported to local health
sure dressing over the puncture site. department officials, who will ques-
➤ Promptly transport the specimen to tion him or her regarding sexual
the laboratory for processing and partners.
analysis. ➤ Social and cultural considerations:
➤ The results are recorded manually Offer support, as appropriate, to
or in a computerized system for patients who may be the victims of
recall and postprocedure interpreta- rape or sexual assault. Educate the
tion by the appropriate health care patient regarding access to counsel-
practitioner. ing services. Provide a nonjudgmen-
a discussion during which risks of
Post-test: sexually transmitted diseases are ex-
➤ Observe venipuncture site for bleed- plained. It is also important to dis-
ing or hematoma formation. Apply cuss problems the patient may
paper tape or other adhesive to experience (e.g., guilt, depression,
hold pressure bandage in place, or anger).
replace with a plastic bandage. ➤ Inform the patient that retesting may
➤ A written report of the examination be necessary.
will be sent to the requesting health ➤ Reinforce information given by the
care practitioner, who will discuss patient’s health care provider regard-
the results with the patient. ing further testing, treatment, or
➤ Warn the patient that false-positive referral to another health care
results occur and that the absence provider. Answer any questions or

patient or family.
➤ Depending on the results of this pro- ➤ Related laboratory tests include
cedure, additional testing may be CD4/CD8 enumeration, Chlamydia
performed to evaluate or monitor group antibody, complete blood
progression of the disease process count, cytomegalovirus, hepatitis B
and determine the need for a change antibody and antigen, hepatitis C
in therapy. Evaluate test results in antibody, human T-cell lymphotropic
relation to the patient’s symptoms virus types I and II, 2-microglobulin,
and other tests performed. skin culture, and syphilis serology.
HUMAN LEUKOCYTE ANTIGEN B27

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HLA-B27.
SPECIMEN: Whole blood (5 mL) collected in green-top (heparin) or yellow-
top (acid-citrate-dextrose [ACD]) tube.
REFERENCE VALUE: (Method: Flow cytometry) Negative (indicating absence

of the antigen).
RESULT
human leukocyte antigens (HLAs) are Positive findings in:
gene products of the major histocom- • Ankylosing spondylitis
patibility complex, derived from their
• Juvenile rheumatoid arthritis
respective loci on the short arm of
chromosome 6. There are more than • Psoriatic arthritis
27 identified HLAs. HLA-B27 is an
• Reiter’s syndrome
allele (one of two or more genes for an
inheritable trait that occupy the same
location on each chromosome, pater-
nal and maternal) of the HLA-B INTERFERING FACTORS:
locus. The presence of HLA-B27 is • The specimen should be stored at
associated with several specific condi- room temperature and should be
tions, as listed later, but HLA-B27 received by the laboratory perform-
should not be used as a screening test ing the assay within 24 hours of collec-
for these conditions. ■ tion. It is highly recommended that
the laboratory be contacted before
INDICATIONS: Assist in diagnosing anky- specimen collection to avoid specimen
losing spondylitis and Reiter’s syndrome rejection.
Human Leukocyte Antigen B27 779

used to evaluate ankylosing spondy- Appendix A. Positively identify the
litis and other disorders associated patient, and label the appropriate
with HLA-B27. tubes with the corresponding patient
➤ Obtain a history of the patient’s com- collection. Perform a venipuncture;
plaints, including a list of known collect the specimen in a 5-mL
allergens (especially allergies or sen- green- or yellow-top tube.
appropriate health care practitioner ➤ Remove the needle, and apply a pres-
accordingly. sure dressing over the puncture site.
immune and musculoskeletal sys- the laboratory for processing and
tems as well as results of previously analysis.
performed laboratory tests, surgical ➤ The results are recorded manually
tests, refer to the Immune and tion by the appropriate health care
Musculoskeletal System tables. practitioner.
these products so that their effects pressure bandage in place, or
can be taken into consideration replace with a plastic bandage.
when reviewing results. ➤ A written report of the examina-
➤ Review the procedure with the tion will be sent to the requesting
patient. Inform the patient that spec- health care practitioner, who will dis-
imen collection takes approximately cuss the results with the patient.
5 to 10 minutes. Address concerns ➤ Recognize anxiety related to test
about pain related to the procedure. results, and be supportive of per-
Explain to the patient that there may ceived loss of independence and and
be some discomfort during the fear of shortened life expectancy.
venipuncture. These diseases can be moderately
➤ Sensitivity to social and cultural to severely debilitating, resulting in
issues, as well as concern for mod- significant lifestyle changes. Discuss
esty, is important in providing psy- the implications of abnormal test
chological support before, during, results on the patient’s lifestyle.
and after the procedure. Provide teaching and information
➤ There are no food, fluid, or medica- the test results, as appropriate.
tion restrictions, unless by medical Educate the patient regarding access
direction. to counseling services.
Intratest: ➤ Reinforce information given by the
➤ If the patient has a history of severe ing further testing, treatment, or
allergic reaction to latex, care should referral to another health care pro-
be taken to avoid the use of equip- vider. Inform the patient that false-
ment containing latex. positive test results occur and that
retesting may be required. Answer in therapy. Evaluate test results in

any questions or address any con- relation to the patient’s symptoms
cerns voiced by the patient or family. and other tests performed.
progression of the disease process ➤ A related laboratory test is rheuma-
and determine the need for a change toid factor.
HUMAN T-LYMPHOTROPIC VIRUS

TYPE I AND TYPE II ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HTLV-I/HTLV-II.
DESCRIPTION & RATIONALE: Human units be tested for HTLV-I/HTLV-II

T-lymphotropic virus type I (HTLV-I) before release for transfusion. ■
and type II (HTLV-II) are two closely
related retroviruses known to remain INDICATIONS:
latent for extended periods before • Distinguish HTLV-I/HTLV-II infec-
becoming reactive. The viruses are tion from spastic myelopathy
transmitted by sexual contact, contact • Establish HTLV-I as the causative
with blood, placental transfer from agent in adult lymphoblastic (T-cell)
mother to fetus, or ingestion of breast leukemia
milk. As with human immunodefi- • Evaluate donated blood units before
ciency virus type 1 (HIV-1) and type transfusion
2 (HIV-2), HTLV targets the T4 lym- • Evaluate HTLV-II as a contributing
phocytes. The disease is uncommon cause of chronic neuromuscular disease
in the United States, but retrospective
studies conducted by the American RESULT
Red Cross demonstrated that a small
Positive findings in: HTLV-I/
percentage of transfusion recipients HTLV-II infection
became infected by HTLV-positive
blood. The results of this study led to CRITICAL VALUES: N/A
a requirement that all donated blood
Human T-Lymphotropic Virus Type I and Type II Antibodies 781
INTERFERING FACTORS: N/A and to follow directions. Direct the

Procedure ● ● ● ● ● ● ● ● ● ● ●
used to test blood for the presence
of antibodies that would indicate
top tube.
past or current HTLV infection.
site.
sitivities to latex), and inform the ➤ Promptly transport the specimen to
appropriate health care practitioner the laboratory for processing and
accordingly. analysis.
➤ Obtain a history of the patient’s ➤ The results are recorded manually
immune system, a history of high- or in a computerized system for
risk behaviors, and results of previ- recall and postprocedure interpreta-
ously performed laboratory tests, tion by the appropriate health care
surgical procedures, and other diag- practitioner.
ratory tests, refer to the Immune Post-test:
System table. ➤ Observe venipuncture site for bleed-
➤ Obtain a list of the medications ing or hematoma formation. Apply
the patient is taking, including herbs, paper tape or other adhesive to hold
nutritional supplements, and nutra- pressure bandage in place, or
ceuticals. The requesting health care replace with a plastic bandage.
these products so that their effects care practitioner, who will discuss
can be taken into consideration the results with the patient.
➤ Warn the patient that false-positive
➤ Review the procedure with the results occur and that the absence
patient. Inform the patient that spec- of antibody does not guarantee
imen collection takes approximately absence of infection, because the
5 to 10 minutes. Address concerns virus may be latent or not have pro-
about pain related to the procedure. duced detectable antibody at the
Explain to the patient that there may time of testing.
be some discomfort during the ➤ Social and cultural considerations:
venipuncture. Recognize anxiety related to test
➤ There are no food, fluid, or medica- results, and be supportive of im-
tion restrictions, unless by medical paired activity related to weakness,
direction. perceived loss of independence, and
fear of shortened life expectancy.
Intratest: Discuss the implications of positive
➤ If the patient has a history of severe Provide teaching and information
allergic reaction to latex, care should regarding the clinical implications of
be taken to avoid the use of equip- the test results, as appropriate.
ment containing latex. Educate the patient regarding access
➤ Instruct the patient to cooperate fully to counseling services.
➤ Social and cultural considerations: referral to another health care

Counsel the patient, as appropriate, provider. Answer any questions or
regarding risk of transmission and address any concerns voiced by the
proper prophylaxis, and reinforce the patient or family.
importance of strict adherence to ➤ Depending on the results of this pro-
the treatment regimen. cedure, additional testing may be
➤ Inform the patient that the presence performed to evaluate or monitor
of HTLV-I/HTLV-II antibodies pre- progression of the disease process
cludes blood donation, but it does and determine the need for a change
not mean that leukemia or a neuro- in therapy. Evaluate test results in
logic disorder is present or will relation to the patient’s symptoms
develop. and other tests performed.
➤ Inform the patient that subsequent Related laboratory tests:
retesting may be necessary.
➤ Reinforce information given by the complete blood count, hepatitis B, C,
patient’s health care provider regard- and D antigens and antibodies, and
ing further testing, treatment, or HIV-1/HIV-2.
5-HYDROXYINDOLEACETIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: 5-HIAA.
SPECIMEN: Urine (10 mL) from a timed specimen collected in a clean plas-
tic collection container with boric acid as a preservative.
REFERENCE VALUE: (Method: High-pressure liquid chromatography)

2–7 mg/24 h 10.5–36.6 mol/24 h
DESCRIPTION & RATIONALE: Because tumors. This test, which replaces sero-
5-hydroxyindoleacetic acid (5-HIAA) tonin measurement, is most accurate
is a metabolite of serotonin, 5-HIAA when obtained from a 24-hour urine
levels reflect plasma serotonin concen- specimen. ■
trations. 5-HIAA is excreted in the
urine. Increased urinary excretion INDICATIONS: Detect early, small, or
occurs in the presence of carcinoid intermittently secreting carcinoid tumors
5-Hydroxyindoleacetic Acid 783
RESULT 24-hour test period invalidates the

results.
Increased in:
• Celiac and tropical sprue before the procedure may cause the
• Cystic fibrosis procedure to be canceled or repeated.
• Foregut and midgut carcinoid tumors
• Oat cell carcinoma of the bronchus Nursing Implications and
• Ovarian carcinoid tumors Procedure ● ● ● ● ● ● ● ● ● ● ●
• Whipple’s disease Pretest:
Decreased in: ➤ Inform the patient that the test is

used to diagnose carcinoid tumors.
• Depressive illnesses
• Hartnup disease complaints, including a list of known
• Mastocytosis sitivities to latex), and inform the
• Phenylketonuria appropriate health care practitioner
accordingly.
• Renal disease ➤ Obtain a history of the patient’s
• Small intestine resection endocrine, gastrointestinal, and im-
mune system and results of previ-
CRITICAL VALUES: N/A surgical procedures, and other diag-
INTERFERING FACTORS: ratory tests, refer to the Endocrine,
• Drugs that may increase 5-HIAA lev- Gastrointestinal, and Immune Sys-
els include acetaminophen, cisplatin, tem tables.
ephedrine, fluorouracil, cough syrups ➤ Obtain a list of the medications the
containing glyceryl guaiacolate, mel- patient is taking, including herbs,
phalan, mephenesin, methocarbamol, nutritional supplements, and nutra-
naproxen, phenacetin, pindolol, and ceuticals. The requesting health care
rauwolfia alkaloids. practitioner and laboratory should be
• Drugs that may decrease 5-HIAA these products so that their effects
levels include corticotropin, ethanol, can be taken into consideration
imipramine, isoniazid, levodopa, when reviewing results.
methenamine, methyldopa, monoa- ➤ Review the procedure with the
mine oxidase inhibitors, and phenoth- patient. Provide a nonmetallic urinal,
iazines. bedpan, or toilet-mounted collection
• Foods containing serotonin, such as device. Address concerns about pain
avocados, bananas, chocolate, eggplant,
pineapples, plantain, red plums, toma- discomfort during the procedure.
toes, and walnuts, can falsely elevate
levels if ingested within 4 days of spec- ➤ Inform the patient that all urine col-
lected over a 24-hour period must be
imen collection. saved; if a preservative has been
• Severe gastrointestinal disturbance or added to the container, instruct the
diarrhea can interfere with test results. patient not to discard the preserva-
tive. Instruct the patient not to void
• Failure to collect all the urine and directly into the container. Instruct
store the specimen properly during the the patient to avoid defecating in the
collection device and to keep toilet of the specimen container). The

tissue out of the collection device to specimen must be refrigerated or
prevent contamination of the speci- kept on ice throughout the entire
men. Place a sign in the bathroom as collection period. If an indwelling
a reminder to save all urine. urinary catheter is in place, the drain-
➤ Instruct the patient to void all urine age bag must be kept on ice.
into the collection device, then pour ➤ Begin the test between 6 and 8 a.m.,
the urine into the laboratory collec- if possible. Collect first voiding and
tion container. Alternatively, the discard. Record the time the speci-
specimen can be left in the collection men was discarded as the beginning
device for a health care staff mem- of the timed collection period. The
ber to add to the laboratory collec- next morning, ask the patient to void
tion container. at the same time the collection was
➤ Sensitivity to social and cultural started, and add this last voiding to
issues, as well as concern for mod- the container.
esty, is important in providing psy- ➤ If an indwelling catheter is in place,
chological support before, during, replace the tubing and container sys-
and after the procedure. tem at the start of the collection
➤ There are no fluid restrictions unless time. Keep the container system on
by medical direction. ice during the collection period, or
empty the urine into a larger con-
➤ Inform the patient that foods and tainer periodically during the collec-
medications (herbs, nutritional sup- tion period; monitor to ensure
plements, and nutraceuticals) listed continued drainage. Conclude the
under “Interfering Factors” should test the next morning at the same
be restricted by medical direction for hour the collection was begun.
at least 4 days before specimen col-
lection. ➤ At the conclusion of the test, com-
Intratest: urinary output record for the collec-
tion; if the specimen contains less
➤ Ensure that the patient has complied than what was recorded as output,
with dietary and medication restric- some urine may have been dis-
tions; assure foods and medications carded, invalidating the test.
listed under “Interfering Factors” ➤ Include on the specimen collec-
have been restricted for at least 4 tion container’s label the amount of
days prior to the procedure. urine, test start and stop times, and
➤ If the patient has a history of severe ingestion of any foods or medica-
allergic reaction to latex, care should tions that can affect test results.
be taken to avoid the use of equip- Promptly transport the specimen to
ment containing latex. the laboratory for processing and
➤ Instruct the patient to cooperate fully analysis.
and to follow directions. ➤ The results are recorded manually
➤ Observe standard precautions, and or in a computerized system for
follow the general guidelines in recall and postprocedure interpreta-
Appendix A. Positively identify the tion by the appropriate health care
patient, and label the appropriate col- practitioner.
ding patient demographics, date, and Post-test:
time of collection. ➤ Instruct the patient to resume usual
diet, as directed by the health care
Timed specimen:
practitioner. Consideration may be
➤ Obtain a clean 3-L urine specimen given to niacin supplementation and
container, toilet-mounted collection increased protein, if appropriate, for
device, and plastic bag (for transport patients with abnormal findings. In
Hypersensitivity Pneumonitis Serology 785
some cases, the tumor may divert ing further testing, treatment, or
dietary tryptophan to serotonin, re- referral to another health care pro-
sulting in pellagra. vider. Answer any questions or ad-
➤ A written report of the examination patient or family.
results. Discuss the implications of and determine the need for a change
abnormal test results on the pain therapy. Evaluate test results in
tient’s lifestyle. Provide teaching and relation to the patient’s symptoms
information regarding the clinical and other tests performed.
appropriate. Related laboratory tests:
➤ Reinforce information given by the ➤ A related laboratory test is biopsy of
patient’s health care provider regard- the affected tissue.
HYPERSENSITIVITY PNEUMONITIS
SEROLOGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Farmer’s lung disease serology, extrinsic allergic

alveolitis.

REFERENCE VALUE: (Method: Immunodiffusion) Negative.
DESCRIPTION & RATIONALE: Hyper- plexing and cell-mediated immuno-

sensitivity pneumonitis is a respiratory pathogenesis results in a chronic
disease caused by the inhalation of granulomatous pneumonitis of the
organisms from an organic source. interstitial space of the lung. Hyper-
Affected and symptomatic individuals sensitivity pneumonitis serology
will demonstrate acute bronchospastic includes detection of antibodies to
reaction 4 to 6 hours after exposure to Aspergillus fumigatus, Micropolyspora
the offending antigen. Inhalation of faeni, Thermoactinomyces vulgaris, and
the antigen stimulates the production T. candidus. A negative test result does
of immunoglobulin (Ig) G antibodies. not rule out hypersensitivity pneu-
The combination of immunecom- monitis as a possible diagnosis, nor

does a positive test result confirm the
diagnosis. Also, individuals with a advised if the patient regularly uses
positive test result may not exhibit the these products so that their effects
typical symptoms, and patients with can be taken into consideration
severe symptoms may not have when reviewing results.
detectable levels of antibody while ➤ Review the procedure with the
their disease is inactive. To confirm imen collection takes approximately
the diagnosis, it is necessary to obtain 5 to 10 minutes. Address concerns
a sputum culture and chest x-rays. ■ about pain related to the procedure.
INDICATIONS: Assist in establishing a be some discomfort during the
diagnosis of hypersensitivity pneumoni- venipuncture.
tis in patients experiencing fever, chills, ➤ There are no food, fluid, or medica-
and dyspnea after repeated exposure to tion restrictions, unless by medical
moist organic sources direction.
Intratest:
RESULT
Increased in: Hypersensitivity pneu- allergic reaction to latex, care should
monitis be taken to avoid the use of equip-
CRITICAL VALUES: N/A and to follow directions. Direct the
INTERFERING FACTORS: N/A avoid unnecessary movement.
Nursing Implications and Appendix A. Positively identify the
Procedure ● ● ● ● ● ● ● ● ● ● ● patient, and label the appropriate
Pretest: demographics, date, and time of
➤ Inform the patient that the test is collect the specimen in a 5-mL red-
used to establish a diagnosis of top tube.
hypersensitivity pneumonitis.
➤ Obtain a history of the patient’s com- sure dressing over the puncture site.
allergens (especially allergies or sen- ➤ Promptly transport the specimen to
sitivities to latex), and inform the the laboratory for processing and
appropriate health care practitioner analysis.
accordingly. ➤ The results are recorded manually
➤ Obtain a history of the patient’s or in a computerized system for
immune and respiratory systems, as recall and postprocedure interpreta-
well as results of previously per- tion by the appropriate health care
formed laboratory tests, surgical practitioner.
procedures. For related laboratory Post-test:
tests, refer to the Immune and ➤ Observe venipuncture site for bleed-
Respiratory System tables. ing or hematoma formation. Apply
➤ Obtain a list of the medications the paper tape or other adhesive to hold
patient is taking, including herbs, pressure bandage in place, or re-
nutritional supplements, and nutra- place with a plastic bandage.
Hysterosalpingography 787
➤ Nutritional considerations: Positive ened life expectancy. Discuss the

test results may be associated with implications of abnormal test results
respiratory disease. Malnutrition is on the patient’s lifestyle. Provide
commonly seen in patients with teaching and information regarding
severe respiratory disease for rea- the clinical implications of the test
sons including fatigue and lack of results, as appropriate. Educate the
appetite. The importance of follow- patient regarding access to counsel-
ing the prescribed diet should be ing services. Provide contact infor-
stressed to the patient and/or care- mation, if desired, for the American
giver. Lung Association (http://www.lun-
➤ Instruct the patient in preventive gusa.org).
measures for protecting his or her ➤ Reinforce information given by the
lungs (e.g., avoid contact with per- patient’s health care provider regard-
sons who have respiratory or other ing further testing, treatment, or
infections, avoid use of tobacco, referral to another health care pro-
avoid highly polluted areas as well as vider. Answer any questions or
work environments with hazards address any concerns voiced by the
such as fumes, dust, and other res- patient or family.
piratory pollutants). ➤ Depending on the results of this pro-
➤ Instruct the patient in deep breathing cedure, additional testing may be
and pursed-lip breathing to enhance performed to evaluate or monitor
breathing patterns, as appropriate. progression of the disease process
➤ Inform the patient of smoking cessa- and determine the need for a change
tion programs, as appropriate. in therapy. Evaluate test results in
➤ A written report of the examination and other tests performed.
the results with the patient. Related laboratory tests:
➤ Recognize anxiety related to test ➤ Related tests include allergen-specific
results, and be supportive of IgE, arterial/alveolar oxygen ratio,
impaired activity related to lack of chest x-ray, complete blood count,
respiratory function, perceived loss eosinophil count, lung biopsy, and
of independence, and fear of short- sputum culture.
HYSTEROSALPINGOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Uterography, uterosalpingography, hysterogram.

AREA OF APPLICATION: Uterus and fallopian tubes.
• Normal position, shape, and size of the

DESCRIPTION & RATIONALE: Hys- uterine cavity
terosalpingography is generally per-
formed as part of an infertility study Abnormal Findings:
to identify anatomic abnormalities of • Bicornate uterus
the uterus or occlusion of the fallop- • Developmental abnormalities
ian tubes. The procedure allows
visualization of the uterine cavity, fal- • Extrauterine pregnancy
lopian tubes, and peritubal area after • Internal scarring
the injection of contrast medium into
• Kinking of the fallopian tubes due to
the cervix. The contrast medium
adhesions
should flow through the uterine cav-
ity, through the fallopian tubes, and • Partial or complete blockage of fallop-
into the peritoneal cavity, where it ian tube(s)
can be absorbed if no obstruction • Tumors
exists. Passage of the contrast medium
through the tubes may clear mucous • Uterine cavity anomalies
plugs, straighten kinked tubes, or • Uterine fistulas
break up adhesions, thus restoring fer-
tility. This procedure is also used to • Uterine masses or foreign body
evaluate the fallopian tubes after tubal • Uterine fibroid tumors (leiomyomas)
ligation and to evaluate the results of
reconstructive surgery. Risks include INTERFERING FACTORS:
uterine perforation, exposure to radia-
tion, infection, allergic reaction to This procedure is
contrast medium, bleeding, and pul-
monary embolism. ■ • Patients with allergies to shellfish
• Confirm the presence of fistulas or ing allergic reaction. Patients with a
adhesions known hypersensitivity to the contrast
medium may benefit from premedica-
• Confirm tubal abnormalities such as tion with corticosteroids or the use of
adhesions and occlusions nonionic contrast medium.
• Confirm uterine abnormalities such • Patients with bleeding disorders.
as congenital malformation, trauma-
tic injuries, or the presence of foreign • Patients who are pregnant or suspected
bodies of being pregnant, unless the potential
• Detect bicornate uterus the risks to the fetus and mother.
• Evaluate adequacy of surgical tubal • Elderly and other patients who
ligation and reconstructive surgery are chronically dehydrated before
the test, because of their risk of con-
RESULT trast-induced renal failure.
Normal Findings: • Patients who are in renal failure.

• Contrast medium flowing freely into • Patients with menses, undiagnosed
the fallopian tubes and not leaking vaginal bleeding, or pelvic inflamma-
from the uterus tory disease.
Hysterosalpingography 789
• Young patients (17 years and younger), and other pretesting preparations may
unless the benefits of the x-ray diagno- cause the procedure to be canceled or
sis outweigh the risks of exposure to repeated.
high levels of radiation. • Consultation with a health care practi-
Factors that may tioner should occur before the proce-
impair clear imaging: dure for radiation safety concerns
• Gas or feces in the gastrointestinal tract regarding younger patients or patients
resulting from inadequate cleansing or who are lactating.
failure to restrict food intake before the • Risks associated with radiographic over-
study exposure can result from frequent x-ray
• Retained barium from a previous radi- procedures. Personnel in the room with
ologic procedure the patient should wear a protective
• Metallic objects within the examina- leave the area while the examination is
tion field (e.g., jewelry, body rings), being done. Personnel working in the
which may inhibit organ visualization area where the examination is being
and can produce unclear images done should wear badges that reveal
• Improper adjustment of the radi- their level of exposure to radiation.
overexposure or underexposure and a Nursing Implications and
poor-quality study Procedure ● ● ● ● ● ● ● ● ● ● ●

exceed the weight limit for the
equipment ➤ Inform the patient that the procedure
assesses the uterus and fallopian
• Incorrect positioning of the patient, tubes.
which may produce poor visualization ➤ Obtain a history of the patient’s
of the area to be examined complaints, including a list of known
or remain still during the procedure contrast medium, and dyes.
mental status reproductive and genitourinary sys-
• Insufficient injection of contrast me- tems, and results of previously
dium performed diagnostic procedures,
surgical procedures, and laboratory
• Excessive traction during the test or tests. For related diagnostic tests,
tubal spasm, which may cause the refer to the Reproductive and
appearance of a stricture in an other- Genitourinary System tables.
wise normal fallopian tube ➤ Ensure that this procedure is per-
Other considerations: testinal study or barium swallow.
• Excessive traction during the test may ➤ Record the date of the last menstrual
displace adhesions, making the fallop- period and determine the possibil-
ian tubes appear normal. ity of pregnancy in perimenopausal
women.
chest pain or severe cardiac arrhythmias patient is taking.
occur.
• Failure to follow dietary restrictions patient. Address concerns about pain
related to the procedure. Explain to tion’s procedure. Administer enemas

the patient that some pain may or suppositories on the morning of
be experienced during the test, and the test, as ordered.
there may be moments of discom- ➤ Have emergency equipment readily
fort. Explain to the patient that she available.
may feel temporary sensations of
➤ Patients are given a gown and robe
nausea, dizziness, slow heartbeat,
to wear and instructed to void prior
and menstrual-like cramping during
to the procedure.
the procedure and shoulder pain
from subphrenic irritation from the ➤ Instruct the patient to cooperate fully
contrast medium as it spills into the and to follow directions. Instruct the
peritoneal cavity. Explain the pur- patient to remain still throughout the
pose of the test and how the proce- procedure because movement pro-
dure is performed. Inform the patient duces unreliable results.
that the procedure is performed in a ➤ Observe standard precautions, and
radiology department, usually by a follow the general guidelines in
health care practitioner and support Appendix A.
staff, and takes approximately 30 to ➤ Remove any wires connected to
60 minutes. electrodes, if allowed.
➤ Sensitivity to cultural and social ➤ Place the patient in a lithotomy posi-
issues, as well as concern for mod- tion on the fluoroscopy table.
chological support before, during and ➤ A kidney, ureter, and bladder (KUB)
after the procedure. film is taken to ensure that no stool,
gas, or barium will obscure visualiza-
➤ Instruct the patient to fast and tion of the uterus and fallopian tubes.
➤ A speculum is inserted into the
procedure.
vagina, and contrast medium is intro-
➤ Patients receiving metformin (Glu- duced into the uterus through the
cophage) for non–insulin-dependent cervix via a cannula, after which both
(type 2) diabetes should discontinue fluoroscopic and radiographic films
the drug on the day of the test and are taken.
continue to withhold it for 48 hours
➤ To take oblique views, the table
may be tilted or the patient may be
asked to change position during the
➤ Instruct the patient to take a laxative procedure.
or a cathartic, as ordered, on the ➤ The results are recorded manu-
evening before the examination. ally, on film, or by automated equip-
➤ Instruct the patient to remove jew- ment in a computerized system for
elry (including watches), credit cards, recall and postprocedure interpreta-
and other metallic objects. tion by the appropriate health care
➤ Make sure a written and informed practitioner.
procedure and before administering Post-test:
any medications. ➤ Instruct the patient to resume usual
diet, fluids, medications, or activ-
Intratest: ity, as directed by the health care
➤ Ensure that the patient has complied practitioner.
with dietary and medication restric- ➤ Monitor for reaction to iodinated
tions and pretesting preparations contrast medium, including rash,
for at least 6 hours prior to the urticaria, tachycardia, hyperpnea, hy-
procedure. Ensure the patient has pertension, palpitations, nausea, or
removed all external metallic objects vomiting.
prior to the procedure. ➤ Monitor urinary output after the pro-
➤ Assess for completion of bowel cedure. Decreased urine output may
preparation according to the institu- indicate impending renal failure.
Immunofixation Electrophoresis, Blood and Urine 791
➤ Evaluate the patient for signs of infec- and information regarding the clinical
tion, such as pain, fever, increased implications of the test results, as
pulse rate, chills, flushing, abdominal appropriate.
pain, tachycardia, or muscle aches. ➤ Reinforce information given by
➤ Inform the patient that a vaginal dis- the patient’s health care provider
charge is common and that it may regarding further testing, treatment,
be bloody, lasting 1 to 2 days after or referral to another health care
the test. provider. Answer any questions or
➤ Inform the patient that dizziness and address any concerns voiced by the
cramping may follow this procedure, patient or family.
and that analgesia may be given if ➤ Depending on the results of this pro-
there is persistent cramping. Instruct cedure, additional testing may be
the patient to contact the health care needed to evaluate or monitor pro-
practitioner in the event of severe gression of the disease process and
cramping or profuse bleeding. determine the need for a change in
➤ A written report of the examina- therapy. Evaluate test results in rela-
tion will be completed by a health tion to the patient’s symptoms and
care practitioner specializing in this other tests performed.
be sent to the requesting health care Related diagnostic tests:
practitioner, who will discuss the ➤ Related diagnostic tests include com-
results with the patient. puted tomography of the abdomen,
➤ Recognize anxiety related to test kidney and urine bladder studies,
results. Discuss the implications magnetic resonance imaging of the
of abnormal test results on the abdomen, and ultrasound of the
patient’s lifestyle. Provide teaching pelvis.
IMMUNOFIXATION ELECTROPHORESIS,
BLOOD AND URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: IFE.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Urine (10 mL)
from a random collection in a clean plastic container.
REFERENCE VALUE: (Method: Immunoprecipitation combined with
electrophoresis) Test results are interpreted by a pathologist. Normal
placement and intensity of staining provide information about the
immunoglobulin bands.
DESCRIPTION & RATIONALE: Imm- immunoglobulins according to their

unofixation electrophoresis (IFE) is a electrical charges. Abnormalities are
qualitative technique that provides a revealed by changes produced in the
detailed separation of individual individual bands, such as displace-
with respect to the type and quantity

ment, color, or absence of color. Urine
of immunoglobulins in blood and
IFE has replaced the Bence Jones urine.
screening test for light chains. IFE ➤ Obtain a history of the patient’s com-
has replaced immunoelectrophoresis plaints, including a list of known
because it is more sensitive and easier allergens (especially allergies or sen-
to interpret. ■ sitivities to latex), and inform the
INDICATIONS: accordingly.
• Assist in the diagnosis of multiple ➤ Obtain a history of the patient’s
myeloma and amyloidosis hematopoietic and immune sys-
• Assist in the diagnosis of suspected performed laboratory tests, surgi-
immunodeficiency cal procedures, and other diagnostic
• Assist in the diagnosis of suspected tests, refer to the Hematopoietic and
immunoproliferative disorders, such as Immune System tables.
multiple myeloma and Waldenström’s ➤ Note any recent procedures that can
macroglobulinemia interfere with test results. Assess
• Identify biclonal or monoclonal gam- whether the patient received any
mopathies vaccinations or immunizations within
the last 6 months or any blood or
• Identify cryoglobulinemia blood components within the last 6
weeks.
• Monitor the effectiveness of chemother-
apy or radiation therapy
RESULT: See monograph titled “Immuno- ceuticals. The requesting health care
globulins A, D, G, and M.” practitioner and laboratory should be
• Drugs that may increase immunoglob- ➤ Review the procedure with the
ulin levels include asparaginase, cimeti- patient. Inform the patient that spec-
dine, and narcotics. imen collection takes approximately
• Drugs that may decrease immunoglob- about pain related to the procedure.
ulin levels include dextran, oral contra- Explain to the patient that there
ceptives, methylprednisolone (high may be some discomfort during the
doses), and phenytoin. venipuncture.
• Chemotherapy and radiation treat- ➤ Provide a nonmetallic urinal, bedpan,

or toilet-mounted collection device.
ments may alter the width of the bands
and make interpretation difficult. ➤ Usually a 24-hour time frame for
Nursing Implications and Instruct the patient not to void
Procedure ● ● ● ● ● ● ● ● ● ● ● directly into the laboratory collection
container. Instruct the patient to
Pretest: avoid defecating in the collection
device and to keep toilet tissue out
➤ Inform the patient that the test is of the collection device to prevent
used to assess the immune system contamination of the specimen.
Immunofixation Electrophoresis, Blood and Urine 793
Place a sign in the bathroom to thoroughly wash her hands; (2)

remind the patient to save all urine. cleanse the labia from front to back;
➤ Instruct the patient to void all urine (3) while keeping the labia separated,
into the collection device and then to void a small amount into the toilet;
pour the urine into the laboratory col- and (4) without interrupting the urine
lection container. Alternatively the stream, void directly into the speci-
specimen can be left in the collection men container.
Blood or urine:
tion container. ➤ Promptly transport the specimen to
➤ Sensitivity to cultural and social the laboratory for processing and
issues, as well as concern for mod- analysis.
esty, is important in providing psy- ➤ The results are recorded manually
chological support before, during, or in a computerized system for
and after the procedure. recall and postprocedure interpreta-
➤ There are no food, fluid, or medication by the appropriate health care
tion restrictions, unless by medical practitioner.
direction.
Post-test:
Intratest:
allergic reaction to latex, care should paper tape or other adhesive to hold
be taken to avoid the use of equip- pressure bandage in place, or re-
ment containing latex. place with a plastic bandage.
Appendix A. Positively identify the ing further testing, treatment, or
patient, and label the appropriate referral to another health care pro-
specimen containers with the corre- vider. Answer any questions or
sponding patient demographics, address any concerns voiced by the
date, and time of collection. patient or family.
Blood: cedure, additional testing may be
➤ Perform a venipuncture; collect the performed to evaluate or monitor
specimen in a 5-mL red-top tube. progression of the disease process
➤ Remove the needle, and apply a and determine the need for a change
pressure dressing over the puncture in therapy. Evaluate test results in
site. relation to the patient’s symptoms
Urine:
➤ Instruct the male patient to (1) thor- bone marrow biopsy, lymph node
oughly wash his hands, (2) cleanse biopsy, complete blood count with
the meatus, (3) void a small amount examination of peripheral smear,
into the toilet, and (4) void directly quantitative immunoglobulin levels,
into the specimen container. protein quantitative (blood and urine)
➤ Instruct the female patient to (1) and fractions, and urinalysis.
IMMUNOGLOBULIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: IgE.
SI Units
Newborn Less than 12 IU/mL Less than 120 mg/L
Less than 1 y Less than 50 IU/mL Less than 500 mg/L
2–4 y Less than 100 IU/mL Less than 1000 mg/L
5 y and older Less than 300 IU/mL Less than 3000 mg/L
DESCRIPTION & RATIONALE: Imm- The inflammatory response allows

unoglobulin E (IgE) is an antibody proteins from the bloodstream to
whose primary response is to allergic enter the tissues. Helminths (worm
reactions and parasitic infections. parasites) are especially susceptible to
Most of the body’s IgE is bound to immunoglobulin-mediated cytotoxic
specialized tissue cells; little is avail- chemicals. The inflammatory reaction
able in the circulating blood. IgE proteins attract macrophages from the
binds to the membrane of special circulatory system and granulocytes,
granulocytes called basophils in the such as eosinophils, from circulation
circulating blood and mast cells in the and bone marrow. Eosinophils also
tissues. Basophil and mast cell mem- contain enzymes effective against the
branes have receptors for IgE. Mast parasitic invaders. ■
cells are abundant in the skin and
the tissues lining the respiratory INDICATIONS: Assist in the evaluation of
and alimentary tracts. When IgE allergy and parasitic infection
antibody becomes cross-linked with
RESULT
antigen/allergen, the release of hista-
mine, heparin, and other chemicals Increased in:
from the granules in the cells is trig- • Alcoholism
gered. A sequence of events follows • Allergy
activation of IgE that affects smooth
muscle contraction, vascular perme- • Asthma
ability, and inflammatory reactions. • Bronchopulmonary aspergillosis
Immunoglobulin E 795
• Dermatitis ➤ Obtain a history of the patient’s

• Eczema as well as results of previously per-
• Hay fever formed laboratory tests, surgical
procedures, and other diagnos-
• IgE myeloma tic procedures. For related laboratory
• Parasitic infestation Respiratory System tables.
• Rhinitis ➤ Obtain a list of the medications the
• Sinusitis nutritional supplements, and neutra-
• Wiskott-Aldrich syndrome ceuticals. The requesting health care
Decreased in:
• Advanced carcinoma can be taken into consideration
• Agammaglobulinemia when reviewing results.
• Ataxia-telangiectasia patient. Inform the patient that spec-
• IgE deficiency imen collection takes approximately
CRITICAL VALUES: N/A Explain to the patient that there may
INTERFERING FACTORS: venipuncture.
• Drugs that may cause a decrease in IgE ➤ There are no food, fluid, or medica-
levels include phenytoin and trypto- tion restrictions, unless by medical
phan. direction.
• Penicillin G has been associated with
increased IgE levels in some patients Intratest:
with drug-induced acute interstitial ➤ If the patient has a history of severe
nephritis. allergic reaction to latex, care should
• Normal IgE levels do not elimi- ment containing latex.
nate allergic disorders as a possible
diagnosis. ➤ Instruct the patient to cooperate fully
Nursing Implications and ➤ Observe standard precautions, and
Procedure ● ● ● ● ● ● ● ● ● ● ● follow the general guidelines in
Pretest: patient, and label the appropriate
➤ Inform the patient that the test is demographics, date, and time of col-
used to assess IgE levels in order to lection. Perform a venipuncture; col-
identify the presence of an allergic or lect the specimen in a 5-mL red- or
inflammatory immune system tiger-top tube.
response.
➤ Obtain a history of the patient’s com- sure dressing over the puncture site.
allergens (especially allergies or sen- ➤ Promptly transport the specimen to
sitivities to latex), and inform the the laboratory for processing and
appropriate health care practitioner analysis.
accordingly. ➤ The results are recorded manually
or in a computerized system for ing further testing, treatment, or

recall and postprocedure interpreta- referral to another health care pro-
tion by the appropriate health care vider. Answer any questions or
practitioner. address any concerns voiced by the
patient or family.
➤ Observe venipuncture site for bleed- procedure, additional testing may
ing or hematoma formation. Apply be performed to evaluate or monitor
paper tape or other adhesive to progression of the patient’s condi-
hold pressure bandage in place, or tion and determine the need for a
replace with a plastic bandage. change in therapy. Evaluate test
results in relation to the patient’s
➤ A written report of the examination symptoms and other tests per-
will be sent to the requesting health formed.
➤ Nutritional considerations: Increased Related laboratory tests:
IgE levels may be associated with ➤ Related laboratory tests include
allergy. Consideration should be allergen-specific IgE, alveolar/arterial
given to diet if the patient has food gradient and arterial/alveolar oxygen
allergies. ratio, blood gases, complete blood
➤ Reinforce information given by the count, eosinophil count, hypersensi-
patient’s health care provider regard- tivity pneumonitis, and theophylline.
IMMUNOGLOBULINS A, D, G, AND M
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: IgA, IgD, IgG, and IgM.


Immunoglobulin A
Newborn 1–4 mg/dL 0.01–0.04 g/L
1–9 mo 2–80 mg/dL 0.02–0.80 g/L
10–12 mo 15–90 mg/dL 0.15–0.90 g/L
2–3 y 18–150 mg/dL 0.18–1.50 g/L
4–5 y 25–160 mg/dL 0.25–1.60 g/L
6–8 y 35–200 mg/dL 0.35–2.00 g/L
9–12 y 45–250 mg/dL 0.45–2.50 g/L
Older than 12 y 40–350 mg/dL 0.40–3.50 g/L
Immunoglobulins A, D, G, and M 797

Immunoglobulin D
Newborn Greater than 2 mg/dL Greater than 20 mg/L
Adult Less than 15 mg/dL Less than 150 mg/L
Immunoglobulin G
Newborn 650–1600 mg/dL 6.5–16 g/L
1–9 mo 250–900 mg/dL 2.5–9 g/L
10–12 mo 290–1070 mg/dL 2.9–10.7 g/L
2–3 y 420–1200 mg/dL 4.2–12 g/L
4–6 y 460–1240 mg/dL 4.6–12.4 g/L
Greater than 6 y 650–1600 mg/dL 6.5–16 g/L
Immunoglobulin M
Newborn Less than 25 mg/dL Less than 0.25 g/L
1–9 mo 20–125 mg/dL 0.2–1.25 g/L
10–12 mo 40–150 mg/dL 0.4–1.5 g/L
2–8 y 45–200 mg/dL 0.45–2.0 g/L
9–12 y 50–250 mg/dL 0.5–2.5 g/L
Greater than 12 y 50–300 mg/dL 0.5–3.0 g/L
DESCRIPTION & RATIONALE: Imm- long-term defense against disease. It

unoglobulins A, D, E, G, and M are is the only antibody that crosses
made by plasma cells in response to the placenta. IgM is the largest
foreign particles. Immunoglobulins immunoglobulin, and it is the first
neutralize toxic substances, support antibody to react to an antigenic stim-
phagocytosis, and destroy invading ulus. IgM also forms natural antibod-
microorganisms. They are made up of ies, such as ABO blood group
heavy and light chains. Immunoglob- antibodies. The presence of IgM in
ulins produced by the proliferation of cord blood is an indication of congen-
a single plasma cell (clone) are called ital infection. ■
monoclonal. Polyclonal increases result
when multiple cell lines produce anti-
body. IgA is found mainly in secre-
INDICATIONS:
• Assist in the diagnosis of multiple
tions such as tears, saliva, and breast
myeloma
milk. It is believed to protect mucous
membranes from viruses and bacteria. • Evaluate humoral immunity status
The function of IgD is not well under- • Monitor therapy for multiple myeloma
stood. For details on IgE, see the • IgA: Evaluate patients suspected of IgA
monograph titled “Immunoglobulin deficiency prior to transfusion. Evaluate
E.” IgG is the predominant serum anaphylaxis associated with the transfu-
immunoglobulin and is important in sion of blood and blood products (anti-
IgA antibodies may develop in patients Chronic hepatocellular disease

with low levels of IgA, possibly result- Collagen vascular disease
ing in anaphylaxis when donated blood Early response to bacterial or
is transfused) parasitic infection
Hyper-IgM dysgammaglobulinemia
RESULT Rheumatoid arthritis
Increases in: Variable in nephrotic syndrome
Viral infection (hepatitis or
IgA: mononucleosis)
• Polyclonal:
• Monoclonal:
Chronic liver disease
Cold agglutinin hemolysis disease
Immunodeficiency states, such as
Wiskott-Aldrich syndrome Malignant lymphoma
Inflammatory bowel disease Neoplasms (especially GI tract)
Lower GI cancer Reticulosis
Rheumatoid arthritis Waldenström’s macroglobulinemia
• Monoclonal: Decreases in:

IgA-type multiple myeloma
IgA:
• Ataxia-telangiectasia
IgD:
• Polyclonal: • Chronic sinopulmonary disease
Certain liver diseases • Genetic IgA deficiency
Chronic infections
Connective tissue disorders IgD:
• Monoclonal: • Genetic IgD deficiency
IgD-type multiple myeloma • Malignant melanoma of the skin
• Pre-eclampsia
IgG:
• Polyclonal: IgG:
Autoimmune diseases, such as • Burns
systemic lupus erythematosus,
rheumatoid arthritis, and
• Genetic IgG deficiency
Sjögren’s syndrome • Nephrotic syndrome
Chronic liver disease
• Pregnancy
Chronic or recurrent infections
Intrauterine devices IgM:
Sarcoidosis • Burns
• Monoclonal: • Secondary IgM deficiency associated
IgG-type multiple myeloma with IgG or IgA gammopathies
Leukemias
Lymphomas CRITICAL VALUES: N/A
IgM: • Drugs that may increase immunoglob-
• Polyclonal: ulin levels include asparaginase, cimeti-
Active sarcoidosis dine, and narcotics.
Immunoglobulins A, D, G, and M 799
• Drugs that may decrease immunoglob- imen collection takes approximately

ulin levels include dextran, oral contra- 5 to 10 minutes. Address concerns
ceptives, methylprednisolone (high about pain related to the procedure.
doses), and phenytoin. Explain to the patient that there may
• Chemotherapy, immunosuppressive venipuncture.
therapy, and radiation treatments ➤ There are no food, fluid, or medica-
decrease immunoglobulin levels. tion restrictions, unless by medical
direction.
• Specimens with macroglobulins, cryo-
globulins, or cold agglutinins tested at
cold temperatures may give falsely low Intratest:
values. ➤ If the patient has a history of severe
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to assess the immune system follow the general guidelines in
with respect to the quantity of Appendix A. Positively identify the
immunoglobulin levels present in the patient, and label the appropriate
blood. tubes with the corresponding patient
plaints, including a list of known lection. Perform a venipuncture;
accordingly. sure dressing over the puncture site.
gastrointestinal, hematopoietic,
immune, and musculoskeletal sys-
analysis.
performed laboratory tests, surgical ➤ The results are recorded manually
tests, refer to the Gastrointestinal, tion by the appropriate health care
Hematopoietic, Immune, and practitioner.
➤ Obtain a list of medications the Post-test:
practitioner and laboratory should be paper tape or other adhesive to hold
advised if the patient regularly uses pressure bandage in place, or
can be taken into consideration ➤ A written report of the examination
when reviewing results. will be sent to the requesting health
➤ Note any recent procedures that can care practitioner, who will discuss
interfere with test results. the results with the patient.
patient. Inform the patient that spec- patient’s health care provider regard-
ing further testing, treatment, or relation to the patient’s symptoms

referral to another health care and other tests performed.
patient or family.
➤ Related laboratory tests include bone
➤ Depending on the results of this pro- marrow biopsy, blood groups and anti-
cedure, additional testing may be bodies, complete blood count with
performed to evaluate or monitor evaluation of peripheral smear, immu-
progression of the disease process nofixation electrophoresis (blood and
and determine the need for a change urine), protein quantitative (blood and
in therapy. Evaluate test results in urine) and fractions, and urinalysis.
IMMUNOSUPPRESSANTS:
CYCLOSPORINE,
METHOTREXATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Cyclosporine (Sandimmune), methotrexate (MTX,

amethopterin, Folex, Rheumatrex), methotrexate sodium (Mexate).
SPECIMEN: Whole blood (1 mL) collected in lavender-top tube for

cyclosporine. Serum (1 mL) collected in a red-top tube for methotrexate.
Immunosuppressant Administration Collection Time
Cyclosporine Oral 12 h after dose
Methotrexate Oral Varies according to dosing
protocol
Intramuscular Varies according to dosing
protocol
Important note: This information must be clearly and accurately communi-

cated to avoid misunderstanding of the dose time in relation to the collection
time. Miscommunication between the individual administering the medica-
tion and the individual collecting the specimen is the most frequent cause of
subtherapeutic levels, toxic levels, and misleading information used in calcula-
tion of future doses.

Immunosuppressants: Cyclosporine, Methotrexate 801
Therapeutic Half- Volume of Protein Excre-

Dose Life Distribution Binding tion
Conven- SI Units
tional (Conven-
Units (tional
Units
0.832)
Cyclo- 100–250 83–208 8–24 h 4–6 L/kg 90% Renal
sporine ng/mL nmol/L
Renal
transplant
100–400 83–333 8–24 h 4–6 L/kg 90% Renal
ng/mL nmol/L
Cardiac
transplant
100–300 83–250 8–24 h 4–6 L/kg 90% Renal
ng/mL nmol/L
Bone
marrow
transplant
100–400 83–333 8–24 h 4–6 L/kg 90% Renal
ng/mL nmol/L
Liver
transplant
Metho- 0.01–5.00 8–15 h 0.4–1.0 50–70% Renal
trexate mol/L* L/kg
*Dependent on therapeutic approach.
DESCRIPTION & RATIONALE: Cyclo- as foods, herbals, vitamins, and miner-

sporine is an immunosuppressive drug als that can either potentiate or inhibit
used in the management of organ the intended target concentration. ■
rejection, especially rejection of heart,
liver, and kidney transplants. Its most INDICATIONS
serious side effect is renal impairment
Cyclosporine:
or renal failure. Methotrexate is a
highly toxic drug that causes cell • Assist in the management of treatments
to prevent organ rejection
death by disrupting DNA synthesis.
Many factors must be considered in • Monitor for toxicity
therapeutic drugs, including patient Methotrexate:
age, weight, interacting medications, • Monitor effectiveness of treatment of
electrolyte balance, protein levels, cancer and some autoimmune disor-
water balance, and conditions that ders
affect absorption and excretion; as well • Monitor for toxicity
RESULT (citrovorum or leucovorin). 5-Formylte-

trahydrofolate allows higher doses of
methotrexate to be given.
Normal levels Therapeutic
effect INTERFERING FACTORS:
Toxic levels Adjust dose • Numerous drugs interact with
as indicated cyclosporine and either increase
Cyclosporine Renal cyclosporine levels or increase the
impairment risk of toxicity. These drugs include
Methotrexate Renal acyclovir, aminoglycosides, amio-
impairment darone, amphotericin B, anabolic
steroids, cephalosporins, cimetidine,
danazol, erythromycin, furosemide,
CRITICAL VALUES: It is important ketoconazole, melphalan, methylpred-
to note the adverse effects of toxic and nisolone, miconazole, nonsteroidal
subtherapeutic levels. Care must be taken anti-inflammatory drugs (NSAIDs),
to investigate signs and symptoms of too oral contraceptives, and trimethoprim-
little and too much medication. Note and sulfamethoxazole.
immediately report to the health care • Drugs that may decrease cyclosporine
practitioner any critically increased values levels include carbamazepine, ethotoin,
and related symptoms. mephenytoin, phenobarbital, pheny-
Cyclosporine: Greater than 400 toin, primidone, and rifampin.
ng/mL
Signs and symptoms of cyclosporine • Drugs that may increase methotrexate
toxicity include increased severity of levels or increase the risk of toxicity
expected side effects, which include nau- include NSAIDs, probenecid, salicy-
sea, stomatitis, vomiting, anorexia, hyper- late, and sulfonamides.
tension, infection, fluid retention, • Antibiotics may decrease the absorp-
hypercalcemic metabolic acidosis, tremor, tion of methotrexate.
seizures, headache, and flushing. Possible
interventions include close monitoring of
blood levels to make dosing adjustments, Nursing Implications and
inducing emesis (if orally ingested), per- Procedure ● ● ● ● ● ● ● ● ● ● ●
forming gastric lavage (if orally ingested),
withholding the drug, and initiating Pretest:
alternative therapy for a short time until
the patient is stabilized. ➤ Inform the patient that the test is
Methotrexate: Greater than 5.00
toxic drug levels.
mol/L after 24 h; greater than
0.50 mol/L after 48 h; greater ➤ Obtain a history of the patient’s com-
than 0.05 mol/L after 72 h plaints, including a list of known
Signs and symptoms of methotrexate
toxicity include increased severity of appropriate health care practitioner
expected side effects, which include nau- accordingly.
sea, stomatitis, vomiting, anorexia, bleed-
ing, infection, bone marrow depression, genitourinary and immune systems,
and, over a prolonged period of use, as well as results of previously
hepatotoxicity. The effect of methotrexate performed laboratory tests, surgical
on normal cells can be reversed by admin- procedures, and other diagnostic
istration of 5-formyltetrahydrofolate procedures. For related laboratory
Immunosuppressants: Cyclosporine, Methotrexate 803
tests, refer to the Genitourinary and pressure dressing over the puncture
Immune System and Therapeutic/ site.
Toxicology table. ➤ Promptly transport the specimen to
➤ Obtain a list of the medications the the laboratory for processing and
patient is taking, including herbs, analysis.
nutritional supplements, and nutra- ➤ The results are recorded manually
ceuticals. Note the last time and or in a computerized system for
dose of medication taken. The re- recall and postprocedure interpreta-
questing health care practitioner and tion by the appropriate health care
laboratory should be advised if the practitioner.
into consideration when reviewing Post-test:
results.
➤ Review the procedure with the ing or hematoma formation. Apply
patient. Inform the patient that spec- paper tape or other adhesive to
imen collection takes approximately hold pressure bandage in place, or
5 to 10 minutes. Address concerns replace with a plastic bandage.
Explain to the patient that there may ➤ Nutritional considerations: Patients
be some discomfort during the taking immunosuppressant therapy
venipuncture. tend to have decreased appetites
due to the side effects of the
➤ Sensitivity to cultural and social medication. Instruct patients to con-
issues, as well as concern for mod- sume a variety of foods within the
esty, is important in providing psy- basic food groups, maintain a healthy
chological support before, during, weight, be physically active, limit salt
and after the procedure. intake, limit alcohol intake, and be a
➤ There are no food, fluid, or medica- nonsmoker.
tion restrictions, unless by medical ➤ A written report of the examination
direction. will be sent to the requesting health
Intratest: the results with the patient.
➤ If the patient has a history of severe ➤ Recognize anxiety related to test
allergic reaction to latex, care should results, and offer support. Patients
be taken to avoid the use of equip- receiving these drugs usually have
ment containing latex. conditions that can be intermittently
➤ Instruct the patient to cooperate fully moderately to severely debilitat-
and to follow directions. Direct the ing, resulting in significant lifestyle
patient to breathe normally and to changes. Educate the patient regard-
avoid unnecessary movement. ing access to counseling services, as
appropriate.
follow the general guidelines in ➤ Reinforce information given by the
Appendix A. Consider recommended patient’s health care provider regard-
collection time with regard to dosing ing further testing, treatment, or
schedule. Positively identify the referral to another health care pro-
patient, and label the appropriate vider. Explain to the patient the
tubes with the corresponding patient importance of following the medica-
demographics, date, and time of col- tion regimen and give instructions
lection. Perform a venipuncture; col- regarding drug interactions. Answer
lect the specimen in a lavender-top any questions or address any con-
tube for cyclosporine and a red-top cerns voiced by the patient or family.
tube for methotrexate. ➤ Instruct the patient to be prepared to
➤ Remove the needle, and apply a provide the pharmacist with a list of
other medications he or she is and determine the need for a change

already taking in the event that the in therapy. Evaluate test results in
requesting health care practitioner relation to the patient’s symptoms
prescribes a medication. and other tests performed.
be performed to evaluate or monitor ➤ Related laboratory tests include
progression of the disease process blood urea nitrogen and creatinine.
INFECTIOUS MONONUCLEOSIS SCREEN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Monospot, heterophil antibody test, IM serology.

REFERENCE VALUE: (Method: Agglutination) Negative.
DESCRIPTION & RATIONALE: Infec- phoma, nasopharyngeal carcinoma,

tious mononucleosis is caused by the and chronic fatigue syndrome. If the
Epstein-Barr virus (EBV). The incu- results of the heterophil antibody
bation period is 10 to 50 days, and screening test are negative and infec-
the symptoms last 1 to 4 weeks after tious mononucleosis is highly sus-
the infection has fully developed. The pected, EBV-specific serology should
hallmark of EBV infection is the pres- be requested. ■
ence of heterophil antibodies, also
called Paul-Bunnell-Davidsohn anti- INDICATIONS: Assist in confirming infec-
bodies, which are immunoglobulin M tious mononucleosis
(IgM) antibodies that agglutinate RESULT
sheep or horse red blood cells. The
disease induces formation of abnor- Positive findings in:
mal lymphocytes in the lymph Infectious mononucleosis
nodes; stimulates increased formation
of heterophil antibodies; and is char- CRITICAL VALUES: N/A
acterized by fever, cervical lym- INTERFERING FACTORS:
phadenopathy, tonsillopharyngitis, • False-positive results may occur in
and hepatosplenomegaly. EBV is also the presence of narcotic addiction,
thought to play a role in Burkitt’s lym- serum sickness, lymphomas, hepatitis,
Infectious Mononucleosis Screen 805
leukemia, cancer of the pancreas, and Intratest:

phenytoin therapy.
• A false-negative result may occur if allergic reaction to latex, care should
treatment was begun before antibodies be taken to avoid the use of equip-
developed or if the test was done less ment containing latex.
than 6 days after exposure to the virus. ➤ Instruct the patient to cooperate fully
Procedure ● ● ● ● ● ● ● ● ● ● ●
mononucleosis infection. lection. Perform a venipuncture;
➤ Obtain a history of the patient’s com- collect the specimen in a 5-mL red-
plaints, including a list of known top tube.
allergens (especially allergies or sen- ➤ Remove the needle, and apply a pres-
accordingly. Obtain a history of the laboratory for processing and
exposure. analysis.
hepatobiliary and immune systems, or in a computerized system for
as well as results of previously per- recall and postprocedure interpreta-
formed laboratory tests, surgical tion by the appropriate health care
procedures, and other diagnostic practitioner.
Immune System tables. Post-test:
➤ Note any recent therapies that can ➤ Observe venipuncture site for bleed-
➤ Obtain a list of medications the paper tape or other adhesive to hold
patient is taking, including herbs, pressure bandage in place, or
nutritional supplements, and nutra- replace with a plastic bandage.
ceuticals. The requesting health care ➤ Inform the patient that approxi-
practitioner and laboratory should be mately 10% of all results are false-
advised if the patient regularly uses negative or false-positive. Inform the
these products so that their effects patient that signs and symptoms of
can be taken into consideration infection include fever, chills, sore
when reviewing results. throat, enlarged lymph nodes, and
➤ Review the procedure with the fatigue. Self-care while the disease
patient. Inform the patient that spec- runs its course includes adequate
imen collection takes approximately fluid and nutritional intake along with
5 to 10 minutes. Address concerns sufficient rest. Activities that cause
about pain related to the procedure. fatigue or stress should be avoided.
Explain to the patient that there may ➤ A written report of the examination
be some discomfort during the will be sent to the requesting health
tion restrictions, unless by medical ➤ Reinforce information given by
direction. the patient’s health care provider
regarding further testing, treatment, progression of the disease process

or referral to another health care and determine the need for a change
provider. Advise the patient to refrain in therapy. Evaluate test results in
from direct contact with others relation to the patient’s symptoms
because the disease is transmitted and other tests performed.
through saliva. Answer any ques-
by the patient or family. Related laboratory tests:
➤ Depending on the results of this ➤ Related laboratory tests include
procedure, additional testing may be complete blood count with periph-
performed to evaluate or monitor eral blood smear evaluation.
INSULIN AND INSULIN RESPONSE

TO GLUCOSE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units Tolerance
(Conventional for Glucose
Insulin Units 6.945) (Hypoglycemia)
Fasting Less than 25 Less than 174 65–115 mg/dL
mIU/L pmol/L
30 min 30–230 mIU/L 208–1597 pmol/L N/A
1h 18–276 mIU/L 125–1917 pmol/L Less than 200 mg/dL
2h 16–166 mIU/L 111–1153 pmol/L Less than 140 mg/dL
3h Less than 25 Less than 174 65–120 mg/dL
mIU/L pmol/L
mIU/L pmol/L
mIU/L pmol/L
Insulin and Insulin Response to Glucose 807
DESCRIPTION & RATIONALE: Insulin • Diabetes
is secreted in response to elevated
blood glucose, and its overall effect is • Excessive administration of insulin
to promote glucose use and energy • Insulin- and proinsulin-secreting tu-
storage. The insulin response test mors (insulinomas)
measures the rate of insulin secreted • Obesity
by the beta cells of the islets of
• Reactive hypoglycemia in developing
Langerhans in the pancreas; it may diabetes
be performed simultaneously with a
5-hour glucose tolerance test for • Severe liver disease
hypoglycemia. ■
Decreased in:
• Beta cell failure
INDICATIONS:
• Assist in the diagnosis of early or devel- CRITICAL VALUES: NA
oping non–insulin-dependent (type 2)
diabetes, as indicated by excessive pro- INTERFERING FACTORS:
duction of insulin in relation to blood • Drugs and substances that may increase
glucose levels (best shown with glucose insulin levels include acetohexamide,
tolerance tests or 2-hour postprandial alanine, albuterol, amino acids,
tests) beclomethasone, betamethasone, brox-
• Assist in the diagnosis of insulinoma, as aterol, calcium gluconate, cannabis,
indicated by sustained high levels of chlorpropamide, cyclic AMP, glibor-
insulin and absence of blood nuride, glipizide, glisoxepide, glucagon,
glucose–related variations glyburide, ibopamine, insulin, insulin-
like growth factor–I, oral contracep-
• Confirm functional hypoglycemia, as tives, pancreozymin, prednisolone,
indicated by circulating insulin levels prednisone, rifampin, salbutamol,
appropriate to changing blood glucose terbutaline, tolazamide, tolbutamide,
levels trichlormethiazide, and verapamil.
• Differentiate between insulin-resistant • Drugs that may decrease insulin levels
diabetes, in which insulin levels are include acarbose, asparaginase, calci-
high, and non–insulin-resistant dia- tonin, cimetidine, clofibrate, dexfenflu-
betes, in which insulin levels are low ramine, diltiazem, doxazosin, enalapril,
• Evaluate fasting hypoglycemia of enprostil, ether, hydroxypropyl methyl-
unknown cause cellulose, insulin-like growth factor–I,
metformin, niacin, nifedipine, nitren-
• Evaluate postprandial hypoglycemia of dipine, octreotide, phenytoin, propra-
unknown cause nolol, and psyllium.
• Evaluate uncontrolled insulin-depend- • Administration of insulin or oral hypo-
ent (type 1) diabetes glycemic agents within 8 hours of the
test can lead to falsely elevated levels.
RESULT • Hemodialysis destroys insulin and
affects test results.
Increased in:
• Acromegaly
can interfere with test results when
• Alcohol use radioimmunoassay is the test method.
➤ Hypoglycemia: Serial specimens for

Nursing Implications and insulin levels are collected in con-
Procedure ● ● ● ● ● ● ● ● ● ● ● junction with glucose levels after
administration of a 100-g glucose
Pretest: load. The patient should be prepared
as for a standard oral glucose toler-
➤ Inform the patient that the test is ance test over a 5-hour period.
used to assist in the evaluation of
fasting hypoglycemia.
plaints, including a list of known Intratest:
sitivities to latex), and inform the ➤ Ensure that the patient has complied
appropriate health care practitioner with dietary or medication restric-
accordingly. tions and other pretesting prepara-
➤ Obtain a history of the patient’s tions; assure that food or medications
endocrine system and results of pre- have been restricted as instructed
viously performed laboratory tests, prior to the specific procedure’s
surgical procedures, and other diag- protocol.
nostic procedures. For related labo- ➤ If the patient has a history of severe
ratory tests, refer to the Endocrine allergic reaction to latex, care should
System table. be taken to avoid the use of equip-
➤ Note any recent procedures that can ment containing latex.
interfere with test results. ➤ Instruct the patient to cooperate fully
➤ Obtain a list of the medications the and to follow directions. Direct the
patient is taking, including herbs, patient to breathe normally and to
nutritional supplements and nutra- avoid unnecessary movement.
ceuticals. Note the last time and dose ➤ Observe standard precautions, and
of medication taken. The requesting follow the general guidelines in
health care practitioner and labora- Appendix A. Positively identify the
tory should be advised if the patient patient, and label the appropriate
regularly uses these products so their tubes with the corresponding patient
effects can be taken into considera- demographics, date, and time of col-
tion when reviewing results. lection. Perform a venipuncture;
➤ Review the procedure with the collect the specimen in a 5-mL red-
patient. Inform the patient that multi- top tube.
ple specimens may be required. ➤ Remove the needle, and apply a
Inform the patient that specimen col- pressure dressing over the puncture
lection takes approximately 5 to 10 site.
minutes. Address concerns about ➤ Promptly transport the specimen to
pain related to the procedure. the laboratory for processing and
Explain to the patient that there may analysis.
venipuncture. ➤ The results are recorded manually
or in a computerized system for re-
➤ Sensitivity to cultural and social call and postprocedure interpretation
issues, as well as concern for mod- by the appropriate health care practi-
esty, is important in providing psy- tioner.
Post-test:
➤ If a single sample is to be collected,
the patient should have fasted and ➤ Observe venipuncture site for bleed-
refrained, with medical direction, ing or hematoma formation. Apply
from taking insulin or other oral paper tape or other adhesive to hold
hypoglycemic agents for at least 8 pressure bandage in place, or
hours before specimen collection. replace with a plastic bandage.
Insulin Antibodies 809
➤ Instruct the patient to resume usual test results on the patient’s lifestyle.
diet and medication, as directed by Provide teaching and information
the health care practitioner. regarding the clinical implications of
➤ Nutritional considerations: Increased the test results, as appropriate.
insulin levels may be associated with Emphasize, as appropriate, that good
diabetes. The nutritional needs of glycemic control delays the onset of
each diabetic patient need to be and slows the progression of dia-
determined individually (especially betic retinopathy, nephropathy, and
during pregnancy) by a health care neuropathy. Educate the patient
practitioner trained in nutrition. regarding access to counseling serv-
Patients who adhere to dietary rec- ices. Provide contact information, if
ommendations report a better gen- desired, for the American Diabetes
eral feeling of health, better weight Association (http://www.diabetes.
management, greater control of glu- org).
cose and lipid values, and improved ➤ Reinforce information given by the
use of insulin. There is no “diabetic patient’s health care provider regard-
diet”; however, many meal-planning ing further testing, treatment, or
approaches with nutritional goals are referral to another health care pro-
endorsed by the American Dietetic vider. Answer any questions or
Association. address any concerns voiced by the
➤ Impaired glucose tolerance may be patient or family.
associated with diabetes. Instruct the ➤ Depending on the results of this pro-
patient and caregiver to report signs cedure, additional testing may be
and symptoms of hypoglycemia performed to evaluate or monitor
(weakness, confusion, diaphoresis, progression of the disease process
rapid pulse) or hyperglycemia (thirst, and determine the need for a change
polyuria, hunger, lethargy). in therapy. Evaluate test results in
the results with the patient. Related laboratory tests:
➤ Recognize anxiety related to test ➤ Related laboratory tests include
results, and be supportive of per- C-peptide, fructosamine, glucose,
ceived loss of independence and glucose tolerance tests, glycated
fear of shortened life expectancy. hemoglobin, insulin antibodies, and
Discuss the implications of abnormal microalbumin.
INSULIN ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
REFERENCE VALUE: (Method: Radioimmunoassay) Less than 3%; includes
binding of human, beef, and pork insulin to antibodies in patient’s serum.
nosis, and management of type I

DESCRIPTION & RATIONALE: The diabetes.
most common anti-insulin antibody ➤ Obtain a history of the patient’s com-
is immunoglobulin (Ig) G, but IgA, plaints, including a list of known
IgM, IgD, and IgE antibodies also
have anti-insulin properties. These appropriate health care practitioner
antibodies usually do not cause clini- accordingly.
cal problems, but they may compli- ➤ Obtain a history of the patient’s
cate insulin assay testing. IgM is endocrine and immune systems, as
thought to participate in insulin well as results of previously per-
resistance and IgE in insulin allergy.
Improvements in the purity of animal procedures. For related laboratory
insulin and increased use of human tests, refer to the Endocrine and
insulin have resulted in a significant Immune System tables.
decrease in the incidence of insulin ➤ Note any recent procedures that can
antibody formation. ■ interfere with test results.
INDICATIONS: patient is taking, including herbs,
• Assist in confirming insulin resistance nutritional supplements, and nutra-
ceuticals. Note the last time and dose
• Assist in determining if hypoglycemia of medication taken. The request-
is caused by insulin abuse ing health care practitioner and labo-
ratory should be advised if the patient
• Assist in determining insulin allergy is regularly using these products
RESULT into consideration when reviewing
• Factitious hypoglycemia results.
• Insulin allergy or resistance ➤ Review the procedure with the pa-
• Polyendocrine autoimmune syndromes men collection takes approximately
• Steroid-induced diabetes (a side effect about pain related to the procedure.
of treatment for systemic lupus erythe- Explain to the patient that there may
matosus) be some discomfort during the
venipuncture.
Decreased in: N/A ➤ Sensitivity to cultural and social
CRITICAL VALUES: N/A esty, is important in providing psy-
INTERFERING FACTORS: Recent radioac- and after the procedure.
tive scans or radiation can interfere with ➤ There are no food, fluid, or medica-
test results when radioimmunoassay is the tion restrictions, unless by medical
test method. direction.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to assist in the prediction, diag- and to follow directions. Direct the
Insulin Antibodies 811
patient to breathe normally and to patient and caregiver to report signs

avoid unnecessary movement. and symptoms of hypoglycemia
➤ Observe standard precautions, and (weakness, confusion, diaphoresis,
follow the general guidelines in rapid pulse) or hyperglycemia (thirst,
Appendix A. Positively identify the polyuria, hunger, lethargy).
patient, and label the appropriate ➤ A written report of the examination
tubes with the corresponding patient will be sent to the requesting health
demographics, date, and time of col- care practitioner, who will discuss
lection. Perform a venipuncture; the results with the patient.
top tube.
➤ Remove the needle, and apply a pres- ceived loss of independence and
sure dressing over the puncture site. fear of shortened life expectancy.
➤ Promptly transport the specimen to Discuss the implications of abnormal
the laboratory for processing and test results on the patient’s lifestyle.
Emphasize, as appropriate, that good
glycemic control delays the onset
of and slows the progression of
practitioner.
diabetic retinopathy, nephropathy,
and neuropathy. Educate the patient
Post-test: regarding access to counseling
➤ Observe venipuncture site for bleed- services. Provide contact informa-
ing or hematoma formation. Apply tion, if desired, for the American
paper tape or other adhesive to Diabetes Association (http://www.
hold pressure bandage in place, or diabetes.org).
replace with a plastic bandage. ➤ Reinforce information given by the
➤ Instruct the patient to resume usual patient’s health care provider regard-
diet and medication, as directed by ing further testing, treatment, or
the health care practitioner. referral to another health care pro-
➤ Nutritional considerations: The nutri- vider. Answer any questions or
tional needs of each diabetic patient address any concerns voiced by the
need to be determined individu- patient or family.
ally (especially during pregnancy) ➤ Depending on the results of this
by a health care practitioner trained procedure, additional testing may
in nutrition. Patients who adhere be performed to evaluate or monitor
to dietary recommendations report a progression of the disease process
better general feeling of health, bet- and determine the need for a change
ter weight management, greater in therapy. Evaluate test results in
control of glucose and lipid values, relation to the patient’s symptoms
and improved use of insulin. There is and other tests performed.
no “diabetic diet”; however, many
meal-planning approaches with nutri-
tional goals are endorsed by the Related laboratory tests:
American Dietetic Association. ➤ Related laboratory tests include C-
➤ Impaired glucose tolerance may be peptide, glucose, glucose tolerance
associated with diabetes. Instruct the tests, and insulin.
INTRAOCULAR MUSCLE FUNCTION

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: IOM function.

CONTRAST: N/A.
DESCRIPTION & RATIONALE: Evalua- movement is controlled by three

tion of ocular motility is performed nerves. The actions of the muscles vary
to detect and measure muscle imbal- depending on the position of the eye
ance in conditions classified as het- when they become innervated. The
erotropias or heterophorias. This cover test is commonly used because it
evaluation is performed in a manner is reliable, easy to perform, and does
to assess fixation of each eye, align- not require special equipment. The
ment of both eyes in all directions, and cover test method is described in this
the ability of both eyes to work monograph. Another method for eval-
together binocularly. Heterophorias uation of ocular muscle function is the
are latent ocular deviations kept in corneal light reflex test. It is useful
check by the binocular power of with patients who cannot cooperate
fusion, and made intermittent by dis- for prism cover testing or for patients
rupting fusion. Heterotropias are con- who have poor fixation. ■
ditions that manifest constant ocular
deviations. The prefixes eso- (tendency INDICATIONS:
for the eye to turn in), exo- (tendency • Detection and evaluation of extraocular
for the eye to turn out), and hyper- muscle imbalance
(tendency for one eye to turn up) indi- RESULT
cate the direction in which the affected The examiner should determine the range
eye moves spontaneously. Strabismus is of ocular movements in all gaze positions,
the failure of both eyes to sponta- usually to include up and out, in, down
neously fixate on the same object and out, up and in, down and in, and
because of a muscular imbalance out. Limited movements in gaze position
(crossed eyes). Amblyopia, or lazy eye, can be recorded semiquantitatively as –1
is a term used for loss of vision in one (minimal), –2 (moderate), –3 (severe), or
–4 (total).
or both eyes that cannot be attributed
to an organic pathologic condition of Normal Findings:
the eye or optic nerve. There are six • Normal range of ocular movements in
extraocular muscles in each eye whose all gaze positions.
Intraocular Muscle Function 813
Abnormal Findings: the patient regularly uses these

• Amblyopia products so that their effects can
be taken into consideration when
• Heterophorias reviewing results.
• Heterotropias patient. Address concerns about pain
• Strabismus related to the procedure. Explain to
the patient that no discomfort will
be experienced during the test.
CRITICAL VALUES: N/A Inform the patient that a technician,
optometrist, orthoptist, or physician
INTERFERING FACTORS: performs the test, in a quiet room,
and that to evaluate both eyes, the
Factors that may impair the test can take 2 to 4 minutes.
results of the examination: ➤ Instruct the patient to remove con-
• Inability of the patient to cooperate tact lenses or glasses, as appropri-
and remain still during the test because ate. Instruct the patient regarding
of age, significant pain, or mental sta- the importance of keeping the eyes
tus may interfere with the test results. open for the test.
• Rubbing or squeezing the eyes may tion restrictions, unless by medical
affect results. direction.
Intratest:
Nursing Implications and ➤ Instruct the patient to cooperate
Procedure ● ● ● ● ● ● ● ● ● ● ● fully and to follow directions. Ask
the patient to remain still during the
Pretest: procedure because movement pro-
➤ Inform the patient that the proce-
dure evaluates extraocular muscle ➤ One eye is tested at a time. The
function. patient is given a fixation point, usu-
ally the testing personnel’s index
➤ Obtain a history of the patient’s finger. An object, such as a small
complaints, including a list of known toy, can be used to ensure fixation
allergens. in pediatric patients. The patient
➤ Obtain a history of the patient’s is asked to follow the fixation point
known or suspected vision loss, with his or her gaze in the direction
changes in visual acuity, including the fixation point moves. When test-
type and cause; use of glasses or ing is completed, the procedure is
contact lenses; eye conditions with repeated using the other eye. The
treatment regimens; eye surgery; procedure is performed at distance
and other tests and procedures to and near, first with and then without
assess and diagnose visual deficit. corrective lenses.
➤ Obtain a history of results of previ- ➤ The results are recorded manually
ously performed laboratory tests, for recall and postprocedure interpre-
surgical procedures, and other diag- tation by the appropriate health care
nostic procedures. practitioner.
➤ Obtain a list of the medications Post-test:
herbs, nutritional supplements, and ➤ A written report of the examina-
nutraceuticals. The requesting health tion will be completed by a health
care practitioner should be advised if care practitioner specializing in this
branch of medicine. The report will retraining. The mode of therapy in

be sent to the requesting health care itself does not correct vision. It is the
practitioner, who will discuss the process by which the brain becomes
results with the patient. readapted to accept, receive, and
➤ Recognize anxiety related to test store visual images received by the
results, and be supportive of eye that results in vision correction.
impaired activity related to vision Therefore, the patient must be pre-
loss, perceived loss of driving privi- pared to be alert, cooperative, and
leges, or the possibility of requiring properly motivated. Answer any
corrective lenses (self-image). questions or address any concerns
ing further testing, treatment, or performed to evaluate or monitor
provider. Educate the patient, as and determine the need for a change
appropriate, that he or she may be in therapy. Evaluate test results in
referred for special therapy to correct relation to the patient’s symptoms
the anomaly, which may include and other tests performed.
glasses, prisms, eye exercises, eye
patches, or chemical patching with
drugs that modify the focusing power
of the eye. The patient and family ➤ Related diagnostic tests include
should be educated that the chosen refraction and slit-lamp biomi-
therapy involves a process of mental croscopy.
INTRAOCULAR PRESSURE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: IOP.
CONTRAST: N/A.
DESCRIPTION & RATIONALE: The hydration of the body. Individual eyes

pressure of the eye depends on a num- respond to intraocular pressures dif-
ber of factors. The two most signifi- ferently. Some can tolerate high pres-
cant are the amount of aqueous sures (20 to 30 mm Hg), and some
humor present in the eye and the cir- will incur optic nerve damage at lower
cumstances by which it leaves the eye. pressures. With respiration, variations
Other physiologic variables that affect of up to 4 mm Hg in IOP can occur,
intraocular pressure (IOP) include and changes of 1 to 2 mm Hg occur
respiration, pulse, and the degree of with every pulsation of the central
Intraocular Pressure 815
retinal artery. IOP is measured with a pupil fixed and dilated, accompanied
tonometer; normal values indicate the by a complaint of moderate pain. Pupil
pressure at which no damage is done dilation can be initiated by emotional
to the intraocular contents. arousal or fear, conditions in which the
The rate of fluid leaving the eye, or eye must adapt to darkness (movie
its ability to leave the eye unimpeded, is theaters), or mydriatics. Angle-closure
the most important factor regulating glaucoma is an ocular emergency
IOP. There are three primary condi- that is resolved by a peripheral iridec-
tions that result in occlusion of the out- tomy to allow movement of fluid
flow channels for fluid. The most between the anterior and posterior
common condition is open-angle glau- chambers. This procedure constitutes
coma, in which the diameter of the removal of a portion of the peripheral
openings of the trabecular meshwork iris either by surgery or by use of an
becomes narrowed, resulting in an argon or yttrium-aluminum-garnet
increased IOP due to an increased (YAG) laser. ■
resistance of fluid moving out of the
eye. In secondary glaucoma, the tra- INDICATIONS:
becular meshwork becomes occluded • Diagnosis or ongoing monitoring of
by tumor cells, pigment, red blood cells glaucoma
in hyphema, or other material. Addi- • Screening test included in a routine eye
tionally, the obstructing material may examination
cover parts of the meshwork itself, as
with scar tissue or other types of adhe- RESULT
sions that form after severe iritis, an Normal Findings:
angle closure glaucoma attack, or a • Normal intraocular pressure is between
central retinal vein occlusion. The 13 and 22 mm Hg.
third condition impeding fluid out-
flow in the trabecular channels occurs Abnormal Findings:
with pupillary block, most commonly • Open-angle glaucoma
associated with primary angle-closure • Primary angle closure glaucoma
glaucoma. In eyes predisposed to this
condition, dilation of the pupil causes • Secondary glaucoma
the iris to fold up like an accordion
against the narrow-angle structures of
the eye. Fluid in the posterior chamber INTERFERING FACTORS:
has difficulty circulating into the ante- • Inability of the patient to remain still
rior chamber; therefore, pressure in the and cooperative during the test may
posterior chamber increases, causing interfere with the test results.
the iris to bow forward and obstruct
the outflow channels even more. Nursing Implications and
Angle-closure attacks occur quite sud- Procedure ● ● ● ● ● ● ● ● ● ● ●
denly and therefore do not give the eye

a chance to adjust itself to the sudden Pretest:
increase in pressure. The eye becomes ➤ Inform the patient that the procedure
very red, the cornea edematous (pa- measures the intraocular pressure of
tient may report seeing halos), and the the eye.
➤ Obtain a history of the patient’s tion restrictions, unless by medical

complaints, including a list of known direction.
sitivities to topical anesthetic eye- Intratest:
drops.
➤ Obtain a history of the patient’s and to follow directions. Ask the
known or suspected vision loss, patient to remain still during the pro-
changes in visual acuity, including cedure because any movement,
type and cause; use of glasses or such as coughing, breath holding, or
contact lenses; eye conditions with wandering eye movements, pro-
treatment regimens; eye surgery; duces unreliable results.
and other tests and procedures to
assess and diagnose visual deficit. ➤ Seat the patient comfortably. Instruct
the patient to look at directed target
➤ Obtain a history of results of previ- while the eyes are examined.
surgical procedures, and other diag- ➤ Instill ordered topical anesthetic in
nostic procedures. each eye, as ordered, and allow
time for it to work. Topical anesthetic
➤ Obtain a list of the medications the drops are placed in the eye with the
patient is taking, including herbs, patient looking up and the solution
nutritional supplements, and nutra- directed at the six o’clock position of
ceuticals. The requesting health care the sclera (white of the eye) near the
practitioner should be advised if the limbus (grey, semitransparent area
patient regularly uses these products of the eyeball where the cornea and
so that their effects can be taken sclera meet). The dropper bottle
into consideration when reviewing should not touch the eyelashes.
results.
➤ Instruct the patient to look straight
➤ Review the procedure with the ahead, keeping the eyes open and
patient. Explain that the patient will unblinking.
ing the procedure. Address concerns ➤ A number of techniques are used
about pain related to the procedure. to measure intraocular pres-sure.
Explain to the patient that he or Intraocular pressure can be meas-
she may feel coldness or a slight sting ured at the slit lamp or with a
when the anesthetic drops are in- miniaturized, handheld applanation
stilled at the beginning of the proce- tonometer or an airpuff tonometer.
dure, but that no discomfort will be ➤ When the applanation tonometer is
experienced during the test. Instruct positioned on the patient’s cornea,
the patient as to what should be place the instrument’s headrest
expected with the use of the tonome- against the patient’s forehead. The
ter. The patient will experience less tonometer should be held at an
anxiety if he or she understands that angle with the handle slanted away
the tonometer tip will touch the from the patient’s nose. The tonome-
tear film and not the eye directly. ter tip should not touch the eyelids.
Inform the patient that a technician, ➤ When the tip is properly aligned and
optometrist, or physician performs in contact with the fluorescein-
the test, in a quiet, darkened room, stained tear film, force is applied to
and that to evaluate both eyes, the the tip using an adjustment control
test can take 1 to 3 minutes. to the desired endpoint. The tonome-
➤ Instruct the patient to remove con- ter is removed from the eye. The
tact lenses or glasses, as appropri- reading is taken a second time and,
ate. Instruct the patient regarding if the pressure is elevated, a third
the importance of keeping the eyes reading is taken. The procedure is
open for the test. repeated on the other eye.
➤ There are no food, fluid, or medica- ➤ With the airpuff tonometer, an air
Intravenous Pyelography 817
pump blows air onto the cornea, and referral to another health care
the time it takes for the air puff to provider. Answer any questions or
flatten the cornea is detected by address any concerns voiced by the
infrared light and photoelectric cells. patient or family.
This time is directly related to the ➤ Instruct the patient in the use of any
intraocular pressure. ordered medications, usually eye-
➤ The results are recorded manually, drops, that are intended to decrease
taking care to denote left and right intraocular pressure. Explain the
readings, for recall and postproce- importance of adhering to the ther-
dure interpretation by the appropri- apy regimen, especially since in-
ate health care practitioner. creased intraocular pressure does
not present symptoms. Instruct the
Post-test: patient in both the ocular side effects
➤ A written report of the examina- with the prescribed medication.
tion will be completed by a health Encourage him or her to review cor-
care practitioner specializing in this responding literature provided by a
branch of medicine. The report will pharmacist.
practitioner, who will discuss the ➤ Depending on the results of this pro-
results with the patient. cedure, additional testing may be
results, and be supportive of impaired and determine the need for a change
activity related to vision loss or per- in therapy. Evaluate test results in
ceived loss of driving privileges. relation to the patient’s symptoms
Discuss the implications of abnormal and other tests performed.
regarding the clinical implications of Related diagnostic tests:
the test results, as appropriate. ➤ Related diagnostic tests include
➤ Reinforce information given by the fundus photography, gonioscopy,
patient’s health care provider regard- nerve fiber analysis, slit-lamp biomi-
ing further testing, treatment, or croscopy, and visual field testing.
INTRAVENOUS PYELOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Excretory urography (EUG), intravenous urogra-

phy (IVU, IUG), IVP.
AREA OF APPLICATION: Kidneys, ureters, bladder, and renal pelvis.

CONTRAST: Intravenous radiopaque iodine-based contrast medium.
RESULT
DESCRIPTION & RATIONALE: Intra-
venous pyelography (IVP) is the most Normal Findings:
commonly performed test to deter- • Normal size and shape of kidneys,
mine urinary tract dysfunction or ureters, and bladder
renal disease. IVP uses IV radiopaque
• Normal bladder and absence of masses
contrast medium to visualize the kid- or renal calculi, with prompt visualiza-
neys, ureters, bladder, and renal pelvis. tion of contrast medium through the
The contrast medium concentrates in urinary system
the blood and is filtered out by the
glomeruli; it passes out through the Abnormal Findings:
renal tubules and is concentrated in • Absence of a kidney (congenital mal-
the urine. Renal function is reflected formation)
by the length of time it takes the con-
• Benign and malignant kidney tumors
trast medium to appear and to be
excreted by each kidney. A series of • Bladder tumors
x-rays is performed during a 30- • Congenital renal or urinary tract
minute period to view passage of the abnormalities
medium through the kidneys and
ureters into the bladder. A final film is
taken after the patient empties the • Hydronephrosis
bladder (postvoiding film). Com- • Prostatic enlargement
puted tomography may be employed
during the examination to permit the • Pyelonephritis
examination of an individual layer • Renal cysts
or plane of the organ that may be
obscured by surrounding overlying • Renal hematomas
structures. ■ • Renal or ureteral calculi
• Soft-tissue masses
INDICATIONS:
• Aid in the diagnosis of renovascular • Tumors of the collecting system
hypertension
• Evaluate the cause of blood in the urine
• Evaluate the effects of urinary system INTERFERING FACTORS:
trauma
This procedure is
• Evaluate function of the kidneys, contraindicated for:
ureters, and bladder • Patients with allergies to shellfish
• Evaluate known or suspected ureteral or iodinated dye. The contrast
obstruction medium used may cause a life-threaten-
• Evaluate the presence of renal, ureter, known hypersensitivity to the contrast
or bladder calculi medium may benefit from premedica-
• Evaluate space-occupying lesions or
congenital anomalies of the urinary sys-
tem • Patients with bleeding disorders.
Intravenous Pyelography 819
• Patients who are pregnant or suspected • Inability of the patient to cooperate

of being pregnant, unless the potential or remain still during the procedure
benefits of the procedure far outweigh because of age, significant pain, or
the risks to the fetus and mother. mental status
• Elderly and other patients who are • End-stage renal disease, which may
chronically dehydrated before the produce an examination of poor quality
test, because of their risk of contrast-
induced renal failure. Other considerations:
• Patients who are in renal failure. • The procedure may be terminated if
• Patients with renal insufficiency, indi- occur.
cated by a blood urea nitrogen value
greater than 40 mg/dL, because con- • Failure to follow dietary restrictions
trast medium can complicate kidney and other pretesting preparations may
function. cause the procedure to be canceled or
repeated.
younger), unless the benefits of the x- • Consultation with a health care practi-
ray diagnosis outweigh the risks of tioner should occur before the proce-
exposure to high levels of radiation. dure for radiation safety concerns
• Patients with multiple myeloma, who who are lactating.
may experience decreased kidney func-
tion subsequent to administration of • Risks associated with radiographic over-
contrast medium. exposure can result from frequent x-ray
Factors that may the patient should wear a protective
impair clear imaging: lead apron, stand behind a shield, or
• Gas or feces in the gastrointestinal tract leave the area while the examination is
resulting from inadequate cleansing or being done. Personnel working in the
failure to restrict food intake before the area where the examination is being
study done should wear badges that reveal
ologic procedure
• Metallic objects within the examina- Nursing Implications and
tion field (e.g., jewelry, body rings), Procedure ● ● ● ● ● ● ● ● ● ● ●
and can produce unclear images Pretest:
• Improper adjustment of the radi- ➤ Inform the patient that the procedure
ographic equipment to accommodate assesses the kidneys, ureters, and
obese or thin patients, which can cause bladder.
overexposure or underexposure and a ➤ Obtain a history of the patient’s com-
poor-quality study plaints or symptoms, including a list
• Patients who are very obese, who of known allergens, especially aller-
may exceed the weight limit for the gies or sensitivities to latex, iodine,
equipment
• Incorrect positioning of the patient, gastrointestinal and genitourinary
which may produce poor visualization systems, and results of previously
of the area to be examined performed diagnostic procedures,
surgical procedures, and laboratory Intratest:

tests. For related diagnostic tests,
refer to the Gastrointestinal and ➤ Ensure that the patient has complied
Genitourinary System tables. with dietary and medication restric-
➤ Ensure that this procedure is per- tions and pretesting preparations for
formed before an upper gastroin- at least 8 hours prior to the proce-
testinal study or barium swallow. dure. Ensure that the patient has
➤ Record the date of the last menstrual prior to the procedure.
ity of pregnancy in perimenopausal ➤ Assess for completion of bowel pre-
women. paration according to the institution’s
procedure. Administer enemas or
➤ Obtain a list of the medications the suppositories on the morning of the
patient is taking. test, as ordered.
➤ Review the procedure with the pa- ➤ Have emergency equipment readily
tient. Address concerns about pain available.
➤ Patients are given a gown and robe
the patient that some pain may
to wear and instructed to void prior
be experienced during the test, and
to the procedure.
fort. Explain the purpose of the test ➤ Instruct the patient to cooperate fully
and how the procedure is performed. and to follow directions. Instruct the
Inform the patient that the procedure patient to remain still throughout the
is performed in a radiology depart- procedure because movement pro-
ment, usually by a technologist and duces unreliable results.
support staff, and takes approxi- ➤ Observe standard precautions, and
mately 30 to 60 minutes. follow the general guidelines in Ap-
➤ Sensitivity to cultural and social pendix A.
issues, as well as concern for mod- ➤ Place the patient in the supine posi-
esty, is important in providing psy- tion on an exam table.
and after the procedure. ➤ For male patients, place lead protec-
tion over the testicles to prevent
➤ Instruct the patient to fast and re- their irradiation but remove it for
strict fluids for 8 hours prior to the bladder exposures.
procedure.
➤ A kidney, ureter, and bladder (KUB)
➤ Patients receiving metformin (Glu- or plain film is taken to ensure that
cophage) for non–insulin-dependent no barium or stool obscures visuali-
(type 2) diabetes should discontinue zation of the urinary system.
➤ Insert an IV line, if one is not already
continue to withhold it for 48 hours
in place, and inject the contrast me-
dium.
➤ X-ray exposures are made at 1, 5, 10,
➤ Instruct the patient to take a laxative
15, 20, and 30 minutes to follow
or a cathartic, as ordered, on the eve-
the course of the contrast medium
ning before the examination.
through the urinary system. Instruct
➤ Instruct the patient to remove jew- the patient to exhale deeply and to
elry (including watches), credit cards, hold his or her breath while the x-ray
and other metallic objects. is taken, and then to breathe after
➤ Make sure a written and informed the film is taken.
consent has been signed prior to the ➤ Ask the patient to void; a postvoiding
procedure and before administering exposure is done to visualize the
any medications. empty bladder.
Intrinsic Factor Antibodies 821
➤ The results are recorded manually, on sults, and offer support. Discuss the
film, or by automated equipment in a implications of abnormal test results
computerized system for recall and on the patient’s lifestyle. Provide
postprocedure interpretation by the teaching and information regarding
appropriate health care practitioner. the clinical implications of the test
results, as appropriate.
Post-test: ➤ Reinforce information given by the
➤ Instruct the patient to resume usual patient’s health care provider regard-
diet, fluids, medications, or activity, ing further testing, treatment, or
as directed by the health care practi- referral to another health care pro-
tioner. vider. Answer any questions or ad-
➤ Monitor for reaction to iodinated patient or family.
contrast medium, including rash,
urticaria, tachycardia, hyperpnea, hy-
pertension, palpitations, nausea, or
vomiting.
➤ Monitor urinary output after the pro- determine the need for a change in
cedure. Decreased urine output may therapy. Evaluate test results in rela-
indicate impending renal failure. tion to the patient’s symptoms and
➤ A written report of the examina- other tests performed.
care practitioner specializing in this Related diagnostic tests:
branch of medicine. The report will ➤ Related diagnostic tests include com-
be sent to the requesting health care puted tomography of the abdomen,
practitioner, who will discuss the magnetic resonance imaging of the
results with the patient. abdomen, renogram, and ultrasound
➤ Recognize anxiety related to test re- of the kidney.
INTRINSIC FACTOR ANTIBODIES

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: IF antibodies.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Plasma (1 mL) col-
lected in a lavender-top (EDTA) tube is also acceptable.
REFERENCE VALUE: (Method: Radioimmunoassay) None detected.


DESCRIPTION & RATIONALE: Intrin- can interfere with test results when
sic factor (IF) is produced by the pari- radioimmunoassay is the test method.
etal cells of the gastric mucosa and is • Failure to follow dietary restrictions
required for the normal absorption of before the procedure may cause the
vitamin B12. In some diseases, anti- procedure to be canceled or repeated.
bodies are produced that bind the
cobalamin-IF complex, prevent the
complex from binding to ileum Nursing Implications and
receptors, and prevent vitamin B12 Procedure ● ● ● ● ● ● ● ● ● ● ●
absorption. There are two types of

antibodies: type 1, the more com- Pretest:
monly present blocking antibody; and ➤ Inform the patient that the test is
type 2, the binding antibody. The used to assist in the investigation of
blocking antibody inhibits uptake of suspected pernicious anemia.
vitamin B12 at the binding site of IF. ➤ Obtain a history of the patient’s com-
Binding antibody combines with plaints, including a list of known
either free or complexed IF. ■ sitivities to latex), and inform the
INDICATIONS: accordingly.
• Assist in the diagnosis of pernicious ➤ Obtain a history of the patient’s
anemia hematopoietic and gastrointestinal
systems, as well as results of previ-
• Evaluate patients with decreased vita- ously performed laboratory tests,
min B12 levels surgical procedures, and other diag-
tory tests, refer to the Hematopoietic
RESULT and Gastrointestinal System tables.
Increased in: ➤ Note any recent procedures that can
• Megaloblastic anemia
• Pernicious anemia patient is taking, including herbs,
• Some patients with hyperthyroidism ceuticals. The requesting health care
• Some patients with insulin-dependent practitioner and laboratory should be
(type 1) diabetes advised if the patient is regularly
using these products so that their
Decreased in: N/A tion when reviewing results.
CRITICAL VALUES: N/A tient. Inform the patient that speci-
men collection takes approximately
INTERFERING FACTORS: 5 to 10 minutes. Address concerns
• Recent treatment with methotrexate or about pain related to the procedure.
another folic acid antagonist can inter-
fere with test results. venipuncture.
• Vitamin B12 injected or ingested within ➤ There are no food or fluid restric-
48 hours of the test invalidates results. tions, unless by medical direction.
Iron 823
Administration of vitamin B12 should tion by the appropriate health care

be withheld within 48 hours before practitioner.
testing.
Post-test:
Intratest:
➤ Ensure that vitamin B12 has been ing or hematoma formation. Apply
withheld within 48 hours before paper tape or other adhesive to
testing. hold pressure bandage in place, or
➤ If the patient has a history of severe replace with a plastic bandage.
allergic reaction to latex, care should ➤ A written report of the examination
be taken to avoid the use of equip- will be sent to the requesting health
ment containing latex. care practitioner, who will discuss
➤ Instruct the patient to cooperate fully the results with the patient.
and to follow directions. Direct the ➤ Reinforce information given by the
patient to breathe normally and to patient’s health care provider regard-
avoid unnecessary movement. ing further testing, treatment, or
➤ Observe standard precautions, and referral to another health care pro-
follow the general guidelines in vider. Answer any questions or ad-
Appendix A. Positively identify the dress any concerns voiced by the
patient, and label the appropriate patient or family.
tubes with the corresponding patient ➤ Depending on the results of this
demographics, date, and time of col- procedure, additional testing may
lection. Perform a venipuncture; col- be performed to evaluate or monitor
lect the specimen in a 5-mL red-top progression of the disease process
tube. and determine the need for a change
➤ Remove the needle, and apply a pres- in therapy. Evaluate test results in
sure dressing over the puncture site. relation to the patient’s symptoms
analysis. Related laboratory tests:
➤ The results are recorded manually ➤ Related laboratory tests include
or in a computerized system for complete blood count, folic acid, red
recall and postprocedure interpreta- blood cell indices, and vitamin B12.
IRON
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Fe.
SI Units
Newborn 100–250 g/dL 17.9–44.8 mol/L
Infant–9 y 20–105 g/dL 3.6–18.8 mol/L
10–14 y 20–145 g/dL 3.6–26.0 mol/L
Adult
Male 65–175 g/dL 11.6–31.3 mol/L
Female 50–170 g/dL 9–30.4 mol/L
• Assist in the diagnosis of hemochro-

DESCRIPTION & RATIONALE: Iron matosis or other disorders of iron me-
plays a principal role in erythro- tabolism and storage
poiesis. Iron is necessary for the pro- • Determine the differential diagnosis of
liferation and maturation of red blood anemia
cells and is required for hemoglobin
• Determine the presence of disorders
synthesis. Of the body’s normal 4 g of
that involve diminished protein synthe-
iron, approximately 65% resides in sis or defects in iron absorption
hemoglobin and 3% in myoglobin. A
small amount is also found in cellular • Evaluate accidental iron poisoning
enzymes that catalyze the oxidation • Evaluate iron overload in dialysis pa-
and reduction of iron. The remainder tients or patients with transfusion-
of iron is stored in the liver, bone mar- dependent anemias
row, and spleen as ferritin or hemo- • Evaluate thalassemia and sideroblastic
siderin. Any iron present in the serum anemia
is in transit among the alimentary
• Monitor hematologic responses during
tract, the bone marrow, and available
pregnancy, when serum iron is usually
iron storage forms. Iron travels in the decreased
bloodstream bound to transferrin, a
protein manufactured by the liver. • Monitor response to treatment for
Normally, iron enters the body by anemia
oral ingestion; only 10% is absorbed,
but up to 20% can be absorbed in RESULT
patients with iron-deficiency anemia.
Increased in:
Unbound iron is highly toxic, but
• Acute iron poisoning (children)
there is generally an excess of transfer-
rin available to prevent the buildup of • Acute leukemia
unbound iron in the circulation. Iron • Acute liver disease
overload is as clinically significant as
iron deficiency, especially in the acci- • Aplastic anemia
dental poisoning of children caused • Excessive iron therapy
by excessive intake of iron-containing
• Hemochromatosis
multivitamins. ■
• Hemolytic anemias
INDICATIONS: • Lead toxicity
• Assist in the diagnosis of blood loss, as
evidenced by decreased serum iron • Nephritis
Iron 825
• Pernicious anemias • Gross hemolysis can interfere with test

results.
• Sideroblastic anemias
• Failure to withhold iron-containing
• Thalassemia medications 24 hours before the test
may falsely increase values.
• Transfusions (repeated)
• Vitamin B6 deficiency before the procedure may cause the
Decreased in:
• Acute and chronic infection
• Carcinoma Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Chronic blood loss (gastrointestinal,

uterine) Pretest:
• Hypothyroidism ➤ Inform the patient that the test is
used in the differential diagnosis of
• Iron-deficiency anemia anemia.
• Nephrosis ➤ Obtain a history of the patient’s com-
• Postoperative state allergens (especially allergies or sen-
• Protein malnutrition (kwashiorkor) appropriate health care practitioner
accordingly.
• Remission of pernicious anemia
gastrointestinal and hematopoietic
CRITICAL VALUES: systems and results of previously
Mild toxicity: greater than 350 performed laboratory tests, surgical
g/dL procedures, and other diagnostic
Serious toxicity: greater than 400 procedures. For related laboratory
g/dL tests, refer to the Gastrointestinal
and Hematopoietic System tables.
Lethal: greater than 1000 g/dL
Note and immediately report to the ➤ Note any recent therapies that can
health care practitioner any critically interfere with test results. Specimen
collection should be delayed for sev-
increased values and related symptoms. eral days after blood transfusion.
Intervention may include chelation ther-
apy by administration of deferoxamine ➤ Obtain a list of medications the
mesylate (Desferal). nutritional supplements, and nutra-
INTERFERING FACTORS: practitioner and laboratory should be
• Drugs that may increase iron levels these products so that their effects
include blood transfusions, chemother- can be taken into consideration
apy drugs, iron (intramuscular), when reviewing results.
iron dextran, iron-protein-succinylate, ➤ Review the procedure with the pa-
methimazole, methotrexate, oral con- tient. Inform the patient that speci-
traceptives, and rifampin. men collection takes approximately
• Drugs that may decrease iron levels about pain related to the procedure.
include acetylsalicylic acid, allopurinol, Explain to the patient that there
cholestyramine, corticotropin, corti- may be some discomfort during the
sone, deferoxamine, and metformin. venipuncture.
➤ Sensitivity to social and cultural ➤ Instruct the patient to resume usual

issues, as well as concern for mod- diet, fluids, medications, or activ-
esty, is important in providing psy- ity, as directed by the health care
chological support before, during, practitioner.
and after the procedure. ➤ Nutritional considerations: Educate
➤ Instruct the patient to fast for at least the patient with abnormally elevated
12 hours before testing, and with iron values, as appropriate, on the
medical direction, to refrain from tak- importance of reading food labels.
ing iron-containing medicines before Foods high in iron include meats
specimen collection. (especially liver), eggs, grains, and
green leafy vegetables. It is also
important to explain that iron levels in
foods can be increased if foods are
cooked in cookware containing iron.
Intratest:
➤ Nutritional considerations: Educate
➤ Ensure that the patient has complied the patient with abnormal iron values
with dietary and medication restric- that numerous factors affect the
tions; assure that food has been absorption of iron, enhancing or
restricted for at least 12 hours prior decreasing absorption regardless of
to the procedure. the original content of the iron-
➤ If the patient has a history of severe containing dietary source. Consump-
allergic reaction to latex, care should tion of large amounts of alcohol
be taken to avoid the use of equip- damages the intestine and allows
ment containing latex. increased absorption of iron. A high
intake of calcium and ascorbic acid
also increases iron absorption. Iron
absorption after a meal is also in-
creased by factors in meat, fish, or
poultry. Iron absorption is decreased
➤ Observe standard precautions, and by the absence (gastric resection)
follow the general guidelines in or diminished presence (use of
Appendix A. Positively identify the antacids) of gastric acid. Phytic acids
patient, and label the appropriate from cereals, tannins from tea and
tubes with the corresponding patient coffee, oxalic acid from vegetables,
demographics, date, and time of and minerals such as copper, zinc,
collection. Perform a venipuncture; and manganese interfere with iron
collect the specimen in a 5-mL red- absorption.
or tiger-top tube.
➤ Remove the needle, and apply a pres- will be sent to the requesting health
sure dressing over the puncture site. care practitioner, who will discuss
➤ Promptly transport the specimen to the results with the patient.
➤ The results are recorded manually ing further testing, treatment, or
or in a computerized system for referral to another health care pro-
recall and postprocedure interpreta- vider. Answer any questions or ad-
tion by the appropriate health care dress any concerns voiced by the
Post-test: procedure, additional testing may
be performed to evaluate or monitor
➤ Observe venipuncture site for bleed- progression of the disease process
ing or hematoma formation. Apply and determine the need for a change
paper tape or other adhesive to hold in therapy. Evaluate test results in
pressure bandage in place, or re- relation to the patient’s symptoms
place with a plastic bandage. and other tests performed.
Iron-Binding Capacity (Total), Transferrin, and Iron Saturation 827
blood count, erythropoietin, ferritin,

hemosiderin, iron/total iron-binding
➤ Related laboratory tests include bone capacity, lead, porphyrins, and trans-
marrow biopsy, liver biopsy, complete ferrin.
IRON-BINDING CAPACITY
(TOTAL), TRANSFERRIN,
AND IRON SATURATION
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: TIBC, Fe Sat.

REFERENCE VALUE: (Method: Spectrophotometry for TIBC and
nephelometry for transferrin)
Test Conventional Units SI Units

TIBC 250–350 g/dL 45–63 mol/L
Transferrin 200–380 mg/dL 2–3.8 g/L
Iron saturation 20–50%
TIBC total iron-binding capacity.
DESCRIPTION & RATIONALE: Iron hemoglobin and about 3% in myo-

plays a principal role in erythro- globin. A small amount is also found
poiesis. It is necessary for proliferation in cellular enzymes that catalyze the
and maturation of red blood cells and oxidation and reduction of iron. The
for hemoglobin synthesis. Of the remainder of iron is stored in the liver,
body’s normal 4 g of iron (less in bone marrow, and spleen as ferritin or
women), about 65% is present in hemosiderin. Any iron present in the
serum is in transit among the alimen- • Neoplastic diseases

tary tract, the bone marrow, and avail- • Protein depletion
able iron storage forms. Iron travels in • Renal disease
the bloodstream bound to transport
• Sideroblastic anemias
proteins. Transferrin is the major iron-
transport protein, carrying 60% to • Thalassemia
70% of the body’s iron. For this rea-
son, total iron-binding capacity CRITICAL VALUES: N/A
(TIBC) and transferrin are sometimes
referred to interchangeably, even • Drugs that may increase TIBC levels
though other proteins carry iron and include mestranol and oral contra-
contribute to the TIBC. Unbound ceptives.
iron is highly toxic, but there is gener-
• Drugs that may decrease TIBC levels
ally an excess of transferrin available
include asparaginase, chloramphenicol,
to prevent the buildup of unbound corticotropin, cortisone, and testos-
iron in the circulation. The percentage terone.
of iron saturation is calculated by
dividing the serum iron value by the
TIBC value and multiplying by 100. ■ Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
INDICATIONS:
• Assist in the diagnosis of iron-defi- Pretest:
ciency anemia ➤ Inform the patient that the test is
• Differentiate between iron-deficiency used in the differential diagnosis of
anemia and anemia secondary to anemia.
chronic disease ➤ Obtain a history of the patient’s com-
• Monitor hematologic response to ther- allergens (especially allergies or sen-
apy during pregnancy and iron-defi- sitivities to latex) and inform the
ciency anemias appropriate health care practitioner
accordingly.
• Provide support for diagnosis of
hemochromatosis or diseases of iron ➤ Obtain a history of the patient’s he-
matopoietic system and results of
metabolism and storage previously performed laboratory
RESULT diagnostic procedures. For related
laboratory tests, refer to the Hemat-
Increased in: opoietic System table.
• Acute liver disease ➤ Obtain a list of the medications
• Hypochromic (iron-deficiency) ane- the patient is taking, including herbs,
mias nutritional supplements, and nutra-
• Late pregnancy practitioner and laboratory should be
Decreased in: using these products so that their
• Chronic infections
• Cirrhosis ➤ Review the procedure with the pa-
• Hemochromatosis tient. Inform the patient that speci-
• Hemolytic anemias 5 to 10 minutes. Address concerns
Ketones, Blood and Urine 829
about pain related to the procedure. tion by the appropriate health care
Explain to the patient that there may practitioner.
venipuncture. Post-test:
➤ There are no food, fluid, or medica- ➤ Observe venipuncture site for bleed-
tion restrictions, unless by medical ing or hematoma formation. Apply
direction. paper tape or other adhesive to hold
pressure bandage in place, or re-
Intratest: place with a plastic bandage.
➤ If the patient has a history of severe ➤ A written report of the examination
allergic reaction to latex, care should will be sent to the requesting health
be taken to avoid the use of equip- care practitioner, who will discuss
ment containing latex. the results with the patient.
and to follow directions. Direct the patient’s health care provider regard-
patient to breathe normally and to ing further testing, treatment, or
avoid unnecessary movement. referral to another health care pro-
➤ Observe standard precautions, and vider. Answer any questions or ad-
follow the general guidelines in dress any concerns voiced by the
Appendix A. Positively identify the patient or family.
patient, and label the appropriate ➤ Depending on the results of this
tubes with the corresponding patient procedure, additional testing may be
demographics, date, and time of col- performed to evaluate or monitor
lection. Perform a venipuncture; col- progression of the disease process
lect the specimen in a 5-mL red- or and determine the need for a change
tiger-top tube. in therapy. Evaluate test results in
➤ Remove the needle, and apply a pres- relation to the patient’s symptoms
sure dressing over the puncture site. and other tests performed.
the laboratory for processing and Related laboratory tests:
analysis. ➤ Related laboratory tests include bone
➤ The results are recorded manually marrow biopsy, complete blood
or in a computerized system for count, erythropoietin, ferritin, hemo-
recall and postprocedure interpreta- siderin, iron, lead, and porphyrins.
KETONES, BLOOD AND URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Ketone bodies, acetoacetate, acetone.

SPECIMEN: Serum (1 mL) collected from red- or tiger-top tube. Urine
(5 mL), random or timed specimen, collected in a clean plastic collection
container.
REFERENCE VALUE: (Method: Colorimetric nitroprusside reaction) Negative.

• Screen for ketonuria due to acute ill-

DESCRIPTION & RATIONALE: Ketone ness or stress in nondiabetic patients
bodies refer to the three intermediate
• Screen for ketonuria to assist in the
products of metabolism: acetone, ace- assessment of inborn errors of metabo-
toacetic acid, and -hydroxybutyrate. lism
Even though -hydroxybutyrate is
not a ketone, it is usually listed with • Screen for ketonuria to assist in the
diagnosis of suspected isopropyl alco-
the ketone bodies. In healthy individ-
hol poisoning
uals, ketones are produced and com-
pletely metabolized by the liver so that
RESULT
measurable amounts are not normally
present in serum. Ketones appear in Increased in:
the urine before a significant serum • Acidosis
level is detectable. If the patient has
excessive fat metabolism, ketones are • Branched-chain ketonuria
found in blood and urine. Excessive • Carbohydrate deficiency
fat metabolism may occur if the • Eclampsia
patient has impaired ability to metab-
olize carbohydrates, inadequate carbo- • Fasting or starvation
hydrate intake, inadequate insulin • Gestational diabetes
levels, excessive carbohydrate loss, or
• Glycogen storage diseases
increased carbohydrate demand. A
strongly positive acetone result with- • High-fat or high-protein diet
out severe acidosis, accompanied by • Hyperglycemia
normal glucose, electrolyte, and bicar-
• Ketoacidosis of alcoholism and diabetes
bonate levels, is strongly suggestive of
isopropyl alcohol poisoning. A low- • Illnesses with marked vomiting and
carbohydrate or low-fat diet may diarrhea
cause a positive acetone test. Ketosis • Isopropyl alcohol ingestion
in diabetics is usually accompanied by
• Methylmalonic aciduria
increased glucose and decreased bicar-
bonate and pH. Extremely elevated • Postanesthesia period
levels of ketone bodies can result in • Propionyl coenzyme A carboxylase
coma. This situation is particularly deficiency
life-threatening in children younger
than 10 years old. ■ Decreased in: N/A
INDICATIONS: CRITICAL VALUES:

• Assist in the diagnosis of starvation, Strongly positive test results for
stress, alcoholism, suspected isopropyl glucose and ketones
alcohol ingestion, glycogen storage dis- Note and immediately report to the
ease, and other metabolic disorders health care practitioner strongly positive
results in urine and related symptoms.
• Detect and monitor treatment of dia-
An elevated level of ketone bodies is
betic ketoacidosis
evidenced by fruity-smelling breath, aci-
• Monitor the control of diabetes dosis, ketonuria, and decreased level of
Ketones, Blood and Urine 831
consciousness. Administration of insulin

and frequent blood glucose measurement Nursing Implications and
may be indicated. Procedure ● ● ● ● ● ● ● ● ● ● ●
INTERFERING FACTORS: Pretest:

• Drugs that may cause an increase in ➤ Inform the patient that the test
serum ketone levels include acetylsali- is most commonly used to investi-
cylic acid (if therapy results in acidosis, gate diabetes as the cause of
especially in children), albuterol, fen- ketoacidosis.
fluramine, levodopa, nifedipine, and ➤ Obtain a history of the patient’s com-
paraldehyde. plaints, including a list of known
• Drugs that may cause a decrease in sitivities to latex), and inform the
serum ketone levels include acetylsali- appropriate health care practitioner
cylic acid and valproic acid. Increases accordingly.
have been shown in hyperthyroid ➤ Obtain a history of the patient’s
patients receiving propranolol and endocrine system and results of pre-
propylthiouracil. viously performed laboratory tests,
• Drugs that may increase urine ketone nostic procedures. For related labo-
levels include acetylsalicylic acid (if ratory tests, refer to the Endocrine
therapy results in acidosis, especially in System table.
children), captopril, dimercaprol,
ether, ifosfamide, insulin, levodopa, patient is taking, including herbs,
mesna, metformin, methyldopa, N- nutritional supplements, and nutra-
acetylcysteine, niacin, paraldehyde, ceuticals. The requesting health care
penicillamine, phenazopyridine, phe- practitioner and laboratory should be
nolphthalein, phenolsulfonphthalein, advised if the patient regularly uses
pyrazinamide, streptozocin, sulfobro- these products so that their effects
mophthalein, and valproic acid. can be taken into consideration
• Drugs that may decrease urine ketone
levels include acetylsalicylic acid and patient. Inform the patient that blood
phenazopyridine. specimen collection takes approxi-
mately 5 to 10 minutes. The amount
• Urine should be checked within 60
of time required to collect a urine
minutes of collection. specimen depends on the level
• Bacterial contamination of urine can of cooperation from the patient.
cause false-negative results.
• Failure to keep reagent strip container patient that there may be some
tightly closed can cause false-negative discomfort during the venipunc-
ture.
results. Light and moisture affect the
ability of the chemicals in the strip to ➤ Sensitivity to social and cultural
perform as expected. issues, as well as concern for mod-
• False-negative or weakly false-positive chological support before, during,
test results can be obtained when and after the procedure.
-hydroxybutyrate is the predominat- ➤ There are no food, fluid, or medica-
ing ketone body in cases of lactic tion restrictions, unless by medical
acidosis. direction.
Intratest: Blood or urine:

analysis.
Appendix A.
Blood: or in a computerized system for
➤ If the patient has a history of severe tion by the appropriate health care
allergic reaction to latex, care should practitioner.
➤ Instruct the patient to cooperate fully Post-test:
and to follow directions. Direct the ➤ Observe venipuncture site for bleed-
patient to breathe normally and to ing or hematoma formation. Apply
avoid unnecessary movement. paper tape or other adhesive to hold
➤ Positively identify the patient, and pressure bandage in place, or
label the appropriate tubes with the replace with a plastic bandage.
corresponding patient demograph-
➤ Nutritional considerations: Increased
ics, date, and time of collection. Per-
levels of ketone bodies may be asso-
form a venipuncture; collect the
ciated with diabetes. The nutritional
specimen in a 5-mL red- or tiger-top
needs of each diabetic patient need
tube. Alternatively, a finger- or heel-
to be determined individually (espe-
stick method of specimen collection
cially during pregnancy) by a health
can be used.
care practitioner trained in nutrition.
➤ Remove the needle, and apply a pres- Patients who adhere to dietary rec-
sure dressing over the puncture site. ommendations report a better gen-
eral feeling of health, better weight
Urine: management, greater control of glu-
cose and lipid values, and improved
➤ Review the procedure with the use of insulin. There is no “diabetic
patient. Explain to the patient how to diet”; however, many meal-planning
collect a second-voided midstream approaches with nutritional goals are
specimen: (1) void, then drink a glass endorsed by the American Dietetic
of water; and (2) wait 30 minutes, Association.
and then try to void again.
➤ Impaired glucose tolerance may be
➤ Instruct the patient to avoid exces-
associated with diabetes. Instruct the
sive exercise and stress before spec-
patient and caregiver to report signs
imen collection.
and symptoms of hypoglycemia
(weakness, confusion, diaphoresis,
Clean-catch specimen: rapid pulse) or hyperglycemia (thirst,
➤ Instruct the male patient to (1) thor- polyuria, hunger, lethargy).
oughly wash his hands, (2) cleanse ➤ Nutritional considerations: Increased
the meatus, (3) void a small amount levels of ketone bodies may be asso-
into the toilet, and (4) void directly ciated with poor carbohydrate intake;
into the specimen container. therefore, the body breaks down fat
➤ Instruct the female patient to (1) instead of carbohydrate for energy.
thoroughly wash her hands; (2) Increasing carbohydrate intake in the
cleanse the labia from front to back; patient’s diet reduces the levels of
(3) while keeping the labia separated, ketone bodies. Carbohydrates can be
void a small amount into the toilet; found in starches and sugars. Starch
and (4) without interrupting the urine is a complex carbohydrate that can
stream, void directly into the speci- be found in foods such as grains
men container. (breads, cereals, pasta, rice) and
Kidney, Ureter, and Bladder Study 833
starchy vegetables (corn, peas, pota- mation, if desired, for the American
toes). Sugar is a simple carbohydrate Diabetes Association (http://www.
that can be found in natural diabetes.org).
foods (fruits and natural honey) and ➤ Reinforce information given by the
processed foods (desserts and patient’s health care provider regard-
candy). ing further testing, treatment, or
➤ A written report of the examination referral to another health care pro-
will be sent to the requesting health vider. Answer any questions or ad-
care practitioner, who will discuss dress any concerns voiced by the
the results with the patient. patient or family.
➤ Recognize anxiety related to test ➤ Depending on the results of this
results, and be supportive of per- procedure, additional testing may
ceived loss of independence and be performed to evaluate or monitor
fear of shortened life expectancy. progression of the disease process
Discuss the implications of abnormal and determine the need for a change
test results on the patient’s lifestyle. in therapy. Evaluate test results in
Provide teaching and information relation to the patient’s symptoms
regarding the clinical implications of and other tests performed.
Emphasize, as appropriate, that Related laboratory tests:
good glycemic control delays the
onset of and slows the progression ➤ Related laboratory tests include ani-
of diabetic retinopathy, nephropa- on gap, blood gases, electrolytes,
thy, and neuropathy. Educate the glucose, glycated hemoglobin, lactic
patient regarding access to counsel- acid, osmolality (blood and urine),
ing services. Provide contact infor- phosphorus, and routine urinalysis.
KIDNEY, URETER, AND

BLADDER STUDY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Flat plate of the abdomen, plain film of the

abdomen, scout film, KUB.
AREA OF APPLICATION: Kidneys, ureters, bladder, and abdomen.

CONTRAST: None.
DESCRIPTION & RATIONALE: A kid- tion of the abdominal organs; it also

ney, ureter, and bladder (KUB) x-ray indicates whether there is any obstruc-
examination provides information tion or abnormality of the abdomen
regarding the structure, size, and posi- caused by disease or congenital mal-
formation. Calcifications of the renal • Bladder distention

calyces or renal pelvis, as well as any • Congenital renal anomaly
radiopaque calculi present in the • Hydronephrosis
urinary tract or surrounding organs,
may be visualized. Patterns of air and • Intestinal obstruction
gas appear light and bright on the • Organomegaly
image. Air normally remains con-
• Renal calculi
tained within the intestinal tract; per-
foration of either the stomach or the • Renal hematomas
intestines causes air to escape into the • Ruptured viscus
abdominal cavity. When there is an
• Soft-tissue masses
intestinal obstruction, air and fluid
collect above the area of obstruction, • Trauma to liver, spleen, kidneys, and
distending the lumen of the intestine. bladder
KUB x-rays are among the first exam- • Vascular calcification
inations done to diagnose intra-
abdominal diseases such as intestinal CRITICAL VALUES: N/A
obstruction, masses, tumors, ruptured
organs, abnormal gas accumulation, INTERFERING FACTORS:
and ascites. ■
This procedure is
INDICATIONS: • Patients who are pregnant or suspected
• Determine the cause of acute abdomi-
nal pain or palpable mass
• Evaluate the effects of lower abdominal the risks to the fetus and mother
trauma, such as internal hemorrhage
• Evaluate known or suspected intestinal Factors that may
obstruction impair clear imaging:
• Evaluate the presence of renal, ureter, remain still during the procedure
or other organ calculi because of age, significant pain, or
• Evaluate the size, shape, and position of mental status
the liver, kidneys, and spleen
• Evaluate suspected abnormal fluid, air, tion field (e.g., jewelry, body rings),
or metallic object or obstruction in the which may inhibit organ visualization
abdomen and can produce unclear images
RESULT ographic equipment to accommodate
Normal Findings: obese or thin patients, which can cause
• Normal size and shape of kidneys
poor-quality study
• Normal bladder, absence of masses and
renal calculi, and no abnormal accu- • Patients who are very obese, who
mulation of air or fluid may exceed the weight limit for the
equipment
Abnormal Findings:
• Abnormal accumulation of bowel gas which may produce poor visualization
• Ascites of the area to be examined, especially
Kidney, Ureter, and Bladder Study 835
for oblique and decubitus views and for ➤ Record the date of the last menstrual
films done by portable equipment period and determine the possibility
• Retained barium from a previous radi- women.
ologic procedure ➤ Obtain a list of the medications the
• Gas or feces in the gastrointestinal tract patient is taking.
resulting from inadequate cleansing or ➤ Review the procedure with the
failure to restrict food intake before the patient. Address concerns about pain
study related to the procedure. Explain to
the patient that little or no pain is
• Ascites, uterine tumors, and ovarian expected during the test, but there
tumors, which can interfere with the may be moments of discomfort.
quality of the procedure Inform the patient that the procedure
is performed in the radiology depart-
ment or at the bedside, by a regis-
tered radiologic techologist, and
• Consultation with a health care practi- takes approximately 5 to 15 minutes
to complete.
dure for radiation safety concerns ➤ Sensitivity to cultural and social
regarding younger patients or patients issues, as well as concern for mod-
who are lactating. chological support before, during,
• Risks associated with radiographic over- and after the procedure.
exposure can result from frequent x-ray ➤ There are no food, fluid, or medica-
procedures. Personnel in the room with tion, restrictions unless by medical
the patient should wear a protective direction.
lead apron, stand behind a shield, or ➤ Instruct the patient to remove jew-
leave the area while the examination is elry (including watches), credit cards,
being done. Personnel working in the and other metallic objects.
done should wear badges that reveal Intratest:
their level of exposure to radiation. ➤ Ensure that jewelry, watches, chains,
belts, and any other metallic objects
have been removed from the abdom-
inal area.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
➤ Inform the patient that the procedure and to follow directions. Instruct the
assesses the status of the abdomen. patient to remain still throughout the
➤ Obtain a history of the patient’s com- procedure because movement pro-
plaints and symptoms. duces unreliable results.
gastrointestinal and genitourinary
Appendix A.
systems, and results of previously
performed diagnostic procedures, ➤ Remove any wires connected to
surgical procedures, and laboratory electrodes, if allowed.
tests. For related diagnostic tests, ➤ Place the patient on the table in a
refer to the Gastrointestinal and Gen- supine position with hands over the
itourinary System tables. head or relaxed at the side.
➤ Schedule intravenous pyelography ➤ For male patients, place lead protec-
(IVP) or gastrointestinal studies after tion over the testicles to prevent
this study. their irradiation.
➤ For portable examinations, elevate ➤ Reinforce information given by the

the head of the bed to the high patient’s health care provider regard-
Fowler’s position. ing further testing, treatment, or
➤ Ask the patient to inhale deeply and referral to another health care pro-
hold his or her breath while the x-ray vider. Answer any questions or
images are taken, and then to exhale address any concerns voiced by the
after the images are taken. patient or family.
➤ The results are recorded on a sheet ➤ Depending on the results of this pro-
of x-ray film or electronically, in a cedure, additional testing may be
computerized system, for recall and performed to evaluate or monitor
postprocedure interpretation by the progression of the disease process
appropriate health care practitioner. and determine the need for a change
will be completed by a health care Related diagnostic tests:
of medicine. The report will be sent to ➤ Related diagnostic tests include IVP
the requesting health care practi- as well as computed tomography,
tioner, who will discuss the results ultrasound, and magnetic resonance
with the patient. imaging of the abdomen.
KLEIHAUER-BETKE TEST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Fetal hemoglobin, hemoglobin F, acid elution

slide test.

(EDTA) tube. Freshly prepared blood smears are also acceptable.
Cord blood may be requested for use as a positive control.
REFERENCE VALUE: (Method: Microscopic examination of treated and

stained peripheral blood smear) Less than 1%.
DESCRIPTION & RATIONALE: The The test can also be used to distinguish
Kleihauer-Betke test is used to deter- some forms of thalassemia from the
mine the degree of fetal-maternal hem- hereditary persistence of fetal hemoglo-
orrhage and to help calculate the bin, but hemoglobin electrophoresis
dosage of RhoGAM to be given in and flow cytometry methods are more
some cases of Rh-negative mothers. commonly used for this purpose. ■
Kleihauer-Betke Test 837
INDICATIONS: nutritional supplements, and nutra-

• Assist in the diagnosis of certain types ceuticals. The requesting health care
of anemia
• Calculating dosage of RhoGAM these products so that their effects
• Screening postpartum maternal blood when reviewing results.
for the presence of fetal-maternal hem- ➤ Review the procedure with the
orrhage patient. Inform the patient that spec-
RESULT 5 to 10 minutes. Address concerns
Positive in: Explain to the patient that there may
• Fetal-maternal hemorrhage be some discomfort during the
venipuncture.
• Hereditary persistence of fetal hemo- ➤ There are no food, fluid, or medica-
globin tion restrictions, unless by medical
direction.
Negative in: N/A
Intratest:
INTERFERING FACTORS: Specimens must be taken to avoid the use of equip-
be obtained before transfusion. ment containing latex.
used to determine occurrence and patient, and label the appropriate
extent of fetal-maternal bleed. It is tubes with the corresponding patient
also used to calculate Rh immune demographics, date, and time of
globulin dosage. collection. Perform a venipunc-
ture; collect the specimen in a 5-mL
➤ Obtain a history of the patient’s com- lavender-top tube.
allergens (especially allergies or sen- ➤ Remove the needle and apply a pres-
➤ Obtain a history of the patient’s analysis. Sample must be less than 6
hematopoietic and reproductive sys- hours old.
tems, as well as results of previously ➤ The results are recorded manually
performed laboratory tests, surgi- or in a computerized system for
cal procedures, and other diagnos- recall and postprocedure interpreta-
tic procedures. For related laboratory tion by the appropriate health care
tests, refer to the Hematopoietic and practitioner.
Reproductive System tables.
➤ Note any recent procedures that can Post-test:
interfere with test results. ➤ Observe venipuncture site for bleed-
patient is taking, including herbs, paper tape or other adhesive to
hold pressure bandage in place, or ➤ Depending on the results of this

replace with a plastic bandage. procedure, additional testing may
➤ A written report of the examination be performed to evaluate or monitor
ing further testing, treatment, or Related laboratory tests:
vider. Answer any questions or ad- ➤ Related laboratory tests include
dress any concerns voiced by the blood group and type and hemoglo-
patient or family. bin electrophoresis.
LACTATE DEHYDROGENASE
AND ISOENZYMES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: LDH and isos, LD and isos.

REFERENCE VALUE: (Method: Enzymatic [L to P] for lactate dehydrogenase,
electrophoretic analysis for isoenzymes) Reference ranges are method
dependent and may vary from laboratory to laboratory.
Lactate Dehydrogenase
Age Conventional & SI Units

0–2 y 125–275 U/L
2–3 y 166–232 U/L
4–6 y 104–206 U/L
7–12 y 90–203 U/L
13–14 y 90–199 U/L
15–43 y 90–156 U/L
Greater than 43 y 90–176 U/L
Lactate Dehydrogenase and Isoenzymes 839
LDH Fraction % of Total Fraction of Total

LDH1 14–26 0.14–0.26
LDH2 29–39 0.29–0.39
LDH3 20–26 0.20–0.26
LDH4 8–16 0.08–0.16
LDH5 6–16 0.06–0.16
DESCRIPTION & RATIONALE: Lactate 12 hours, causing a “flip” isoenzyme

dehydrogenase (LDH) is an enzyme pattern within 48 hours of MI, and
that catalyzes the reversible conversion levels remain elevated 1 to 2 weeks
of lactate to pyruvate within cells. after CK and aspartate aminotrans-
Because many tissues contain LDH, ferase have returned to normal levels. ■
elevated total LDH is considered a
nonspecific indicator of cellular dam- INDICATIONS:
• Differentiate acute MI, as evidenced by
age unless other clinical data make the
elevated LDH1 and LDH2, from pul-
tissue origin obvious. Determining tis- monary infarction and liver problems,
sue origin is aided by electrophoretic which elevate LDH4 and LDH5
analysis of the five isoenzymes specific
• Evaluate the degree of muscle wasting
to certain tissues. The heart and ery-
in muscular dystrophy (LDH levels rise
throcytes are rich sources of LDH1, early in this disorder and approach
LDH2, and LDH3; the kidneys con- normal as muscle mass is reduced by
tain large amounts of LDH3 and atrophy)
LDH4; and the liver and skeletal mus-
• Evaluate the effectiveness of cancer
cles are high in LDH4 and LDH5. chemotherapy (LDH levels should fall
Certain glands (e.g., thyroid, adrenal, with successful treatment)
thymus), the pancreas, spleen, lungs,
• Evaluate red cell hemolysis or renal
lymph nodes, and white blood cells
infarction, especially as indicated by
contain LDH3, whereas the ilium is an reversal of the LDH1:LDH2 ratio
additional source of LDH5. There
have been documented reports of a • Investigate acute MI or extension
thereof, as indicated by elevation (usu-
sixth isoenzyme of LDH. It is seen in
ally) of total LDH, elevation of LDH1
patients with severe liver disease and is and LDH2, and reversal of the
an indicator of a very poor prognosis. LDH1:LDH2 ratio within 48 hours of
LDH is found in every tissue of the the infarction
body. It is of no use as a specific diag-
• Investigate chronicity of liver, lung, and
nostic marker. Testing for the presence kidney disorders, as evidenced by LDH
of LDH and isoenzymes is rarely used levels that remain persistently high
anymore to confirm acute myocardial
infarction (MI), having been replaced RESULT
by more sensitive and specific creatine
Total LDH increased in:
kinase (CK-MB) and troponin assays.
Acute myocardial infarction releases • Carcinoma of the liver
LDH into the serum within the first • Chronic alcoholism
• Cirrhosis fluosol-DA, methotrexate, oxacillin,

plicamycin, propoxyphene, and strep-
• Congestive heart failure tokinase.
• Hemolytic anemias • Drugs that may decrease total LDH
• Hypoxia levels include ascorbic acid, cefotaxime,
enalapril, fluorides, naltrexone, and
• Leukemias oxylate.
• Megaloblastic and pernicious anemia • Hemolysis will cause significant false
elevations in total LDH and a false
• MI or pulmonary infarction “flip” pattern of the isoenzymes because
• Musculoskeletal disease LDH1 fraction is of red blood cell
origin.
• Obstructive jaundice
• Some isoenzymes are temperature sen-
• Pancreatitis sitive; therefore, prolonged storage at
refrigerated temperatures may cause
• Renal disease (severe)
false decreases.
• Shock
• Viral hepatitis Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
Total LDH decreased in: N/A

Pretest:
LDH Isoenzymes:
• LDH1 fraction increased over LDH2 marily used to monitor MI.
can be seen in acute MI, anemias (per-
nicious, hemolytic, acute sickle cell,
megaloblastic, hemolytic), and acute allergens (especially allergies or sen-
renal cortical injury due to any cause. sitivities to latex), and inform the
The LDH1 fraction in particular is ele- appropriate health care practitioner
vated in cases of germ cell tumors. accordingly.
• Increases in the middle fractions are ➤ Obtain a history of the patient’s car-
associated with conditions in which diovascular, hematopoietic, hepato-
biliary, and musculoskeletal systems,
massive platelet destruction has
as well as results of previously per-
occurred (e.g., pulmonary embolism, formed laboratory tests, surgical
post-transfusion period), and in lym- procedures, and other diagnostic
phatic system disorders (e.g., infectious procedures. For related laboratory
mononucleosis, lymphomas, lympho- tests, refer to the Cardiovascular,
cytic leukemias). Hematopoietic, Hepatobiliary, and
• An increase in LDH5 occurs with mus-
culoskeletal damage and many types of
liver damage (e.g., cirrhosis, cancer, nutritional supplements, and nutra-
hepatitis). ceuticals. The requesting health care
CRITICAL VALUES: N/A advised if the patient regularly uses
INTERFERING FACTORS: can be taken into consideration
• Drugs that may increase total LDH when reviewing results.
levels include amiodarone, etretinate, ➤ Review the procedure with the
Lactate Dehydrogenase and Isoenzymes 841
patient. (Samples at time of admis- LDH levels may be associated

sion, 2 to 4 hours, 6 to 8 hours, and with coronary artery disease (CAD).
12 hours after admission are the min- Nutritional therapy is recommended
imal recommendations. Additional for individuals identified to be at
samples may be requested.) Inform high risk for developing CAD. If
the patient that specimen collection overweight, the patient should
takes approximately 5 to 10 minutes. be encouraged to achieve a nor-
Address concerns about pain related mal weight. The American Heart
to the procedure. Explain to the Association Step 1 and Step 2 diets
patient that there may be some dis- may be helpful in achieving a goal of
comfort during the venipuncture. lowering total cholesterol and triglyc-
➤ There are no food, fluid, or medica- eride levels. The Step 1 diet empha-
tion restrictions, unless by medical sizes a reduction in foods high in
direction. saturated fats and cholesterol. Red
meats, eggs, and dairy products are
the major sources of saturated fats
Intratest: and cholesterol. If triglycerides are
➤ If the patient has a history of severe also elevated, the patient should be
allergic reaction to latex, care should advised to eliminate or reduce alco-
be taken to avoid the use of equip- hol and simple carbohydrates from
ment containing latex. the diet. The Step 2 diet recom-
➤ Instruct the patient to cooperate fully mends stricter reductions.
and to follow directions. Direct the ➤ A written report of the examination
patient to breathe normally and to will be sent to the requesting health
avoid unnecessary movement. care practitioner, who will discuss
➤ Observe standard precautions, and the results with the patient.
follow the general guidelines in ➤ Recognize anxiety related to test
Appendix A. Positively identify the results, and be supportive of fear of
patient, and label the appropriate shortened life expectancy. Discuss
tubes with the corresponding patient the implications of abnormal test
demographics, date, and time of col- results on the patient’s lifestyle.
lection. Perform a venipuncture; Provide teaching and information
collect the specimen in a 5-mL red- regarding the clinical implications
or tiger-top tube. of the test results, as appropriate.
➤ Remove the needle, and apply a Educate the patient regarding access
pressure dressing over the puncture to counseling services. Provide con-
site. tact information, if desired, for the
American Heart Association (http://
➤ Promptly transport the specimen to www.americanheart.org).
analysis. ➤ Reinforce information given by the
practitioner.
patient or family.
➤ Observe venipuncture site for bleed- performed to evaluate or monitor
ing or hematoma formation. Apply progression of the disease process
paper tape or other adhesive to hold and determine the need for a change
pressure bandage in place, or in therapy. Evaluate test results in
replace with a plastic bandage. relation to the patient’s symptoms
➤ Nutritional considerations: Increased and other tests performed.
Related laboratory tests: cholesterol (total, HDL, and LDL), C-

reactive protein, creatine kinase and
➤ Related laboratory tests include isoenzymes, -glutamyltranspepti-
antiarrhythmic drugs, apolipoprotein dase, glucose, glycated hemoglobin,
A, apolipoprotein B, aspartate amino- homocysteine, ketones, pleural fluid
transferase, atrial natriuretic peptide, LDH, lipoprotein electrophoresis,
blood gases, B-type natriuretic pep- magnesium, myoglobin, potassium,
tide, calcium (blood and ionized), triglycerides, and troponin.
LACTIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Lactate.
SPECIMEN: Plasma (1 mL) collected in a gray-top (sodium fluoride) or
green-top (lithium heparin) tube. Specimen should be transported tightly
capped and in an ice slurry.
REFERENCE VALUE: (Method: Spectrophotometry/enzymatic analysis)
SI Units lactate in emergency situations when

Conventional (Conventional energy is needed but there is insuffi-
Units Units 0.111) cient oxygen in the system to favor the
3–23 mg/dL 0.3–2.6 mmol/L aerobic and customary energy cycle.
When hypoxia or circulatory collapse
increases production of lactate, or
when the hepatic system does not
metabolize lactate sufficiently, lactate
DESCRIPTION & RATIONALE: Lactic levels become elevated. The lactic acid
acid (present in blood as lactate) is a test can be performed in conjunction
byproduct of carbohydrate metabo- with pyruvic acid testing to monitor
lism. Normally metabolized in the tissue oxygenation. Lactic acidosis can
liver, lactate concentration is based on be differentiated from ketoacidosis by
the rate of production and metabo- the absence of ketosis and grossly ele-
lism. Levels increase during strenuous vated glucose levels. ■
exercise, which results in insufficient
oxygen delivery to the tissues. INDICATIONS:
Pyruvate, the normal end product of • Assess tissue oxygenation
glucose metabolism, is converted to • Evaluate acidosis
Lactic Acid 843
RESULT ing a venipuncture can cause elevated

levels.
Increased in:
• Engaging in strenuous physical activity
• Cardiac failure (i.e., activity in which blood flow and
• Diabetes oxygen distribution cannot keep pace
with increased energy needs) before
• Hemorrhage specimen collection can cause an ele-
• Hepatic coma vated result.
• Ingestion of large doses of ethanol or • Delay in transport of the specimen
acetaminophen to the laboratory must be avoided.
Specimens not processed by centrifuga-
• Lactic acidosis tion in a tightly stoppered collection
• Pulmonary embolism container within 15 minutes of collec-
tion should be rejected for analysis. It is
• Pulmonary failure preferable to transport specimens to the
• Reye’s syndrome laboratory in an ice slurry to further
retard cellular metabolism that might
• Shock shift lactate levels in the sample before
• Strenuous exercise analysis.
Decreased in: N/A
CRITICAL VALUES:
Greater than or equal to 31 mg/dL
health care practitioner any critically Nursing Implications and
increased values and related symptoms. Procedure ● ● ● ● ● ● ● ● ● ● ●
Observe the patient for signs and symp-

toms of elevated levels, such as Kussmaul’s Pretest:
breathing and increased pulse rate. In gen- ➤ Inform the patient that the test is
eral, there is an inverse relationship used to investigate suspected lactic
between critically elevated lactate levels acidosis, most commonly caused by
and survival. hypoperfusion.
INTERFERING FACTORS: plaints, including a list of known
• Drugs that may increase lactate allergens (especially allergies or sen-
levels include albuterol, anticonvul- sitivities to latex), and inform the
sants (long-term use), epinephrine, appropriate health care practitioner
intravenous glucose, isoniazid, lactose, accordingly.
metformin, oral contraceptives, sodium ➤ Obtain a history of the patient’s
bicarbonate, and sorbitol. cardiovascular, endocrine, hepatobil-
iary, musculoskeletal, and respira-
• Falsely low lactate levels are obtained in tory systems, as well as results of
samples with elevated levels of the previously performed laboratory
enzyme lactate dehydrogenase (LDH) tests, surgical procedures, and other
because this enzyme reacts with the diagnostic procedures. For related
available lactate substrate. laboratory tests, refer to the Cardio-
vascular, Endocrine, Hepatobiliary,
• Using a tourniquet or instructing Musculoskeletal, and Respiratory
the patient to clench his or her fist dur- System tables.
➤ Obtain a list of the medications the Appendix A. Positively identify the

patient is taking, including herbs, patient, and label the appropriate
nutritional supplements, and nutra- tubes with the corresponding patient
ceuticals. The requesting health care demographics, date, and time of col-
practitioner and laboratory should be lection. Instruct the patient not to
advised if the patient regularly uses clench and unclench fist immedi-
these products so that their effects ately before or during specimen
can be taken into consideration collection. Do not use a tourniquet.
when reviewing results. Perform a venipuncture; collect
➤ Review the procedure with the the specimen in a 5-mL gray- or
patient. Instruct the patient to rest green-top tube. The tightly capped
for 1 hour before specimen collec- sample should be placed in an ice
tion. Inform the patient that speci- slurry immediately after collection.
men collection takes approximately Information on the specimen label
5 to 10 minutes. Address concerns can be protected from water in the
about pain related to the procedure. ice slurry if the specimen is first
Explain to the patient that there may placed in a protective plastic bag.
be some discomfort during the ➤ Remove the needle, and apply a
venipuncture. pressure dressing over the puncture
➤ Instruct the patient to fast and to site.
restrict fluids overnight. Instruct the ➤ Promptly transport the specimen to
patient not to ingest alcohol for 12 the laboratory for processing and
hours before the test. analysis.
➤ Sensitivity to social and cultural ➤ The results are recorded manually
issues, as well as concern for mod- or in a computerized system for
esty, is important in providing psy- recall and postprocedure interpreta-
chological support before, during, tion by the appropriate health care
and after the procedure. practitioner.
➤ There are no medication restrictions,
unless by medical direction. Post-test:
➤ Prepare an ice slurry in a cup or plas- ➤ Observe venipuncture site for bleed-
tic bag to have on hand for immedi- ing or hematoma formation. Apply
ate transport of the specimen to the paper tape or other adhesive to
laboratory. hold pressure bandage in place, or
Intratest:
➤ Nutritional considerations: Instruct
➤ Ensure that the patient has complied patients to consume water when
with dietary restrictions and other exercising. Dehydration may occur
pretesting preparations; assure that when the body loses water during
food and liquids have been restricted exercise. Early signs of dehydration
for at least 12 hours prior to the pro- include dry mouth, thirst, and con-
cedure. centrated dark yellow urine. If
➤ If the patient has a history of severe replacement fluids are not con-
allergic reaction to latex, care should sumed at this time, the patient may
be taken to avoid the use of equip- become moderately dehydrated and
ment containing latex. exhibit symptoms of extreme thirst,
dry oral mucus membranes, inabil-
➤ Instruct the patient to cooperate fully ity to produce tears, decreased uri-
and to follow directions. Direct the nary output, and light-headedness.
patient to breathe normally and to Severe dehydration manifests as
avoid unnecessary movement. confusion, lethargy, vertigo, tachy-
➤ Observe standard precautions, and cardia, anuria, diaphoresis, and loss
follow the general guidelines in of consciousness.
Lactose Tolerance Test 845
➤ Instruct the patient to resume usual ➤ Depending on the results of this pro-
diet and fluids, as directed by the cedure, additional testing may be
health care practitioner. performed to evaluate or monitor
referral to another health care ➤ Related laboratory tests include
provider. Answer any questions or anion gap, arterial/alveolar oxygen
address any concerns voiced by the ratio, blood gases, electrolytes, glu-
patient or family. cose, and ketones.
LACTOSE TOLERANCE TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: LTT.
SPECIMEN: Plasma (1 mL) collected in gray-top (fluoride/oxalate) tube.
SI Units
Change in Conventional (Conventional
Glucose Value Units Units 0.0555)
Normal* Greater than 30 mg/dL Greater than 1.7 mmol/L
Inconclusive* 20–30 mg/dL 1.1–1.7 mmol/L
Abnormal* Less than 20 mg/dL Less than 1.1 mmol/L
*Compared to fasting sample.
DESCRIPTION & RATIONALE: Lactose abdominal bloating, pain, flatus, and

is a disaccharide found in dairy prod- diarrhea. The lactose tolerance test
ucts. When ingested, lactose is broken screens for lactose intolerance by
down in the intestine, by the sugar- monitoring glucose levels after inges-
splitting enzyme lactase, into glucose tion of a dose of lactose. ■
and galactose. When sufficient lactase
is not available, intestinal bacteria INDICATIONS: Evaluate patients for sus-
metabolize the lactose, resulting in pected lactose intolerance
RESULT ance and other malabsorption disor-

ders.
Glucose levels increased in: N/A ➤ Obtain a history of the patient’s com-
Glucose levels decreased in: allergens (especially allergies or sen-
Lactose intolerance sitivities to latex), and inform the
accordingly.
CRITICAL VALUES:
Less than 40 mg/dL ➤ Obtain a history of the patient’s gas-
trointestinal system and results of
Greater than 400 mg/dL previously performed laboratory
Note and immediately report to the tests, surgical procedures, and other
health care practitioner any critically diagnostic procedures. For related
increased or decreased values and symp- laboratory tests, refer to the Gas-
toms. trointestinal System table.
Symptoms of decreased glucose levels ➤ Obtain a list of the medications the
include headache, confusion, hunger, irri- patient is taking, including herbs,
tability, nervousness, restlessness, sweat- nutritional supplements, and nutra-
ing, and weakness. Possible interventions ceuticals. The requesting health care
include oral or intravenous (IV) adminis- practitioner and laboratory should be
tration of glucose, IV or intramuscular advised if the patient regularly uses
glucose monitoring. when reviewing results.
Symptoms of elevated glucose levels
include abdominal pain, fatigue, muscle ➤ Review the procedure with the
cramps, nausea, vomiting, polyuria, and patient. Obtain the pediatric patient’s
weight to calculate dose of lactose
thirst. Possible interventions include sub- to be administered. Inform the pa-
cutaneous or IV injection of insulin with tient that multiple samples will be
continuous glucose monitoring. collected over a 90-minute interval.
Inform the patient that each speci-
INTERFERING FACTORS: men collection takes approximately
• Numerous medications may alter glu- 5 to 10 minutes. Address concerns
cose levels (see monograph titled about pain related to the procedure.
“Glucose”). Inform the patient that the test may
produce symptoms such as cramps
• Delayed gastric emptying may decrease and diarrhea. Instruct the patient not
glucose levels. to smoke cigarettes or chew gum
during the test. Explain to the patient
• Smoking may falsely increase glucose that there may be some discomfort
levels. during the venipuncture.
• Failure to follow dietary and activity ➤ Sensitivity to social and cultural
restrictions before the procedure may issues, as well as concern for mod-
cause the procedure to be canceled or esty, is important in providing psy-
repeated. chological support before, during,
➤ Inform the patient that fasting for at
Nursing Implications and least 12 hours before the test is
Procedure ● ● ● ● ● ● ● ● ● ● ● required and that strenuous activity
should also be avoided for at least 12
Pretest: hours before the test.
➤ Inform the patient that the test ➤ There are no medication restrictions,
is used to evaluate lactose intoler- unless by medical direction.
Lactose Tolerance Test 847
Intratest: tion by the appropriate health care

practitioner.
with dietary and activity restrictions Post-test:
as well as other pretesting prepara-
restricted for at least 12 hours prior
to the procedure.
pressure bandage in place, or re-
➤ If the patient has a history of severe place with a plastic bandage.
allergic reaction to latex, care should ➤ Instruct the patient that resuming his
be taken to avoid the use of equip- or her usual diet may not be possible
ment containing latex. if lactose intolerance is identified.
➤ Administer 50 g of lactose dis- Educate patients on the importance
solved in a small amount of water to of following the dietary advice of a
adults over a 5- to 10-minute period. nutritionist to ensure proper nutri-
Pediatric dosage is based on weight: tional balance.
0.6 to 1.3 g lactose per kilogram of ➤ Nutritional considerations: Instruct
body weight for infants less than 12 the patient with lactose intolerance
months old; 1.7 g lactose per kilo- to avoid milk products and to care-
gram of body weight for children 1 to fully read labels on prepared prod-
12 years old. Record time of inges- ucts. Yogurt, which contains inactive
tion. Encourage the patient to drink lactase enzyme, may be ingested.
one to two glasses of water. The lactase in yogurt is activated by
➤ Instruct the patient to cooperate fully the temperature and pH of the duo-
and to follow directions. Direct the denum and substitutes for the lack
patient to breathe normally and to of endogenous lactase. Advise the
avoid unnecessary movement. patient that products such as Lactaid
tablets or drops may allow ingestion
➤ Observe standard precautions, and of milk products without sequelae.
follow the general guidelines in Many lactose-free food products are
Appendix A. Positively identify the now available in grocery stores.
red- or tiger-top tube or red pediatric ➤ Recognize anxiety related to test
Microtainer. Samples should be col- results, and be supportive of con-
lected at baseline, 30, 45, 60, and 90 cerns related to a perceived change
minutes. Record any symptoms the in lifestyle. Discuss the implications
patient reports throughout the of abnormal test results on the
course of the test. patient’s lifestyle. Provide teaching
➤ Remove the needle, and apply a pres- implications of the test results, as
sure dressing over the puncture site. appropriate.
➤ Promptly transport the specimen to ➤ Reinforce information given by
the laboratory for processing and the patient’s health care provider
analysis. Glucose values change rap- regarding further testing, treatment,
idly in an unprocessed, unpreserved or referral to another health care
specimen; therefore, if a Microtainer provider. Answer any questions or
is used, each sample should be trans- address any concerns voiced by the
ported immediately after collection. patient or family.
or in a computerized system for procedure, additional testing may
recall and postprocedure interpreta- be performed to evaluate or monitor
progression of the disease process Related laboratory tests:

in therapy. Evaluate test results in ➤ Related laboratory tests include D-
relation to the patient’s symptoms xylose absorption, fecal analysis, and
and other tests performed. glucose.
LAPAROSCOPY, ABDOMINAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Abdominal peritoneoscopy.

CONTRAST: Carbon dioxide (CO2).
INDICATIONS:
DESCRIPTION & RATIONALE: Abdom- • Assist in performing surgical proce-
inal or gastrointestinal laparoscopy dures such as cholecystectomy, appen-
provides direct visualization of the dectomy, hernia repair, hiatal hernia
liver, gallbladder, spleen, and stomach repair, and bowel resection
after insufflation of carbon dioxide
• Detect cirrhosis of the liver
(CO2). In this procedure, a rigid
laparoscope is introduced into the • Detect pancreatic disorders
body cavity through a 1- to 2-cm
• Evaluate abdominal pain or abdominal
abdominal incision. The endoscope
mass of unknown origin
has a microscope to allow visualization
of the organs, and it can be used to • Evaluate abdominal trauma in an emer-
insert instruments for performing cer- gency
tain procedures, such as biopsy and • Evaluate and treat appendicitis
tumor resection. Under general anes-
thesia, the peritoneal cavity is inflated • Evaluate the extent of splenomegaly
with 2 to 3 L of CO2. The gas distends due to portal hypertension
the abdominal wall so that the instru- • Evaluate jaundice of unknown origin
ments can be inserted safely. Advan-
tages of this procedure compared to an • Obtain biopsy specimens of benign or
open laparotomy include reduced cancerous tumors
pain, reduced length of stay at the hos- • Stage neoplastic disorders such as lym-
pital or surgical center, and reduced phomas, Hodgkin’s disease, and hepatic
time off from work. ■ carcinoma
Laparoscopy, Abdominal 849
RESULT Factors that may impair

clear visualization:
Normal Findings: • Gas or feces in the gastrointestinal tract
• Normal appearance of the liver, spleen, resulting from inadequate cleansing or
gallbladder, pancreas, and other ab- failure to restrict food intake before the
dominal contents study
• Abdominal adhesions • Patients who are very obese, who may
• Appendicitis exceed the weight limit for the equip-
ment
• Ascites
• Cancer of any of the organs which may produce poor visualization
• Cirrhosis of the liver of the area to be examined
• Gangrenous gallbladder • Inability of the patient to cooperate or

• Intra-abdominal bleeding because of age, significant pain, or
mental status
• Portal hypertension
• Splenomegaly Other considerations:
CRITICAL VALUES: N/A chest pain or severe cardiac arrhythmias
occur.
INTERFERING FACTORS: • Failure to follow dietary restrictions
This procedure is
repeated.
of being pregnant, unless the potential • Patients who are in a hypoxemic or
benefits of the procedure far outweigh hypercapnic state will require continu-
the risk of radiation exposure to the ous oxygen administration.
fetus • Patients with acute infection or
• Patients with bleeding disorders, espe- advanced malignancy involving the
cially those associated with uremia and abdominal wall are at increased risk
cytotoxic chemotherapy because organisms may be introduced
into the normally sterile peritoneal
• Patients with cardiac conditions or dys- cavity.
rhythmias
• Patients with advanced respiratory or
cardiovascular disease Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients with intestinal obstruction,

abdominal mass, abdominal hernia, or Pretest:
suspected intra-abdominal hemorrhage
• Patients with a history of peritonitis or assesses the abdominal organs.
multiple abdominal operations causing ➤ Obtain a history of the patient’s com-
dense adhesions plaints, including a list of known
allergens, especially allergies or sen- cleansing enemas on the morning of

sitivities to latex, iodine, seafood, the procedure, depending on the
contrast medium, and dyes. Assess institution’s policy.
if the patient has an allergy to local ➤ Instruct the patient to remove jew-
anesthetics, and inform the health elry (including watches), credit cards,
care practitioner accordingly. and other metallic objects.
➤ Obtain a history of the patient’s gas- ➤ Make sure a written and informed
trointestinal, genitourinary, reproduc- consent has been signed prior to the
tive, and hepatobiliary systems, as procedure and before administering
well as results of previously per- any medications.
formed diagnostic procedures, surgi-
cal procedures, and laboratory tests.
For related diagnostic tests, refer to Intratest:
the Gastrointestinal, Genitourinary, ➤ Ensure that the patient has complied
Reproductive, and Hepatobiliary Sys- with dietary and medication restric-
tem tables. tions and pretesting preparations for
➤ Ensure that this procedure is per- at least 8 hours prior to the proce-
formed before an upper gastroin- dure. Ensure that the patient has
testinal study or barium swallow. removed all external metallic objects
➤ Record the date of the last menstrual prior to the procedure.
period and determine the possibility ➤ Ensure that nonallergy to anesthesia
of pregnancy in perimenopausal is confirmed before the procedure is
women. performed under general anesthesia.
➤ Obtain a list of the medications the ➤ Assess for completion of bowel
patient is taking. preparation according to the institu-
tion’s procedure.
patient. Address concerns about pain ➤ Have emergency equipment readily
related to the procedure. Explain to available.
the patient that some pain may be ➤ Patients are given a gown, robe, and
experienced during the test, and foot coverings to wear and instructed
there may be moments of discom- to void prior to the procedure.
fort. Explain the purpose of the test
and how the procedure is performed. ➤ Instruct the patient to cooperate fully
Inform the patient that the procedure and to follow directions. Instruct the
is performed in a surgery depart- patient to remain still throughout the
ment, usually by a health care practi- procedure because movement pro-
tioner and support staff, and takes duces unreliable results.
approximately 30 to 60 minutes. ➤ Obtain and record baseline vital
➤ Explain that an intravenous (IV) line signs.
may be inserted to allow infusion ➤ Observe standard precautions, and
of IV fluids, anesthetics, analgesics, follow the general guidelines in
or IV sedation. Appendix A.
➤ Sensitivity to cultural and social ➤ Administer medications, as ordered,
issues, as well as concern for mod- to reduce discomfort and to promote
esty, is important in providing psy- relaxation and sedation.
chological support before, during, ➤ Insert an IV line or venous access
and after the procedure. device at a low “keep open” rate.
➤ Instruct the patient to fast and ➤ Place the patient on the laparoscopy
restrict fluids for 8 hours prior to the table. If general anesthesia is to
procedure. be used, it is administered at this
➤ Inform the patient that a laxative and time. Then place the patient in a
cleansing enema may be needed the modified lithotomy position with the
day before the procedure, with head tilted downward. Cleanse the
Laparoscopy, Abdominal 851
abdomen with an antiseptic solu- 2 days after the procedure as a result

tion, and drape and catheterize the of abdominal distention caused by
patient, if ordered. insufflation of CO2 into the abdomen,
➤ The physician identifies the site for and that mild analgesics and cold
the scope insertion, and administers compresses, as ordered, can be
local anesthesia if that is to be used. used to relieve the discomfort.
After deeper layers are anesthetized, ➤ Emphasize that any persistent shoul-
a pneumoperitoneum needle is der pain, abdominal pain, vaginal
placed between the visceral and bleeding, fever, redness, or swell-
parietal peritoneum. ing of the incisional area must be
➤ CO2 is insufflated through the pneu- reported to the health care practi-
moperitoneum needle to separate tioner immediately.
the abdominal wall from the viscera ➤ A written report of the examination
and to aid in visualization of the will be completed by a health care
abdominal structures. The pneu- practitioner specializing in this
moperitoneum needle is removed, branch of medicine. The report will
and the trocar and laparoscope are be sent to the requesting health care
inserted through the incision. practitioner, who will discuss the
➤ After the examination, collection of results with the patient.
tissue samples, and performance of ➤ Recognize anxiety related to test
therapeutic procedures, the scope is results. Discuss the implications
withdrawn. All possible CO2 is evac- of abnormal test results on the
uated via the trocar, which is then patient’s lifestyle. Provide teaching
removed. The skin incision is closed and information regarding the clinical
with sutures, clips, or sterile strips, implications of the test results, as
and a small dressing or adhesive appropriate.
strip is applied.
Post-test: ing further testing, treatment, or re-
➤ Monitor vital signs and neurologic ferral to another health care provider.
status every 15 minutes for 1 hour, Answer any questions or address any
then every 2 hours for 4 hours, and concerns voiced by the patient or
as ordered. Take temperature every family.
4 hours for 24 hours. Compare ➤ Depending on the results of this pro-
with baseline values. Notify the cedure, additional testing may be
health care practitioner if tempera- needed to evaluate or monitor pro-
ture is elevated. Protocols may vary gression of the disease process and
from facility to facility. determine the need for a change in
➤ Instruct the patient to resume usual therapy. Evaluate test results in rela-
diet, fluids, and medication, as tion to the patient’s symptoms and
directed by the health care practi- other tests performed.
tioner.
➤ Instruct the patient to restrict activity Related diagnostic tests:
for 2 to 7 days after the procedure.
➤ If indicated, inform the patient of computed tomography of the ab-
a follow-up appointment for the domen; hepatobiliary scan; kidney,
removal of sutures. ureter, and bladder study; magnetic
➤ Inform the patient that shoulder dis- resonance imaging of the abdomen;
comfort may be experienced for 1 or and ultrasound of the abdomen.
LAPAROSCOPY, GYNECOLOGIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gynecologic pelviscopy, gynecologic laparoscopy,

pelvic endoscopy, peritoneoscopy.

CONTRAST: Carbon dioxide (CO2).
• Detect uterine fibroids, ovarian cysts,

DESCRIPTION & RATIONALE: Gyn- and uterine malformations (ovarian
ecologic laparoscopy provides direct cysts may be aspirated during the
visualization of the internal pelvic con- procedure)
tents, including the ovaries, fallopian • Evaluate amenorrhea and infertility
tubes, and uterus, after insufflation of
carbon dioxide (CO2). It is done to • Evaluate fallopian tubes and anato-
diagnose and treat pelvic organ disor- mic defects to determine the cause of
infertility
ders, as well as to perform surgical
procedures on the organs. In this pro- • Evaluate known or suspected endo-
cedure, a rigid laparoscope is intro- metriosis, salpingitis, and hydrosalpinx
duced into the body cavity through a • Evaluate pelvic pain or masses of
1- to 2-cm periumbilical incision. The unknown cause
endoscope has a microscope to allow
• Evaluate reproductive organs after ther-
visualization of the organs, and it can
apy for infertility
be used to insert instruments for per-
forming certain procedures, such as • Obtain biopsy specimens to confirm
biopsy and tumor resection. Under suspected pelvic malignancies or metas-
general or local anesthesia, the peri- tasis
toneal cavity is inflated with 2 to 3 L of • Perform tubal sterilization and ovarian
CO2. The gas distends the abdominal biopsy
wall so that the instruments can be
• Perform vaginal hysterectomy
inserted safely. Advantages of this pro-
cedure compared to an open laparo- • Remove adhesions or foreign bodies
tomy include reduced pain, reduced such as intrauterine devices (IUDs)
length of stay at the hospital or surgical • Treat endometriosis through electro-
center, and reduced time off from cautery or laser vaporization
work. ■
INDICATIONS: RESULT
• Detect ectopic pregnancy and deter- Normal Findings:
mine the need for surgery • Normal appearance of uterus, ovaries,
• Detect pelvic inflammatory disease or fallopian tubes, and other pelvic con-
abscess tents
Laparoscopy, Gynecologic 853
Abnormal Findings: • Incorrect positioning of the patient,

• Ectopic pregnancy which may produce poor visualization
• Endometriosis
• Ovarian cyst remain still during the procedure
• Ovarian tumor because of age, significant pain, or
mental status
• Pelvic adhesions
• Pelvic inflammatory disease Other considerations:
• Pelvic tumor chest pain or severe cardiac arrhythmias
• Salpingitis occur.
• Uterine fibroids • Failure to follow dietary restrictions

CRITICAL VALUES: N/A repeated.
INTERFERING FACTORS: • Patients who are in a hypoxemic or
hypercapnic state will require continu-
This procedure is ous oxygen administration.
• Patients with acute infection or
• Patients who are pregnant or suspected advanced malignancy involving the
of being pregnant, unless the potential abdominal wall are at increased risk
benefits of the procedure far outweigh because organisms may be introduced
the risks to the fetus and mother into the normally sterile peritoneal
• Patients with bleeding disorders, espe- cavity
cially those associated with uremia and
cytotoxic chemotherapy
• Patients with cardiac conditions or dys- Nursing Implications and
rhythmias Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients with advanced respiratory or Pretest:

cardiovascular disease
• Patients with intestinal obstruction, assesses the abdominal and pelvic
abdominal mass, abdominal hernia, or organs.
suspected intra-abdominal hemorrhage ➤ Obtain a history of the patient’s com-
Factors that may impair clear allergens, especially allergies or sen-
visualization: sitivities to latex, iodine, seafood,
• Gas or feces in the gastrointestinal tract contrast medium, and dyes. Assess
resulting from inadequate cleansing or if the patient has an allergy to local
anesthetics, and inform the health
care practitioner accordingly.
study
• Retained barium from a previous radi- gastrointestinal, genitourinary, and
ologic procedure reproductive systems, as well as
results of previously performed diag-
• Patients who are very obese, who nostic procedures, surgical proce-
may exceed the weight limit for the dures, and laboratory tests. For
equipment related diagnostic tests, refer to the
Gastrointestinal, Genitourinary, and tions and pretesting preparations for

Reproductive System tables. at least 8 hours prior to the proce-
➤ Ensure that this procedure is per- dure. Ensure the patient has re-
formed before an upper gastroin- moved all external metallic objects
testinal study or barium swallow. prior to the procedure.
➤ Record the date of the last menstrual ➤ Ensure that nonallergy to anesthesia
period and determine the possibility is confirmed before the procedure is
of pregnancy in perimenopausal performed under general anesthesia.
women. ➤ Assess for completion of bowel pre-
➤ Obtain a list of the medications the paration according to the institution’s
patient is taking. procedure.
➤ Review the procedure with the pa- ➤ Have emergency equipment readily
tient. Address concerns about pain available.
related to the procedure. Explain to ➤ Patients are given a gown, robe, and
the patient that some pain may be foot coverings to wear and instructed
experienced during the test, and to void prior to the procedure.
fort. Explain the purpose of the test ➤ Instruct the patient to cooperate fully
and how the procedure is performed. and to follow directions. Instruct the
Inform the patient that the procedure patient to remain still throughout the
is performed in a surgery depart- procedure because movement pro-
ment, usually by a health care practi- duces unreliable results.
tioner and support staff and takes ➤ Obtain and record baseline vital
approximately 30 to 60 minutes. signs.
➤ Sensitivity to cultural and social ➤ Observe standard precautions, and
issues, as well as concern for mod- follow the general guidelines in Ap-
esty, is important in providing psy- pendix A.
➤ Administer medications, as ordered,
to reduce discomfort and to promote
➤ Explain that an intravenous (IV) line relaxation and sedation.
IV fluids, anesthetics, analgesics, or ➤ Insert an IV line or venous access
IV sedation. device at a low “keep open” rate.
➤ Instruct the patient to fast and re- ➤ Place the patient on the laparoscopy
strict fluids for 8 hours prior to the table. If general anesthesia is to be
procedure. used, it is administered at this time.
Then place the patient in a modi-
➤ Inform the patient that a laxative and fied lithotomy position with the
cleansing enema may be needed the head tilted downward. Cleanse the
day before the procedure, with abdomen with an antiseptic solution,
cleansing enemas on the morning of and drape and catheterize the pa-
the procedure, depending on the in- tient, if ordered.
stitution’s policy.
➤ The physician identifies the site for
the scope insertion, and administers
elry (including watches), credit cards,
local anesthesia if that is to be used.
and other metallic objects.
After deeper layers are anesthetized,
➤ Make sure a written and informed a pneumoperitoneum needle is
consent has been signed prior to the placed between the visceral and pa-
procedure and before administering rietal peritoneum.
any medications.
➤ CO2 is insufflated through the pneu-
Intratest: moperitoneum needle to separate
the abdominal wall from the viscera
➤ Ensure that the patient has complied and to aid in visualization of the
with dietary, and medication restric- abdominal structures. The pneu-
Laparoscopy, Gynecologic 855
moperitoneum needle is removed, and that mild analgesics and cold

and the trocar and laparoscope are compresses, as ordered, can be
inserted through the incision. used to relieve the discomfort.
➤ The physician inserts a uterine ➤ Emphasize that any persistent shoul-
manipulator through the vagina and der pain, abdominal pain, vaginal
cervix and into the uterus so that the bleeding, fever, redness, or swelling
uterus, fallopian tubes, and ovaries of the incisional area must be
can be moved to permit better visu- reported to the health care practi-
alization. tioner immediately.
➤ After the examination, collection of ➤ A written report of the examina-
tissue samples, and performance of tion will be completed by a health
therapeutic procedures (e.g., tubal care practitioner specializing in this
ligation), the scope is withdrawn. All branch of medicine. The report will
possible CO2 is evacuated via the be sent to the requesting health care
trocar, which is then removed. The practitioner, who will discuss the
skin incision is closed with sutures, results with the patient.
clips, or sterile strips, and a small ➤ Recognize anxiety related to test
dressing or adhesive strip is applied. results. Discuss the implications
After the perineum is cleansed, the of abnormal test results on the pa-
uterine manipulator is removed and a tient’s lifestyle. Provide teaching and
sterile pad applied. information regarding the clinical
Post-test: appropriate.
➤ Monitor vital signs and neurologic ➤ Reinforce information given by the
status every 15 minutes for 1 hour, patient’s health care provider regard-
then every 2 hours for 4 hours, and ing further testing, treatment, or
as ordered. Take temperature every referral to another health care pro-
4 hours for 24 hours. Compare with vider. Answer any questions or
baseline values. Notify the health address any concerns voiced by the
care practitioner if temperature is patient or family.
elevated. Protocols may vary from ➤ Depending on the results of this pro-
facility to facility. cedure, additional testing may be
diet, fluids, and medication, as di- gression of the disease process and
rected by the health care practi- determine the need for a change in
tioner. therapy. Evaluate test results in rela-
➤ Instruct the patient to restrict activity tion to the patient’s symptoms and
for 2 to 7 days after the procedure. other tests performed.
➤ If indicated, inform the patient of
a follow-up appointment for the Related diagnostic tests:
removal of sutures. ➤ Related diagnostic tests include
➤ Inform the patient that shoulder dis- computed tomography of the ab-
comfort may be experienced for 1 or domen; hepatobiliary scan; kidney,
2 days after the procedure as a result ureter, and bladder study; magnetic
of abdominal distention caused by resonance imaging of the abdomen;
insufflation of CO2 into the abdomen, and ultrasound of the abdomen.
LATEX ALLERGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
DESCRIPTION & RATIONALE: Latex is history of chronic illness, or multiple

found in numerous medical supplies, surgeries. ■
such as gloves, catheters, and band-
ages. Some individuals who are rou- INDICATIONS: Suspected latex allergy
tinely exposed to latex products,
particularly as part of their occupa- RESULT
tion, have become highly allergic to
latex. Health care workers are classi- Positive findings in: Latex allergy
fied as high risk, especially since the
1987 mandate of standard/universal Negative findings in: N/A
precautions that resulted in increased
use of latex gloves. It is estimated that CRITICAL VALUES: N/A
8% to 17% of health care workers
have become allergic to latex. There INTERFERING FACTORS: N/A
are two types of allergic reactions.
Type IV allergic contact dermatitis is
caused by chemicals used in the
process of manufacturing latex. It is a
Procedure ● ● ● ● ● ● ● ● ● ● ●
delayed reaction occurring within 6 to Pretest:

48 hours of direct skin or mucous
membrane contact with latex prod- ➤ Inform the patient that the test is
used to detect latex sensitivity.
ucts. The type I allergic reaction
occurs in response to proteins in plaints, including a list of known al-
the natural latex products by direct lergens, and inform the appropriate
skin or mucous membrane contact health care practitioner accordingly.
or by inhaling aerosolized powder ➤ Obtain a history of the patient’s im-
from a latex glove. Other high-risk mune system, a history of latex
individuals include people with spina exposure, and results of previously
bifida, spinal cord injury, myelodys- procedures, and other diagnostic pro-
plasia, atopic dermatitis, eczema, his- cedures. For related laboratory tests,
tory of allergies (personal or family), refer to the Immune System table.
Latex Allergy 857
➤ Obtain a list of the medications the the laboratory for processing and
patient is taking, including herbs, analysis.
nutritional supplements, and nutra- ➤ The results are recorded manually
ceuticals. The requesting health care or in a computerized system for re-
practitioner and laboratory should be call and postprocedure interpretation
advised if the patient regularly uses by the appropriate health care practi-
these products so that their effects tioner.
when reviewing results. Post-test:
tient. Inform the patient that speci- ➤ Observe venipuncture site for bleed-
men collection takes approximately ing or hematoma formation. Apply
5 to 10 minutes. Address concerns paper tape or other adhesive to hold
about pain related to the procedure. pressure bandage in place, or replace
Explain to the patient that there may with a plastic bandage.
be some discomfort during the ➤ Assist the patient, as appropriate, in
venipuncture. identifying sources of exposure in
➤ There are no food, fluid, or medica- order for the patient to eliminate or
tion restrictions, unless by medical reduce the opportunity for continued
direction. exposure.
➤ If the patient has a history of severe the results with the patient.
allergic reaction to latex, care should ➤ Reinforce information given by the
be taken to avoid the use of equip- patient’s health care provider regard-
ment containing latex. ing further testing, treatment, or
➤ Instruct the patient to cooperate fully referral to another health care pro-
and to follow directions. Direct the vider. Answer any questions or ad-
patient to breathe normally and to dress any concerns voiced by the
avoid unnecessary movement. patient or family.
➤ Observe standard precautions, and ➤ Depending on the results of this
follow the general guidelines in procedure, additional testing may be
Appendix A. Positively identify the performed to evaluate or monitor
patient, and label the appropriate progression of the disease process
tubes with the corresponding patient and determine the need for a change
demographics, date, and time of in therapy. Evaluate test results in
collection. Perform a venipuncture; relation to the patient’s symptoms
collect the specimen in a 5-mL red- and other tests performed.
top tube.
➤ Remove the needle, and apply a Related laboratory tests:
pressure dressing over the puncture ➤ Related laboratory tests include com-
site. plete blood count, eosinophil count,
➤ Promptly transport the specimen to and immunoglobulin E.
LEAD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Pb.
SPECIMEN: Whole blood (1 mL) collected in a special lead-free royal
blue– or tan-top tube. Plasma (1 mL) collected in lavender-top
(EDTA) tube is also acceptable.
REFERENCE VALUE: (Method: Atomic absorption spectrophotometry)

Units Units 0.0483)
Children 0–9.9 g/dL 0–0.48 mol/L
Adults 0–25.0 g/dL 0–1.20 mol/L
OSHA action limit for Up to 40 g/dL Up to 1.93 mol/L
occupational exposure
OSHA Occupational Safety and Health Administration.
INDICATIONS: Assist in the diagnosis and

DESCRIPTION & RATIONALE: Lead is treatment of lead poisoning
a heavy metal and trace element. It is
absorbed through the respiratory and RESULT
gastrointestinal systems. It can also be
transported from mother to fetus Increased in:
through the placenta. When there is • Anemia of lead intoxication
frequent exposure to lead-containing
• Lead encephalopathy
items (e.g., paint, batteries, gasoline,
pottery, bullets, printing materials) or • Metal poisoning
occupations (mining, automobile,
Decreased in: N/A
printing, and welding industries),
many organs of the body are affected.
CRITICAL VALUES:
Lead poisoning can cause severe
Levels greater than 30 g/dL
behavioral and neurologic effects. The indicate significant exposure.
blood test is considered the best indi-
Levels greater than 60 g/dL
cator of lead poisoning, and confirma- require chelation therapy.
tion is made by the lead mobilization Note and immediately report to the
test performed on a 24-hour urine health care practitioner any critically
specimen. ■ increased values and related symptoms.
Lead 859
INTERFERING FACTORS: Contamination tion restrictions, unless by medical

of the collection site and/or specimen direction.
with lead in dust can be avoided by tak-
Intratest:
ing special care to have the surfaces sur-
rounding the collection location cleaned. ➤ If the patient has a history of severe
Extra care should also be used to avoid allergic reaction to latex, care should
contamination during the actual be taken to avoid the use of equip-
venipuncture. ment containing latex.
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to detect lead toxicity and mon- tubes with the corresponding patient
itor exposure to lead. demographics, date, and time of col-
plaints, including a list of known lect the specimen in a 5-mL royal
allergens (especially allergies or sen- blue– or tan-top tube.
sitivities to latex), and inform the ➤ Remove the needle, and apply a pres-
appropriate health care practitioner sure dressing over the puncture site.
hematopoietic system and results analysis.
of previously performed labora- ➤ The results are recorded manually
tory tests, surgical procedures, and or in a computerized system for
other diagnostic procedures. For re- recall and postprocedure interpreta-
lated laboratory tests, refer to the tion by the appropriate health care
Hematopoietic System and Thera- practitioner.
peutic/Toxicology tables.
➤ Obtain a history of the patient’s ex- Post-test:
posure to lead.
ceuticals. The requesting health care pressure bandage in place, or re-
practitioner and laboratory should be place with a plastic bandage.
patient. Inform the patient that spec- patient’s health care practitioner
imen collection takes approximately regarding further testing, treatment,
5 to 10 minutes. Address concerns or referral to another health care
about pain related to the procedure. practitioner. Answer any questions
Explain to the patient that there may or address any concerns voiced by
be some discomfort during the the patient or family.
venipuncture. ➤ Depending on the results of this pro-
➤ There are no food, fluid, or medica- cedure, additional testing may be
performed to evaluate or monitor Related laboratory tests:

and determine the need for a change ➤ Related laboratory tests include -
in therapy. Evaluate test results in aminolevulinic acid, complete blood
relation to the patient’s symptoms count, erythrocyte protoporphyrin,
and other tests performed. and urine porphyrins.
LECITHIN/SPHINGOMYELIN RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: L/S ratio.

SPECIMEN: Amniotic fluid (10 mL) collected in a sterile, brown glass or
plastic tube or bottle protected from light.
REFERENCE VALUE: (Method: Thin-layer chromatography)

Mature (nondiabetic): Greater than 2:1 in the presence of phosphatidyl
glycerol
Borderline: 1.5 to 1.9:1
Immature: Less than 1.5:1
DESCRIPTION & RATIONALE: Res- a procedure by which fluid is removed

piratory distress syndrome (RDS) is from the amniotic sac, is used to assess
the most common problem encoun- fetal lung maturity.
tered in the care of premature infants. Lecithin is the primary surfactant
RDS, also called hyaline membrane phospholipid, and it is a stabilizing fac-
disease, results from a deficiency of tor for the alveoli. It is produced at a
phospholipid lung surfactants. The low but constant rate until the 35th
phospholipids in surfactant are pro- week of gestation, after which its
duced by specialized alveolar cells and production sharply increases. Sphin-
stored in granular lamellar bodies in gomyelin, another phospholipid com-
the lung. In normally developed ponent of surfactant, is also produced
lungs, surfactant coats the surface of at a constant rate after the 26th week of
the alveoli. Surfactant reduces the sur- gestation. Before the 35th week, the
face tension of the alveolar wall during lecithin/sphingomyelin (L/S) ratio is
breathing. When there is an insuffi- usually less than 1.6:1. The ratio
cient quantity of surfactant, the alveoli increases to 2.0 or greater when the
are unable to expand normally and gas rate of lecithin production increases
exchange is inhibited. Amniocentesis, after the 35th week of gestation. Other
Lecithin/Sphingomyelin Ratio 861
phospholipids, such as phosphatidyl CRITICAL VALUES:

glycerol (PG) and phosphatidyl inosi- An L/S ratio less than 1.5:1 is
tol (PI), increase over time in amniotic predictive of RDS at the time of
delivery.
fluid as well. The presence of PG indi-
cates that the fetus is within 2 to 6 health care practitioner any critically
weeks of lung maturity (i.e., at full increased or decreased values and related
term). Simultaneous measurement of symptoms. Infants known to be at risk for
PG with the L/S ratio improves diag- RDS can be treated with surfactant by
nostic accuracy. Production of phos- intratracheal administration at birth.
pholipid surfactant is delayed in
diabetic mothers. Therefore, caution INTERFERING FACTORS:
must be used when interpreting the • Fetal blood falsely elevates the L/S ratio.
results obtained from a diabetic • Exposing the specimen to light may
patient, and a higher ratio is expected cause falsely decreased values.
to predict maturity. ■
• There is some risk to having an amnio-
INDICATIONS: centesis performed, and this should be
• Assist in the evaluation of fetal lung weighed against the need to obtain the
maturity desired diagnostic information. A small
percentage (0.5%) of patients have
• Determine the optimal time for obstet-
experienced complications including
ric intervention in cases of threatened
premature rupture of the membranes,
fetal survival caused by stresses
premature labor, spontaneous abortion,
related to maternal diabetes, toxemia,
and stillbirth.
hemolytic diseases of the newborn, or
postmaturity
• Identify fetuses at risk of developing
RDS
Procedure ● ● ● ● ● ● ● ● ● ● ●
RESULT Pretest:
Increased in: ➤ Inform the patient that the test is pri-
• Hypertension marily used to obtain an estimate of
fetal age.
• Intrauterine growth retardation ➤ Obtain a history of the patient’s com-
• Malnutrition plaints, including a list of known
• Maternal diabetes sitivities to latex), and inform the
• Placenta previa accordingly.
• Placental infarction ➤ Obtain a history of the patient’s
reproductive and respiratory systems
• Premature rupture of the membranes and results of previously performed
laboratory tests, surgical procedures,
Decreased in: and other diagnostic procedures.
• Advanced maternal age Include any family history of genetic
disorders such as cystic fibrosis,
• Immature fetal lungs Duchenne’s muscular dystrophy,
• Multiple gestation hemophilia, sickle cell disease, Tay-
Sachs disease, thalassemia, and tri-
• Polyhydramnios somy 21. Obtain maternal Rh type.
If Rh-negative, check for prior sensiti- ➤ Make sure a written and informed
zation. A standard RhoGAM dose consent has been signed prior to the
is indicated after amniocentesis; procedure and before administering
repeat doses should be considered any medications.
if repeated amniocentesis is per-
formed. For related laboratory tests, Intratest:
refer to the Reproductive and Respi-
➤ Ensure that the patient has voided
ratory System tables.
before the procedure if gestation is
➤ Record the date of the last menstrual 21 weeks or more.
period, and determine that the preg- ➤ Have emergency equipment readily
nancy is in the third trimester bet- available.
ween the 28th and 40th weeks.
➤ Have patient remove clothes below
➤ Obtain a list of the medications the the waist. Assist the patient to a
patient is taking, including herbs, supine position on the exam table
nutritional supplements, and nutra- with abdomen exposed. Drape the
ceuticals. The requesting health care patient’s legs, leaving the abdomen
practitioner and laboratory should be exposed. Raise her head or legs
advised if the patient regularly uses slightly to promote comfort and to
these products so that their effects relax abdominal muscles. If the
can be taken into consideration uterus is large, place a pillow or rolled
when reviewing results. blanket under the patient’s right side
➤ Review the procedure with the to prevent hypertension caused by
patient. Warn the patient that normal great-vessel compression.
results do not guarantee a normal ➤ Instruct the patient to cooperate fully
fetus. Assure the patient that pre- and to follow directions. Direct the
cautions to avoid injury to the fetus patient to breathe normally and to
will be taken by localizing the fetus avoid unnecessary movement dur-
with ultrasound. Address concerns ing the local anesthetic and the
about pain related to the procedure. procedure.
Explain that during the transabdomi-
nal procedure, any discomfort with a ➤ Record maternal and fetal baseline
needle biopsy will be minimized with vital signs and continue to monitor
local anesthetics. Patients who are throughout the procedure. Moni-
at 20 weeks’ gestation or beyond tor for uterine contractions. Monitor
should void before the test, because fetal vital signs using ultrasound.
an empty bladder is less likely to be Protocols may vary from facility to
accidentally punctured during speci- facility.
men collection. Encourage relaxation ➤ Observe standard precautions, and
and controlled breathing during the follow the general guidelines in
procedure to aid in reducing any mild Appendix A. Positively identify the
discomfort. Inform the patient that patient, and label the appropriate col-
specimen collection is performed by lection containers with the corre-
health care practitioner specializing sponding patient demographics,
in this procedure and usually takes date and time of collection, and site
approximately 20 to 30 minutes to location.
complete. ➤ Assess the position of the amnio-
➤ Sensitivity to social and cultural tic fluid, fetus, and placenta using
issues, as well as concern for mod- ultrasound.
esty, is important in providing psy- ➤ Assemble the necessary equipment,
chological support before, during, including an amniocentesis tray with
and after the procedure. solution for skin preparation, local
➤ There are no food, fluid, or medica- anesthetic, 10- or 20-mL syringe,
tion restrictions, unless by medical needles of various sizes (including
direction. a 22-gauge, 5-inch spinal needle),
Lecithin/Sphingomyelin Ratio 863
sterile drapes, sterile gloves, and foil- site. Instruct the patient to report any
covered or amber specimen collec- redness, edema, bleeding, or pain at
tion containers. the site. Instruct the patient to keep
➤ Cleanse suprapubic area with an the site clean and change the dress-
antiseptic solution and protect with ing as needed.
sterile drapes. A local anesthetic is ➤ Instruct the patient to expect mild
injected. Explain that this may cause cramping, leakage of small amount
a stinging sensation. of amniotic fluic, and vaginal spotting
➤ A 22-gauge, 5-inch spinal needle is for up to 2 days following the pro-
inserted through the abdominal and cedure. Instruct the patient to imme-
uterine walls. Explain that a sensa- diately report moderate to severe
tion of pressure may be experienced abdominal pain or cramps, change in
when the needle is inserted. Explain fetal activity, increased or prolonged
to the patient how to use focusing leaking of amniotic fluid from ab-
and controlled breathing for relax- dominal needle site, vaginal bleeding
ation during the procedure. that is heavier than spotting, and
either chills or fever to the health
➤ After the fluid is collected and the care practitioner.
needle withdrawn, apply slight pres-
sure to the site. Apply a sterile adhe- ➤ Instruct the patient to rest until all
sive bandage to the site. symptoms have disappeared before
resuming normal levels of activity.
➤ Administer standard RhoGAM dose
related to the procedure (e.g., pre-
to maternal Rh-negative patients to
mature labor, allergic reaction, ana-
prevent maternal Rh sensitization
phylaxis).
should the fetus be Rh-positive.
➤ Place samples in properly labeled
➤ Administer mild analgesic and antibi-
specimen container and promptly
otic therapy as ordered. Remind the
patient of the importance of com-
pleting the entire course of antibiotic
➤ The results are recorded manually therapy, even if signs and symptoms
or in a computerized system for re- disappear before completion of
call and postprocedure interpretation therapy.
by the appropriate health care practi- ➤ A written report of the examina-
tioner. tion will be completed by a health
Post-test: branch of medicine. The report will
➤ Fetal heart rate and maternal be sent to the requesting health care
vital signs (i.e., heart rate, blood practitioner, who will discuss the
pressure, pulse, and respiration) results with the patient.
must be compared to baseline values ➤ Recognize anxiety related to test
and closely monitored every 15 min- results, and offer support. Provide
utes for 30 to 60 minutes after the teaching and information regarding
amniocentesis procedure. Protocols the clinical implications of the test
may vary from facility to facility results, as appropriate. Encourage
➤ Observe for delayed allergic reac- the family to seek counseling if con-
tions, such as rash, urticaria, tachy- cerned with pregnancy termina-
cardia, hyperpnea, hypertension, tion or to seek genetic counseling
palpitations, nausea, or vomiting. if a chromosomal abnormality is
determined. Provide teaching and
➤ Observe the amniocentesis site information regarding the clinical
for bleeding, inflammation, or hema- implications of the test results, as
toma formation. appropriate. Decisions regarding
➤ Instruct the patient in the care and elective abortion should take place in
assessment of the amniocentesis the presence of both parents. Pro-
vide a nonjudgmental, nonthreaten- the patient in significant side effects

ing atmosphere for discussing the and systemic reactions associated
risks and difficulties of delivering and with the prescribed medication.
raising a developmentally challenged Encourage her to review corre-
infant, as well as exploring other sponding literature provided by a
options (termination of pregnancy or pharmacist.
adoption). It is also important to dis- ➤ Depending on the results of this pro-
cuss feelings the mother and father cedure, additional testing may be
may experience (e.g., guilt, depres- performed to evaluate or monitor
sion, anger) if fetal abnormalities are progression of the disease process
detected. and determine the need for a change
ing further testing, treatment, or re- and other tests performed.
or family. ➤ Related laboratory tests include
➤ Instruct the patient in the use of any amniotic fluid analysis, blood groups
ordered medications. Explain the and antibodies, chromosome analy-
importance of adhering to the ther- sis, -fetoprotein, and Kleihauer-
apy regimen. As appropriate, instruct Betke test.
LEUKOCYTE ALKALINE PHOSPHATASE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: LAP, LAP score, LAP smear.

(EDTA) tube.
REFERENCE VALUE: (Method: Microscopic evaluation of specially stained

blood smears) 32 to 182 (score based on 0 to 4 rating of 100 neutrophils).
DESCRIPTION & RATIONALE: Alkaline presence of infection, stress, chronic

phosphatase is an enzyme important inflammatory diseases, Hodgkin’s dis-
for intracellular metabolic processes. It ease, and hematologic disorders. Levels
is present in the cytoplasm of neu- are low in leukemic leukocytes and
trophilic granulocytes from the meta- high in normal white blood cells
myelocyte to the segmented stage. (WBCs), making this test useful as a
Leukocyte alkaline phosphatase (LAP) supportive test in the differential diag-
concentrations may be altered by the nosis of leukemia. It should be noted
Leukocyte Alkaline Phosphatase 865
that test results must be correlated with Nursing Implications and

the patient’s condition because LAP Procedure ● ● ● ● ● ● ● ● ● ● ●
levels increase toward normal in

response to therapy. ■ Pretest:
INDICATIONS: used to evaluate disorders of the
• Differentiate chronic myelocytic leuke- hematologic system.
mia from other disorders that increase
the WBC count ➤ Obtain a history of the patient’s com-
• Monitor response of Hodgkin’s disease allergens (especially allergies or sen-
to therapy sitivities to latex), and inform the
RESULT accordingly.
Increased in: hematopoietic and immune sys-
• Aplastic leukemia tems, as well as results of previously
• Chronic inflammation procedures, and other diagnostic
• Down syndrome tests, refer to the Hematopoietic and
• Hairy cell leukemia Immune System tables.
• Hodgkin’s disease ➤ Obtain a list of the medications the

• Leukemia (acute and chronic lym- nutritional supplements, and nutra-
phoblastic) ceuticals. The requesting health care
• Myelofibrosis with myeloid metaplasia advised if the patient regularly uses
• Multiple myeloma these products so that their effects
• Polycythemia vera when reviewing results.
• Pregnancy ➤ Review the procedure with the
• Stress imen collection takes approximately
• Thrombocytopenia 5 to 10 minutes. Address concerns
Decreased in: be some discomfort during the
• Chronic myelogenous leukemia venipuncture.
• Hereditary hypophosphatemia ➤ There are no food, fluid, or medica-
• Idiopathic thrombocytopenia purpura direction.
Intratest:
• Paroxysmal nocturnal hemoglobinuria
• Sickle cell anemia allergic reaction to latex, care should
• Sideroblastic anemia be taken to avoid the use of equip-
CRITICAL VALUES: N/A ➤ Instruct the patient to cooperate fully
INTERFERING FACTORS: Drugs that may patient to breathe normally and to
increase the LAP score include steroids. avoid unnecessary movement.

follow the general guidelines in Ap- the results with the patient.
pendix A. Positively identify the ➤ Recognize anxiety related to test
patient, and label the appropriate results, and be supportive of per-
tubes with the corresponding patient ceived loss of independence and
demographics, date, and time of col- fear of shortened life expectancy.
lection. Perform a venipuncture; col- Discuss the implications of abnormal
lect the specimen in a 5-mL test results on the patient’s lifestyle.
lavender-top tube. Provide teaching and information
➤ Remove the needle, and apply a regarding the clinical implications of
pressure dressing over the puncture the test results, as appropriate.
site. Educate the patient regarding access
➤ Promptly transport the specimen to to counseling services.
in a computerized system for recall referral to another health care
and postprocedure interpretation by provider. Answer any questions or
the appropriate health care practi- address any concerns voiced by the
tioner. patient or family.
➤ Instruct the patient to avoid expo-
sure to infection if WBC count is
decreased. Related laboratory tests:
➤ A written report of the examination ➤ Related laboratory tests include bone
will be sent to the requesting health marrow biopsy and WBC count.
LIPASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Triacylglycerol acylhydrolase.

REFERENCE VALUE: (Method: Spectrophotometry) Plasma values may be

15% lower than serum values.
Lipase 867

cholate, didanosine, glycocholate,
indomethacin, methacholine, methyl-
40–375 U/L prednisolone, morphine, narcotics,
pancreozymin, pentazocine, and tauro-
cholate.
• Drugs that may decrease lipase levels
DESCRIPTION & RATIONALE: Lipases include protamine and saline (intra-
are digestive enzymes secreted by the venous infusions).
pancreas into the duodenum. Differ-
• Endoscopic retrograde cholangiopan-
ent lipolytic enzymes have specific creatography may increase lipase levels.
substrates, but overall activity is col-
lectively described as lipase. Lipase • Serum lipase levels increase with hemo-
participates in fat digestion by break- dialysis. Therefore, predialysis speci-
mens should be collected for lipase
ing down triglycerides into fatty acids
analysis.
and glycerol. Lipase is released into
the bloodstream when damage occurs
to the pancreatic acinar cells. Its pres-
ence in the blood indicates pancreatic
Procedure ● ● ● ● ● ● ● ● ● ● ●
disease because the pancreas is the
only organ that secretes this enzyme. ■ Pretest:
INDICATIONS: ➤ Inform the patient that the test is pri-
• Assist in the diagnosis of acute and marily used to diagnose pancreatitis.
chronic pancreatitis ➤ Obtain a history of the patient’s
• Assist in the diagnosis of pancreatic car- allergens (especially allergies or sen-
cinoma sitivities to latex), and inform the
RESULT accordingly.
Increased in: trointestinal and hepatobiliary sys-
• Acute cholecystitis tems, as well as results of previously
• Obstruction of the pancreatic duct procedures, and other diagnostic
• Pancreatic carcinoma (early) procedures. For related laboratory
• Pancreatic cyst or pseudocyst and Hepatobiliary System tables.
• Pancreatic inflammation ➤ Note any recent procedures that can
• Pancreatitis (acute and chronic) ➤ Obtain a list of the medications
• Renal failure (early) the patient is taking, including herbs,
Decreased in: N/A
• Drugs that may increase lipase ➤ Review the procedure with the pa-
levels include asparaginase, azathio- tient. Inform the patient that speci-
prine, cholinergics, codeine, deoxy- men collection takes approximately
5 to 10 minutes. Address concerns the patient to ingest small, frequent

about pain related to the procedure. meals if he or she has a gastroin-
Explain to the patient that there may testinal disorder; advise the patient
be some discomfort during the to consider other dietary alterations
venipuncture. as well. After acute symptoms sub-
➤ There are no food, fluid, or medica- side and bowel sounds return,
tion restrictions, unless by medical patients are usually prescribed a
direction. clear liquid diet, progressing to a low-
fat, high-carbohydrate diet.
Intratest: ➤ Administer vitamin B12, as ordered,
to the patient with decreased lipase
➤ If the patient has a history of severe levels, especially if his or her disease
allergic reaction to latex, care should prevents adequate absorption of the
be taken to avoid the use of equip- vitamin.
ment containing latex. ➤ Encourage the alcoholic patient to
➤ Instruct the patient to cooperate fully avoid alcohol and to seek appropriate
and to follow directions. Direct the counseling for substance abuse.
follow the general guidelines in the results with the patient.
Appendix A. Positively identify the ➤ Reinforce information given by the
patient, and label the appropriate patient’s health care provider regard-
tubes with the corresponding patient ing further testing, treatment, or
demographics, date, and time of col- referral to another health care pro-
lection. Perform a venipuncture; col- vider. Answer any questions or
lect the specimen in a 5-mL red- or address any concerns voiced by the
tiger-top tube. patient or family.
➤ Remove the needle, and apply a pres- ➤ Depending on the results of this
sure dressing over the puncture site. procedure, additional testing may
➤ Promptly transport the specimen to be performed to evaluate or monitor
the laboratory for processing and progression of the disease process
analysis. and determine the need for a change
or in a computerized system for relation to the patient’s symptoms
recall and postprocedure interpreta- and other tests performed.
practitioner. Related laboratory tests:
Post-test: alanine aminotransferase, alkaline
phosphatase, amylase, aspartate
➤ Observe venipuncture site for bleed- aminotransferase, bilirubin, CA 19-9,
ing or hematoma formation. Apply calcium, fecal fat, -glutamyltrans-
paper tape or other adhesive to peptidase, magnesium, mumps
hold pressure bandage in place, or serology, pleural fluid amylase,
replace with a plastic bandage. triglycerides, and white blood cell
➤ Nutritional considerations: Instruct count.
Lipoprotein Electrophoresis 869
LIPOPROTEIN ELECTROPHORESIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Lipid fractionation; lipoprotein phenotyping;

3ga1-lipoprotein cholesterol, high-density lipoprotein (HDL); -lipoprotein
cholesterol, low-density lipoprotein (LDL); pre--lipoprotein cholesterol,
very-low-density lipoprotein (VLDL).
REFERENCE VALUE: (Method: Electrophoresis and 4 C test for specimen
appearance) There is no quantitative interpretation of this test. The specimen
appearance and electrophoretic pattern is visually interpreted.
Hyperlipoproteinemia: Specimen Electrophoretic

Fredrickson Type Appearance Pattern
Type I Clear with creamy top Heavy chylomicron
layer band
Type IIa Clear Heavy band
Type IIb Clear or faintly turbid Heavy and pre-
band
Type III Slightly to moderately Heavy band
turbid
Type IV Slightly to moderately Heavy pre- band
turbid
Type V Slightly to moderately Intense chylomicron
turbid with creamy band and heavy
top layer pre- band
DESCRIPTION & RATIONALE: Lipo- crons and VLDL contain the highest
protein electrophoresis measures lip- levels of triglycerides and lower
oprotein fractions to determine amounts of cholesterol and protein.
abnormal distribution and concentra- LDL and HDL contain the lowest
tion of lipoproteins in the serum, an amounts of triglycerides and relatively
important risk factor in the develop- higher amounts of cholesterol and
ment of coronary artery disease protein. ■
(CAD). The lipoprotein fractions, in
order of increasing density, are (1) INDICATIONS:
chylomicrons, (2) very-low-density • Evaluate known or suspected disorders
lipoprotein (VLDL), (3) low-density associated with altered lipoprotein
lipoprotein (LDL), and (4) high- levels
density lipoprotein (HDL). Chylomi- • Evaluate patients with serum choles-
terol levels greater than 250 mg/dL, inherited characteristics; or

which indicate a high risk for CAD secondary, caused by poorly
controlled diabetes, alcoholism,
• Evaluate the response to treatment for nephrotic syndrome, chronic
high cholesterol, and determine the renal failure, and dysgammag-
need for drug therapy lobulinemia. Total cholesterol is
normal to moderately elevated,
RESULT: triglycerides are moderately to
grossly elevated, and LDLC is
Type I: Hyperlipoproteinemia or
normal.
increased chylomicrons can
be primary, resulting from an Type V: Hyperlipoproteinemia
inherited deficiency of lipopro- can be primary, resulting from
tein lipase; or secondary, cau- inherited characteristics; or
sed by uncontrolled diabetes, secondary, caused by uncon-
systemic lupus erythematosus, trolled diabetes, alcoholism,
and dysgammaglobulinemia. nephrotic syndrome, and
Total cholesterol is normal dysgammaglobulinemia. Total
to moderately elevated and cholesterol is normal to moder-
triglycerides (mostly exoge- ately elevated, triglycerides are
nous chylomicrons) are grossly grossly elevated, and LDLC is
elevated. If the condition is normal.
inherited, symptoms will
appear in childhood. CRITICAL VALUES: N/A
Type IIa: Hyperlipoproteinemia
can be primary, resulting from INTERFERING FACTORS:
inherited characteristics, or • Failure to follow usual diet for 2 weeks
secondary, caused by hypothy- before the test can yield results that do
roidism, nephrotic syndrome, not accurately reflect the patient’s cho-
and dysgammaglobulinemia. lesterol values.
Total cholesterol is elevated,
triglycerides are normal, and • Ingestion of alcohol 24 hours before
LDL cholesterol (LDLC) is the test, ingestion of food 12 hours
elevated. If the condition is before the test, and excessive exercise
inherited, symptoms will 12 hours before the test can alter
appear in childhood. results.
Type IIb: Hyperlipoproteinemia
can occur for the same reasons
• Numerous drugs can alter results (see
as in type IIa. Total cholesterol, monographs titled “Cholesterol, Total”
triglycerides, and LDLC are all and “Triglycerides”).
elevated. • Failure to follow dietary restrictions
Type III: Hyperlipoproteinemia before the procedure may cause the
can be primary, resulting procedure to be canceled or repeated.
from inherited characteristics;
or secondary, caused by
hypothyroidism, uncontrolled
diabetes, alcoholism, and Nursing Implications and
dysgammaglobulinemia. Total Procedure ● ● ● ● ● ● ● ● ● ● ●
cholesterol and triglycerides

are elevated, whereas LDLC Pretest:
is normal. ➤ Inform the patient that the test is
Type IV: Hyperlipoproteinemia used to assist in evaluating risk for
can be primary, resulting from cardiovascular disease.
Lipoprotein Electrophoresis 871
➤ Obtain a history of the patient’s com- ➤ Instruct the patient to cooperate fully
plaints, including a list of known and to follow directions. Direct the
allergens (especially allergies or sen- patient to breathe normally and to
sitivities to latex), and inform the avoid unnecessary movement.
accordingly. follow the general guidelines in Ap-
➤ Obtain a history of the patient’s car- pendix A. Positively identify the
diovascular system and risk for heart patient, and label the appropriate
disease, as well as results of previ- tubes with the corresponding patient
ously performed laboratory tests, demographics, date, and time of col-
surgical procedures, and other diag- lection. Perform a venipuncture; col-
nostic procedures. For related labora- lect the specimen in a 5-mL red- or
tory tests, refer to the Cardiovascular tiger-top tube.
System table. ➤ Remove the needle, and apply a
➤ Obtain a list of the medications the pressure dressing over the puncture
patient is taking, including herbs, site.
nutritional supplements, and nutra- ➤ Promptly transport the specimen to
ceuticals. The requesting health care the laboratory for processing and
practitioner and laboratory should be analysis.
these products so that their effects ➤ The results are recorded manually
can be taken into consideration or in a computerized system for re-
when reviewing results. call and postprocedure interpretation
by the appropriate health care practi-
➤ Review the procedure with the pa- tioner.
venipuncture.
➤ Instruct the patient to follow his or with a plastic bandage.
her usual diet for 2 weeks before
testing. ➤ Instruct the patient to resume usual
diet, fluids, and activity, as directed
➤ Instruct the patient to fast and to by the health care practitioner.
avoid excessive exercise for at least
12 hours before testing, and to re- ➤ Nutritional considerations: Abnormal
frain from alcohol consumption for lipoprotein electrophoresis patterns
24 hours before testing. may be associated with cardiovascu-
lar disease. Nutritional therapy is rec-
➤ There are no medication restrictions, ommended for the patient identified
unless by medical direction. to be at high risk for developing CAD.
If overweight, the patient should
Intratest: be encouraged to achieve a normal
weight. The American Heart Associa-
➤ Ensure that the patient has complied tion Step 1 and Step 2 diets may be
with dietary and activity restrictions helpful in achieving a goal of lower-
as well as other pretesting prepara- ing total cholesterol and triglyceride
tions; assure that food, fluids, and levels. The Step 1 diet emphasizes a
activity have been restricted for at reduction in foods high in saturated
least 12 hours prior to the procedure. fats and cholesterol. Red meats,
➤ If the patient has a history of severe eggs, and dairy products are the
allergic reaction to latex, care should major sources of saturated fats and
be taken to avoid the use of equip- cholesterol. If triglycerides also
ment containing latex. are elevated, the patient should be
advised to eliminate or reduce alco- American Heart Association (http://

hol and simple carbohydrates from www.americanheart.org).
the diet. The Step 2 diet recom- ➤ Reinforce information given by the
mends stricter reductions. patient’s health care provider regard-
➤ Social and cultural considerations: ing further testing, treatment, or re-
Numerous studies point to the prev- ferral to another health care provider.
alence of excess body weight in Answer any questions or address
American children and adolescents. any concerns voiced by the patient
Experts estimate that obesity is or family.
present in 25% of the population ➤ Depending on the results of this
ages 6 to 11 years. The medical, procedure, additional testing may be
social, and emotional consequences performed to evaluate or monitor pro-
of excess body weight are signifi- gression of the disease process and
cant. Special attention should be determine the need for a change in
given to instructing the child and therapy. Evaluate test results in rela-
caregiver regarding health risks and tion to the patient’s symptoms and
weight control education. other tests performed.
antiarrhythmic drugs, apolipoprotein
➤ Recognize anxiety related to test re- A, apolipoprotein B, aspartate amino-
sults, and be supportive of fear of transferase, atrial natriuretic peptide,
shortened life expectancy. Discuss blood gases, B-type natriuretic pep-
the implications of abnormal test tide, calcium (blood and ionized), cho-
results on the patient’s lifestyle. lesterol (total, HDL, and LDL),
Provide teaching and information C-reactive protein, creatine kinase
regarding the clinical implications of and isoenzymes, glucose, glycated
the test results, as appropriate. hemoglobin, homocysteine, ketones,
Educate the patient regarding access lactate dehydrogenase and isoen-
to counseling services. Provide con- zymes, magnesium, myoglobin, pot-
tact information, if desired, for the assium, triglycerides, and troponin.
LIVER AND SPLEEN SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Liver and spleen scintigraphy, liver-spleen scan,

radionuclide liver scan, spleen scan.

CONTRAST: Intravenous radioactive technetium-99m sulfur colloid.
Liver and Spleen Scan 873
INDICATIONS:
DESCRIPTION & RATIONALE: The • Assess the condition of the liver and
liver and spleen scan is performed to spleen after abdominal trauma
help diagnose abnormalities in the
• Detect a bacterial or amebic abscess
function and structure of the liver and
spleen. It is often performed in com- • Detect and differentiate between pri-
bination with lung scanning to help mary and metastatic tumor focal dis-
diagnose masses or inflammation in ease
the diaphragmatic area. This proce- • Detect benign tumors, such as ade-
dure is useful for evaluating right- noma and cavernous hemangioma
upper-quadrant pain, metastatic • Detect cystic focal disease
disease, jaundice, cirrhosis, ascites,
• Detect diffuse hepatocellular disease,
traumatic infarction, and radiation-
such as hepatitis and cirrhosis
induced organ cellular necrosis.
Technetium-99m (Tc-99m) sulfur • Detect infiltrative processes that affect
colloid is injected intravenously and the liver, such as sarcoidosis and amy-
loidosis
rapidly taken up through phagocyto-
sis by the reticuloendothelial cells, • Determine superior vena cava obstruc-
which normally function to remove tion or Budd-Chiari syndrome
particulate matter, including radioac- • Differentiate between splenomegaly
tive colloids in the liver and spleen. and hepatomegaly
False-negative results may occur in • Evaluate the effects of lower abdominal
patients with space-occupying lesions trauma, such as internal hemorrhage
(e.g., tumors, cysts, abscesses) smaller
than 2 cm. This scan can detect portal • Evaluate jaundice
hypertension, demonstrated by a • Evaluate liver and spleen damage
greater uptake of the radionuclide in caused by radiation therapy or toxic
the spleen than in the liver. Single- drug therapy
photon emission computed tomogra- • Evaluate palpable abdominal masses
phy (SPECT) has significantly
improved the resolution and accuracy RESULT
of liver scanning. SPECT enables
images to be recorded from multiple Normal Findings:
angles around the body and recon- • Normal size, contour, position, and
structed by a computer to produce function of the liver and spleen
images or “slices” representing the
Abnormal Findings:
organ at different levels. For evalua-
• Abscesses
tion of a suspected hemangioma, the
patient’s red blood cells are combined • Cirrhosis
with Tc-99m and images are recorded • Cysts
over the liver. To confirm the diagno-
sis, liver and spleen scans are done in • Hemangiomas
conjunction with computed tomogra- • Hematoma
phy (CT), magnetic resonance imag- • Hepatitis
ing (MRI), ultrasonography, and
SPECT scans and interpreted in light • Hodgkin’s disease
of the results of liver function tests. ■ • Infarction
• Infection • Improper injection of the radionuclide

may allow the tracer to seep deep into
• Infiltrative process (amyloidosis and
the muscle tissue, producing erroneous
sarcoidosis)
hot spots.
• Inflammation of the diaphragmatic
area • Consultation with a health care practi-
• Metastatic tumors dure for radiation safety concerns
• Nodular hyperplasia regarding younger patients or patients
who are lactating.
• Portal hypertension
• Risks associated with radiologic overex-
• Primary benign or malignant tumors posure can result from frequent x-ray
• Traumatic lesions procedures. Personnel in the room with
CRITICAL VALUES: N/A lead apron, stand behind a shield, or
INTERFERING FACTORS: being done. Personnel working in the
This procedure is done should wear badges that reveal
contraindicated for: their level of exposure to radiation.
benefits of the procedure far outweigh Nursing Implications and
the risks to the fetus and mother Procedure ● ● ● ● ● ● ● ● ● ● ●
Factors that may Pretest:

• Inability of the patient to cooperate or ➤ Inform the patient that the procedure
assesses liver and spleen function.
cause of age, significant pain, or mental ➤ Obtain a history of the patient’s com-
status plaints and symptoms, including a
• Metallic objects within the examina- ➤ Obtain a history of the patient’s gas-
tion field (e.g., jewelry, body rings), trointestinal and hepatobiliary sys-
which may inhibit organ visualization tems, signs and symptoms of liver
and can produce unclear images and spleen dysfunction, and results
of previously performed diagnostic
• Patients who are very obese, who procedures, surgical procedures, and
may exceed the weight limit for the laboratory tests. For related diagnos-
equipment tic tests, refer to the Gastrointestinal
and Hepatobiliary System tables.
which may produce poor visualization ➤ Note any recent procedures that can
of the area to be examined, especially interfere with test results, including
for oblique and decubitus views examinations using iodine-based
contrast medium.
• Other nuclear scans done within the ➤ Record the date of the last menstrual
preceding 24 to 48 hours period and determine the possibility
Other considerations: women.
• The scan may fail to detect focal lesions ➤ Obtain a list of the medications
smaller than 2 cm in diameter. the patient is taking, including anti-
Liver and Spleen Scan 875
coagulant therapy, aspirin and other (jewelry, dentures, etc.) prior to the
salicylates, herbs, nutritional supple- procedure.
ments, and nutraceuticals, especially ➤ Have emergency equipment readily
those known to affect coagulation available.
(see Appendix F). It is recommended
that use be discontinued 14 days ➤ If the patient has a history of severe
before surgical procedures. The allergic reactions to any substance or
requesting health care practitioner drug, administer ordered prophylac-
and laboratory should be advised if tic steroids or antihistamines before
the patient regularly uses these the procedure. Use nonionic contrast
products so that their effects can be medium for the procedure.
taken into consideration when re- ➤ Patients are given a gown, robe, and
viewing results. foot coverings to wear and instructed
➤ Review the procedure with the pa- to void prior to the procedure.
tient. Address concerns about pain ➤ Record baseline vital signs and as-
related to the procedure. Explain to sess neurologic status. Protocols
the patient that some pain may be may vary from facility to facility.
experienced during the test, or there
Reassure the patient that the radio-
nuclide poses no radioactive hazard
and rarely produces side effects.
is performed in a special depart- ➤ Observe standard precautions, and
ment, usually in a radiology depart- follow the general guidelines in Ap-
ment, by a health care practitioner pendix A.
and support staff and takes approxi- ➤ Administer an antianxiety agent, as
mately 30 to 60 minutes. ordered, if the patient has claustro-
➤ Sensitivity to social and cultural phobia. Administer a sedative to a
issues, as well as concern for mod- child or to an uncooperative adult, as
esty, is important in providing psy- ordered.
chological support before, during, ➤ Place the patient in a supine position
and after the procedure. on a flat table with foam wedges,
➤ The patient should fast and restrict which help maintain position and
fluids for 8 hours prior to the proce- immobilization. The radionuclide is
dure. Instruct the patient to avoid administered intravenously and the
taking anticoagulant medication or to abdomen is scanned immediately
reduce dosage as ordered prior to for 1 minute to screen for vascular
the procedure. lesions. Then images are taken in the
anterior, oblique, lateral, and poste-
➤ Instruct the patient to remove den-
rior oblique positions.
tures, jewelry (including watches),
hairpins, credit cards, and other ➤ Wear gloves during the radionuclide
metallic objects in the area to be injection and while handling the pa-
examined. tient’s urine.
tions; assure that food, fluids, and ➤ Monitor the patient for complica-
medications have been restricted for tions related to the procedure (e.g.,
at least 8 hours prior to the proce- allergic reaction, anaphylaxis, bron-
dure. Ensure that the patient has chospasm).
removed all external metallic objects ➤ The needle or catheter is removed,
and a pressure dressing is applied ➤ Instruct all caregivers to wear gloves

over the puncture site. when discarding urine for 24 hours
➤ The results are recorded on x-ray film after the procedure. Wash gloved
or electronically, in a computerized hands with soap and water before
system, for recall and postprocedure removing gloves. Then wash hands
interpretation by the appropriate after the gloves are removed.
health care practitioner. ➤ If a woman who is breast-feeding
➤ The patient may be imaged by must have a nuclear scan, she
SPECT techniques to further clarify should not breast-feed the infant
areas of suspicious radionuclide loca- until the radionuclide has been elimi-
lization. nated. This could take as long as 3
express the milk and discard it dur-
Post-test:
ing the 3-day period to prevent ces-
➤ Instruct the patient to resume usual sation of milk production.
diet, fluids, medication, or activity, ➤ Nutritional considerations: A low-fat,
as directed by the health care practi- low-cholesterol, and low-sodium diet
tioner. should be consumed to reduce cur-
➤ Monitor vital signs and neurologic rent disease processes. High fat con-
status every 15 minutes for 1 hour, sumption increases the amount of
then every 2 hours for 4 hours, and bile acids in the colon and should be
then as ordered by the health care avoided.
practitioner. Compare with baseline ➤ No other radionuclide tests should
values. Protocols may vary from fa- be scheduled for 24 to 48 hours after
cility to facility. this procedure.
➤ Observe for delayed allergic reac- ➤ A written report of the examina-
tions, such as rash, urticaria, tachy- tion will be completed by a health
cardia, hyperpnea, hypertension, care practitioner specializing in this
palpitations, nausea, or vomiting. branch of medicine. The report will
➤ Instruct the patient to immediately be sent to the requesting health care
report symptoms such as fast heart practitioner, who will discuss the re-
rate, difficulty breathing, skin rash, sults with the patient.
itching, or decreased urinary output. ➤ Recognize anxiety related to test
➤ Instruct the patient to apply cold com- Provide teaching and information
presses to the puncture site, regarding the clinical implications of
as needed, to reduce discomfort or the test results, as appropriate.
edema. ➤ Reinforce information given by the
➤ Instruct patient to drink increased patient’s health care provider regard-
amounts of fluids for 24 to 48 hours ing further testing, treatment, or re-
to eliminate the radionuclide from ferral to another health care provider.
the body, unless contraindicated. Tell Answer any questions or address
the patient that radionuclide is elimi- any concerns voiced by the patient
nated from the body within 6 to 24 or family.
hours. ➤ Instruct the patient in the use of any
➤ Instruct the patient to flush the toilet ordered medications. Explain the
immediately after each voiding fol- importance of adhering to the ther-
lowing the procedure, and to wash apy regimen. As appropriate, instruct
hands meticulously with soap and the patient in significant side effects
water after each voiding for 24 hours and systemic reactions associated
after the procedure. with the prescribed medication.
Lung Perfusion Scan 877
Encourage him or her to review cor- tion to the patient’s symptoms and
responding literature provided by a other tests performed.
pharmacist.
cedure, additional testing may be ➤ Related diagnostic tests include com-
needed to evaluate or monitor pro- puted tomography of the abdomen,
gression of the disease process and hepatobiliary scan, liver ultrasound,
determine the need for a change in and magnetic resonance imaging of
therapy. Evaluate test results in rela- the abdomen.
LUNG PERFUSION SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Radioactive perfusion scan, lung scintiscan, lung

perfusion scintigraphy, ventilation-perfusion scan, pulmonary scan, radionu-
clide perfusion lung scan, V/Q scan.

CONTRAST: Intravenous radioactive material, usually macroaggregated
albumin (MAA).
DESCRIPTION & RATIONALE: The ily becomes lodged in the pulmonary

lung perfusion scan is a nuclear vasculature. A gamma camera detects
medicine study performed to evaluate the radiation emitted from the
a patient for pulmonary embolus injected radioactive material, and a
(PE) or other pulmonary disorders. representative image of the lung is
Technetium (Tc-99m) is injected obtained. This procedure is often
intravenously and distributed throug- done in conjunction with the lung
hout the pulmonary vasculature ventilation scan to obtain clinical
because of the gravitational effect on information that assists in differentiat-
perfusion. The scan, which produces a ing among the many possible patho-
visual image of pulmonary blood flow, logic conditions revealed by the
is useful in diagnosing or confirming procedure. The results are correlated
pulmonary vascular obstruction. The with other diagnostic studies, such as
diameter of the intravenously injected pulmonary function, chest x-ray, pul-
macroaggregated albumin (MAA) is monary angiography, and arterial
larger than that of the pulmonary cap- blood gases. A recent chest x-ray is
illaries; therefore, the MAA temporar- essential for accurate interpretation of
the lung perfusion scan. An area of CRITICAL VALUES: N/A

nonperfusion seen in the same area as
a pulmonary parenchymal abnormal- INTERFERING FACTORS:
ity on the chest x-ray indicates that a
This procedure is
PE is not present; the defect may rep-
resent some other pathologic condi-
tion, such as pneumonia. ■ of being pregnant, unless the potential
INDICATIONS: the risks to the fetus and mother
• Aid in the diagnosis of PE in a patient
• Patients with atrial and ventricular sep-
with a normal chest x-ray
tal defects, because the MAA particles
• Detect malignant tumor will not reach the lungs
• Differentiate between PE and other • Patients with pulmonary hypertension
pulmonary diseases, such as pneumo-
nia, pulmonary effusion, atelectasis,
asthma, bronchitis, emphysema, and clear imaging:
tumors
• Evaluate perfusion changes associated remain still during the procedure be-
with congestive heart failure and pul- cause of age, significant pain, or mental
monary hypertension status
• Evaluate pulmonary function preopera- • Metallic objects within the examina-
tively in a patient with pulmonary tion field (e.g., jewelry, body rings),
disease which may inhibit organ visualization
RESULT • Patients who are very obese, who
Normal Findings:
equipment
• Diffuse and homogeneous uptake of
the radioactive material by the lungs • Incorrect positioning of the patient,
Abnormal Findings: of the area to be examined, especially
• Asthma for oblique and decubitus views and for
films done by portable equipment
• Atelectasis
• Bronchitis • Other nuclear scans done on the
same day
• Chronic obstructive pulmonary disease
• Emphysema Other considerations:
• Left atrial or pulmonary hypertension • Improper injection of the radionuclide
may allow the tracer to seep deep into
• Lung displacement by fluid or chest the muscle tissue, producing erroneous
masses hot spots.
• Pneumonia • Consultation with a health care practi-
• Pneumonitis tioner should occur before the proce-
• Pulmonary embolism regarding younger patients or patients
• Tuberculosis who are lactating.
Lung Perfusion Scan 879
• Risks associated with radiologic overex- requesting health care practitioner

posure can result from frequent x-ray and laboratory should be advised if
procedures. Personnel in the room with the patient regularly uses these
the patient should wear a protective products so that their effects can
be taken into consideration when re-
lead apron, stand behind a shield, or viewing results.
being done. Personnel working in the ➤ Review the procedure with the
area where the examination is being related to the procedure. Explain to
done should wear badges that reveal the patient that some pain may be
their level of exposure to radiation. experienced during the test, or there
may be moments of discom-
fort. Reassure the patient that the
radionuclide poses no radioactive
Nursing Implications and hazard and rarely produces side
Procedure ● ● ● ● ● ● ● ● ● ● ● effects. Inform the patient that the
procedure is performed in a special
Pretest: department, usually in a radiology
department, by a health care practi-
➤ Inform the patient that the procedure tioner and support staff and takes
assesses blood flow to the lungs. approximately 60 minutes.
plaints and symptoms, including a issues, as well as concern for mod-
list of known allergens. esty, is important in providing psy-
➤ Obtain a history of the patient’s res- chological support before, during,
piratory system, as well as results and after the procedure.
of previously performed diagnostic ➤ Instruct the patient to remove den-
procedures, surgical procedures, and tures, jewelry (including watches),
laboratory tests. For related diagnos- hairpins, credit cards, and other
tic tests, refer to the Respiratory metallic objects in the area to be
System table. examined.
➤ Obtain a history of signs and symp-
toms of pulmonary embolism, such Intratest:
as sudden sharp chest pain, short-
ness of breath, chest pain that wors- ➤ Ensure that the patient has complied
ens with deep breathing/coughing, with dietary, fluids, and medication
coughing up blood, rapid heart rate, restrictions and pretesting prepara-
sweating, and/or anxiety. tions; assure that food, fluids, and
medications have been restricted for
at least 8 hours prior to the proce-
interfere with test results, includ-
dure. Ensure that the patient has
ing examinations using iodine-based
contrast medium.
(jewelry, dentures, etc.) prior to the
➤ Record the date of the last menstrual procedure.
ity of pregnancy in perimenopausal ➤ Have emergency equipment readily
women. available.
➤ Obtain a list of the medications ➤ If the patient has a history of severe
the patient is taking, including anti- allergic reactions to any substance or
coagulant therapy, aspirin and other drug, administer ordered prophylac-
salicylates, herbs, nutritional supple- tic steroids or antihistamines before
ments, and nutraceuticals, especially the procedure. Use nonionic contrast
those known to affect coagula- medium for the procedure.
tion (see Appendix F). It is recom- ➤ Patients are given a gown, robe, and
mended that use be discontinued 14 foot coverings to wear and instructed
days before surgical procedures. The to void prior to the procedure.
➤ Record baseline vital signs and ➤ Monitor vital signs and neurologic
assess neurologic status. Protocols status every 15 minutes for 1 hour,
may vary from facility to facility. then every 2 hours for 4 hours, and
➤ Instruct the patient to cooperate fully then as ordered health care practi-
and to follow directions. Instruct the tioner. Compare with baseline val-
patient to remain still throughout the ues. Protocols may vary from facility
procedure because movement pro- to facility.
duces unreliable results. ➤ Observe for delayed allergic reac-
➤ Observe standard precautions, and tions, such as rash, urticaria, tachy-
follow the general guidelines in cardia, hyperpnea, hypertension,
Appendix A. palpitations, nausea, or vomiting.
➤ Administer an antianxiety agent, as ➤ Instruct the patient to immediately
ordered, if the patient has claustro- report symptoms such as fast heart
phobia. Administer a sedative to a rate, difficulty breathing, skin rash,
child or to an uncooperative adult, as itching, or decreased urinary output.
ordered. ➤ Observe the needle/catheter inser-
➤ Place the patient in a supine position tion site for bleeding, inflammation,
on a flat table with foam wedges, or hematoma formation.
which help maintain position and ➤ Instruct the patient to apply cold
immobilization. The radionuclide is compresses to the puncture site, as
administered intravenously after the needed, to reduce discomfort or
syringe is shaken to resuspend the edema.
particles. Images of the lungs are
obtained in the anterior, posterior, ➤ Instruct patient to drink increased
both lateral, and both oblique views. amounts of fluids for 24 to 48 hours
to eliminate the radionuclide from
➤ Wear gloves during the radionuclide the body, unless contraindicated. Tell
administration and while handling the patient that radionuclide is elimi-
the patient’s urine. nated from the body within 24 to 48
➤ Instruct the patient to take slow, hours.
deep breaths if nausea occurs during ➤ Instruct the patient to flush the toilet
the procedure. Monitor and adminis- immediately after each voiding fol-
ter an antiemetic agent if ordered. lowing the procedure, and to wash
Ready an emesis basin for use. hands meticulously with soap and
➤ Monitor the patient for complications water after each voiding for 24 hours
related to the procedure (e.g., aller- after the procedure.
gic reaction, anaphylaxis, bron- ➤ Instruct all caregivers to wear gloves
chospasm). when discarding urine for 24 hours
➤ The needle or catheter is removed, after the procedure. Wash gloved
and a pressure dressing is applied hands with soap and water before
over the puncture site. removing gloves. Then wash hands
➤ The results are recorded on x-ray film
or electronically, in a computerized ➤ If a woman who is breast-feeding
system, for recall and postprocedure must have a nuclear scan, she
interpretation by the appropriate should not breast-feed the infant
health care practitioner. until the radionuclide has been elimi-
nated. This could take as long as 3
Post-test: express the milk and discard it dur-
sation of milk production.
diet, fluids, medication, or activity,
as directed by the health care ➤ Nutritional considerations: A low-fat,
practitioner. low-cholesterol, and low-sodium diet
Lung Ventilation Scan 881
should be consumed to reduce cur- any concerns voiced by the patient

rent disease processes and/or de- or family.
crease risk of hypertension and
➤ No other radionuclide tests should importance of adhering to the ther-
be scheduled for 24 to 48 hours after apy regimen. As appropriate, instruct
this procedure. the patient in significant side effects
➤ A written report of the examination and systemic reactions associated
will be completed by a health care with the prescribed medication.
practitioner specializing in this Encourage him or her to review cor-
branch of medicine. The report will responding literature provided by a
be sent to the requesting health care pharmacist.
practitioner, who will discuss the ➤ Depending on the results of this pro-
results with the patient. cedure, additional testing may be
➤ Recognize anxiety related to test needed to evaluate or monitor pro-
results, and be supportive of per- gression of the disease process and
ceived loss of independent function. determine the need for a change in
Discuss the implications of abnormal therapy. Evaluate test results in rela-
test results on the patient’s lifestyle. tion to the patient’s symptoms and
Provide teaching and information other tests performed.
patient’s health care provider regard- ➤ Related diagnostic tests include
ing further testing, treatment, or re- chest x-ray, computed tomography of
ferral to another health care provider. the thorax and magnetic resonance
Answer any questions or address imaging of the chest.
LUNG VENTILATION SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Radioactive ventilation scan, VQ lung scan,

aerosol lung scan, ventilation scan, xenon lung scan.

CONTRAST: Done with inhaled radioactive material (xenon gas or
technetium-DTPA).
• Identify areas of the lung that are capa-

DESCRIPTION & RATIONALE: The ble of ventilation
lung ventilation scan is a nuclear med-
• Locate hypoventilation (regional),
icine study performed to evaluate a which can result from chronic obstruc-
patient for pulmonary embolus (PE) tive pulmonary disease (COPD) or
or other pulmonary disorders. It can excessive smoking
evaluate respiratory function (i.e.,
demonstrating areas of the lung that RESULT
are patent and capable of ventilation)
and dysfunction (e.g., parenchymal Normal Findings:
abnormalities affecting ventilation, • Equal distribution of radioactive gas
such as pneumonia). The procedure is throughout both lungs and a normal
performed after the patient inhales air wash-out phase
mixed with a radioactive gas through a
face mask and mouthpiece. The Abnormal Findings:
radioactive gas delineates areas of the • Atelectasis
lung during ventilation. The distribu- • Bronchitis
tion of the gas throughout the lung is
measured in three phases: • Bronchogenic carcinoma
Wash-in phase: Phase during • COPD
buildup of the radioactive gas
• Emphysema
Equilibrium phase: Phase after the
patient rebreathes from a closed • PE
delivery system
• Pneumonia
Wash-out phase: Phase after the
radioactive gas has been • Regional hypoventilation
removed
This procedure is usually performed • Sarcoidosis
along with a lung perfusion scan. • Tuberculosis
When PE is present, ventilation scans
• Tumor
display a normal wash-in and wash-
out of radioactivity from the lung
areas. Parenchymal disease responsible
for perfusion abnormalities will pro-
duce abnormal wash-in and wash-out
phases. This test can be used to quan- This procedure is
tify regional ventilation in patients contraindicated for:
with pulmonary disease. ■ • Patients who are pregnant or suspected
INDICATIONS: benefits of the procedure far outweigh
• Aid in the diagnosis of PE the risks to the fetus and mother
• Differentiate between PE and other Factors that may
pulmonary diseases, such as pneumo- impair clear imaging:
nia, pulmonary effusion, atelectasis,
asthma, bronchitis, emphysema, and
or remain still during the proce-
tumors
dure because of age, significant pain, or
• Evaluate regional respiratory function mental status
Lung Ventilation Scan 883
• Metallic objects within the examina- list of known allergens.

tion field (e.g., jewelry, body rings), ➤ Obtain a history of the patient’s respi-
which may inhibit organ visualization ratory system, as well as results of
and can produce unclear images previously performed diagnostic pro-
• Patients who are very obese, who may laboratory tests. For related diagnos-
exceed the weight limit for the equip- tic tests, refer to the Respiratory
ment System table.
• Incorrect positioning of the patient, ➤ Record the date of the last menstrual
which may produce poor visualization ity of pregnancy in perimenopausal
of the area to be examined, especially women.
for oblique and decubitus views and for
films done by portable equipment medications.
• Other nuclear scans done within the ➤ Review the procedure with the
preceding 24 to 48 hours patient. Address concerns about pain
Other considerations: the patient that some pain may be
• The presence of conditions that affect there may be moments of discom-
perfusion or ventilation (e.g., tumors fort. Explain the purpose of the test
that obstruct the pulmonary artery, vas- and how the procedure is performed.
culitis, pulmonary edema, sickle cell Reassure the patient that the radionu-
disease, parasitic disease, emphysema, clide poses no radioactive hazard and
effusion, infection) can simulate a per- rarely produces side effects. Inform
fusion defect similar to PE. the patient that the procedure is per-
formed in a nuclear medicine depart-
• Consultation with a health care practi- ment, usually by a technologist and
tioner should occur before the proce- support staff, and takes approxi-
dure for radiation safety concerns mately 30 to 60 minutes.
regarding younger patients or patients ➤ Sensitivity to cultural and social
who are lactating. issues, as well as concern for mod-
• Risks associated with radiographic over- esty, is important in providing psy-
exposure can result from frequent x-ray and after the procedure.
the patient should wear a protective lead ➤ There are no food, fluid, or medica-
apron, stand behind a shield, or leave direction.
the area while the examination is being
done. Personnel working in the area ➤ Instruct the patient to remove den-
where the examination is being done hairpins, credit cards, and other
should wear badges that reveal their metallic objects in the area to be
level of exposure to radiation. examined.
Intratest:
➤ Make sure jewelry, chains, and any
Procedure ● ● ● ● ● ● ● ● ● ● ●
other metallic objects have been
removed from the chest area.
Pretest:
➤ Inform the patient that the procedure foot coverings to wear and instructed
assesses airflow to the lungs. to void prior to the procedure.
➤ Obtain a history of the patient’s com- ➤ Obtain and record baseline vital
plaints and symptoms, including a signs.
➤ Instruct the patient to cooperate fully cardia, hyperpnea, hypertension,

and to follow directions. Instruct the palpitations, nausea, or vomiting.
patient to remain still throughout the ➤ Instruct the patient to immediately
procedure because movement pro- report symptoms such as fast heart
duces unreliable results. rate, difficulty breathing, skin rash,
➤ Observe standard precautions, and itching, or decreased urinary output.
follow the general guidelines in ➤ Advise patient to drink increased
Appendix A. amounts of fluids for 24 to 48 hours
➤ Administer an antianxiety agent, as to eliminate the radionuclide from
ordered, if the patient has claustro- the body, unless contraindicated. Tell
phobia. Administer sedative to a the patient that radionuclide is elimi-
child or to an uncooperative adult, as nated from the body within 6 to 24
ordered. hours.
➤ Place the patient in a supine position ➤ Instruct the patient to flush the toilet
on a flat table with foam wedges, immediately after each voiding fol-
which help maintain position and im- lowing the procedure, and to wash
mobilization. The radionuclide is hands meticulously with soap and
administered through a mask, which water after each voiding for 24 hours
is placed over the patient’s nose and after the procedure.
mouth. The patient is asked to hold ➤ Tell all caregivers to wear gloves
his or her breath for a short period of when discarding urine for 24 hours
time while the scan is taken. The dis- after the procedure. Wash gloved
tribution of the radioactive gas is hands with soap and water before
monitored and measured on a removing gloves. Then wash hands
nuclear scanner. The patient’s chest after the gloves are removed.
is imaged while the gas is in the
➤ If a woman who is breast-feeding
lungs. Images of the lungs are
must have a nuclear scan, she
obtained in the posterior and, when
should not breast-feed the infant
possible, both oblique views.
until the radionuclide has been elimi-
➤ Wear gloves during the radionuclide nated. This could take as long as 3
administration and while handling days. She should be instructed to
the patient’s urine. express the milk and discard it dur-
➤ Instruct the patient to take slow, ing the 3-day period to prevent ces-
deep breaths if nausea occurs during sation of milk production.
the procedure. Monitor and adminis- ➤ A written report of the examination
ter an antiemetic agent if ordered. will be completed by a health care
Ready an emesis basin for use. practitioner specializing in this
➤ Monitor the patient for complica- branch of medicine. The report will
tions related to the procedure (e.g., be sent to the requesting health care
allergic reaction, anaphylaxis, bron- practitioner, who will discuss the
chospasm). results with the patient.
➤ The results are recorded on film or in ➤ Recognize anxiety related to test
a computerized system for recall and results, and be supportive of per-
postprocedure interpretation by the ceived loss of independent function.
appropriate health care practitioner. Discuss the implications of abnormal
Post-test: Provide teaching and information
➤ Evaluate the patient’s vital signs. the test results, as appropriate.
Monitor vital signs every 15 to 30 ➤ Reinforce information given by the
minutes and compare with baseline patient’s health care provider regard-
readings until the patient is stable. ing further testing, treatment, or
➤ Observe for delayed allergic reac- referral to another health care pro-
tions, such as rash, urticaria, tachy- vider. Answer any questions or ad-
Lupus Anticoagulant Antibodies 885
dress any concerns voiced by the tion to the patient’s symptoms and
patient or family. other tests performed.
gression of the disease process and chest x-ray, computed tomography of
determine the need for a change in the thorax, and magnetic resonance
therapy. Evaluate test results in rela- imaging of the chest.
LUPUS ANTICOAGULANT ANTIBODIES

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Lupus inhibitor phospholipid type, lupus antiphos-

pholipid antibodies.

REFERENCE VALUE: (Method: Dilute Russell venom viper test time)
Negative.
RESULT
DESCRIPTION & RATIONALE: Lupus
anticoagulant antibodies are immuno- Positive in:
globulins, usually of the immuno- • Fetal loss
globulin G class. They are also
• Raynaud’s disease
referred to as lupus antiphospholipid
antibodies because they interfere with • Rheumatoid arthritis
phospholipid-dependent coagulation • Systemic lupus erythematosus
tests such as activated partial throm-
boplastin time by reacting with the • Thromboembolism
phospholipids in the test system. They Negative in: N/A
are not associated with a bleeding dis-
order unless thrombocytopenia or CRITICAL VALUES: N/A
antiprothrombin antibodies are
already present. They are associated INTERFERING FACTORS:
with an increased risk of thrombosis. ■ • Drugs that may cause a positive lupus
anticoagulant test result include chlor-
INDICATIONS: promazine and heparin.
• Evaluate prolonged activated partial
• Placement of a tourniquet for longer
thromboplastin times
• Investigate reasons for fetal death sis and changes in the concentration
of plasma proteins to be measured. ➤ Review the procedure with the

Platelet activation may also occur patient. Inform the patient that spec-
under these conditions, causing erro- imen collection takes approximately
neous results. 5 to 10 minutes. Address concerns
• Vascular injury during phlebotomy can Explain to the patient that there may
activate platelets and coagulation fac- be some discomfort during the
tors, causing erroneous results. venipuncture.
• Hemolyzed specimens must be rejected ➤ Heparin therapy should be discontin-
ued 2 days before specimen col-
because hemolysis is an indication lection, with medical direction.
of platelet and coagulation factor acti- Coumarin therapy should be discon-
vation. tinued 2 weeks before specimen col-
• Incompletely filled tubes contaminated lection, with medical direction.
with heparin or clotted specimens must ➤ There are no food or fluid restric-
be rejected. tions, unless by medical direction.
• Icteric or lipemic specimens interfere
with optical testing methods, produc- Intratest:
ing erroneous results. ➤ Ensure that the patient has complied
with pretesting preparations; assure
that anticoagulent therapy has been
Nursing Implications and restricted as required prior to the
Procedure ● ● ● ● ● ● ● ● ● ● ●
procedure.
used to evaluate coagulation disor-
ders. ➤ Instruct the patient to cooperate
➤ Obtain a history of the patient’s com- the patient to breathe normally
plaints, including a list of known and to avoid unnecessary move-
allergens (especially allergies or sen- ment.
accordingly. follow the general guidelines in
➤ Obtain a history of the patient’s patient, and label the appropriate
hematopoietic, immune, musculos- tubes with the corresponding patient
keletal, and reproductive systems, as demographics, date, and time of col-
well as results of previously per- lection. Perform a venipuncture;
formed laboratory tests, surgical collect the specimen in a 5-mL blue-
procedures, and other diagnostic pro- top tube. Important note: Two differ-
cedures. For related laboratory tests, ent concentrations of sodium citrate
refer to the Hematopoietic, Immune, preservative are currently added to
Musculoskeletal, and Reproductive blue-top tubes for coagulation stud-
System tables. ies: 3.2% and 3.8%. The Clinical and
➤ Obtain a list of the medications the Laboratory Standards Institute/CLSI
patient is taking, including herbs, (formerly the National Committee
nutritional supplements, and nutra- for Clinical Laboratory Standards/
ceuticals. The requesting health care NCCLS) guideline for sodium citrate
practitioner and laboratory should be is 3.2%. Laboratories establish refer-
advised if the patient regularly uses ence ranges for coagulation testing
these products so that their effects based on numerous factors, includ-
can be taken into consideration ing sodium citrate concentration,
when reviewing results. test equipment, and test reagents. It
Luteinizing Hormone 887
is important to inquire from the labo- paper tape or other adhesive to hold
ratory which concentration it recom- pressure bandage in place, or replace
mends, because each concentration with a plastic bandage.
will have its own specific reference
range.
medications, as directed by the
➤ When multiple specimens are health care practitioner.
drawn, the blue-top tube should be
collected after sterile (i.e., blood cul- ➤ A written report of the examination
ture) and red-top tubes. When coag- will be sent to the requesting health
ulation testing is the only test to be care practitioner, who will discuss
done, an extra red-top tube should the results with the patient.
be collected before the blue-top tube ➤ Reinforce information given by the
to avoid contaminating the specimen patient’s health care provider regard-
with tissue thromboplastin, which ing further testing, treatment, or
can falsely decrease values. referral to another health care
➤ Remove the needle, and apply a pres- provider. Answer any questions or
patient or family.
analysis. The CLSI recommendation cedure, additional testing may be
for processed and unprocessed sam- performed to evaluate or monitor
ples stored in unopened tubes is that progression of the disease process
testing should be completed within and determine the need for a change
1 to 4 hours of collection. in therapy. Evaluate test results in
or in a computerized system for recall
tioner.
➤ Related laboratory tests include anti-
Post-test: cardiolipin antibody, antinuclear
antibody, activated partial thrombo-
➤ Observe venipuncture site for bleed- plastin time, protein S, and rheuma-
ing or hematoma formation. Apply toid factor.
LUTEINIZING HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: LH, luteotropin, interstitial cell–stimulating hor-

mone (ICSH).


Concentration by
Sex and by Phase Conventional SI Units
(in Women) Units (Conversion Factor 1)
Male
Less than 2 y 0.5–1.9 mIU/mL 0.5–1.9 IU/L
2–10 y Less than 0.5 mIU/mL Less than 0.5 IU/L
11–20 y 0.5–5.3 mIU/mL 0.5–5.3 IU/L
Adult 1.2–7.8 mIU/mL 1.2–7.8 IU/L
Female
Less than 2–10 y Less than 0.5 mIU/mL Less than 0.5 IU/L
11–20 y 0.5–9.0 mIU/mL 0.5–9.0 IU/L
Phase in Women
Follicular 1.7–15.0 mIU/mL 1.7–15.0 IU/L
Ovulatory 21.9–56.6 mIU/mL 21.9–56.6 IU/L
Luteal 0.6–16.3 mIU/mL 0.6–16.3 IU/L
Postmenopausal 14.2–52.3 mIU/mL 14.2–52.3 IU/L
DESCRIPTION & RATIONALE: the normal intermittent secretion of

Luteinizing hormone (LH) is secreted gonadotropin-releasing hormone. ■
by the anterior pituitary gland in
response to stimulation by gonado- INDICATIONS:
tropin-releasing hormone, the same • Distinguish between primary and sec-
hypothalamic releasing factor that ondary causes of gonadal failure
stimulates follicle-stimulating hor- • Evaluate children with precocious
mone release. LH affects gonadal puberty
function in both men and women. In
• Evaluate male and female infertility, as
women, a surge of LH normally indicated by decreased LH levels
occurs at the midpoint of the men-
strual cycle (ovulatory phase); this • Evaluate response to therapy to induce
surge is believed to be induced by high ovulation
estrogen levels. LH causes the ovum • Support diagnosis of infertility caused
to be expelled from the ovary and by anovulation, as evidenced by lack of
stimulates development of the corpus LH surge at the midpoint of the men-
luteum and progesterone production. strual cycle
As progesterone levels rise, LH pro-
duction decreases. In males, LH stim- RESULT
ulates the interstitial cells of Leydig,
located in the testes, to produce Increased in:
testosterone. For this reason, in refer- • Anorchia
ence to males, LH is sometimes called • Gonadal failure
interstitial cell–stimulating hormone.
Secretion of LH is pulsatile and fol- • Menopause
lows a circadian rhythm in response to • Primary gonadal dysfunction
Luteinizing Hormone 889
Decreased in: ➤ Obtain a history of the patient’s

• Anorexia nervosa endocrine and reproductive sys-
• Kallmann’s syndrome performed laboratory tests, surgi-
• Malnutrition procedures. For related laboratory
tests, refer to the Endocrine and
• Pituitary or hypothalamic dysfunction Reproductive System tables.
• Severe stress ➤ Record the date of the last menstrual
CRITICAL VALUES: N/A ity of pregnancy in perimenopausal
women.
INTERFERING FACTORS: ➤ Obtain a list of the medications the
• Drugs and hormones that may increase nutritional supplements, and nutra-
LH levels include clomiphene, ceuticals. The requesting health care
gonadotropin-releasing hormone, practitioner and laboratory should be
goserelin, ketoconazole, mestranol, advised if the patient regularly uses
nafarelin, naloxone, nilutamide, these products so that their effects
spironolactone, and tamoxifen. can be taken into consideration
• Drugs and hormones that may decrease ➤ Review the procedure with the
LH levels include anabolic steroids, patient. If the test is being per-
anticonvulsants, conjugated estrogens, formed to detect ovulation, inform
danazol, digoxin, D-Trp-6-LHRH, the patient that it may be necessary
estrogen/progestin therapy, goserelin, to obtain a series of samples over a
megestrol, norethindrone, octreotide, period of several days to detect peak
LH levels. Inform the patient that
oral contraceptives, phenothiazine,
pimozide, pravastatin, progesterone, mately 5 to 10 minutes. Address
stanozolol, and tamoxifen. concerns about pain related to the
• In menstruating women, values vary in
relation to the phase of the menstrual ing the venipuncture.
cycle.
• LH secretion follows a circadian tion restrictions, unless by medical
rhythm, with higher levels occurring direction.
during sleep.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: ➤ Instruct the patient to cooperate
fully and to follow directions. Dir-
➤ Inform the patient that the test is ect the patient to breathe normally
used to evaluate disorders of the and to avoid unnecessary move-
hypothalmic-pituitary-gonadal axis. ment.
lection. Perform a venipuncture; col- care practitioner, who will discuss

lect the specimen in a 5-mL red- or the results with the patient.
tiger-top tube. ➤ Reinforce information given by the
➤ Remove the needle, and apply a patient’s health care provider regard-
pressure dressing over the puncture ing further testing, treatment, or re-
site. ferral to another health care provider.
➤ Promptly transport the specimen to Answer any questions or address any
the laboratory for processing and concerns voiced by the patient or
analysis. family.
or in a computerized system for procedure, additional testing may
recall and postprocedure interpreta- be performed to evaluate or monitor
paper tape or other adhesive to ➤ Related laboratory tests include
hold pressure bandage in place, or adrenocorticotropic hormone, anti-
replace with a plastic bandage. sperm antibody, estradiol, follicle-
➤ A written report of the examination stimulating hormone, progesterone,
will be sent to the requesting health prolactin, and testosterone.
LYME ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative.
DESCRIPTION & RATIONALE: Borrelia thema migrans can appear 3 to 30

burgdorferi, a deer tick–borne spiro- days after the tick bite. About one-
chete, is the organism that causes half of patients in the early stage of
Lyme disease. Lyme disease affects Lyme disease (stage 1) and generally
multiple systems and is characterized all of those in the advanced stage
by fever, arthralgia, and arthritis. The (stage 2)—with cardiac, neurologic,
circular, red rash characterizing ery- and rheumatoid manifestations—will
Lyme Antibody 891

have a positive test result. Patients in
remission will also have a positive test
response. The presence of immuno- patient is taking, including herbs,
globulin M (IgM) antibodies indicates nutritional supplements, and nutra-
acute infection. The presence of IgG ceuticals. The requesting health care
antibodies indicates current or past practitioner and laboratory should be
infection. ■ these products so that their effects
INDICATIONS: Assist in establishing a when reviewing results.
diagnosis of Lyme disease ➤ Review the procedure with the
patient. Inform the patient that sev-
RESULT eral tests may be necessary to con-
firm diagnosis. Inform the patient that
Positive findings in: Lyme disease specimen collection takes approxi-
mately 5 to 10 minutes. Address con-
Negative findings in: N/A cerns about pain related to the
there may be some discomfort during
CRITICAL VALUES: N/A the venipuncture.
INTERFERING FACTORS: tion restrictions, unless by medical
• High rheumatoid-factor titers as well as direction.
cross-reactivity with Epstein-Barr virus
and other spirochetes (e.g., Rickettsia, Intratest:
Treponema) may cause false-positive ➤ If the patient has a history of severe
results. allergic reaction to latex, care should
• Positive test results should be con- be taken to avoid the use of equip-
firmed by the Western blot method.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
used to detect antibodies to Borrrelia tubes with the corresponding patient
burgdorferi. demographics, date, and time of col-
top tube.
immune and musculoskeletal sys- analysis.
tems and a history of exposure, as ➤ The results are recorded manually
well as results of previously per- or in a computerized system for
formed laboratory tests, surgical recall and postprocedure interpreta-
procedures, and other diagnostic pro- tion by the appropriate health care
cedures. For related laboratory tests, practitioner.
Post-test: the clinical implications of the test

results, as appropriate. Educate the
➤ Observe venipuncture site for bleed- patient regarding access to counsel-
ing or hematoma formation. Apply ing services.
paper tape or other adhesive to hold ➤ Reinforce information given by the
pressure bandage in place, or patient’s health care provider regard-
replace with a plastic bandage. ing further testing, treatment, or
➤ Advise the patient to wear light- referral to another health care
colored clothing that covers extremi- provider. Warn the patient that false-
ties when in areas infested by deer positive test results can occur and
ticks, and to check body for ticks that false-negative test results fre-
after returning from infested area. quently occur. Answer any questions
➤ A written report of the examination or address any concerns voiced by
will be sent to the requesting health the patient or family.
results, and be supportive of impaired
activity related to perceived loss of
independence and fear of shortened
life expectancy. Lyme disease can be
debilitating and can result in signifi-
cant changes in lifestyle. Discuss the Related laboratory tests:
implications of abnormal test results
on the patient’s lifestyle. Provide ➤ A related test is synovial fluid
teaching and information regarding analysis.
LYMPHANGIOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Lymphangiogram.
AREA OF APPLICATION: Lymphatic system.
DESCRIPTION: Lymphangiography lymph vessels and nodes. Assessment

involves visualization of the lymphatic of this system is important because
system after the injection of an iodi- cancer (lymphomas and Hodgkin’s
nated oil–based contrast medium into disease) often spreads via the lym-
a lymphatic vessel in the hand or foot. phatic system. When the lymphatic
The lymphatic system consists of system becomes obstructed, painful
Lymphangiography 893
Abnormal Findings:
edema of the extremities usually
results. The procedure is usually per- • Abnormal lymphatic vessels
formed for cancer staging in patients • Hodgkin’s disease
with an established diagnosis of lym- • Metastatic tumor involving the lymph
phoma or metastatic tumor. Injection glands
into the hand allows visualization of
the axillary and supraclavicular nodes. • Nodal lymphoma
Injection into the foot allows visuali- • Retroperitoneal lymphomas associated
zation of the lymphatics of the leg, with Hodgkin’s disease
inguinal and iliac regions, and
retroperitoneum up to the thoracic CRITICAL VALUES: N/A
duct. Less commonly, injection into
the foot can be used to visualize the INTERFERING FACTORS:
cervical region (retroauricular area).
This procedure is
This procedure can assess progres-
sion of the disease, assist in planning
• Patients with pulmonary insufficien-
surgery, and monitor the effective- cies, cardiac diseases, or severe renal or
ness of chemotherapy or radiation hepatic disease.
treatment. ■
• Determine the extent of adenopathy ing allergic reaction. Patients with a
• Determine lymphatic cancer staging known hypersensitivity to the contrast
medium may benefit from premedica-
• Distinguish primary from secondary tion with corticosteroids or the use of
lymphedema nonionic contrast medium.
• Evaluate edema of an extremity with- • Patients who are pregnant or suspected
out known cause of being pregnant, unless the potential
• Evaluate effects of chemotherapy or benefits of the procedure far outweigh
radiation therapy the risks to the fetus and mother
• Plan surgical treatment or evaluate • Elderly and other patients who

effectiveness of chemotherapy or radia- are chronically dehydrated before
tion therapy in controlling malignant the test, because of their risk of
tumors contrast-induced renal failure.
RESULT • Young patients (17 years old and
Normal Findings: x-ray diagnosis outweigh the risks of
• Normal lymphatic vessels and nodes exposure to high levels of radiation.
that fill completely with contrast
medium on the initial films. On the Factors that may
24-hour films, the lymph nodes are impair clear imaging:
fully opacified and well circumscribed. • Inability of the patient to cooperate or
The lymphatic channels are emptied a remain still during the procedure
few hours after injection of the contrast because of age, significant pain, or
medium. mental status

tion field (e.g., jewelry, body rings), Nursing Implications and
which may inhibit organ visualization Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
ographic equipment to accommodate ➤ Inform the patient that the procedure
obese or thin patients, which can cause assesses the lymphatic system.
overexposure or underexposure and a ➤ Obtain a history of the patient’s
poor-quality study complaints or clinical symptoms,
including a list of known allergens,
• Patients who are very obese, who especially allergies or sensitivities to
may exceed the weight limit for the iodine, seafood, or other contrast
equipment mediums.
• Incorrect positioning of the patient, ➤ Obtain a history of the patient’s
lymphatic system and previously
performed diagnostic procedures,
of the area to be examined surgical procedures, and labora-
• Gas or feces in the gastrointestinal tract tory tests. Include specific tests as
resulting from inadequate cleansing or they apply (e.g., blood urea nitrogen
failure to restrict food intake before the [BUN], creatinine, coagulation tests,
platelets, bleeding time). Ensure that
study
the results of blood tests are
• Retained barium from a previous radi- obtained and recorded before the
ologic procedure procedure, especially BUN and crea-
tinine, if contrast medium is to be
• Inability to cannulate the lymphatic used. For related diagnostic tests,
vessels refer to the Endocrine and
Immunologic System tables.
• Be aware of risks associated with interfere with test results, including
the contrast medium. The oil- examinations using iodine-based
based contrast medium may embolize contrast medium or barium.
into the lungs and will temporarily ➤ Record the date of the last menstrual
diminish pulmonary function. This can period and determine the possibil-
produce lipid pneumonia, which is a ity of pregnancy in perimenopausal
life-threatening complication. women.
• Consultation with a health care practi- ➤ Obtain a list of the medications the
tioner should occur before the proce- patient is taking, including anti-
dure for radiation safety concerns acid, herbs, nutritional supplements,
regarding younger patients or patients and nutraceuticals, especially those
who are lactating. known to affect coagulation (see Ap-
• Risks associated with radiographic over- pendix F). It is recommended that
procedures. Personnel in the room with health care practitioner and labora-
the patient should wear a protective lead tory should be advised if the patient
apron, stand behind a shield, or leave regularly uses these products so that
the area while the examination is being their effects can be taken into con-
done. Personnel working in the area sideration when reviewing results.
where the examination is being done ➤ Review the procedure with the
should wear badges that reveal their patient. Address concerns about
level of exposure to radiation. pain related to the procedure. Inform
Lymphangiography 895
the patient that he or she may feel ➤ Observe standard precautions, and
some discomfort when the contrast follow the general guidelines in
medium and anesthesia are injected. Appendix A.
Reassure the patient that the ➤ Administer a mild sedative, as
radionuclide poses no radioactive ordered.
hazard and rarely produces side
effects. Inform the patient that the ➤ Place the patient in a supine posi-
procedure is performed by a health tion on an x-ray table. Cleanse the
care practitioner and takes 1 to 2 selected vein and cover with a sterile
hours. Inform the patient that he or drape.
she may have to return the next day, ➤ A local anesthetic is injected at the
but that this set of images will take site, and a small incision is made
only 30 minutes. or a needle inserted. The contrast
➤ Instruct the patient to remove den- medium is injected intradermally into
tures, jewelry (including watches), the area between the toes or fin-
hairpins, credit cards, and other gers. The lymphatic vessels are iden-
metallic objects. tified as the contrast medium
moves. A local anesthetic is then
➤ There are no food or fluid restric- injected into the dorsum of each foot
tions, unless by medical direction. or hand, and a small incision is made
➤ Instruct patient to withhold anticoag- and cannulated for injection of the
ulant medication or to reduce dosage contrast medium.
before the procedure, as ordered by
➤ The contrast medium is then
injected, and the flow of the contrast
➤ Make sure a written and informed medium is followed by fluoroscopy.
consent has been signed prior to the When the contrast medium reaches
procedure and before administering the upper lumbar level, the infusion
any medications. of contrast medium is discontinued.
X-ray images are taken of the
Intratest: chest, abdomen, and pelvis to deter-
➤ Ensure that the patient has complied mine the extent of filling of the lym-
with medication restrictions and phatic vessels. Twenty-four–hour
pretesting preparations. Ensure that delayed images may be taken to
the patient has removed all external examine the lymphatic system after
metallic objects (jewelry, dentures, a period of time has elapsed and
etc.) prior to the procedure. to monitor the progress of delayed
➤ Have emergency equipment readily flow.
accessible. ➤ Ask the patient to inhale deeply and
➤ If the patient has a history of severe hold his or her breath while the x-ray
allergic reactions to any substance or images are taken, and then to exhale
drug, administer ordered prophylac- after the images are taken.
tic steroids or antihistamines before ➤ Monitor the patient for complications
the procedure. Use nonionic contrast related to the contrast medium (e.g.,
medium for the procedure. allergic reaction, anaphylaxis, bron-
➤ Patients are given a gown, robe, and chospasm).
foot coverings to wear and instructed ➤ When the procedure is complete,
to void prior to the procedure. the cannula is removed and the inci-
➤ Obtain and record baseline vital sion sutured.
signs, and assess neurologic status. ➤ The results are recorded on film or
➤ Instruct the patient to cooperate fully by automated equipment in a com-
and to follow directions. Instruct the puterized system for recall and
patient to remain still throughout the postprocedure interpretation by
procedure because movement pro- the appropriate health care practi-
duces unreliable results. tioner.
Post-test: ➤ Instruct the patient to apply cold

compresses to the cannulated site,
➤ Monitor vital signs and neurologic as needed, to reduce discomfort or
status every 15 minutes for 30 min- edema.
utes. Compare with baseline values. ➤ Monitor for signs of infection, such
Protocols may vary from facility to as pain, fever, increased pulse rate,
facility. and muscle aches.
➤ Observe for a delayed allergic reac- ➤ A written report of the examination
tion to contrast medium or pul- will be completed by a health care
monary embolus, which may include practitioner specializing in this branch
shortness of breath, increased heart of medicine. The report will be sent to
rate, pleuritic pain, hypotension, low- the requesting health care practi-
grade fever, and cyanosis. tioner, who will discuss the results
➤ Instruct the patient to resume usual with the patient.
medications, as directed by the ➤ Reinforce information given by the
health care practitioner. patient’s health care provider regard-
➤ Instruct the patient to maintain bed ing further testing, treatment, or re-
rest up to 24 hours to reduce extrem- ferral to another health care provider.
ity swelling after the procedure, or as Answer any questions or address
ordered. any concerns voiced by the patient
or family.
➤ Advise the patient to drink increased
amounts of fluids for 24 to 48 hours ➤ Depending on the results of this pro-
to eliminate the radionuclide from the cedure, additional testing may be
body, unless contraindicated. Tell the needed to evaluate or monitor pro-
patient that radionuclide is eliminated gression of the disease process and
from the body within 6 to 24 hours. determine the need for a change in
➤ Advise the patient to immediately tion to the patient’s symptoms and
report symptoms such as fast heart other tests performed.
rate, difficulty breathing, skin rash,
itching, nausea, vomiting, or de-
creased urinary output. Related diagnostic tests:
➤ Observe the cannula insertion ➤ Related diagnostic tests include com-
site for bleeding, inflammation, or puted tomography of the abdomen
hematoma formation. and pelvis.
MAGNESIUM, BLOOD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Mg2.

Magnesium, Blood 897
Alternative Units SI Units

Conventional (Conventional (Conventional
Age Units Units 0.8229) Units 0.4114)
Newborn 1.5–2.2 mg/dL 1.23–1.81 mEq/L 0.62–0.91 mmol/L
Child 1.7–2.1 mg/dL 1.40–1.73 mEq/L 0.70–0.86 mmol/L
Adult 1.6–2.6 mg/dL 1.32–2.14 mEq/L 0.66–1.07 mmol/L
RESULT
DESCRIPTION & RATIONALE: Magne-
sium is required as a cofactor in Increased in:
numerous crucial enzymatic processes, • Addison’s disease
such as protein synthesis, nucleic acid
• Adrenocortical insufficiency
synthesis, and muscle contraction.
Magnesium is also required for the use • Dehydration
of adenosine diphosphate as a source • Diabetic acidosis (severe)
of energy. It is the fourth most abun-
dant cation and the second most • Hypothyroidism
abundant intracellular ion. Magnes- • Multiple myeloma
ium is needed for the transmission of • Overuse of antacids
nerve impulses and muscle relaxation.
It controls absorption of sodium, • Renal insufficiency
potassium, calcium, and phosphorus; • Systemic lupus erythematosus
utilization of carbohydrate, lipid, and
• Tissue trauma
protein; and activation of enzyme sys-
tems that enable the B vitamins to Decreased in:
function. Magnesium is also essential • Alcoholism
for oxidative phosphorylation, nucleic
acid synthesis, and blood clotting. • Diabetic acidosis
Urine magnesium levels reflect mag- • Glomerulonephritis (chronic)
nesium deficiency before serum levels. • Hemodialysis
Magnesium deficiency severe enough
to cause hypocalcemia and cardiac • Hyperaldosteronism
arrhythmias can exist despite normal • Hypercalcemia
serum magnesium levels. ■
• Hypoparathyroidism
INDICATIONS: • Inadequate intake
• Determine electrolyte balance in renal
failure and chronic alcoholism • Inappropriate secretion of antidiuretic
hormone
• Evaluate cardiac arrhythmias (de-
creased magnesium levels can lead to • Long-term hyperalimentation
excessive ventricular irritability) • Malabsorption
• Evaluate known or suspected disorders • Pancreatitis
associated with altered magnesium
levels • Pregnancy
• Monitor the effects of various drugs on • Severe loss of body fluids (diarrhea,
magnesium levels lactation, sweating, laxative abuse)
CRITICAL VALUES: the IV solution combine in the collec-

Less than 1.2 mg/dL tion container, falsely decreasing the
Greater than 4.9 mg/dL
result. There is also the potential of
Note and immediately report to the contaminating the sample with the
health care practitioner any critically substance of interest, if it is present in
increased or decreased values and related the IV solution, falsely increasing the
symptoms. result.
Symptoms such as tetany, weakness,
dizziness, tremors, hyperactivity, nausea,
vomiting, and convulsions occur at Nursing Implications and
decreased (less than 1.2 mg/dL) concen- Procedure ● ● ● ● ● ● ● ● ● ● ●
trations. Electrocardiographic (ECG)

changes (prolonged P-R and Q-T inter- Pretest:
vals, broad flat T waves, and ventricular ➤ Inform the patient that the test is
tachycardia) may also occur. Treatment used to assist in the evaluation of
may include administration of magne- electrolyte balance.
sium salts, monitoring for respiratory ➤ Obtain a history of the patient’s
depression and areflexia (intravenous [IV] complaints, including a list of known
administration of magnesium salts), and allergens (especially allergies or sen-
monitoring for diarrhea and metabolic sitivities to latex), and inform the
alkalosis (oral administration to replace appropriate health care practitioner
accordingly.
magnesium).
Respiratory paralysis, decreased re- ➤ Obtain a history of the patient’s car-
flexes, and cardiac arrest occur at grossly diovascular, endocrine, gastrointesti-
nal, genitourinary, and reproduc-
elevated (greater than 15 mg/dL) levels.
tive systems, as well as results of
ECG changes, such as prolonged P-R and previously performed laboratory
Q-T intervals, and bradycardia may be tests, surgical procedures, and other
seen. Toxic levels of magnesium may be diagnostic procedures. For related
reversed with the administration of cal- laboratory tests, refer to the Cardio-
cium, dialysis treatments, and removal of vascular, Endocrine, Gastrointestinal,
the source of excessive intake. Genitourinary, and Reproductive
System tables.
INTERFERING FACTORS: ➤ Obtain a list of medications the
• Drugs that may increase magnesium patient is taking, including herbs,
levels include acetylsalicylic acid and nutritional supplements, and nutra-
progesterone. practitioner and laboratory should be
• Drugs that may decrease magnesium advised if the patient regularly uses
levels include albuterol, aminoglyco- these products so that their effects
sides, amphotericin B, bendroflume- can be taken into consideration when
reviewing results.
thiazide, chlorthalidone, cisplatin,
citrates, cyclosporines, digoxin, gen- ➤ Review the procedure with the
tamicin, glucagon, and oral contracep- patient. Inform the patient that spec-
tives. 5 to 10 minutes. Address concerns
• Hemolysis results in a false elevation in about pain related to the procedure.
values; such specimens should be Explain to the patient that there may
rejected for analysis. be some discomfort during the
venipuncture.
• Specimens should never be collected ➤ There are no food, fluid, or medica-
above an IV line because of the poten- tion restrictions, unless by medical
tial for dilution when the specimen and direction.
Magnesium, Blood 899
Intratest: tables, seeds, legumes, shrimp,

and some bran cereals. Advise the
➤ If the patient has a history of severe patient that high intake of sub-
allergic reaction to latex, care should stances such as phosphorus, cal-
be taken to avoid the use of equip- cium, fat, and protein interferes with
ment containing latex. the absorption of magnesium.
➤ Instruct the patient to cooperate fully ➤ Instruct the patient to report any
and to follow directions. Direct the signs or symptoms of electrolyte
patient to breathe normally and to imbalance, such as dehydration,
avoid unnecessary movement. diarrhea, vomiting, or prolonged
➤ Observe standard precautions, and anorexia.
follow the general guidelines in ➤ A written report of the examination
Appendix A. Positively identify the will be sent to the requesting health
patient, and label the appropriate care practitioner, who will discuss
tubes with the corresponding patient the results with the patient.
demographics, date, and time of col- ➤ Reinforce information given by the
lection. Perform a venipuncture; col- patient’s health care provider regard-
lect the specimen in a 5-mL red- or ing further testing, treatment, or
tiger-top tube. referral to another health care pro-
➤ Remove the needle, and apply a pres- vider. Answer any questions or
➤ Promptly transport the specimen to patient or family.
analysis. cedure, additional testing may be
➤ The results are recorded manually performed to evaluate or monitor
or in a computerized system for progression of the disease process
recall and postprocedure interpreta- and determine the need for a change
tion by the appropriate health care in therapy. Evaluate test results in
practitioner. relation to the patient’s symptoms
➤ Observe venipuncture site for bleed- ➤ Related laboratory tests include anti-
ing or hematoma formation. Apply arrhythmic drugs, aspartate ami-
paper tape or other adhesive to hold notransferase, calcium, C-reactive
pressure bandage in place, or replace protein, creatine kinase and isoen-
with a plastic bandage. zymes, homocysteine, kidney stone
➤ Nutritional considerations: Educate analysis, lactate dehydrogenase and
the magnesium-deficient patient isoenzymes, urine magnesium, myo-
regarding good dietary sources of globin, potassium, troponin, and vita-
magnesium, such as green vege- min D.
MAGNESIUM, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Urine Mg2.

clean plastic collection container with 6N hydrochloride as a preservative.
Alternative Units SI Units

Conventional (Conventional (Conventional
Units Units 0.8229) Units 0.4114)
7.3–12.2 mg/24 h 6.0–10.0 mEq/24 h 3.0–5.0 mmol/24 h
DESCRIPTION & RATIONALE: Mag- calcemia and cardiac arrhythmias can

nesium is required as a cofactor in exist despite normal serum magne-
numerous crucial enzymatic processes, sium levels.
such as protein synthesis, nucleic acid Regulating electrolyte balance is
synthesis, and muscle contraction. one of the major functions of the kid-
Magnesium is also required for the use neys. In normally functioning kid-
of adenosine diphosphate as a source neys, urine levels increase when serum
of energy. It is the fourth most levels are high and decrease when
abundant cation and the second serum levels are low to maintain
most abundant intracellular ion. homeostasis. Analyzing these urinary
Magnesium is needed for the trans- levels can provide important clues as
mission of nerve impulses and muscle to the functioning of the kidneys and
relaxation. It controls absorption other major organs. Tests for elec-
of sodium, potassium, calcium, and trolytes, such as magnesium, in urine
phosphorus; utilization of carbohy- usually involve timed urine collections
drate, lipid, and protein; and activa- over a 12- or 24-hour period. Meas-
tion of enzyme systems that enable the urement of random specimens may
B vitamins to function. Magnesium is also be requested. ■
also essential for oxidative phosphory-
lation, nucleic acid synthesis, and INDICATIONS:
blood clotting. Urine magnesium lev- • Determine the potential cause of renal
els reflect magnesium deficiency calculi
before serum levels. Magnesium defi- • Evaluate known or suspected endocrine
ciency severe enough to cause hypo- disorder
Magnesium, Urine 901
• Evaluate known or suspected renal

disease Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Evaluate magnesium imbalance

Pretest:
• Evaluate a malabsorption problem
RESULT is used to evaluate magnesium
balance.
• Alcoholism allergens (especially allergies or sen-
• Bartter’s syndrome sitivities to latex), and inform the
• Transplant recipients on cyclosporine accordingly.
and prednisone ➤ Obtain a history of the patient’s
• Use of corticosteroids endocrine, gastrointestinal, and gen-
itourinary systems, as well as results
• Use of diuretics of previously performed labora-
tory tests, surgical procedures, and
Decreased in: other diagnostic procedures. For
related laboratory tests, refer to
• Abnormal renal function the Endocrine, Gastrointestinal, and
• Crohn’s disease Genitourinary System tables.
• Inappropriate secretion of antidiuretic patient is taking, including herbs,
hormone nutritional supplements, and nutra-
• Salt-losing conditions ceuticals. The requesting health care
• Drugs that may increase urine magne- ➤ Review the procedure with the
sium levels include cisplatin, cyclospo- patient. Provide a nonmetallic urinal,
rine, ethacrynic acid, furosemide, bedpan, or toilet-mounted collection
mercaptomerin, mercurial diuretics, device. Address concerns about pain
and thiazides. related to the procedure. Explain to
• Drugs that may decrease urine mag- discomfort during the procedure.
nesium levels include amiloride, ➤ Usually a 24-hour time frame for
angiotensin, oral contraceptives, para- urine collection is ordered. Inform
thyroid extract, and phosphates. the patient that all urine must be
• Magnesium levels follow a circadian Instruct the patient not to void
rhythm, and for this reason 24-hour directly into the laboratory collection
collections are recommended. container. Instruct the patient to
avoid defecating in the collection
• All urine voided for the timed collec- device and to keep toilet tissue out
tion period must be included in the of the collection device to prevent
collection, or else falsely decreased val- contamination of the specimen.
ues may be obtained. Compare output Place a sign in the bathroom to
records with volume collected to verify remind the patient to save all urine.
that all voids were included in the col- ➤ Instruct the patient to void all urine
lection. into the collection device and then to
pour the urine into the laboratory col- stream, void directly into the speci-
lection container. Alternatively, the men container.
device for a health care staff mem- Indwelling catheter:
tion container. ➤ Put on gloves. Empty drainage tube
➤ Sensitivity to social and cultural clamp off the catheter for 15 to 30
issues, as well as concern for mod- minutes before specimen collection.
esty, is important in providing psy- Cleanse specimen port with antisep-
chological support before, during, tic swab, and then aspirate 5 mL of
and after the procedure. urine with a 21- to 25-gauge needle
➤ Instruct the patient to avoid exces- and syringe. Transfer urine to a ster-
sive exercise and stress during the ile container.
24-hour collection of urine.
➤ There are no food, fluid, or medica- Timed specimen:
tion restrictions, unless by medical ➤ Obtain a clean 3-L urine specimen
direction. container, toilet-mounted collection
Intratest: of the specimen container). The
specimen must be refrigerated or
➤ Ensure that the patient has complied kept on ice throughout the entire
with activity restrictions during the collection period. If an indwelling
procedure. urinary catheter is in place, the drain-
➤ If the patient has a history of severe age bag must be kept on ice.
allergic reaction to latex, care should ➤ Begin the test between 6 and 8 a.m.,
be taken to avoid the use of equip- if possible. Collect first voiding and
ment containing latex. discard. Record the time the speci-
➤ Instruct the patient to cooperate fully men was discarded as the beginning
and to follow directions. of the timed collection period. The
next morning, ask the patient to void
at the same time the collection was
started and add this last voiding to
the container.
tubes with the corresponding patient ➤ If an indwelling catheter is in place,
demographics, date, and time of replace the tubing and container sys-
collection. tem at the start of the collection
Random specimen (collect ice during the collection period, or
in early morning): empty the urine into a larger con-
tion period; monitor to ensure
Clean-catch specimen: continued drainage, and conclude
➤ Instruct the male patient to (1) thor- the test the next morning at the
oughly wash his hands, (2) cleanse same hour the collection was begun.
the meatus, (3) void a small amount ➤ At the conclusion of the test, com-
into the toilet, and (4) void directly pare the quantity of urine with the
into the specimen container. urinary output record for the collec-
➤ Instruct the female patient to (1) tion; if the specimen contains less
thoroughly wash her hands; (2) than what was recorded as output,
cleanse the labia from front to back; some urine may have been dis-
(3) while keeping the labia separated, carded, invalidating the test.
void a small amount into the toilet; ➤ Include on the collection container’s
and (4) without interrupting the urine label the amount of urine, test start
Magnetic Resonance Angiography 903
and stop times, and ingestion of any care practitioner, who will discuss
foods or medications that can affect the results with the patient.
test results. ➤ Recognize anxiety related to test
➤ Promptly transport the specimen results. Discuss the implications
to the laboratory for processing and of abnormal test results on the
analysis. patient’s lifestyle. Provide teaching
➤ The results are recorded manually and information regarding the clinical
or in a computerized system for implications of the test results, as
recall and postprocedure interpreta- appropriate.
tion by the appropriate health care ➤ Reinforce information given by the
practitioner. patient’s health care provider regard-
Post-test: referral to another health care
➤ Nutritional considerations: Educate address any concerns voiced by the
the magnesium-deficient patient patient or family.
regarding good dietary sources of
magnesium, such as green vege- ➤ Depending on the results of this pro-
tables, seeds, legumes, shrimp, cedure, additional testing may be
and some bran cereals. Advise performed to evaluate or monitor
the patient that high intake of sub- progression of the disease process
stances such as phosphorus, cal- and determine the need for a change
cium, fat, and protein interferes with in therapy. Evaluate test results in
the absorption of magnesium. relation to the patient’s symptoms
➤ Instruct the patient to report any
signs or symptoms of electrolyte
imbalance, such as dehydration, Related laboratory tests:
diarrhea, vomiting, or prolonged ➤ Related laboratory tests include cal-
anorexia. cium, kidney stone analysis, magne-
➤ A written report of the examination sium, phosphorus, potassium, and
will be sent to the requesting health vitamin D.
MAGNETIC RESONANCE
ANGIOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: MRA.
AREA OF APPLICATION: Vascular.
CONTRAST: Can be done with or without intravenous (IV) contrast
(gadolinium).
DESCRIPTION & RATIONALE: Mag- small arteries (laminar flow), but it

netic resonance imaging (MRI) uses a does not accurately depict blood flow
magnet and radio waves to produce an in tortuous sections of vessels and dis-
energy field that can be displayed as tal to bifurcations and stenosis.
an image. The magnetic field causes Swirling blood may cause a signal loss
the hydrogen atoms in tissue to line and result in inadequate images, and
up, and when radio waves are directed the degree of vessel stenosis may be
toward the magnetic field, the atoms overestimated. Images can be obtained
absorb the radio waves and change in two-dimensional (series of slices) or
their position. When the radio waves three-dimensional sequences. ■
are turned off, the atoms go back to
their original position, this change in INDICATIONS:
the energy field is sensed by the equip- • Detect pericardial abnormalities
ment, and an image is generated by • Detect peripheral vascular disease
the attached computer system. MRI • Detect thoracic and abdominal vascu-
produces cross-sectional images of the lar diseases
vessels in multiple planes without the
use of ionizing radiation or the inter- • Determine renal artery stenosis
ference of bone or surrounding tissue. • Differentiate aortic aneurysms from
Magnetic resonance angiography tumors near the aorta
(MRA) is an application of MRI that • Evaluate cardiac chambers and pul-
provides images of blood flow and dis- monary vessels
eased and normal blood vessels. In • Evaluate postoperative angioplasty sites
patients who are allergic to iodinated and bypass grafts
contrast medium, MRA is used in
place of angiography. MRA is particu- • Identify congenital vascular diseases
larly useful for visualizing vascular • Monitor and evaluate the effectiveness
abnormalities, dissections, and other of medical or surgical treatment
pathology. Special imaging sequences
allow the visualization of moving RESULT
blood within the vascular system. Two Normal Findings:
common techniques to obtain images
• Normal blood flow in the area being
of flowing blood are time-of-flight and examined, including blood flow rate
phase-contrast MRA. In time-of-flight
imaging, incoming blood makes the Abnormal Findings:
vessels appear bright and surrounding • Coarctations
tissue is suppressed. Phase-contrast
• Dissections
images are produced by subtracting
the stationary tissue surrounding the • Thrombosis within a vessel
vessels where the blood is moving • Tumor invasion of a vessel
through vessels during the imaging, • Vascular abnormalities
producing high-contrast images. MRA
is the most accurate technique for • Vessel occlusion
imaging blood flowing in veins and • Vessel stenosis
Magnetic Resonance Angiography 905
CRITICAL VALUES: N/A Nursing Implications and

INTERFERING FACTORS Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
This procedure is
contraindicated for: ➤ Inform the patient that the procedure
• Patients with certain ferrous metal pros- assesses the vascular system.
thetics, valves, aneurysm clips, inner ear ➤ Obtain a history of the patient’s com-
prostheses, or other metallic objects plaints, including a list of known
• Patients with metal in their body, such sitivities to contrast medium), and
as shrapnel or ferrous metal in the eye inform the appropriate health care
practitioner accordingly.
• Patients with cardiac pacemakers,
because the pacemaker can be ➤ Obtain a history of the patient’s car-
diovascular system, as well as
deactivated by MRI
• Patients who are claustrophobic nostic procedures, surgical proce-
dures, and laboratory tests. For
• Patients who are pregnant or suspected related diagnostic tests, refer to the
of being pregnant, unless the potential Cardiovascular System table.
benefits of the procedure far outweigh ➤ Determine if the patient has ever had
the risks to the fetus and mother any device implanted into his or her
body, including copper intrauterine
Factors that may devices, pacemakers, ear implants,
impair clear imaging: and heart valves.
• Metallic objects within the examina- ➤ Obtain occupational history to deter-
tion field (e.g., jewelry, body rings, mine the presence of metal in the
dental amalgams), which may inhibit body, such as shrapnel or flecks of
organ visualization and can produce ferrous metal in the eye (which can
unclear images cause retinal hemorrhage).
• Patients who are very obese, who interfere with test results.
may exceed the weight limit for the ➤ Record the date of the last menstrual
equipment period and determine the possibil-
• Incorrect positioning of the patient, ity of pregnancy in perimenopausal
which may produce poor visualization women.
of the area to be examined ➤ Obtain a list of the medications the
patient is taking.
• Inability of the patient to cooperate ➤ Review the procedure with the
or remain still during the procedure patient. Address concerns about pain
because of age, significant pain, or related to the procedure. Explain to
mental status the patient that no pain will be expe-
rienced during the test, but there
• Patients with extreme cases of claustro- may be moments of discomfort.
phobia, unless sedation is given before Inform the patient that the procedure
the study is performed in an MRI department,
usually by a technologist and support
Other considerations: staff, and takes approximately 30 to
• If contrast medium is allowed to seep 60 minutes.
deep into the muscle tissue, vascular ➤ Inform the patient that the technolo-
visualization will be impossible. gist will place him or her in a supine
position on a flat table in a large gating is to be performed in con-

cylindrical scanner. junction with the scan, apply MRI-
➤ Tell the patient to expect to hear safe electrodes to the appropriate
loud banging from the scanner and sites.
possibly to see magnetophosphenes ➤ The patient can communicate with
(flickering lights in the visual field); the technologist during the exami-
these will stop when the procedure nation via a microphone within the
is over. machine.
➤ Sensitivity to cultural and social ➤ Establish intravenous fluid line for
issues, as well as concern for mod- the injection of emergency drugs,
esty, is important in providing psy- and sedatives.
chological support before, during, ➤ Administer an antianxiety agent, as
and after the procedure. ordered, if the patient has claustro-
➤ Explain that an IV line may be phobia. Administer a sedative to a
inserted to allow infusion of IV fluids, child or to an uncooperative adult, as
contrast medium, dye, or sedatives. ordered.
Usually normal saline is infused. ➤ Place the patient in the supine posi-
➤ There are no food, fluid, or medication on an exam table.
tion restrictions, unless by medical ➤ If ordered with contrast, the contrast
direction. medium is injected, and a series of
images is taken during and after the
filling of the vessels to be examined.
Delayed images may be taken
hairpins, credit cards, and other
to monitor the venous phase of the
metallic objects.
procedure.
the procedure.
➤ Ensure that the patient has removed
jewelry, dentures, all external metal- ➤ Monitor the patient for complica-
lic objects etc. prior to the procedure. tions related to the procedure (e.g.,
➤ Have emergency equipment readily chospasm).
available.
➤ If the patient has a history of severe on automated equipment in a com-
the procedure.
➤ Patients are given a gown, robe, and Post-test:
➤ If contrast is administered, observe
for delayed allergic reactions, such as
➤ Instruct the patient to cooperate fully rash, urticaria, tachycardia, hyperp-
and to follow directions. Instruct the nea, hypertension, palpitations, nau-
patient to remain still throughout the sea, or vomiting.
procedure because movement pro- ➤ Advise the patient to immediately
duces unreliable results. report symptoms such as fast heart
➤ Observe standard precautions, and rate, difficulty breathing, skin rash,
follow the general guidelines in itching or decreased urinary output
Appendix A. ➤ Observe the needle/catheter inser-
➤ Supply earplugs to the patient to tion site for bleeding, inflammation,
block out the loud, banging sounds or hematoma formation.
that occur during the test. ➤ Instruct the patient to apply cold
➤ If an electrocardiogram or respiratory compresses to the puncture site, as
Magnetic Resonance Imaging, Abdomen 907
needed, to reduce discomfort or ➤ Depending on the results of this pro-

edema. cedure, additional testing may be
will be completed by a health care progression of the disease process
practitioner specializing in this and determine the need for a change
branch of medicine. The report will in therapy. Evaluate test results in
be sent to the requesting health care relation to the patient’s symptoms
practitioner, who will discuss the and other tests performed.
➤ Reinforce information given by the Related diagnostic tests:
ing further testing, treatment, or re- ➤ Related diagnostic tests include
ferral to another health care provider. angiography of the body area of
Explain the importance of adhering interest, computed tomography an-
to the therapy regimen. Answer any giography, and ultrasound arterial
questions or address any concerns Doppler carotid and venous Doppler
voiced by the patient or family. ultrasound.
MAGNETIC RESONANCE
IMAGING, ABDOMEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Abdominal MRI.

AREA OF APPLICATION: Liver/abdominal area.
CONTRAST: Can be done with or without intravenous (IV) contrast medium
(gadolinium).
DESCRIPTION & RATIONALE: Mag- line up, and when radio waves are
netic resonance imaging (MRI) uses a directed toward the magnetic field,
magnet and radio waves to produce an the atoms absorb the radio waves and
energy field that can be displayed as change their position. When the radio
an image. Use of magnetic fields with waves are turned off, the atoms go
the aid of radiofrequency energy pro- back to their original position; this
duces images primarily based on water change in the energy field is sensed by
content of tissue. The magnetic field the equipment, and an image is gener-
causes the hydrogen atoms in tissue to ated by the attached computer system.
MRI produces cross-sectional images • Detect soft tissue abnormalities

of the abdomen in multiple planes • Determine and monitor tissue damage
without the use of ionizing radiation in renal transplant patients
or the interference of bone.
• Determine the presence of blood clots,
Abdominal MRI is performed to
cysts, fluid or fat accumulation in tis-
assist in diagnosing abnormalities of sues, hemorrhage, and infarctions
abdominal and hepatic structures.
Contrast-enhanced imaging is effec- • Determine vascular complications of
tive for distinguishing peritoneal pancreatitis, venous thrombosis, or
metastases from primary tumors of pseudoaneurysm
the gastrointestinal tract. Primary • Differentiate aortic aneurysms from
tumors of the stomach, pancreas, tumors near the aorta
colon, and appendix often spread by
• Differentiate liver tumors from liver
intraperitoneal tumor shedding and abnormalities, such as cysts, cavernous
subsequent peritoneal carcinomatosis. hemangiomas, and hepatic amebic
MRI uses the noniodinated contrast abscesses
medium gadopentetate dimeglumine
(Magnevist), which is administered • Evaluate postoperative angioplasty sites
and bypass grafts
intravenously to enhance contrast dif-
ferences between normal and abnor- • Monitor and evaluate the effectiveness
mal tissues. of medical or surgical interventions and
Magnetic resonance angiography the course of the disease
(MRA) is an application of MRI that
provides images of blood flow and dis- RESULT
eased and normal blood vessels. In
Normal Findings:
patients who are allergic to iodinated
• Normal anatomic structures, soft tissue
contrast medium, MRA is used in density, and biochemical constituents
place of angiography (see monograph of body tissues, including blood flow
titled “Magnetic Resonance Angiogra-
phy”). When the Food and Drug Abnormal Findings:
Administration approves gastrointesti- • Acute tubular necrosis
nal contrast agents, these agents would
• Aneurysm
assist in identifying areas of bowel wall
thickening, stricture, and intraluminal • Cholangitis
abnormalities, such as tumors, sites of
perforation, and fistula. ■
• Hydronephrosis
INDICATIONS: • Internal bleeding
• Detect abdominal aortic diseases
• Masses, lesions, infections, or inflam-
• Detect and stage cancer (primary or mations
metastatic tumors of liver, pancreas,
• Renal vein thrombosis
prostate, uterus, and bladder)
• Vena cava obstruction
• Detect chronic pancreatitis
• Detect renal vein thrombosis CRITICAL VALUES: N/A
Magnetic Resonance Imaging, Abdomen 909

This procedure is
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
• Patients with certain ferrous metal
prostheses, valves, aneurysm clips, in- ➤ Inform the patient that the procedure
ner ear prostheses, or other metallic assesses the organs and structures
objects inside the abdomen.
• Patients with metal in their body, such plaints, including a list of known
as shrapnel or ferrous metal in the eye allergens (especially allergies or sen-
• Patients with cardiac pacemakers, sitivities to contrast medium), and
because the pacemaker can be inform the appropriate health care
deactivated by MRI
• Patients with intrauterine devices gastrointestinal, genitourinary, and
• Patients with iron pigments in tattoos hepatobiliary systems, as well as
• Patients who are claustrophobic nostic procedures, surgical proce-
dures, and laboratory tests. Ensure
• Patients who are pregnant or suspected that the results of blood tests
of being pregnant, unless the potential are obtained and recorded before
benefits of the procedure far outweigh the procedure, especially coagula-
the risks to the fetus and mother tion tests, blood urea nitrogen, and
creatinine, if contrast medium is to
Factors that may be used. For related diagnostic tests,
impair clear imaging: refer to the Gastrointestinal, Geni-
• Metallic objects within the examina- tourinary, and Hepatobiliary System
tion field (e.g., jewelry, body rings, tables.
dental amalgams), which may inhibit ➤ Determine if the patient has ever had
organ visualization and can produce any device implanted into his or her
unclear images body, including copper intrauterine
devices, pacemakers, ear implants,
• Patients who are very obese, who may and heart valves.
exceed the weight limit for the equip- ➤ Obtain occupational history to deter-
ment mine the presence of metal in the
• Incorrect positioning of the patient, body, such as shrapnel or flecks of
which may produce poor visualization ferrous metal in the eye (which can
of the area to be examined cause retinal hemorrhage).
• Inability of the patient to cooperate or interfere with test results, includ-
remain still during the procedure being examinations using iodine-based
cause of age, significant pain, or mental contrast medium or barium.
status ➤ Record the date of the last menstrual
• Patients with extreme cases of claustro- period and determine the possibility
phobia, unless sedation is given before of pregnancy in perimenopausal
the study or an open MRI is utilized women.
Other considerations: patient is taking.
• If contrast medium is allowed to seep ➤ Review the procedure with the
deep into the muscle tissue, vascular patient. Address concerns about pain
visualization will be impossible. related to the procedure. Explain to
the patient that no pain will be expe- elry, dentures, etc.) prior to the pro-
rienced during the test, but there cedure.
may be moments of discomfort. ➤ Have emergency equipment readily
Reassure the patient that, if contrast available.
is used, the radionuclide poses no
radioactive hazard and rarely pro- ➤ If the patient has a history of severe
duces side effescts. Inform the allergic reactions to any substance or
patient that the procedure is per- drug, administer ordered prophylac-
formed in an MRI department, usu- tic steroids or antihistamines before
ally by a technologist and support the procedure.
staff, and takes approximately 30 to ➤ Patients are given a gown, robe, and
60 minutes. foot coverings to wear and instructed
➤ Inform the patient that the technolo- to void prior to the procedure.
gist will place him or her in a supine ➤ Instruct the patient to cooperate fully
position on a flat table in a large and to follow directions. Instruct the
cylindrical scanner. patient to remain still throughout the
➤ Tell the patient to expect to hear loud procedure because movement pro-
banging from the scanner and pos- duces unreliable results.
sibly to see magnetophosphenes ➤ Observe standard precautions, and
(flickering lights in the visual field); follow the general guidelines in
these will stop when the procedure Appendix A.
is over.
➤ Supply earplugs to the patient to
➤ Sensitivity to social and cultural block out the loud, banging sounds
issues, as well as concern for mod- that occur during the test.
chological support before, during, ➤ The patient can communicate with
and after the procedure. the technologist during the exami-
nation via a microphone within the
➤ Explain that an IV line may be machine.
inserted to allow infusion of IV fluids,
contrast medium, dye, or sedatives. ➤ Establish an IV fluid line for the injec-
Usually normal saline is infused. tion of emergency drugs and of
sedatives.
➤ Inform the patient that a burning
and flushing sensation may be felt ➤ Administer an antianxiety agent, as
throughout the body during injection ordered, if the patient has claustro-
of the contrast medium. After injec- phobia. Administer a sedative to a
tion of the contrast medium, the child or to an uncooperative adult, as
patient may experience an urge to ordered.
cough, flushing, nausea, or a salty or ➤ Place the patient in the supine posi-
metallic taste. tion on an exam table.
➤ There are no food, fluid, or medica- ➤ If ordered with contrast, the contrast
tion restrictions, unless by medical medium is injected, and a series of
direction. images is taken during and after the
➤ Instruct the patient to remove den- filling of the vessels to be examined.
tures, jewelry (including watches), Delayed images may be taken to
hairpins, credit cards, and other monitor the venous phase of the pro-
metallic objects. cedure.
➤ Make sure a written and informed ➤ Instruct the patient to take slow,
consent has been signed prior to the deep breaths if nausea occurs during
procedure and before administering the procedure.
any medications. ➤ Monitor the patient for complica-
Intratest: allergic reaction, anaphylaxis, bron-
➤ Ensure that the patient has removed chospasm).
all external metallic objects (jew- ➤ The needle or catheter is removed,
Magnetic Resonance Imaging, Brain 911
and a pressure dressing is applied practitioner, who will discuss the

over the puncture site. results with the patient.
➤ The results are recorded on film or on ➤ Recognize anxiety related to test
automated equipment in a computer- results, and be supportive of per-
ized system for recall and postproce- ceived loss of independent function.
dure interpretation by the appropriate Discuss the implications of abnormal
health care practitioner. test results on the patient’s lifestyle.
Post-test: the test results, as appropriate.
➤ Observe for delayed allergic reac- ➤ Reinforce information given by the
tions, such as rash, urticaria, tachy- patient’s health care provider regard-
cardia, hyperpnea, hypertension, ing further testing, treatment, or
palpitations, nausea, or vomiting, if referral to another health care pro-
contrast medium was used. vider. Explain the importance of
➤ Instruct the patient to immediately adhering to the therapy regimen.
report symptoms such as fast heart Answer any questions or address
rate, difficulty breathing, skin rash, any concerns voiced by the patient
itching or decreased urinary output or family.
➤ Observe the needle/catheter inser- ➤ Depending on the results of this
tion site for bleeding, inflammation, procedure, additional testing may be
or hematoma formation. performed to evaluate or monitor
➤ Instruct the patient to apply cold and determine the need for a change
compresses to the puncture site, as in therapy. Evaluate test results in
needed, to reduce discomfort or relation to the patient’s symptoms
edema. and other tests performed.
be scheduled for 24 to 48 hours after Related diagnostic tests:
this procedure.
➤ A written report of the examina- angiography of the abdomen; com-
tion will be completed by a health puted tomography of the abdomen;
care practitioner specializing in this kidney, ureter, and bladder (KUB)
branch of medicine. The report will study; and ultrasound of the liver and
be sent to the requesting health care biliary system.
MAGNETIC RESONANCE
IMAGING, BRAIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Brain MRI.

AREA OF APPLICATION: Brain area.
medium (gadolinium).
DESCRIPTION & RATIONALE: Mag- Magnetic resonance angiography

netic resonance imaging (MRI) uses a (MRA) is an application of MRI that
magnet and radio waves to produce an provides images of blood flow and
energy field that can be displayed as diseased and normal blood vessels. In
an image. Use of magnetic fields with patients who are allergic to iodinated
the aid of radiofrequency energy pro- contrast medium, MRA is used in
duces images primarily based on water place of angiography (see mono-
content of tissue. The magnetic field graph titled “Magnetic Resonance
causes the hydrogen atoms in tissue to Angiography”). ■
line up, and when radio waves are
directed toward the magnetic field, INDICATIONS:
the atoms absorb the radio waves and • Detect and locate brain tumors
change their position. When the radio • Detect cause of cerebrovascular acci-
waves are turned off, the atoms go dent, cerebral infarct, or hemorrhage
back to their original position, this • Detect cranial bone, face, throat, and
change in the energy field is sensed by neck soft tissue lesions
the equipment, and an image is gener-
• Evaluate the cause of seizures, such as
ated by the attached computer system.
intracranial infection, edema, or
MRI produces cross-sectional images increased intracranial pressure
of pathologic lesions of the brain in
multiple planes without the use of • Evaluate cerebral changes associated
with dementia
ionizing radiation or the interference
of bone or surrounding tissue. • Evaluate demyelinating disorders
Brain MRI can distinguish solid, • Evaluate intracranial infections
cystic, and hemorrhagic components
• Evaluate optic and auditory nerves
of lesions. This procedure is done to
aid in the diagnosis of intracranial • Evaluate the potential causes of
abnormalities, including tumors, headache, visual loss, and vomiting
ischemia, infection, and multiple scle- • Evaluate shunt placement and function
rosis, and in assessment of brain matu- in patients with hydrocephalus
ration in pediatric patients. Rapidly • Evaluate the solid, cystic, and hemor-
flowing blood on spin-echo MRI rhagic components of lesions
appears as an absence of signal or a void
• Evaluate vascularity of the brain and
in the vessel’s lumen. Blood flow can be
vascular integrity
evaluated in the cavernous and carotid
arteries. Aneurysms may be diagnosed • Monitor and evaluate the effectiveness
without traditional iodine-based con- of medical or surgical interventions,
chemotherapy, and radiation therapy
trastangiography, and old clotted
and the course of disease
blood in the walls of the aneurysms
appears white. MRI uses the noniodi- RESULT
nated contrast medium gadopentetate
dimeglumine (Magnevist), which is Normal Findings:
administered intravenously to enhance • Normal anatomic structures, soft tissue
contrast differences between normal density, blood flow rate, face, nasophar-
and abnormal tissues. ynx, neck, tongue, and brain
Abnormal Findings: • Patients who are claustrophobic

• Abscess • Patients who are pregnant or suspected
• Acoustic neuroma of being pregnant, unless the potential
• Alzheimer’s disease the risks to the fetus and mother
• Aneurysm
• Arteriovenous malformation Factors that may
• Benign meningioma • Metallic objects within the examina-
• Cerebral aneurysm tion field (e.g., jewelry, body rings,
• Cerebral infarction organ visualization and can produce
• Craniopharyngioma or meningioma unclear images
• Granuloma • Patients who are very obese, who

• Intraparenchymal hematoma or hem- equipment
orrhage
• Lipoma which may produce poor visualization
• Metastasis of the area to be examined
• Multiple sclerosis • Inability of the patient to cooperate or

• Optic nerve tumor because of age, significant pain, or
• Parkinson’s disease mental status
• Pituitary microadenoma • Patients with extreme cases of claustro-

phobia, unless sedation is given before
• Subdural empyema the study or an open MRI is utilized
• Ventriculitis
CRITICAL VALUES: N/A • If contrast medium is allowed to seep
deep into the muscle tissue, vascular
INTERFERING FACTORS: visualization will be impossible.
This procedure is
contraindicated for: Nursing Implications and
• Patients with certain ferrous metal Procedure ● ● ● ● ● ● ● ● ● ● ●
prostheses, valves, aneurysm clips,

inner ear prostheses, or other metallic Pretest:
objects
• Patients with metal in their body, such assesses the brain.
as shrapnel or ferrous metal in the eye ➤ Obtain a history of the patient’s com-
• Patients with cardiac pacemakers, allergens (especially allergies or sen-
because the pacemaker can be sitivities to contrast medium), and
deactivated by MRI inform the appropriate health care
• Patients with intrauterine devices
• Patients with iron pigments in tattoos diovascular and endocrine systems,
as well as results of previously per- inserted to allow infusion of IV fluids,

formed diagnostic procedures, surgi- contrast medium, dye, or sedatives.
cal procedures, and laboratory tests. Usually normal saline is infused.
For related diagnostic tests, refer to ➤ There are no food, fluid, or medica-
the Cardiovascular and Endocrine tion restrictions, unless by medical
System tables. direction.
➤ Determine if the patient has ever had ➤ Instruct the patient to remove den-
any device implanted into his or her tures, jewelry (including watches),
body, including copper intrauterine hairpins, credit cards, and other
devices, pacemakers, ear implants, metallic objects.
and heart valves.
➤ Obtain occupational history to deter- Intratest:
mine the presence of metal in the
body, such as shrapnel or flecks of ➤ Ensure that the patient has removed
ferrous metal in the eye (which can all external metallic objects (jewelry,
cause retinal hemorrhage). dentures, etc.) prior to the procedure.
➤ Note any recent procedures that can ➤ Have emergency equipment readily
interfere with test results, including available.
examinations using iodine-based ➤ If the patient has a history of severe
contrast medium or barium. allergic reactions to any substance or
➤ Record the date of the last menstrual drug, administer ordered prophylac-
period and determine the possibil- tic steroids or antihistamines before
ity of pregnancy in perimenopausal the procedure.
women. ➤ Patients are given a gown, robe, and
➤ Obtain a list of the medications the foot coverings to wear and instructed
patient is taking. to void prior to the procedure.
the patient that no pain will be expe-
may be moments of discomfort. In- ➤ Observe standard precautions, and
form the patient that the procedure follow the general guidelines in
is performed in an MRI department, Appendix A.
usually by a technologist and support ➤ Supply earplugs to the patient to
staff, and takes approximately 30 to block out the loud, banging sounds
60 minutes. that occur during the test.
➤ Inform the patient that the technolo- ➤ If an electrocardiogram or respiratory
gist will place him or her in a supine gating is to be performed in conjunc-
position on a flat table in a large tion with the scan, apply MRI-safe
cylindrical scanner. electrodes to the appropriate sites.
➤ Tell the patient to expect to hear loud ➤ The patient can communicate with
banging from the scanner and pos- the technologist during the exami-
sibly to see magnetophosphenes nation via a microphone within the
(flickering lights in the visual field); machine.
these will stop when the procedure ➤ Establish an IV fluid line for the injec-
is over. tion of emergency drugs and of
➤ Sensitivity to social and cultural sedatives.
issues, as well as concern for mod- ➤ Administer an antianxiety agent, as
esty, is important in providing psy- ordered, if the patient has claustro-
chological support before, during, phobia. Administer a sedative to a
and after the procedure. child or to an uncooperative adult, as
➤ Explain that an IV line may be ordered.
➤ Place the patient in the supine posi- needed, to reduce discomfort or

tion on an exam table. edema.
➤ If ordered with contrast, the contrast ➤ A written report of the examination
medium is injected, and a series of will be completed by a health care
images is taken during and after practitioner specializing in this branch
the filling of the vessels to be exam- of medicine. The report will be sent to
ined. Delayed images may be taken the requesting health care practi-
to monitor the venous phase of the tioner, who will discuss the results
procedure. with the patient.
➤ Instruct the patient to take slow, ➤ Recognize anxiety related to test
deep breaths if nausea occurs during results, and be supportive of per-
the procedure. ceived loss of independent function.
➤ Monitor the patient for complica- Discuss the implications of abnormal
tions related to the procedure (e.g., test results on the patient’s lifestyle.
allergic reaction, anaphylaxis, bron- Provide teaching and information
chospasm). regarding the clinical implications of
and a pressure dressing is applied ➤ Reinforce information given by the
over the puncture site. patient’s health care provider regard-
➤ The results are recorded on film or on referral to another health care pro-
automated equipment in a computer- vider. Explain the importance of
ized system for recall and postproce- adhering to the therapy regimen.
dure interpretation by the appropriate Answer any questions or address
health care practitioner. any concerns voiced by the patient
or family.
Post-test:
➤ Observe for delayed allergic reac- cedure, additional testing may be
tions, such as rash, urticaria, tachy- performed to evaluate or monitor
cardia, hyperpnea, hypertension, progression of the disease process
palpitations, nausea, or vomiting, if and determine the need for a change
contrast medium was used. in therapy. Evaluate test results in
➤ Instruct the patient to immediately relation to the patient’s symptoms
report symptoms such as fast heart and other tests performed.
rate, difficulty breathing, skin rash,
itching or decreased urinary output Related diagnostic tests:
➤ Observe the needle/catheter inser- ➤ Related diagnostic tests include
tion site for bleeding, inflammation, angiography of the carotids, com-
or hematoma formation. puted tomography of the brain, and
➤ Instruct the patient to apply cold positron emission tomography scan
compresses to the puncture site, as of the brain.
MAGNETIC RESONANCE
IMAGING, BREAST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Breast MRI.

AREA OF APPLICATION: Breast area.
DESCRIPTION & RATIONALE: Mag- include those who have had breast
netic resonance imaging (MRI) uses a cancer, have an abnormal mutated
magnet and radio waves to produce an breast cancer gene (BRCA1 or
energy field that can be displayed as BRCA2), or have a mother or sister
an image. Use of magnetic fields with who has been diagnosed with breast
the aid of radiofrequency energy pro- cancer. Breast MRI is used most com-
duces images primarily based on water monly in high-risk women when find-
content of tissue. The magnetic field ings of a mammogram or ultrasound
causes the hydrogen atoms in tissue to are inconclusive because of dense
line up, and when radio waves are breast tissue or there is a suspected
directed toward the magnetic field, abnormality that requires further eval-
the atoms absorb the radio waves and uation. MRI is also an excellent exam
change their position. When the radio in the augemented breast, including
waves are turned off, the atoms go both the breast implant itself and the
back to their original position, this breast tissue surrounding the implant.
change in the energy field is sensed by This same exam is also useful for stag-
the equipment, and an image is gener- ing breast cancer and determining the
ated by the attached computer system. most appropriate treatment. MRI uses
MRI produces cross-sectional images the noniodinated contrast medium
of the pathologic lesions in multiple gadopentetate dimeglumine (Mag-
planes without the use of ionizing nevist), which is administered intrave-
radiation or the interference of sur- nously to enhance contrast differences
rounding tissue, breast implants, or between normal and abnormal tis-
surgically implanted clips. sues. ■
MRI imaging of the breast is not a
replacement for traditional mammog- INDICATIONS:
raphy, ultrasound, or biopsy. This • Evaluate breast implants
exam is extremely helpful in evaluat-
ing mammogram abnormalities and • Evaluate dense breasts
identifying early breast cancer in • Evaluate for residual cancer after
women at high risk. High-risk women lumpectomy
Magnetic Resonance Imaging, Breast 917
• Evaluate inverted nipples Factors that may impair clear

imaging:
• Evaluate small abnormalities
• Evaluate tissue after lumpectomy or tion field (e.g., jewelry, body rings),
mastectomy which may inhibit organ visualization
• Evaluate women at high risk for breast
cancer • Patients who are very obese, who may
RESULT ment
Normal Findings: which may produce poor visualization
• Normal anatomic structures, soft tissue of the area to be examined
density, and blood flow rate
Abnormal Findings: remain still during the procedure
• Breast abscess or cyst
mental status, may interfere with the
• Breast cancer test results.
• Breast implant rupture • Patients with extreme cases of claustro-
• Hematoma the study or an open MRI is utilized
• Soft tissue masses
• Vascular abnormalities • The procedure may take 30 to 60 min-
utes to complete, and may require the
CRITICAL VALUES: N/A injection of contrast material.
INTERFERING FACTORS: • If contrast medium is allowed to seep
This procedure is visualization will be impossible.
• The procedure can be nonspecific; the
• Patients with certain ferrous metal exam is unable to image calcifications
prostheses, valves, aneurysm clips, that can indicate breast cancer, and
inner ear prostheses, or other metallic there may be difficulty distinguishing
objects between cancerous and noncancerous
• Patients with metal in their body, tumors.
such as shrapnel or ferrous metal in • The procedure is not widely available,
the eye and costs significantly more than a
• Patients with cardiac pacemakers, mammogram or ultrasound.
because the pacemaker can be
deactivated by MRI
• Patients with intrauterine devices Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients with iron pigments in tattoos

Pretest:
• Patients who are claustrophobic
• Patients who are pregnant or suspected assesses the breast.
of being pregnant, unless the potential ➤ Obtain a history of the patient’s
benefits of the procedure far outweigh complaints, including a list of known
the risks to the fetus and mother allergens (especially allergies or
sensitivities to contrast medium), chological support before, during,

and inform the appropriate health and after the procedure.
care practitioner accordingly. ➤ Explain that an IV line may be
➤ Obtain a history of the patient’s inserted to allow infusion of IV fluids,
reproductive system, as well as contrast medium, dye, or sedatives.
results of previously performed diag- Usually normal saline is infused.
nostic procedures, surgical proce- ➤ There are no food, fluid, or medica-
dures, and laboratory tests. For tion restrictions, unless by medical
related diagnostic tests, refer to the direction.
Reproductive System table.
➤ Determine if the patient has ever had tures, jewelry (including watches),
any device implanted into his or her hairpins, credit cards, and other
body, including copper intrauterine metallic objects.
and heart valves. Intratest:
➤ Obtain occupational history to deter-
mine the presence of metal in the ➤ Ensure that the patient has removed
body, such as shrapnel or flecks of all external metallic objects (jewelry,
ferrous metal in the eye (which can dentures, etc.) prior to the proce-
cause retinal hemorrhage). dure.
available.
the procedure.
➤ Obtain a list of the medications the to void prior to the procedure.
patient is taking.
➤ Review the procedure with the and to follow directions. Instruct the
patient. Address concerns about pain patient to remain still throughout the
related to the procedure. Explain to procedure because movement pro-
the patient that no pain will be expe- duces unreliable results.
may be moments of discomfort. ➤ Observe standard precautions, and
Inform the patient that the procedure follow the general guidelines in
➤ Inform the patient that the technolo- ➤ The patient can communicate with
gist will place him or her in a prone the technologist during the examina-
position on a special imaging table in tion via a microphone within the
a large cylindrical scanner. machine.
➤ Tell the patient to expect to hear loud ➤ Establish an IV fluid line for the injec-
banging from the scanner and possi- tion of emergency drugs and of
bly to see magnetophosphenes (flick- sedatives.
ering lights in the visual field); these ➤ Administer an antianxiety agent, as
will stop when the procedure is over. ordered, if the patient has claustro-
Magnetic Resonance Imaging, Breast 919
➤ Place the patient in the prone posi- compresses to the puncture site, as
tion on a special exam table de- needed, to reduce discomfort or
signed for breast imaging. edema.
➤ If ordered with contrast, the contrast ➤ A written report of the examina-
medium is injected, and a series of tion will be completed by a health
images is taken during and after the care practitioner specializing in this
filling of the vessels to be examined. branch of medicine. The report will
Delayed images may be taken to be sent to the requesting health care
monitor the venous phase of the practitioner, who will discuss the
procedure. results with the patient.
➤ Monitor the patient for complications Discuss the implications of abnormal
related to the procedure (e.g., aller- test results on the patient’s lifestyle.
gic reaction, anaphylaxis, bron- Provide teaching and information
chospasm). regarding the clinical implications of
and a pressure dressing is applied ➤ Reinforce information given by the
over the puncture site. patient’s health care provider regard-
➤ The results are recorded on film or referral to another health care pro-
on automated equipment in a com- vider. Explain the importance of
puterized system for recall and post- adhering to the therapy regimen.
procedure interpretation by the Answer any questions or address
appropriate health care practitioner. any concerns voiced by the patient
or family.
➤ Observe for delayed allergic reac- performed to evaluate or monitor
tions, such as rash, urticaria, tachy- progression of the disease process
cardia, hyperpnea, hypertension, and determine the need for a change
palpitations, nausea, or vomiting, if in therapy. Evaluate test results in
contrast medium was used. relation to the patient’s symptoms
➤ Instruct the patient to immediately and other tests performed.
report symptoms such as fast heart
rate, difficulty breathing, skin rash, Related diagnostic tests:
itching or decreased urinary output
➤ Observe the needle/catheter inser- bone scan, computed tomography of
tion site for bleeding, inflammation, the thorax, mammogram, sterotatic
or hematoma formation. biopsy of the breast, and ultrasound
➤ Instruct the patient to apply cold of the breast.
MAGNETIC RESONANCE
IMAGING, CHEST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Chest MRI.

DESCRIPTION & RATIONALE: Mag- diograph (ECG)–gated multislice

netic resonance imaging (MRI) uses a spin-echo sequence, used to diagnose
magnet and radio waves to produce an anatomic abnormalities of the heart
energy field that can be displayed as and aorta, and the other is the ECG-
an image. Use of magnetic fields with referenced gradient refocused sequ-
the aid of radiofrequency energy pro- ence, used to diagnose heart function
duces images primarily based on water and analyze blood flow patterns.
content of tissue. The magnetic field Magnetic resonance angiography
causes the hydrogen atoms in tissue to (MRA) is an application of MRI that
line up, and when radio waves are provides images of blood flow and
directed toward the magnetic field, diseased and normal blood vessels.
the atoms absorb the radio waves and In patients who are allergic to iodi-
change their position. When the radio nated contrast medium, MRA is used
waves are turned off, the atoms go in place of angiography (see mono-
back to their original position, this graph titled “Magnetic Resonance
change in the energy field is sensed by Angiography”). ■
the equipment, and an image is gener-
ated by the attached computer system. INDICATIONS:
MRI produces cross-sectional images • Confirm diagnosis of cardiac and peri-
of pathologic lesions in multiple cardiac masses
planes without the use of ionizing • Detect aortic aneurysms
radiation or the interference of bone
or surrounding tissue. • Detect myocardial infarction and car-
diac muscle ischemia
Chest MRI scanning is performed
to assist in diagnosing abnormalities • Detect pericardial abnormalities
of cardiovascular and pulmonary • Detect pleural effusion
structures. Two special techniques are
available for evaluation of cardiovas- • Detect thoracic aortic diseases
cular structures. One is the electrocar- • Determine blood, fluid, or fat accumu-
Magnetic Resonance Imaging, Chest 921
lation in tissues, pleuritic space, or • Patients with cardiac pacemakers,

vessels because the pacemaker can be
deactivated by MRI
• Determine cardiac ventricular function
tumors near the aorta • Patients with iron pigments in tattoos
• Evaluate cardiac chambers and pul- • Patients who are claustrophobic
monary vessels
• Evaluate postoperative angioplasty sites of being pregnant, unless the potential
and bypass grafts benefits of the procedure far outweigh
• Identify congenital heart diseases the risks to the fetus and mother
• Monitor and evaluate the effective- Factors that may

ness of medical or surgical therapeutic impair clear imaging:
regimen • Metallic objects within the exami-
nation field (e.g., jewelry, body rings,
RESULT dental amalgams), which may inhibit
Normal Findings: unclear images
• Normal heart and lung structures, soft • Patients who are very obese, who
tissue, and function, including blood may exceed the weight limit for the
flow rate equipment
Abnormal Findings: • Incorrect positioning of the patient,
• Aortic dissection which may produce poor visualization
• Congenital heart diseases, including
pulmonary atresia, aortic coarctation, • Inability of the patient to cooperate or
agenesis of the pulmonary artery, and remain still during the procedure be-
transposition of the great vessels cause of age, significant pain, or mental
status
• Constrictive pericarditis
• Patients with extreme cases of claustro-
• Intramural and periaortic hematoma phobia, unless sedation is given before
• Myocardial infarction the study or an open MRI is utilized
• Pericardial hematoma or effusion Other considerations:
• Pleural effusion • If contrast medium is allowed to seep
CRITICAL VALUES: N/A visualization will be impossible.
This procedure is Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients with certain ferrous metal pros- Pretest:
theses, valves, aneurysm clips, inner ear
prostheses, or other metallic objects assesses the organs and structures
• Patients with metal in their body, such inside the chest.
as shrapnel or ferrous metal in the eye ➤ Obtain a history of the patient’s com-

sitivities to contrast medium), and chological support before, during,
inform the appropriate health care and after the procedure.
practitioner accordingly. ➤ Explain that an IV line may be in-
➤ Obtain a history of the patient’s car- serted to allow infusion of IV fluids,
diovascular and respiratory systems, contrast medium, dye, or sedatives.
as well as results of previously per- Usually normal saline is infused.
formed diagnostic procedures, surgi- ➤ There are no food, fluid, or medica-
cal procedures, and laboratory tests. tion restrictions, unless by medical
For related diagnostic tests, refer to direction.
the Cardiovascular and Respiratory
System tables. ➤ Instruct the patient to remove den-
➤ Determine if the patient has ever had hairpins, credit cards, and other me-
any device implanted into his or her tallic objects.
and heart valves.
Intratest:
➤ Obtain occupational history to deter- ➤ Ensure that the patient has removed
mine the presence of metal in the all external metallic objects (jewelry,
body, such as shrapnel or flecks of dentures, etc.) prior to the procedure.
ferrous metal in the eye (which can ➤ Have emergency equipment readily
cause retinal hemorrhage). available.
➤ Note any recent procedures that can ➤ If the patient has a history of severe
interfere with test results, including allergic reactions to any substance or
examinations using iodine-based drug, administer ordered prophylac-
contrast medium or barium. tic steroids or antihistamines before
➤ Record the date of the last menstrual the procedure.
period and the determine possibility ➤ Patients are given a gown, robe, and
of pregnancy in perimenopausal foot coverings to wear and instructed
women. to void prior to the procedure.
➤ Obtain a list of the medications the ➤ Instruct the patient to cooperate fully
patient is taking. and to follow directions. Instruct the
➤ Review the procedure with the pa- patient to remain still throughout the
tient. Address concerns about pain procedure because movement pro-
pendix A.
is performed in an MRI department, ➤ Supply earplugs to the patient to
usually by a technologist and support block out the loud, banging sounds
staff, and takes approximately 30 to that occur during the test.
60 minutes. ➤ If an electrocardiogram or respiratory
➤ Inform the patient that the technolo- gating is to be performed in conjunc-
gist will place him or her in a supine tion with the scan, apply MRI-safe
position on a flat table in a large cy- electrodes to the appropriate sites.
lindrical scanner. ➤ The patient can communicate with
➤ Tell the patient to expect to hear loud the technologist during the exami-
banging from the scanner and possi- nation via a microphone within the
bly to see magnetophosphenes (flick- machine.
ering lights in the visual field); these ➤ Establish an IV fluid line for the injec-
will stop when the procedure is over. tion of emergency drugs and of sed-
➤ Sensitivity to social and cultural atives.
Magnetic Resonance Imaging, Chest 923
➤ Administer an antianxiety agent, as ➤ Instruct the patient to apply cold

ordered, if the patient has claustro- compresses to the puncture site, as
phobia. Administer a sedative to a needed, to reduce discomfort or
child or to an uncooperative adult, as edema.
ordered. ➤ A written report of the examination
➤ Place the patient in the supine posi- will be completed by a health care
tion on an exam table. practitioner specializing in this branch
➤ If ordered with contrast, the contrast of medicine. The report will be sent to
medium is injected, and a series of the requesting health care practi-
images is taken during and after the tioner, who will discuss the results
filling of the vessels to be examined. with the patient.
Delayed images may be taken to ➤ Recognize anxiety related to test re-
monitor the venous phase of the pro- sults, and be supportive of perceived
cedure. loss of independent function. Dis-
➤ Instruct the patient to take slow, cuss the implications of abnormal
deep breaths if nausea occurs during test results on the patient’s lifestyle.
the procedure. Provide teaching and information
➤ Monitor the patient for complica- the test results, as appropriate.
allergic reaction, anaphylaxis, bron- ➤ Reinforce information given by the
chospasm). patient’s health care provider regard-
➤ The needle or catheter is removed, referral to another health care pro-
and a pressure dressing is applied vider. Explain the importance of
over the puncture site. adhering to the therapy regimen.
➤ The results are recorded on film or Answer any questions or address
on automated equipment in a com- any concerns voiced by the patient
puterized system for recall and post- or family.
procedure interpretation by the ➤ Depending on the results of this pro-
appropriate health care practitioner. cedure, additional testing may be
➤ Observe for delayed allergic reac- and determine the need for a change
tions, such as rash, urticaria, tachy- in therapy. Evaluate test results in
cardia, hyperpnea, hypertension, relation to the patient’s symptoms
palpitations, nausea, or vomiting, if and other tests performed.
contrast medium was used.
➤ Instruct the patient to immediately Related diagnostic tests:
report symptoms such as fast heart ➤ Related diagnostic tests include chest
rate, difficulty breathing, skin rash, x-ray, computed tomography of the
itching or decreased urinary output thorax, echocardiography, myocardial
➤ Observe the needle/catheter inser- infarct scan, mycardial perfusion
tion site for bleeding, inflammation, heart scan, and positron emission
or hematoma formation. tomography scan of the heart.
MAGNETIC RESONANCE
IMAGING, MUSCULOSKELETAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Musculoskeletal (knee, shoulder, hand, wrist, foot,

elbow, hip) MRI.
AREA OF APPLICATION: Bones, joints, soft tissues.

DESCRIPTION & RATIONALE: Mag- with exposure to x-rays and causes no

netic resonance imaging (MRI) uses a harm to cells. Contrast-enhanced
magnet and radio waves to produce an imaging is effective for evaluating
energy field that can be displayed as scarring from previous surgery, vascu-
an image. Use of magnetic fields with lar abnormalities, and differentiation
the aid of radiofrequency energy proof metastases from primary tumors.
duces images primarily based on water MRI uses the noniodinated contrast
content of tissue. The magnetic field medium gadopentetate dimeglumine
causes the hydrogen atoms in tissue to (Magnevist), which is administered
line up, and when radio waves are intravenously to enhance contrast dif-
directed toward the magnetic field, ferences between normal and abnor-
the atoms absorb the radio waves and mal tissues.
change their position. When the radio Magnetic resonance angiography
waves are turned off, the atoms go (MRA) is an application of MRI that
back to their original position, this provides images of blood flow and
change in the energy field is sensed by diseased and normal blood vessels.
the equipment, and an image is gener- In patients who are allergic to iodi-
ated by the attached computer system. nated contrast medium, MRA is used
MRI produces cross-sectional images in place of angiography (see mono-
of bones and joints in multiple planes graph titled “Magnetic Resonance
without the use of ionizing radiation Angiography”). ■
or the interference of bone or sur-
rounding tissue. INDICATIONS:
Musculoskeletal MRI is performed • Confirm diagnosis of osteomyelitis
to assist in diagnosing abnormalities of
bones and joints and surrounding soft • Detect avascular necrosis of the femoral
tissue structures, including cartilage, head or knee
synovium, ligaments, and tendons. • Detect benign and cancerous tumors
MRI eliminates the risks associated and cysts of the bone or soft tissue
Magnetic Resonance Imaging, Musculoskeletal 925
• Detect bone infarcts in the epiphyseal • Rotator cuff tears

or diaphyseal sites
• Spinal stenosis
• Detect changes in bone marrow
• Stress fracture
• Detect tears or degeneration of liga-
ments, tendons, and menisci resulting • Synovitis
from trauma or pathology • Tumor
• Determine cause of low back pain,
including herniated disk and spinal CRITICAL VALUES: N/A
degenerative disease
• Differentiate between primary and sec-
ondary malignant processes of the bone This procedure is
marrow contraindicated for:
• Differentiate between a stress fracture • Patients with cardiac pacemakers,
and a tumor because the pacemaker can be
deactivated by MRI
• Evaluate meniscal detachment of the
temporomandibular joint • Patients with certain ferrous metal
prostheses, valves, aneurysm clips, in-
RESULT ner ear prostheses, or other metallic
objects
Normal Findings:
• Normal bones, joints, and surrounding • Patients with metal in their body, such
tissue structures; no articular disease, as shrapnel or ferrous metal in the eye
bone marrow disorders, tumors, infec-
tions, or trauma to the bones, joints, or • Patients with intrauterine devices
muscles
Abnormal Findings:
• Avascular necrosis of femoral head or • Patients who are claustrophobic
knee, as found in Legg-Calvé-Perthes
disease • Patients who are pregnant or suspected
• Bone marrow disease, such as benefits of the procedure far outweigh
Gaucher’s disease, aplastic anemia, the risks to the fetus and mother
sickle cell disease, or polycythemia
• Degenerative spinal disease, such as Factors that may
spondylosis or arthritis impair clear imaging:
• Fibrosarcoma tion field (e.g., jewelry, body rings,
• Hemangioma (muscular or osseous) dental amalgams), which may inhibit
• Herniated disk unclear images
• Infection • Patients who are very obese, who
• Meniscal tears or degeneration may exceed the weight limit for the
equipment
• Osteochondroma
• Osteogenic sarcoma
• Osteomyelitis of the area to be examined
• Inability of the patient to cooperate or of pregnancy in perimenopausal

remain still during the procedure women.
because of age, significant pain, or ➤ Obtain a list of the medications the
mental status patient is taking.
• Patients with extreme cases of claus- ➤ Review the procedure with the
trophobia, unless sedation is given patient. Address concerns about pain
before the study or an open MRI is uti-
lized rienced during the test, but there
may be moments of discomfort. In-
Other considerations: form the patient that the procedure
• If contrast medium is allowed to seep is performed in an MRI department,
deep into the muscle tissue, vascular usually by a technologist and support
visualization will be impossible. staff, and takes approximately 30 to
60 minutes.
➤ Inform the patient that the technolo-
gist will place him or her in a supine
Nursing Implications and position on a flat table in a large
Procedure ● ● ● ● ● ● ● ● ● ● ● cylindrical scanner.
➤ Tell the patient to expect to hear loud
Pretest: banging from the scanner and possi-
➤ Inform the patient that the procedure bly to see magnetophosphenes
assesses muscles, bones, and joints. (flickering lights in the visual field);
these will stop when the procedure
➤ Obtain a history of the patient’s com- is over.
allergens (especially allergies or sen- ➤ Sensitivity to social and cultural
sitivities to contrast medium), and issues, as well as concern for mod-
inform the appropriate health care esty, is important in providing psy-
practitioner accordingly. chological support before, during,
diovascular and musculoskeletal sys- ➤ Explain that an IV line may be
tems, as well as results of previously inserted to allow infusion of IV
performed diagnostic procedures, fluids, contrast medium, dye, or
surgical procedures, and laboratory sedatives. Usually normal saline is
tests. For related diagnostic tests, infused.
refer to the Cardiovascular and Mus- ➤ There are no food, fluid, or medica-
culoskeletal System tables. tion restrictions, unless by medical
➤ Determine if the patient has ever had direction.
any device implanted into his or her ➤ Instruct the patient to remove den-
body, including copper intrauterine tures, jewelry (including watches),
devices, pacemakers, ear implants, hairpins, credit cards, and other
and heart valves. metallic objects.
mine the presence of metal in the Intratest:
body, such as shrapnel or flecks of
ferrous metal in the eye (which can ➤ Ensure that the patient has removed
cause retinal hemorrhage). all external metallic objects (jewelry,
➤ Note any recent procedures that can dentures, etc.) prior to the procedure.
interfere with test results, including ➤ Have emergency equipment readily
examinations using iodine-based available.
contrast medium or barium. ➤ If the patient has a history of severe
➤ Record the date of the last menstrual allergic reactions to any substance or
period and determine the possibility drug, administer ordered prophylac-
Magnetic Resonance Imaging, Musculoskeletal 927
tic steroids or antihistamines before Post-test:

the procedure.
cardia, hyperpnea, hypertension,
palpitations, nausea, or vomiting, if
➤ Instruct the patient to cooperate fully contrast medium was used.
and to follow directions. Instruct the ➤ Instruct the patient to immediately
patient to remain still throughout the report symptoms such as fast heart
procedure because movement pro- rate, difficulty breathing, skin rash,
duces unreliable results. itching or decreased urinary output
➤ Observe standard precautions, and ➤ Observe the needle/catheter inser-
follow the general guidelines in Ap- tion site for bleeding, inflammation,
pendix A. or hematoma formation.
➤ Supply earplugs to the patient to ➤ Instruct the patient to apply cold com-
block out the loud, banging sounds presses to the puncture site, as need-
that occur during the test. ed, to reduce discomfort or edema.
➤ The patient can communicate with ➤ A written report of the examination
the technologist during the exami- will be completed by a health care
nation via a microphone within the practitioner specializing in this
machine. branch of medicine. The report will
➤ Establish an IV fluid line for the injec- be sent to the requesting health care
tion of emergency drugs and of practitioner, who will discuss the
sedatives. results with the patient.
ordered.
➤ Place the patient in the supine posi- regarding the clinical implications of
tion on an exam table. the test results, as appropriate.
➤ If ordered with contrast, the contrast ➤ Reinforce information given by the
medium is injected, and a series of patient’s health care provider regard-
images is taken during and after the ing further testing, treatment, or
filling of the vessels to be examined. referral to another health care pro-
Delayed images may be taken to vider. Explain the importance of
monitor the venous phase of the adhering to the therapy regimen.
procedure. Answer any questions or address
➤ Instruct the patient to take slow, any concerns voiced by the patient
deep breaths if nausea occurs during or family.
the procedure. ➤ Depending on the results of this pro-
chospasm).
➤ The needle or catheter is removed, relation to the patient’s symptoms
and a pressure dressing is applied and other tests performed.
on automated equipment in a com- ➤ Related diagnostic tests include
puterized system for recall and arthroscopy, bone mineral densitom-
postprocedure interpretation by the etry, bone scan, and radiography of
appropriate health care practitioner. the bone.
MAGNETIC RESONANCE
IMAGING, PANCREAS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Pancreatic MRI.

AREA OF APPLICATION: Pancreatic/upper abdominal area.
(gadolinium).
DESCRIPTION & RATIONALE: Mag- best for evaluating the pancreatic

netic resonance imaging (MRI) uses a parenchyma. This sequence is ideal for
magnet and radio waves to produce an showing fat planes between the pan-
energy field that can be displayed as creas and peripancreatic structures
an image. Use of magnetic fields with and for identifying abnormalities,
the aid of radiofrequency energy pro- such as fatty infiltration of the pan-
duces images primarily based on water creas, hemorrhage, adenopathy, and
content of tissue. The magnetic field carcinomas. T2-weighted images are
causes the hydrogen atoms in tissue to most useful for depicting intrapancre-
line up, and when radio waves are atic or peripancreatic fluid collections,
directed toward the magnetic field, pancreatic neoplasms, and calculi.
the atoms absorb the radio waves and Imaging sequences can be adjusted to
change their position. When the radio display fluid in the biliary tree and
waves are turned off, the atoms go pancreatic ducts. MRI uses the nonio-
back to their original position, this dinated contrast medium gadopente-
change in the energy field is sensed by tate dimeglumine (Magnevist), which
the equipment, and an image is gener- is administered intravenously to en-
ated by the attached computer system. hance contrast differences between
MRI produces cross-sectional images normal and abnormal tissues.
of the abdominal area in multiple Magnetic resonance angiography
planes without the use of ionizing (MRA) is an application of MRI that
radiation or the interference of bone provides images of blood flow and
or surrounding tissue. diseased and normal blood vessels.
MRI of the pancreas is employed to In patients who are allergic to iodi-
evaluate small pancreatic adenocarci- nated contrast medium, MRA is used
nomas, islet cell tumors, ductal abnor- in place of angiography (see mono-
malities and calculi, or parenchymal graph titled “Magnetic Resonance
abnormalities. A T1-weighted, fat- Angiography”). When the Food and
saturation series of images is probably Drug Administration approves gas-
Magnetic Resonance Imaging, Pancreas 929
trointestinal contrast agents, they may CRITICAL VALUES: N/A

be useful for delineating the exact
relationship among the stomach, duo- INTERFERING FACTORS:
denum, and proximal jejunum and
This procedure is
the pancreas. These agents would contraindicated for:
assist in identifying areas of bowel wall • Patients with certain ferrous metal pros-
thickening, stricture, and intraluminal theses, valves, aneurysm clips, inner ear
abnormalities, such as tumors, sites of prostheses, or other metallic objects
perforation, and fistula. ■
• Patients with metal in their body, such
as shrapnel or ferrous metal in the eye
INDICATIONS:
• Detect pancreatic fatty infiltration, • Patients with cardiac pacemakers,
hemorrhage, and adenopathy because the pacemaker can be
deactivated by MRI
• Detect a pancreatic mass
• Detect pancreatitis
• Detect primary or metastatic tumors of
the pancreas and provide cancer staging • Patients who are claustrophobic
• Detect soft tissue abnormalities
• Determine vascular complications of benefits of the procedure far outweigh
pancreatitis, venous thrombosis, or the risks to the fetus and mother
pseudoaneurysm
Factors that may
• Differentiate tumors from other abnor- impair clear imaging:
malities, such as cysts, cavernous • Metallic objects within the examina-
hemangiomas, and pancreatic abscesses tion field (e.g., jewelry, body rings,
• Monitor and evaluate the effectiveness dental amalgams), which may inhibit
of medical or surgical interventions and organ visualization and can produce
course of disease unclear images
RESULT may exceed the weight limit for the
equipment
Normal Findings:
• Normal anatomic structures and soft • Incorrect positioning of the patient,
tissue density and biochemical con- which may produce poor visualization
stituents of the pancreatic parenchyma, of the area to be examined
including blood flow • Inability of the patient to cooperate or
Abnormal Findings: because of age, significant pain, or
• Islet cell tumor mental status
• Metastasis • Patients with extreme cases of claustro-
• Pancreatic duct obstruction or calculi
the study or an open MRI is utilized
• Pancreatic fatty infiltration, hemor-
rhage, and adenopathy Other considerations:
• If contrast medium is allowed to seep
• Pancreatic mass
• Pancreatitis visualization will be impossible.
staff, and takes approximately 30 to

Nursing Implications and 60 minutes.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that the technolo-
gist will place him or her in a supine
Pretest: position on a flat table in a large
➤ Inform the patient that the procedure cylindrical scanner.
assesses the pancreas and the ➤ Tell the patient to expect to hear loud
organs and structures inside the banging from the scanner and possi-
abdomen. bly to see magnetophosphenes
➤ Obtain a history of the patient’s com- (flickering lights in the visual field);
plaints, including a list of known these will stop when the procedure
allergens (especially allergies or sen- is over.
sitivities to contrast medium), and ➤ Sensitivity to social and cultural
inform the appropriate health care issues, as well as concern for mod-
practitioner accordingly. esty, is important in providing psy-
➤ Obtain a history of the patient’s chological support before, during,
hepatobiliary and endocrine sys- and after the procedure.
tems, as well as results of previously ➤ Explain that an IV line may be
performed diagnostic procedures, inserted to allow infusion of IV fluids,
surgical procedures, and labora- contrast medium, dye, or sedatives.
tory tests. For related diagnostic Usually normal saline is infused.
tests, refer to the Hepatobiliary and ➤ There are no food, fluid, or medica-
Endocrine System tables. tion restrictions, unless by medical
➤ Determine if the patient has ever had direction.
any device implanted into his or her ➤ Instruct the patient to remove den-
body, including copper intrauterine tures, jewelry (including watches),
devices, pacemakers, ear implants, hairpins, credit cards, and other
and heart valves. metallic objects.
mine the presence of metal in the Intratest:
body, such as shrapnel or flecks of
ferrous metal in the eye (which can ➤ Ensure that the patient has removed
cause retinal hemorrhage). all external metallic objects (jewelry,
dentures, etc.) prior to the procedure.
interfere with test results, including ➤ Have emergency equipment readily
examinations using iodine-based available.
contrast medium or barium. ➤ If the patient has a history of severe
➤ Record the date of the last menstrual allergic reactions to any substance or
period and determine the possibil- drug, administer ordered prophylac-
ity of pregnancy in perimenopausal tic steroids or antihistamines before
women. the procedure.
➤ Obtain a list of the medications the ➤ Patients are given a gown, robe, and
patient is taking. foot coverings to wear and instructed
tient. Address concerns about pain ➤ Instruct the patient to cooperate fully
related to the procedure. Explain to and to follow directions. Instruct the
the patient that no pain will be expe- patient to remain still throughout the
rienced during the test, but there procedure because movement pro-
may be moments of discomfort. duces unreliable results.
Inform the patient that the procedure ➤ Observe standard precautions, and
is performed in an MRI department, follow the general guidelines in Ap-
usually by a technologist and support pendix A.
Magnetic Resonance Imaging, Pancreas 931
➤ Supply earplugs to the patient to rate, difficulty breathing, skin rash,

block out the loud, banging sounds itching or decreased urinary output
that occur during the test. ➤ Observe the needle/catheter inser-
➤ The patient can communicate with tion site for bleeding, inflammation,
the technologist during the examina- or hematoma formation.
tion via a microphone within the ➤ Instruct the patient to apply cold
machine. compresses to the puncture site, as
➤ Establish an IV fluid line for the injec- needed, to reduce discomfort or
tion of emergency drugs and of edema.
sedatives. ➤ A written report of the examination
➤ Administer an antianxiety agent, as will be completed by a health care
ordered, if the patient has claustro- practitioner specializing in this
phobia. Administer a sedative to a branch of medicine. The report will
child or to an uncooperative adult, as be sent to the requesting health care
ordered. practitioner, who will discuss the
tion on an exam table. ➤ Recognize anxiety related to test
➤ If ordered with contrast, the contrast
medium is injected, and a series of
images is taken during and after the
filling of the vessels to be examined.
Delayed images may be taken to
monitor the venous phase of the
procedure.
➤ Instruct the patient to take slow, patient’s health care provider regard-
deep breaths if nausea occurs during ing further testing, treatment, or
the procedure. referral to another health care pro-
➤ Monitor the patient for complica- vider. Explain the importance of
tions related to the procedure (e.g., adhering to the therapy regimen.
allergic reaction, anaphylaxis, bron- Answer any questions or address
chospasm). any concerns voiced by the patient
➤ The needle or catheter is removed, or family.
and a pressure dressing is applied ➤ Depending on the results of this pro-
over the puncture site. cedure, additional testing may be
➤ The results are recorded on film or performed to evaluate or monitor
on automated equipment in a com- progression of the disease process
puterized system for recall and and determine the need for a change
postprocedure interpretation by the in therapy. Evaluate test results in
appropriate health care practitioner. relation to the patient’s symptoms
Post-test: Related diagnostic tests:
➤ Observe for delayed allergic reac- ➤ Related diagnostic and laboratory
tions, such as rash, urticaria, tachy- tests include amylase, angiography of
cardia, hyperpnea, hypertension, the abdomen, computed tomography
palpitations, nausea, or vomiting, if of the abdomen, hepatobiliary scan;
contrast medium was used. 5-hydroxyindoleacetic acid, lipase,
➤ Instruct the patient to immediately ultrasound of the liver and biliary sys-
report symptoms such as fast heart tem, and ultrasound of the pancreas.
MAGNETIC RESONANCE
IMAGING, PELVIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Pelvic MRI.

AREA OF APPLICATION: Pelvic area.
CONTRAST: Can be done with or without intravenous (IV)
contrast (gadolinium).
DESCRIPTION & RATIONALE: Mag- ing small-volume peritoneal tumors,

netic resonance imaging (MRI) uses a carcinomatosis, and peritonitis and
magnet and radio waves to produce an for determining the response to
energy field that can be displayed as surgical and chemical therapies. MRI
an image. Use of magnetic fields with uses the noniodinated contrast me-
the aid of radiofrequency energy pro- dium gadopentetate dimeglumine
duces images primarily based on water (Magnevist), which is administered
content of tissue. The magnetic field intravenously to enhance contrast
causes the hydrogen atoms in tissue to differences between normal and
line up, and when radio waves are abnormal tissues. Oral and rectal con-
directed toward the magnetic field, trast administration may be used to
the atoms absorb the radio waves and isolate the bowel from adjacent pelvic
change their position. When the radio organs and improve organ visuali-
waves are turned off, the atoms go zation.
back to their original position, this Magnetic resonance angiography
change in the energy field is sensed by (MRA) is an application of MRI that
the equipment, and an image is gener- provides images of blood flow and
ated by the attached computer system. diseased and normal blood vessels. In
MRI produces cross-sectional images patients who are allergic to iodinated
of the pelvic area in multiple planes contrast medium, MRA is used in
without the use of ionizing radiation place of angiography (see monograph
or the interference of bone or sur- titled “Magnetic Resonance Angio-
rounding tissue. graphy”). When the Food and Drug
Pelvic MRI is performed to assist in Administration approves gastrointesti-
diagnosing abnormalities of the pelvis nal contrast agents, these agents would
and associated structures. Contrast- assist in identifying areas of bowel wall
enhanced MRI is effective for evaluat- thickening, stricture, and intraluminal
ing metastases from primary tumors. abnormalities, such as tumors, sites of
MRI is highly effective for depict- perforation, and fistula. ■
Magnetic Resonance Imaging, Pelvis 933
INDICATIONS: • Patients with metal in their body, such

• Detect cancer (primary or metastatic as shrapnel or ferrous metal in the eye
tumors of ovary, prostate, uterus, and • Patients with cardiac pacemakers,
bladder) and provide cancer staging because the pacemaker can be
• Detect pelvic vascular diseases deactivated by MRI
• Detect peritonitis • Patients with intrauterine devices
• Detect soft tissue abnormalities • Patients with iron pigments in tattoos

• Determine blood clots, cysts, fluid or
fat accumulation in tissues, hemor- • Patients who are pregnant or suspected
rhage, and infarctions of being pregnant, unless the potential
• Differentiate tumors from tissue abnor- the risks to the fetus and mother
malities, such as cysts, cavernous
hemangiomas, and abscesses Factors that may
• Monitor and evaluate the effectiveness
of medical or surgical interventions and • Metallic objects within the examina-
course of the disease tion field (e.g., jewelry, body rings,
RESULT organ visualization and can produce
unclear images
Normal Findings: • Patients who are very obese, who
• Normal pelvic structures and soft may exceed the weight limit for the
tissue density and biochemical con- equipment
stituents of pelvic tissues, including • Incorrect positioning of the patient,
blood flow which may produce poor visualization
Abnormal Findings:
• Adenomyosis • Inability of the patient to cooperate
• Ascites because of age, significant pain, or
• Fibroids mental status
• Masses, lesions, infections, or inflam-
mations
the study or an open MRI is utilized
• Peritoneal tumor or carcinomatosis
• Peritonitis
• If contrast medium is allowed to seep
• Pseudomyxoma peritonei deep into the muscle tissue, vascular
visualization will be impossible.
Procedure ● ● ● ● ● ● ● ● ● ● ●
This procedure is
contraindicated for: Pretest:
• Patients with certain ferrous metal pros- ➤ Inform the patient that the procedure
theses, valves, aneurysm clips, inner ear assesses the organs and structures
prostheses, or other metallic objects inside the pelvis and lower abdomen.

sitivities to contrast medium), and chological support before, during,
inform the appropriate health care and after the procedure.
practitioner accordingly. ➤ Explain that an IV line may be
➤ Obtain a history of the patient’s gas- inserted to allow infusion of IV fluids,
trointestinal and genitourinary sys- contrast medium, dye, or sedatives.
tems, as well as results of previously Usually normal saline is infused.
performed diagnostic procedures, ➤ There are no food, fluid, or medica-
surgical procedures, and labora- tion restrictions, unless by medical
tory tests. For related diagnostic direction.
and Genitourinary System tables. ➤ Instruct the patient to remove den-
➤ Determine if the patient has ever had hairpins, credit cards, and other
any device implanted into his or her metallic objects.
Intratest:
and heart valves.
➤ Obtain occupational history to deter- ➤ Ensure that the patient has removed
mine the presence of metal in the all external metallic objects (jewelry,
body, such as shrapnel or flecks of dentures, etc.) prior to the procedure.
ferrous metal in the eye (which can ➤ Have emergency equipment readily
cause retinal hemorrhage). available.
➤ Note any recent procedures that can ➤ If the patient has a history of severe
interfere with test results, including allergic reactions to any substance or
examinations using iodine-based drug, administer ordered prophylac-
contrast medium or barium. tic steroids or antihistamines before
➤ Record the date of the last menstrual the procedure.
period and determine the possibility ➤ Patients are given a gown, robe, and
of pregnancy in perimenopausal foot coverings to wear and instructed
women. to void prior to the procedure.
➤ Obtain a list of the medications the ➤ Instruct the patient to cooperate fully
patient is taking. and to follow directions. Instruct the
➤ Review the procedure with the patient to remain still throughout the
patient. Address concerns about pain procedure because movement pro-
the patient that no pain will be expe- ➤ Observe standard precautions, and
rienced during the test, but there follow the general guidelines in
may be moments of discomfort. Appendix A.
is performed in an MRI department, ➤ Supply earplugs to the patient to
usually by a technologist and support block out the loud, banging sounds
staff, and takes approximately 30 to that occur during the test.
60 minutes. ➤ The patient can communicate with
➤ Inform the patient that the technolo- the technologist during the examina-
gist will place him or her in a supine tion via a microphone within the
position on a flat table in a large machine.
cylindrical scanner. ➤ Establish an IV fluid line for the injec-
➤ Tell the patient to expect to hear loud tion of emergency drugs and of
banging from the scanner and possi- sedatives.
bly to see magnetophosphenes (flick- ➤ Administer an antianxiety agent, as
ering lights in the visual field); these ordered, if the patient has claustro-
will stop when the procedure is over. phobia. Administer a sedative to a
Magnetic Resonance Imaging, Pelvis 935
child or to an uncooperative adult, as ➤ Instruct the patient to apply cold

ordered. compresses to the puncture site, as
➤ Place the patient in the supine posi- needed, to reduce discomfort or
tion on an exam table. edema.
➤ If ordered with contrast, the contrast ➤ A written report of the examination
medium is injected, and a series of will be completed by a health care
images is taken during and after the practitioner specializing in this branch
filling of the vessels to be examined. of medicine. The report will be sent to
Delayed images may be taken to the requesting health care practi-
monitor the venous phase of the tioner, who will discuss the results
procedure. with the patient.
➤ Monitor the patient for complica- test results on the patient’s lifestyle.
tions related to the procedure (e.g., Provide teaching and information
allergic reaction, anaphylaxis, bron- regarding the clinical implications of
chospasm). the test results, as appropriate.
➤ The needle or catheter is removed, ➤ Reinforce information given by the
and a pressure dressing is applied patient’s health care provider regard-
over the puncture site. ing further testing, treatment, or
➤ The results are recorded on film or on referral to another health care pro-
automated equipment in a computer- vider. Explain the importance of
ized system for recall and postproce- adhering to the therapy regimen.
dure interpretation by the appropriate Answer any questions or address
health care practitioner. any concerns voiced by the patient
or family.
➤ Observe for delayed allergic reac- performed to evaluate or monitor
tions, such as rash, urticaria, tachy- progression of the disease process
cardia, hyperpnea, hypertension, and determine the need for a change
palpitations, nausea, or vomiting, if in therapy. Evaluate test results in
contrast medium was used. relation to the patient’s symptoms
➤ Instruct the patient to immediately and other tests performed.
report symptoms such as fast heart
rate, difficulty breathing, skin rash, Related diagnostic tests:
itching or decreased urinary output. ➤ Related diagnostic tests include
➤ Observe the needle/catheter inser- computed tomography of the pelvis;
tion site for bleeding, inflammation, kidney, ureter, and bladder (KUB)
or hematoma formation. study; and ultrasound of the pelvis.
MAGNETIC RESONANCE
IMAGING, PITUITARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Pituitary MRI, MRI of the perisellar region.

AREA OF APPLICATION: Brain/pituitary area.
(gadolinium).
DESCRIPTION & RATIONALE: Mag- blood on spin-echo MRI appears as an

netic resonance imaging (MRI) uses a absence of signal or a void in the ves-
magnet and radio waves to produce an sel’s lumen. Blood flow can be evalu-
energy field that can be displayed as ated in the cavernous and carotid
an image. Use of magnetic fields with arteries. Suprasellar aneurysms may be
the aid of radiofrequency energy pro- diagnosed without angiography, and
duces images primarily based on water old clotted blood in the walls of the
content of tissue. The magnetic field aneurysms appears white. MRI uses
causes the hydrogen atoms in tissue to the noniodinated contrast medium
line up, and when radio waves are gadopentetate dimeglumine (Mag-
directed toward the magnetic field, nevist), which is administered
the atoms absorb the radio waves and intravenously to enhance contrast dif-
change their position. When the radio ferences between normal and abnor-
waves are turned off, the atoms go mal tissues.
back to their original position, this Magnetic resonance angiography
change in the energy field is sensed by (MRA) is an application of MRI that
the equipment, and an image is gener- provides images of blood flow and dis-
ated by the attached computer system. eased and normal blood vessels. In
MRI produces cross-sectional images patients who are allergic to iodinated
of the pituitary and perisellar region contrast medium, MRA is used
in multiple planes without the use of in place of angiography (see mono-
ionizing radiation or the interference graph titled “Magnetic Resonance
of bone or surrounding tissue. Angiography”). ■
Pituitary MRI shows the relation-
ship of pituitary lesions to the optic INDICATIONS:
• Detect microadenoma or macroade-
chiasm and cavernous sinuses. MRI
noma of the pituitary
has the capability of distinguishing the
solid, cystic, and hemorrhagic compo- • Detect perisellar abnormalities
nents of lesions. Rapidly flowing • Detect tumors of the pituitary
Magnetic Resonance Imaging, Pituitary 937
• Evaluate potential cause of headache, • Patients with iron pigments in tattoos

visual loss, and vomiting
• Evaluate the solid, cystic, and hemor-
rhagic components of lesions • Patients who are pregnant or suspected
• Evaluate vascularity of the pituitary benefits of the procedure far outweigh
• Monitor and evaluate the effectiveness the risks to the fetus and mother
of medical or surgical interventions and
Factors that may
course of disease
• Metallic objects within the examination
RESULT field (e.g., jewelry, body rings, dental
amalgams), which may inhibit organ
Normal Findings:
visualization and can produce unclear
• Normal anatomic structures, density, images
and biochemical constituents of the
pituitary, including blood flow • Patients who are very obese, who
Abnormal Findings: equipment
• Abscess • Incorrect positioning of the patient,
• Aneurysm which may produce poor visualization
• Choristoma
• Craniopharyngioma or meningioma remain still during the procedure
• Empty sella because of age, significant pain, or
mental status
• Granuloma
• Infarct or hemorrhage phobia, unless sedation is given before
• Macroadenoma or microadenoma the study or an open MRI is utilized
• Metastasis
• Parasitic infection • If contrast medium is allowed to seep
CRITICAL VALUES: N/A visualization will be impossible.
This procedure is
contraindicated for: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients with certain ferrous metal pros-

Pretest:
theses, valves, aneurysm clips, inner ear
prostheses, or other metallic objects ➤ Inform the patient that the procedure
assesses the pituitary and surround-
• Patients with metal in their body, such ing brain tissue.
as shrapnel or ferrous metal in the eye
• Patients with cardiac pacemakers, plaints, including a list of known
because the pacemaker can be allergens (especially allergies or sen-
deactivated by MRI sitivities to contrast medium), and
• Patients with intrauterine devices practitioner accordingly.
➤ Obtain a history of the patient’s car- ➤ Explain that an IV line may be

diovascular and endocrine systems, inserted to allow infusion of IV fluids,
as well as results of previously per- contrast medium, dye, or sedatives.
formed diagnostic procedures, surgi- Usually normal saline is infused.
cal procedures, and laboratory tests. ➤ There are no food, fluid, or medica-
For related diagnostic tests, refer to tion restrictions, unless by medical
the Cardiovascular and Endocrine direction.
System tables.
➤ Determine if the patient has ever had tures, jewelry (including watches),
any device implanted into his or her hairpins, credit cards, and other
body, including copper intrauterine metallic objects.
and heart valves.
➤ Obtain occupational history to deter- Intratest:
mine the presence of metal in the ➤ Ensure that the patient has removed
body, such as shrapnel or flecks of all external metallic objects (jewelry,
ferrous metal in the eye (which can dentures, etc.) prior to the procedure.
cause retinal hemorrhage).
➤ Note any recent procedures that can available.
➤ Record the date of the last menstrual tic steroids or antihistamines before
period and determine the possibility the procedure.
patient is taking.
➤ Review the procedure with the ➤ Instruct the patient to cooperate fully
patient. Address concerns about pain and to follow directions. Instruct the
related to the procedure. Explain to patient to remain still throughout the
the patient that no pain will be expe- procedure because movement pro-
rienced during the test, but there duces unreliable results.
may be moments of discomfort. ➤ Observe standard precautions, and
Inform the patient that the procedure follow the general guidelines in
➤ Inform the patient that the technolo- ➤ The patient can communicate with
gist will place him or her in a supine the technologist during the exami-
position on a flat table in a large nation via a microphone within the
cylindrical scanner. machine.
➤ Tell the patient to expect to hear loud
➤ Establish an IV fluid line for the injec-
banging from the scanner and pos-
tion of emergency drugs and of
sibly to see magnetophosphenes
sedatives.
(flickering lights in the visual field);
these will stop when the procedure ➤ Administer an antianxiety agent, as
is over. ordered, if the patient has claustro-
chological support before, during, ➤ Place the patient in the supine posi-
and after the procedure. tion on an exam table.
Magnetic Resonance Imaging, Pituitary 939
➤ If ordered with contrast, the contrast as needed, to reduce discomfort or

medium is injected, and a series of edema.
images is taken during and after the ➤ A written report of the examination
filling of the vessels to be examined. will be completed by a health care
Delayed images may be taken to practitioner specializing in this
monitor the venous phase of the pro- branch of medicine. The report will
cedure. be sent to the requesting health care
➤ Instruct the patient to take slow, practitioner, who will discuss the
deep breaths if nausea occurs during results with the patient.
the procedure. ➤ Recognize anxiety related to test
➤ Monitor the patient for complications results, and be supportive of per-
related to the procedure (e.g., aller- ceived loss of independent function.
gic reaction, anaphylaxis, bron- Discuss the implications of abnormal
chospasm). test results on the patient’s lifestyle.
➤ The needle or catheter is removed, regarding the clinical implications of
and a pressure dressing is applied the test results, as appropriate.
➤ The results are recorded on film or patient’s health care provider regard-
on automated equipment in a com- ing further testing, treatment, or re-
puterized system for recall and post- ferral to another health care provider.
procedure interpretation by the Explain the importance of adhering
appropriate health care practitioner. to the therapy regimen. Answer any
Post-test: voiced by the patient or family.
➤ Observe for delayed allergic reac- cedure, additional testing may be
tions, such as rash, urticaria, tachy- performed to evaluate or monitor
cardia, hyperpnea, hypertension, progression of the disease process
palpitations, nausea, or vomiting, if and determine the need for a change
contrast medium was used. in therapy. Evaluate test results in
➤ Instruct the patient to immedi- relation to the patient’s symptoms
ately report symptoms such as fast and other tests performed.
heart rate, difficulty breathing, skin
rash, itching or decreased urinary Related diagnostic tests:
output
➤ Observe the needle/catheter inser- computed tomography of the brain,
tion site for bleeding, inflammation, electroencephalography, magnetic
or hematoma formation. resonance imaging of the brain, and
➤ Instruct the patient to apply cold positron emission tomography of the
compresses to the puncture site, brain.
MAMMOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Mammogram, breast x-ray.

AREA OF APPLICATION: Breast.
CONTRAST: None.
DESCRIPTION & RATIONALE: Mam- is currently being used. With this

mography, an x-ray examination of technique, a computer performs
the breast, is most commonly used to automated scanning of the mammo-
detect breast cancer; however, it can gram before the physician interprets
also be used to detect and evaluate the findings.
symptomatic changes associated with When a mass is detected, additional
other breast diseases, including masti- studies are performed to help differen-
tis, abscess, cystic changes, cysts, tiate the nature of the mass, as follows:
benign tumors, masses, and lymph Magnification views of the area in
nodes. Mammography is usually per- question
formed with traditional x-ray film, Focal or “spot” views of the area
but totally electronic image recording in question, done with a specialized
is becoming commonplace. This type paddle-style compression device
of radiologic procedure reduces the Ultrasound images of the area in
amount of radiation exposure to the question, which help differentiate
patient and produces detailed images between a fluid-filled cystic lesion and
with excellent contrast. Two views of a solid lesion indicative of cancer
each breast are usually taken. Benign The American Cancer Society rec-
cysts appear as clearly defined, regular, ommends that all women follow a
clear spots that are bilateral; cancer personal breast-care plan according to
appears as irregular, poorly defined, age:
unilateral opaque areas or clusters of Women ages 20 to 39: Clinical
calcifications. Mammography can be breast examination performed by a
used to locate a nonpalpable lesion for health care professional every 3 years
biopsy. Mammography cannot detect and a monthly breast self-examination
breast cancer with 100% accuracy: Women ages 40 and older: Annual
In approximately 15% of breast can- mammogram, clinical breast examina-
cer cases, the cancer is not detected tion every year by a health care
with mammography. To assist in professional (near time of the mam-
early detection of nonpalpable breast mogram), and monthly breast self-
lesions, computer-assisted diagnosis examination. ■
Mammography 941
INDICATIONS: that diagnostic x-rays are of limited

• Differentiate between benign and neo- value
plastic breast disease
Factors that may
• Evaluate breast pain, skin retraction,
nipple erosion, or nipple discharge
• Evaluate known or suspected breast remain still during the procedure
cancer because of age, significant pain, or
mental status
• Evaluate nonpalpable breast masses
• Evaluate opposite breast after mas- tion field (e.g., jewelry, body rings),
tectomy which may inhibit organ visualization
• Monitor postoperative and post– and can produce unclear images
radiation treatment status of the breast • Improper adjustment of the radi-
• Evaluate size, shape, and position of ographic equipment to accommodate
breast masses obese or thin patients, which can cause
RESULT poor-quality study
Normal Findings: which may produce poor visualization
• Normal breast tissue, with no cysts, of the area to be examined
tumors, or calcifications
• Application of substances such as tal-
Abnormal Findings: cum powder or creams to the skin of
breasts or underarms, which may alter
• Breast calcifications
test results
• Breast cysts or abscesses
• Previous breast surgery, breast augmen-
• Breast tumors tation, or the presence of breast
implants, which may decrease the read-
• Hematoma resulting from trauma
ability of the examination
• Mastitis
• Soft-tissue masses Other considerations:
• Vascular calcification tioner should occur before the proce-
CRITICAL VALUES: N/A regarding infants of patients who are
lactating.
This procedure is
contraindicated for: procedures. Personnel in the room with
• Patients younger than age 25, because done should wear badges that reveal
the density of the breast tissue is such their level of exposure to radiation.
➤ Inform the patient not to apply

Nursing Implications and deodorant, body creams, or powders
Procedure ● ● ● ● ● ● ● ● ● ● ● on the day of the procedure.
Pretest: elry and other metallic objects from
➤ Inform the patient that the procedure the field of examination.
assesses breast status.
➤ Obtain a history of the patient’s Intratest:
symptoms and complaints.
➤ Obtain a history of known or sus- foot coverings to wear and instructed
pected breast disease, and family to void prior to the procedure.
history of breast disease, or breast
➤ Make sure jewelry, chains, and any
biopsies.
other metallic objects have been
➤ Obtain a history of results of previ- removed from the chest area.
dures and surgical procedures. For ➤ Instruct the patient to cooperate fully
related diagnostic tests, refer to the and to follow directions. Instruct the
Reproductive System table. patient to remain still throughout the
➤ Record the date of the last menstrual duces unreliable results.
ity of pregnancy in perimenopausal ➤ Observe standard precautions and
women. follow the general guidelines in
Appendix A.
patient is taking. ➤ Assist the patient to a standing
or sitting position in front of the
➤ Review the procedure with the x-ray machine, which is adjusted to
patient. Address concerns about the level of the breasts. Position the
pain related to the procedure. Inform patient’s arms out of the range of
the patient there may be discomfort the area to be filmed.
associated with the study, while the
breast is being compressed, but that ➤ Place breasts, one at a time, between
the compression allows for better the compression apparatus. Usually
visualization of the breast tissue. two views or exposures are taken of
Explain to the patient that the radia- each breast. Ask the patient to hold
tion dose will be kept to an absolute her breath during exposures.
minimum. Inform the patient that the ➤ The results are recorded on a sheet
procedure is performed in the mam- of x-ray film or electronically, in a
mography department by a regis- computerized system, for recall and
tered radiologic techologist and postprocedure interpretation by the
takes approximately 15 to 30 min- appropriate health care practitioner.
utes to complete.
➤ Inform the patient that the best Post-test:
time to schedule the examination is
1 week after menses, when breast ➤ Determine if patient or family mem-
tenderness is decreased. bers have any further questions or
➤ Sensitivity to cultural and social concerns.
issues, as well as concern for mod- ➤ Educate the patient regarding the
esty, is important in providing psy- techniques for breast self-examina-
chological support before, during and tion.
after the procedure. ➤ A written report of the examina-
➤ There are no food, fluid, or medication will be completed by a health
tion restrictions, unless by medical care practitioner specializing in this
direction. branch of medicine. The report will
Meckel’s Diverticulum Scan 943
be sent to the requesting health care address any concerns voiced by the
practitioner, who will discuss the patient or family.
➤ Recognize anxiety related to test procedure, additional testing may be
results, and be supportive of per- performed to evaluate or monitor
ceived loss of independence and progression of the disease process
fear of shortened life expectancy. and determine the need for a change
Discuss the implications of abnormal in therapy. Evaluate test results in
test results on the patient’s lifestyle. relation to the patient’s symptoms
Provide teaching and information and other tests performed.
patient’s health care provider regard- ➤ Related diagnostic tests include
ing further testing, treatment, or breast biopsy, bone scan, computed
referral to another health care pro- tomography scan of the thorax, and
vider. Answer any questions or ultrasound of the breast.
MECKEL’S DIVERTICULUM SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Meckel’s scan, Meckel’s scintigraphy, ectopic gastric

mucosa scan.

CONTRAST: Intravenous radioactive technetium-99m pertechnetate.
DESCRIPTION & RATIONALE: radionuclide is taken up and concen-

Meckel’s diverticulum scan is a trated by parietal cells of the gastric
nuclear medicine study performed to mucosa, whether located in the stom-
assist in diagnosing the cause of ach or in a Meckel’s diverticulum. Up
abdominal pain or occult gastroin- to 25% of Meckel’s diverticulum is
testinal (GI) bleeding, and to assess lined internally with ectopic gastric
the presence and size of a congenital mucosal tissue. This tissue is usually
anomaly of the GI tract. After intra- located in the ileum and right lower
venous injection of technetium-99m quadrant of the abdomen; it secretes
pertechnetate, immediate and delayed acid that causes ulceration of intes-
imaging is performed, with various tinal tissue, which results in abdomi-
views of the abdomen obtained. The nal pain and occult blood in stools. ■
INDICATIONS: • Other nuclear scans done within the

• Aid in the diagnosis of unexplained preceding 24 hours
abdominal pain and GI bleeding
caused by hydrochloric acid and pepsin Other considerations:
secreted by ectopic gastric mucosa, • False-positive results may occur from
which ulcerates nearby mucosa nondiverticular bleeding, intussuscep-
• Detect sites of ectopic gastric mucosa tion, duplication cysts, inflammatory
bowel disease, hemangioma of the
RESULT bowel, and other organ infections.
• Inadequate amount of gastric mucosa
Normal Findings:
within Meckel’s diverticulum can affect
• Normal distribution of radionuclide by the ability to visualize abnormalities.
gastric mucosa at normal sites
• Inaccurate timing for imaging after the
Abnormal Findings: radionuclide injection can affect the
• Meckel’s diverticulum, as evidenced by results.
focally increased radioactive uptake in • Failure to follow dietary restrictions
areas other than normal structures before the procedure may cause the
INTERFERING FACTORS: that allows the tracer to seep deep into
the muscle tissue produces erroneous
This procedure is hot spots.
• Patients who are pregnant or suspected • Consultation with a health care practi-
of being pregnant, unless the potential tioner should occur before the proce-
benefits of the procedure far outweigh dure for radiation safety concerns
the risks to the fetus and mother regarding younger patients or patients
who are lactating.
Factors that may • Risks associated with radiographic over-
impair clear imaging: exposure can result from frequent x-ray
• Inability of the patient to cooperate or procedures. Personnel in the room with
remain still during the procedure the patient should wear a protective lead
because of age, significant pain, or apron, stand behind a shield, or leave
mental status the area while the examination is being
• Metallic objects within the examina- done. Personnel working in the area
tion field (e.g., jewelry, body rings), where the examination is being done
which may inhibit organ visualization should wear badges that reveal their
and can produce unclear images level of exposure to radiation.

may exceed the weight limit for the Nursing Implications and
equipment
Procedure ● ● ● ● ● ● ● ● ● ● ●

which may produce poor visualization Pretest:
of the area to be examined ➤ Inform the patient that the procedure
• Retained barium from a previous radi- assesses GI bleeding.
ologic procedure ➤ Obtain a history of the patient’s com-
Meckel’s Diverticulum Scan 945
plaints and symptoms, including a ➤ Explain that an intravenous (IV) line

list of known allergens. may be inserted to allow infusion of
➤ Obtain a history of the patient’s gas- IV fluids, contrast medium, dye, or
trointestinal and cardiovascular sys- sedatives. Usually normal saline is
tems, as well as results of previously infused.
performed diagnostic procedures, ➤ Ensure that a histamine blocker is
surgical procedures, and laboratory administered, as ordered, 2 days
tests. For related diagnostic tests, before the study to block GI secre-
refer to the Gastrointestinal and tion, as appropriate.
Cardiovascular System tables. ➤ Occasionally, gastrin is given to
➤ Obtain a history of signs and symp- increase the uptake of the radionu-
toms of Meckel’s diverticulum, such clide by the ectopic gastric mucosa.
as bleeding, pain, intussusception, ➤ The patient should fast and restrict
volvulus, or diverticulitis. fluids for 8 hours prior to the proce-
➤ Note any recent procedures that can dure. Instruct the patient to avoid
interfere with test results. taking anticoagulant medication or to
➤ Record the date of the last menstrual reduce dosage as ordered prior to
of pregnancy in perimenopausal ➤ Instruct the patient to remove den-
women. tures, jewelry (including watches),
➤ Obtain a list of the medications the hairpins, credit cards, and other
patient is taking, including anticoagu- metallic objects in the area to be
lant therapy, aspirin and other salicy- examined.
lates, herbs, nutritional supplements,
and nutraceuticals, especially those Intratest:
known to affect coagulation (see
Appendix F). It is recommended that ➤ Ensure that the patient has complied
use be discontinued 14 days before with dietary, fluids, and medication
surgical procedures. The requesting restrictions and pretesting prepara-
health care practitioner and labora- tions; assure that food and medica-
tory should be advised if the patient tions have been restricted for at least
regularly uses these products so that 8 hours prior to the procedure.
their effects can be taken into consid- Ensure that the patient has removed
eration when reviewing results. all external metallic objects (jewelry,
dentures, etc.) prior to the procedure.
patient. Address concerns about pain ➤ Have emergency equipment readily
related to the procedure. Explain to available.
the patient that some pain may be ➤ Patients are given a gown, robe, and
experienced during the test, or there foot coverings to wear and instructed
may be moments of discomfort. to void prior to the procedure.
Reassure the patient that the radionu- ➤ Record baseline vital signs and
clide poses no radioactive hazard and assess neurologic status. Protocols
rarely produces side effects. Inform may vary from facility to facility.
the patient that the procedure is per-
formed in a special department, usu- ➤ Instruct the patient to cooperate fully
ally in a radiology department, by a and to follow directions. Instruct the
health care practitioner and support patient to remain still throughout the
staff, and takes approximately 60 procedure because movement pro-
minutes. duces unreliable results.
➤ Sensitivity to social and cultural ➤ Observe standard precautions, and
issues, as well as concern for mod- follow the general guidelines in
esty, is important in providing psy- Appendix A.
chological support before, during, ➤ Place the patient in a supine position
and after the procedure. on a flat table with foam wedges,
which help maintain position and ➤ Instruct the patient to apply cold
immobilization. The radionuclide is compresses to the puncture site, as
administered intravenously, and the needed, to reduce discomfort or
abdomen is scanned immediately edema.
for 1 minute to screen for vascular ➤ Instruct patient to drink increased
lesions that cause bleeding. Then amounts of fluids for 24 to 48 hours
images are taken every 5 minutes for to eliminate the radionuclide from
the next 60 minutes in the anterior, the body, unless contraindicated. Tell
oblique, and lateral views, and then in the patient that radionuclide is elimi-
a single postvoid anterior view. nated from the body within 6 to 24
➤ Wear gloves during the radionuclide hours.
injection and while handling the ➤ Instruct the patient to flush the toilet
patient’s urine. immediately after each voiding fol-
➤ Instruct the patient to take slow, lowing the procedure, and to wash
deep breaths if nausea occurs during hands meticulously with soap and
the procedure. Monitor and adminis- water after each voiding for 24 hours
ter an antiemetic agent if ordered. after the procedure.
Ready an emesis basin for use. ➤ Instruct all caregivers to wear gloves
➤ Monitor the patient for complications when discarding urine for 24 hours
related to the procedure (e.g., aller- after the procedure. Wash gloved
gic reaction, anaphylaxis, bron- hands with soap and water before
chospasm). removing gloves. Then wash hands
➤ The needle or catheter is removed, after the gloves are removed.
and a pressure dressing is applied ➤ If a woman who is breast-feeding
over the puncture site. must have a nuclear scan, she
➤ The results are recorded on x-ray film should not breast-feed the infant
or electronically, in a computerized until the radionuclide has been elimi-
system, for recall and postprocedure nated. This could take as long as 3
interpretation by the appropriate days. She should be instructed to
health care practitioner. express the milk and discard it dur-
Post-test: sation of milk production.
➤ Instruct the patient to resume usual low-cholesterol, and low-sodium diet
diet, fluids, and medications, as should be consumed to reduce cur-
directed by the health care practi- rent disease processes. High fat con-
tioner. sumption increases the amount of
➤ Monitor vital signs and neurologic bile acids in the colon and should be
status every 15 minutes for 1 hour, avoided.
then every 2 hours for 4 hours, and ➤ No other radionuclide tests should
then as ordered by the health care be scheduled for 24 to 48 hours after
practitioner. Compare with baseline this procedure.
values. Protocols may vary from
facility to facility. ➤ A written report of the examination
➤ Observe for delayed allergic reac- practitioner specializing in this
tions, such as rash, urticaria, tachy- branch of medicine. The report will
cardia, hyperpnea, hypertension, be sent to the requesting health care
palpitations, nausea, or vomiting. practitioner, who will discuss the
➤ Instruct the patient to immediately results with the patient.
report symptoms such as fast heart ➤ Recognize anxiety related to test
rate, difficulty breathing, skin rash, results, and be supportive of per-
itching, or decreased urinary output. ceived loss of independent function.
➤ Observe the needle/catheter inser- Discuss the implications of abnormal
tion site for bleeding, inflammation, test results on the patient’s lifestyle.
or hematoma formation. Provide teaching and information
Mediastinoscopy 947

➤ Instruct the patient in the use of any other tests performed.
importance of adhering to the ther- Related diagnostic tests:
the patient in significant side effects ➤ Related diagnostic tests include com-
and systemic reactions associated puted tomography of the abdomen or
with the prescribed medication. pelvis, and magnetic resonance im-
Encourage him or her to review cor- aging of the abdomen or pelvis.
MEDIASTINOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
AREA OF APPLICATION: Mediastinum.
CONTRAST: None.
DESCRIPTION & RATIONALE: Medi- to visualize and obtain biopsy speci-

astinoscopy provides direct visualiza- mens of the mediastinal lymph nodes,
tion of the structures that lie beneath and to determine the extent of metas-
the mediastinum, which is the area tasis into the mediastinum for the
behind the sternum and between the determination of treatment planning
lungs. The test is performed under in cancer patients. ■
general anesthesia by means of a
mediastinoscope inserted through a INDICATIONS:
surgical incision at the suprasternal • Confirm radiologic evidence of a tho-
notch. Structures that can be viewed racic infectious process of an indeter-
minate nature, coccidioidomycosis, or
include the trachea, the esophagus,
histoplasmosis
the heart and its major vessels, the
thymus gland, and the lymph nodes • Confirm radiologic or cytologic evi-
that receive drainage from the lungs. dence of carcinoma or sarcoidosis
The procedure is performed primarily • Detect Hodgkin’s disease
• Detect metastasis into the anterior of being pregnant, unless the potential
mediastinum or extrapleurally into the benefits of the procedure far outweigh
chest the risks to the fetus and mother
• Determine stage of known bron- Other considerations:
chogenic carcinoma, as indicated by • Failure to follow dietary restrictions
the extent of mediastinal lymph node before the procedure may cause the
involvement procedure to be canceled or repeated.
• Evaluate a patient with signs and symp-
toms of obstruction of mediastinal
lymph flow and a history of head or Nursing Implications and
neck cancer to determine recurrence or Procedure ● ● ● ● ● ● ● ● ● ● ●
spread
Pretest:
RESULT ➤ Inform the patient that the procedure
assesses the mediastinum.
Normal Findings:
• Normal appearance of mediastinal plaints or symptoms, including a list
structures of known allergens (especially aller-
• No abnormal lymph node tissue gies or sensitivities to latex), and
Abnormal Findings:
• Bronchogenic carcinoma immune and respiratory systems,
• Coccidioidomycosis any bleeding disorders, and results
of previously performed labora-
• Granulomatous infections tory tests (especially bleeding time,
• Histoplasmosis
boplastin time, platelets, and pro-
• Hodgkin’s disease thrombin time), surgical procedures,
• Pneumocystis carinii infection related laboratory tests, refer to the
• Sarcoidosis Immune and Respiratory System
tables.
• Tuberculosis ➤ Note any recent procedures that can
interfere with test results. Ensure
CRITICAL VALUES: N/A that this procedure is performed
before an upper gastrointestinal
INTERFERING FACTORS: study or barium swallow.
This procedure is period and determine the possibility
contraindicated for: of pregnancy in perimenopausal
• Patients who have had a previous medi- women.
astinoscopy, because scarring can make ➤ Obtain a list of the medications
insertion of the scope and biopsy of the patient is taking, including anti-
lymph nodes difficult coagulant therapy, acetylsalicylic
• Patients who have superior vena cava and nutraceuticals, especially those
obstruction, because this condition known to affect coagulation. It is rec-
causes increased venous collateral circu- ommended that use be discontinued
lation in the mediastinum 14 days before dental or surgical pro-
• Patients who are pregnant or suspected practitioner and laboratory should be
Mediastinoscopy 949
advised if the patient regularly uses Intratest:

can be taken into consideration ➤ Ensure that the patient has complied
when reviewing results. with dietary, fluids, and medication
➤ Review the procedure with the restrictions and pretesting prepara-
patient. Inform the patient that pro- tions; assure that food and fluids have
phylactic antibiotics may be adminis- been restricted for at least 8 hours
tered prior to the procedure. Address prior to the procedure. Ensure that
concerns about pain related to the the patient has removed all external
procedure. Explain that a general metallic objects (jewelry, dentures,
anesthesia will be administered to etc.) prior to the procedure.
promote relaxation and reduce dis- ➤ Ensure that anticoagulant therapy
comfort prior to the mediastinoscopy. has been withheld for the appropriate
Explain to the patient that some pain amount of days prior to the proce-
may be experienced after the test. dure. Notify the health care practi-
Meperidine (Demerol) or morphine tioner if patient anticoagulant therapy
may be given as a sedative. Inform has not been withheld.
the patient that the procedure is per- ➤ Have emergency equipment readily
formed in the operating room, under available. Keep resuscitation equip-
sterile conditions, by a health care ment on hand in the case of respira-
practitioner specializing in this proce- tory impairment or laryngospasm
dure. The procedure usually takes after the procedure.
about 30 to 60 minutes to complete.
➤ Explain that an intravenous (IV) line patients with asthma or other pul-
will be inserted to allow infusion of monary disease. This drug can fur-
IV fluids, antibiotics, anesthetics, and ther exacerbate bronchospasms and
analgesics. respiratory impairment.
➤ Sensitivity to cultural and social ➤ Patients are given a gown, robe, and
issues, as well as concern for mod- foot coverings to wear and instructed
esty, is important in providing psy- to void prior to the procedure.
➤ The patient should fast and restrict patient to remain still throughout the
fluids for 8 hours prior to the proce- procedure because movement pro-
dure. Instruct the patient to avoid duces unreliable results.
taking anticoagulant medication or
➤ Record baseline vital signs and
to reduce dosage as ordered prior
to the procedure. Number of days to
withhold medication is dependent on
the type of anticoagulant. ➤ Observe standard precautions, and
➤ Instruct the patient to remove den- Appendix A.
hairpins, credit cards, and other ➤ Establish IV fluid line for the injection
metallic objects in the area to be of emergency drugs and of sedatives.
examined. ➤ Place electrocardiographic electrodes
➤ Ensure that the results of blood typ- on the patient for cardiac monitor-
ing and cross-matching are obtained ing. Establish baseline rhythm; deter-
and recorded before the procedure mine if the patient has ventricular
in the event that an emergency tho- arrhythmias.
racotomy is required. ➤ Place the patient in the supine posi-
➤ Make sure a written and informed tion. General anesthesia is adminis-
consent has been signed prior to the tered via an endotracheal tube.
procedure and before administering ➤ An incision is made at the supraster-
any medications. nal notch, and a path for the medi-
astinoscope is made using finger rash, itching, or decreased urinary

dissection. The lymph nodes can be output.
palpated at this time. The lymph ➤ Instruct the patient in the care and
nodes on the right side of the medi- assessment of the site. Observe the
astinum are most accessible and site for bleeding, hematoma forma-
safest to biopsy by medastinoscopy; tion, and inflammation. Note any
the lymph nodes on the left side are pleuritic pain, persistent right shoul-
more difficult to explore and biopsy der pain, or chest pain.
because of their proximity to the
aorta. Biopsy specimens of nodes on ➤ Nutritional considerations: A low-
the left side of the mediastinum may fat, low-cholesterol, and low-sodium
need to be obtained by mediastino- diet should be consumed to reduce
tomy, which involves performing a current disease processes and/or
left anterior thoracotomy. decrease risk of hypertension and
labeled specimen containers, and ➤ Emphasize that any excessive bleed-
promptly transport the specimen to ing, difficulty breathing, excessive
the laboratory for processing and coughing after biopsy, or pain must
analysis. be reported to the health care practi-
tioner immediately.
➤ The scope is removed, and the inci-
sion is closed. ➤ A written report of the examina-
➤ If the patient is stable and if no further
surgery is immediately indicated, the
patient is extubated.
Post-test: results with the patient.
➤ The patient should remain in a semi- ➤ Recognize anxiety related to test
Fowler’s position on either side until results, and be supportive of per-
vital signs revert to preprocedure lev- ceived loss of independent function.
els. Discuss the implications of abnormal
➤ Monitor vital signs and neurologic test results on the patient’s lifestyle.
status every 15 minutes for 1 hour, Provide teaching and information
then every 2 hours for 4 hours, and regarding the clinical implications of
then as ordered by the health care the test results, as appropriate.
practitioner. Take temperature every ➤ Reinforce information given by the
4 hours for 24 hours. Compare with patient’s health care provider regard-
baseline values. Notify the health ing further testing, treatment, or re-
care practitioner if temperature is ferral to another health care provider.
elevated. Protocols may vary from Answer any questions or address
facility to facility. any concerns voiced by the patient
➤ Do not allow the patient to eat or or family.
drink for 12 to 24 hours. Instruct the ➤ Instruct the patient in the use of any
patient to resume normal activity, ordered medications. Explain the
medication, and diet in 24 hours or importance of adhering to the ther-
as tolerated after the examination, apy regimen. As appropriate, instruct
unless otherwise indicated. the patient in significant side effects
➤ Observe for delayed allergic reac- and systemic reactions associated
tions, such as rash, urticaria, tachy- with the prescribed medication. En-
cardia, hyperpnea, hypertension, courage him or her to review corre-
palpitations, nausea, or vomiting. sponding literature provided by a
➤ Instruct the patient to immedi- pharmacist.
ately report symptoms such as fast ➤ Depending on the results of this pro-
heart rate, difficulty breathing, skin cedure, additional testing may be
Metanephrines 951
needed to evaluate or monitor pro- Related diagnostic tests:

determine the need for a change in ➤ Related diagnostic tests include
therapy. Evaluate test results in rela- chest x-ray, computed tomography of
tion to the patient’s symptoms and the thorax, lung scan, and magnetic
other tests performed. resonance imaging of the chest.
METANEPHRINES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
amber plastic collection container with 6N hydrochloride as a preservative.
REFERENCE VALUE: (Method: High-pressure liquid chromatography)

Normetanephrines
0–3 mo 47–156 g/24 h 257–852 nmol/24 h
4–6 mo 31–111 g/24 h 171–607 nmol/24 h
7–9 mo 42–109 g/24 h 230–595 nmol/24 h
10–12 mo 23–103 g/24 h 127–562 nmol/24 h
1–2 y 32–118 g/24 h 175–647 nmol/24 h
2–6 y 50–111 g/24 h 274–604 nmol/24 h
6–10 y 47–176 g/24 h 255–964 nmol/24 h
10–16 y 53–290 g/24 h 289–1586 nmol/24 h
Adult 82–500 g/24 h 448–2730 nmol/24 h
Metanephrines
0–3 mo 5.9–37 g/24 h 30–188 nmol/24 h
4–6 mo 6.1–42 g/24 h 31–213 nmol/24 h
7–9 mo 12–41 g/24 h 61–210 nmol/24 h
10–12 mo 8.5–101 g/24 h 43–510 nmol/24 h
1–2 y 6.7–52 g/24 h 34–264 nmol/24 h
2–6 y 11–99 g/24 h 56–501 nmol/24 h
6–10 y 54–138 g/24 h 275–701 nmol/24 h
10–16 y 39–243 g/24 h 200–1231 nmol/24 h
Adult 45–290 g/24 h 228–1470 nmol/24 h
DESCRIPTION & RATIONALE: Nursing Implications and

Metanephrines are the inactive Procedure ● ● ● ● ● ● ● ● ● ● ●
metabolites of epinephrine and norep- Pretest:

inephrine. Metanephrines are either
excreted or further metabolized into ➤ Inform the patient that the test is
vanillylmandelic acid. Release of meta- pheochromocytoma, neuroblastoma,
nephrines in the urine is indicative of and ganglioblastoma.
disorders associated with excessive cat- ➤ Obtain a history of the patient’s com-
echolamine production, particularly plaints, including a list of known
pheochromocytoma. Vanillylmandelic allergens (especially allergies or sen-
acid and catecholamines are normally
measured with urinary metanephrines. accordingly.
Creatinine is usually measured simul- ➤ Obtain a history of the patient’s
taneously to ensure adequate collec- endocrine system, as well as results
tion and to calculate an excretion ratio of previously performed laboratory
of metabolite to creatinine. ■ tests, surgical procedures, and other
INDICATIONS: Endocrine System table.
• Assist in the diagnosis of suspected ➤ Note any recent procedures that can
pheochromocytoma interfere with test results.
• Assist in identifying the cause of hyper- ➤ Obtain a list of the medications the
tension patient is taking, including herbs,
• Verify suspected tumors associated with ceuticals. The requesting health care
excessive catecholamine secretion practitioner and laboratory should be
RESULT can be taken into consideration
Increased in:
• Ganglioneuroma patient. Provide a nonmetallic urinal,
• Neuroblastoma bedpan, or toilet-mounted collection
device. Address concerns about pain
• Pheochromocytoma related to the procedure. Explain to
• Severe stress discomfort during the procedure.
Decreased in: N/A ➤ Usually a 24-hour time frame for
CRITICAL VALUES: N/A saved during that 24-hour period.
INTERFERING FACTORS: directly into the laboratory collection
• Drugs that may increase metanephrine container. Instruct the patient to
levels include labetalol, monoamine avoid defecating in the collection
oxidase inhibitors, oxprenolol, oxytet- device and to keep toilet tissue out
racycline, and prochlorperazine. of the collection device to prevent
• Methylglucamine in x-ray contrast Place a sign in the bathroom to
medium may cause false-negative remind the patient to save all urine.
results. ➤ Instruct the patient to void all urine
Metanephrines 953
into the collection device and then to at the same time the collection was
pour the urine into the laboratory col- started and add this last voiding to
lection container. Alternatively, the the container.
➤ If an indwelling catheter is in place,
replace the tubing and container sys-
tion container.
time. Keep the container system
➤ Sensitivity to social and cultural on ice during the collection period, or
issues, as well as concern for mod- empty the urine into a larger con-
esty, is important in providing psy- tainer periodically during the collec-
chological support before, during, tion period; monitor to ensure
and after the procedure. continued drainage, and conclude
➤ Instruct the patient to avoid exces- the test the next morning at the
sive exercise and stress during the same hour the collection was begun.
24-hour collection of urine. ➤ At the conclusion of the test, com-
➤ There are no food, fluid, or medica- pare the quantity of urine with the
tion restrictions, unless by medical urinary output record for the collec-
direction. tion; if the specimen contains less
some urine may have been dis-
Intratest:
➤ Ensure that the patient has complied ➤ Include on the collection container’s
with activity restrictions during the label the amount of urine and test
procedure. start and stop times.
➤ If the patient has a history of severe ➤ Promptly transport the specimen to
allergic reaction to latex, care should the laboratory for processing and
be taken to avoid the use of equip- analysis.
➤ Observe standard precautions, and by the appropriate health care practi-
follow the general guidelines in tioner.
lection container with the correspon- Post-test:
time of collection.
activity, as directed by the health
Timed specimen: care practitioner.
specimen must be refrigerated or ➤ Recognize anxiety related to test
kept on ice throughout the entire results, and be supportive of fear of
collection period. If an indwelling shortened life expectancy. Discuss
urinary catheter is in place, the the implications of abnormal test
drainage bag must be kept on ice. results on the patient’s lifestyle. Pro-
➤ Begin the test between 6 and 8 a.m., vide teaching and information regard-
if possible. Collect first voiding and ing the clinical implications of the
discard. Record the time the speci- test results, as appropriate. Educate
men was discarded as the beginning the patient regarding access to coun-
of the timed collection period. The seling services.
next morning, ask the patient to void ➤ Reinforce information given by the
referral to another health care pro- relation to the patient’s symptoms
vider. Answer any questions or and other tests performed.
patient or family.
procedure, additional testing may be ➤ Related laboratory tests include cat-
performed to evaluate or monitor echolamines, homovanillic acid, and
progression of the disease process vanillylmandelic acid.
METHEMOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Hemoglobin, hemoglobin M, MetHb, Hgb M.

SPECIMEN: Whole blood (1 mL) collected in green-top (heparin) tube.

0.06–0.24 g/dL* 9.3–37.2 mol/L*
* Percentage of total hemoglobin 0.41–1.15%.

Note: The conversion factor of 155 is based on the molecular weight of hemoglobin of
64,500 daltons (d), or 64.5 kd.
• Assist in the detection of congeni-

DESCRIPTION & RATIONALE: Methe- tal methemoglobinemia, indicated by
moglobin is a structural hemoglobin deficiency of red blood cell nicotina-
variant formed when the heme por- mide adenine dinucleotide (NADH)-
tion of the deoxygenated hemoglobin methemoglobin reductase or presence
is oxidized to a ferric state that renders of methemoglobin.
it incapable of combining with and • Evaluate cyanosis in the presence of
transporting oxygen to tissues. Visible normal blood gases
cyanosis can result as levels approach
10% to 15% of total hemoglobin. ■ RESULT
Increased in:
INDICATIONS:
• Assist in the detection of acquired • Acquired methemoglobinemia (drugs,
methemoglobinemia caused by the tobacco smoking, or ionizing radiation)
toxic effects of chemicals and drugs • Carbon monoxide poisoning
Methemoglobin 955
• Hereditary methemoglobinemia (defi- • Breast-feeding infants are capable of

ciency of NADH-methemoglobin red- converting inorganic nitrate from com-
uctase or hemoglobinopathy) mon topical anesthetic applications
containing nitrate to the nitrite ion,
Decreased in: N/A causing nitrite toxicity and increased
methemoglobin.
CRITICAL VALUES: • Prompt and proper specimen process-
Cyanosis can occur at levels ing, storage, and analysis are important
greater than 10%. to achieve accurate results. Methemo-
Dizziness, fatigue, headache, and globin is unstable and should be trans-
tachycardia can occur at levels ported on ice within a few hours of
greater than 30%. collection, or else the specimen should
Signs of central nervous system be rejected.
depression can occur at levels
greater than 45%.
Death may occur at levels greater Nursing Implications and
than 70%. Procedure ● ● ● ● ● ● ● ● ● ● ●

health care practitioner any critically Pretest:
increased or decreased values and related ➤ Inform the patient that the test
symptoms. Possible interventions include is used to investigate cyanosis asso-
airway protection, administration of oxy- ciated with polycythemia, hemo-
gen, monitoring neurologic status every globinopathies, and drug toxicity
hour, continuous pulse oximetry, hyper- (inhaled substances).
baric oxygen therapy, and exchange trans- ➤ Obtain a history of the patient’s com-
fusion. Administration of activated plaints, including a list of known
charcoal or gastric lavage may be effective allergens (especially allergies or sen-
if performed soon after the toxic agent is sitivities to latex), and inform the
ingested. Emesis should never be induced appropriate health care practitioner
in patients with no gag reflex because of accordingly.
the risk of aspiration. Methylene blue ➤ Obtain a history of the patient’s
may be used to reverse the process of hematopoietic and respiratory sys-
methemoglobin formation, but it should tems and results of previously per-
be used cautiously when methemoglo- procedures, and other diagnostic pro-
bin levels are greater than 30%. Use of cedures. For related laboratory tests,
methylene blue is contraindicated in the refer to the Hematopoietic and
presence of glucose-6-phosphate dehy- Respiratory System tables.
drogenase deficiency. ➤ Note any recent procedures that can
INTERFERING FACTORS: ➤ Obtain a list of medications the
• Drugs that may increase methemo- patient is taking, including herbs,
globin levels include acetanilid, amyl nutritional supplements, and nutra-
nitrate, aniline derivatives, benzo- ceuticals. The requesting health care
caine, chlorates, chloroquine, dapsone, practitioner and laboratory should be
glucosulfone, isoniazid, lidocaine, advised if the patient regularly uses
nitroglycerin, phenacetin, phenytoin, these products so that their effects
primaquine, resorcinol, sulfonamides, can be taken into consideration
and thiazolsulfone. when reviewing results.
• Well water containing nitrate is the patient. Inform the patient that spec-
most common cause of methemoglo- imen collection takes approximately
binemia in infants. 5 to 10 minutes. Address concerns
about pain related to the procedure. or in a computerized system for

Explain to the patient that there may recall and postprocedure interpreta-
be some discomfort during the tion by the appropriate health care
tion restrictions, unless by medical Post-test:
direction.
➤ Prepare an ice slurry in a cup or plas- ing or hematoma formation. Apply
tic bag to have on hand for immedi- paper tape or other adhesive to
ate transport of the specimen to the hold pressure bandage in place, or
laboratory. replace with a plastic bandage.
➤ Teach the patient to avoid carbon
Intratest: monoxide from first- or second-hand
➤ If the patient has a history of severe smoking, to have home gas furnace
allergic reaction to latex, care should checked yearly for leaks, and to uti-
be taken to avoid the use of equip- lize gas appliances such as gas grills
ment containing latex. in a well-ventilated area.
Appendix A. Positively identify the ing further testing, treatment, or re-
patient, and label the appropriate ferral to another health care provider.
tubes with the corresponding patient Answer any questions or address
demographics, date, and time of col- any concerns voiced by the patient
lection. Perform a venipuncture; or family.
collect the specimen in a 5-mL ➤ Depending on the results of this pro-
green-top tube. cedure, additional testing may be
➤ Remove the needle, and apply a pres- performed to evaluate or monitor
sure dressing over the puncture site. progression of the disease process
analysis. The specimen should be
placed in an ice slurry immediately
after collection. Information on the
specimen label can be protected Related laboratory tests:
from water in the ice slurry if the ➤ Related laboratory tests include
specimen is first placed in a protec- arterial/alveolar oxygen ratio, blood
tive plastic bag. gases, carboxyhemoglobin, and he-
➤ The results are recorded manually moglobin electrophoresis.
Microalbumin 957
MICROALBUMIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Albumin, urine.

clean plastic collection container.
REFERENCE VALUE: (Method: Nephelometry immunoassay)
Test Conventional Units Units 0.001)
Random 0–30 mg/L 0–0.03 g/L
microalbumin
24-h microalbumin Greater than 40 g/24 h Greater than 0.04 g/24 h
Simultaneous measurement of urine creatinine or creatinine clearance may be
requested. Normal ratio of microalbumin to creatinine is less than 15.
• Diabetic nephropathy
DESCRIPTION & RATIONALE: The • Exercise
term microalbumin is used to describe
concentrations of albumin in urine • Hypertension (uncontrolled)
that are greater than normal but unde- • Pre-eclampsia
tectable by dipstick or traditional • Renal disease
spectrophotometry methods. Microal-
• Urinary tract infections
buminuria precedes the nephropathy
associated with diabetes and is often Decreased in: N/A
elevated years before creatinine clear-
ance shows abnormal values. Studies CRITICAL VALUES: N/A
have shown that the median duration
from onset of microalbuminuria to • Drugs that may decrease microalbumin
development of nephropathy is 5 to 7 levels include captopril, dipyridamole,
years. ■ enalapril, furosemide, indapamide,
perindopril, quinapril, ramipril, tolre-
INDICATIONS: stat, and triflusal.
• Evaluate renal disease
• All urine voided for the timed collec-
• Screen diabetic patients for early signs
tion period must be included in the
of nephropathy
collection or else falsely decreased val-
RESULT ues may be obtained. Compare output
records with volume collected to verify
Increased in: that all voids were included in the col-
• Cardiomyopathy lection.

Nursing Implications and pour the urine into the laboratory col-
Procedure ● ● ● ● ● ● ● ● ● ● ● lection container. Alternatively, the
Pretest: device for a health care staff mem-
➤ Inform the patient that the test is tion container.
used to assist in the mangement of
early diabetes in order to avoid or ➤ Sensitivity to social and cultural
delay the onset of renal disease asso- issues, as well as concern for mod-
ciated with diabetes. esty, is important in providing psy-
allergens (especially allergies or sen- ➤ Instruct the patient to avoid exces-
sitivities to latex), and inform the sive exercise and stress during the
appropriate health care practitioner 24-hour collection of urine.
accordingly. ➤ There are no food, fluid, or medica-
➤ Obtain a history of the patient’s tion restrictions, unless by medical
endocrine and genitourinary systems direction.
as well as results results of previously
performed laboratory tests, surgical Intratest:
procedures, and other diagnostic pro-
cedures. For related laboratory tests, ➤ Ensure that the patient has complied
refer to the Endocrine and Genitouri- with activity restrictions during the
nary System tables. procedure.
➤ Obtain a list of medications the ➤ If the patient has a history of severe
patient is taking, including herbs, allergic reaction to latex, care should
nutritional supplements, and nutra- be taken to avoid the use of equip-
ceuticals. The requesting health care ment containing latex.
practitioner and laboratory should be ➤ Instruct the patient to cooperate fully
advised if the patient regularly uses and to follow directions.
➤ Review the procedure with the patient, and label the appropriate col-
patient. Provide a nonmetallic urinal, lection container with the correspon-
bedpan, or toilet-mounted collection ding patient demographics, date, and
device. Address concerns about pain time of collection.
the patient that there should be no Random specimen (collect
in early morning):
➤ Usually a 24-hour time frame for
urine collection is ordered. Inform Clean-catch specimen:
saved during that 24-hour period. ➤ Instruct the male patient to (1) thor-
Instruct the patient not to void oughly wash his hands, (2) cleanse
directly into the laboratory collection the meatus, (3) void a small amount
container. Instruct the patient to into the toilet, and (4) void directly
avoid defecating in the collection into the specimen container.
device and to keep toilet tissue out ➤ Instruct the female patient to (1)
of the collection device to prevent thoroughly wash her hands; (2)
contamination of the specimen. cleanse the labia from front to back;
Place a sign in the bathroom to (3) while keeping the labia separated,
remind the patient to save all urine. void a small amount into the toilet;
➤ Instruct the patient to void all urine and (4) without interrupting the urine
Microalbumin 959
stream, void directly into the speci- General:

men container.
Indwelling catheter: the laboratory for processing and
analysis.
➤ Put on gloves. Empty drainage tube
clamp off the catheter for 15 to 30
practitioner.
tic swab, and then aspirate 5 mL of
and syringe. Transfer urine to a ster- Post-test:
ile container. ➤ Instruct the patient to resume usual
activity, as directed by the health
Timed specimen: care practitioner.
➤ Obtain a clean 3-L urine specimen ➤ Instruct the patient and caregiver to
container, toilet-mounted collection report signs and symptoms of hypo-
device, and plastic bag (for transport glycemia or hyperglycemia.
of the specimen container). The ➤ Nutritional considerations: Instruct
specimen must be refrigerated or the patient, as appropriate, in nutri-
kept on ice throughout the entire col- tional management of diabetes.
lection period. If an indwelling uri- Patients who adhere to dietary rec-
nary catheter is in place, the ommendations report a better gen-
drainage bag must be kept on ice. eral feeling of health, better weight
➤ Begin the test between 6 and 8 a.m., management, greater control of glu-
if possible. Collect first voiding and cose and lipid values, and improved
discard. Record the time the speci- use of insulin. There is no “diabetic
men was discarded as the beginning diet”; however, there are many meal-
of the timed collection period. The planning approaches with nutritional
next morning, ask the patient to void goals endorsed by the American
at the same time the collection was Dietetic Association. The nutritional
started and add this last voiding to needs of each diabetic patient need
the container. to be determined individually with the
appropriate health care professionals,
➤ If an indwelling catheter is in place, particularly professionals trained in
replace the tubing and container sys- nutrition.
time. Keep the container system on ➤ Recognize anxiety related to test
ice during the collection period, or results, and be supportive of per-
empty the urine into a larger con- ceived loss of independence and
tainer periodically during the collec- fear of shortened life expectancy.
tion period; monitor to ensure Discuss the implications of abnormal
continued drainage, and conclude test results on the patient’s lifestyle.
the test the next morning at the Provide teaching and information
same hour the collection was begun. regarding the clinical implications of
➤ At the conclusion of the test, com- Emphasize, if indicated, that good
pare the quantity of urine with the glycemic control delays the onset
urinary output record for the collec- and slows the progression of dia-
tion; if the specimen contains less betic retinopathy, nephropathy, and
than what was recorded as output, neuropathy. Educate the patient
some urine may have been dis- regarding access to counseling serv-
carded, invalidating the test. ices, as appropriate. Provide contact
➤ Include on the collection container’s information, if desired, for the
label the amount of urine and test American Diabetes Association
start and stop times. (http://www.diabetes.org).

care practitioner who will discuss in therapy. Evaluate test results in
ferral to another health care provider. Related laboratory tests:
Answer any questions or address ➤ Related laboratory tests include
any concerns voiced by the patient cortisol, urine creatinine, creatinine
or family. clearance, glucose, glucose toler-
➤ Depending on the results of this ance test, glycated hemoglobin,
procedure, additional testing may be insulin, insulin antibodies, urinalysis,
performed to evaluate or monitor and urine protein and fractions.
2-MICROGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: 2-M.
SPECIMEN: Serum (1 mL) collected in a red-top tube or 5 mL urine
from a timed collection in a clean plastic container with 1N NaOH as
a preservative.
REFERENCE VALUE: (Method: Immunoassay for serum sample, radioim-

munoassay for urine sample)
Sample Conventional Units Units 10)
Serum
Newborn Less than 0.3 mg/dL Less than 3 mg/L
Adult Less than 0.2 mg/dL Less than 2 mg/L
Urine 0.03–0.37 mg/24 h
DESCRIPTION & RATIONALE: 2- conditions and when lymphocyte

Microglobulin is an amino acid pep- turnover increases, such as in lympho-
tide component of human leukocyte cytic leukemia or when T-lymphocyte
antigen (HLA) complexes. 2-Micro- helper (OKT4) cells are attacked
globulin increases in inflammatory by human immunodeficiency virus
2-Microglobulin 961
(HIV). Serum 2-microglobulin • Multiple myeloma

becomes elevated with malfunc- • Poisoning with heavy metals, such as
tioning glomeruli, but decreases with mercury or cadmium
malfunctioning tubules because it
• Renal dialysis
is metabolized by the renal tubules.
Conversely, urine 2-microglobulin • Renal disease (glomerular): serum only
decreases with malfunctioning glo- • Renal disease (tubular): urine only
meruli, but becomes elevated with
malfunctioning tubules. ■ • Sarcoidosis
• Systemic lupus erythematosus
INDICATIONS:
• Detect aminoglycoside toxicity (be- • Vasculitis
comes elevated before creatinine)
• Viral infections (e.g., cytomegalovirus)
• Detect chronic lymphocytic leukemia,
multiple myeloma, lung cancer, Decreased in:
hepatoma, or breast cancer
• Renal disease (glomerular): urine only
• Detect HIV infection (note: levels do
• Renal disease (tubular): serum only
not correlate with stages of infection)
• Response to zidovudine (AZT)
• Evaluate renal disease to differentiate
glomerular from tubular dysfunction
• Monitor antiretroviral therapy

• Drugs and proteins that may increase
Increased in: serum 2-microglobulin levels include
• Acquired immunodeficiency syndrome cefuroxime, cyclosporin A, gentamicin,
(AIDS) interferon alfa, pentoxifylline, and tu-
mor necrosis factor.
• Aminoglycoside toxicity
• Drugs that may decrease serum 2-
• Amyloidosis microglobulin levels include zidovu-
• Autoimmune disorders dine.
• Breast cancer • Drugs that may increase urine 2-

microglobulin levels include azathio-
• Crohn’s disease prine, cisplatin, cyclosporin A,
• Felty’s syndrome furosemide, gentamicin, mannitol,
nifedipine, sisomicin, and tobramycin.
• Hepatitis
• Drugs that may decrease urine 2-
• Hepatoma microglobulin levels include cilostazol.
• Hyperthyroidism
• Urinary 2-microglobulin is unstable
• Inflammation of all types at pH less than 5.5.
• Leukemia (chronic lymphocytic) • Recent radioactive scans or radiation
• Lung cancer within 1 week before the test can inter-
• Lymphoma munoassay is the test method.
Urine:
Procedure ● ● ● ● ● ● ● ● ● ● ●
patient. Provide a nonmetallic urinal,
Pretest:
device.
➤ Inform the patient that the test is ➤ Usually a 24-hour urine collection is
used to evaluate renal disease, AIDS, ordered. Inform the patient that all
and certain malignancies. urine over a 24-hour period must be
➤ Obtain a history of the patient’s com- saved; instruct the patient to avoid
plaints, including a list of known defecating in the collection device
allergens (especially allergies or sen- and to keep toilet tissue out of the
sitivities to latex), and inform the collection device to prevent contam-
appropriate health care practitioner ination of the specimen. Place a sign
accordingly. in the bathroom as a reminder to
save all urine.
itourinary and immune system, as ➤ Instruct the patient to void all urine
well as results of previously per- into the collection device and then
formed laboratory tests, surgical pro- pour the urine into the laboratory col-
cedures, and other diagnostic lection container. Alternatively, the
procedures. For related laboratory specimen can be left in the collection
tests, refer to the Genitourinary and device for a health care staff mem-
Immune System tables. ber to add to the laboratory collec-
tion container.
Intratest:
patient is taking, including herbs, ➤ Instruct the patient to cooperate fully
nutritional supplements, and nutra- and to follow directions. Direct the
ceuticals. The requesting health care patient to breathe normally and to
practitioner and laboratory should be avoid unnecessary movement during
advised if the patient regularly uses the venipuncture.
these products so their effects can ➤ Observe standard precautions, and
be taken into consideration when follow the general guidelines in
reviewing results. Appendix A. Positively identify the
➤ Sensitivity to social and cultural patient, and label the appropriate
issues, as well as concern for mod- tubes or collection containers with
esty, is important in providing psy- the corresponding patient demo-
chological support before, during, graphics, date, and time of collection.
Blood:
tion restrictions, unless by medical ➤ If the patient has a history of severe
direction. allergic reaction to latex, care should
Blood:
➤ Perform a venipuncture; collect the
➤ Review the procedure with the specimen in a 5-mL red-top tube.
patient. Inform the patient that spec- ➤ Remove the needle, and apply a pres-
imen collection takes approximately sure dressing over the puncture site.
Urine:
be some discomfort during the ➤ Obtain a clean 3-L urine specimen
venipuncture. container, toilet-mounted collection
2-Microglobulin 963
device, and plastic bag (for transport pressure bandage in place, or replace
of the specimen container). The with a plastic bandage.
specimen must be refrigerated or ➤ Educate the patient regarding the
kept on ice throughout the entire risk of infection related to immuno-
collection period. If an indwelling suppressed inflammatory response
urinary catheter is in place, the and fatigue related to decreased
drainage bag must be kept on ice. energy production.
➤ If possible, begin the test between 6 ➤ Nutritional considerations: Stress the
and 8 a.m. Collect first voiding and importance of good nutrition, and
discard. Record the time the speci- suggest that the patient meet with
men was discarded as the beginning a nutritional specialist. Also, stress
of the timed collection period. At the the importance of following the care
same time the next morning, ask the plan for medications and follow-up
patient to void and add this last void- visits.
ing to the container.
➤ If an indwelling catheter is in place, will be sent to the requesting health
replace the tubing and container sys- care practitioner, who will discuss
tem at the start of the collection the results with the patient.
ice during the collection period, or ➤ Social and cultural considerations:
empty the urine into a larger con- Recognize anxiety related to test
tainer periodically during the collec- results, and be supportive of im-
tion period; monitor to ensure paired activity related to weakness,
continued drainage, and conclude perceived loss of independence, and
the test the next morning at the fear of shortened life expectancy.
same hour the collection started. Discuss the implications of abnormal
➤ At the conclusion of the test, com- Provide teaching and information
pare the quantity of urine with the regarding the clinical implications of
urinary output record for the collec- the test results, as appropriate.
tion. If the specimen contains less Educate the patient regarding access
than what was recorded as output, to counseling services. Provide con-
some urine may have been dis- tact information, if desired, for AIDS
carded, thus invalidating the test. information provided by the National
Institutes of Health (http://www.
Blood or urine: aidsinfo.nih.gov).
➤ Promptly transport the specimen to ➤ Social and cultural considerations:

the laboratory for processing and Counsel the patient, as appropriate,
analysis. Include on the urine speci- regarding risk of transmission and
men label the amount of urine and proper prophylaxis, and reinforce the
ingestion of any medications that importance of strict adherence to
can affect test results. the treatment regimen.
➤ The results are recorded manually ➤ Social and cultural considerations:

or in a computerized system for Offer support, as appropriate, to
recall and postprocedure interpreta- patients who may be the victims of
tion by the appropriate health care rape or sexual assault. Educate the
practitioner. patient regarding access to counsel-
ing services. Provide a nonjudgmen-
Post-test: a discussion during which risks of
sexually transmitted diseases are
➤ Observe venipuncture site for bleed- explained. It is also important to dis-
ing or hematoma formation. Apply cuss problems the patient may expe-
paper tape or other adhesive to hold rience (e.g., guilt, depression, anger).
➤ Reinforce information given by the relation to the patient’s symptoms

patient’s health care provider regard- and other tests performed.
vider. Inform the patient that retest-
➤ Related laboratory tests include bi-
ing may be necessary. Answer any
opsy of the suspect tissue; CD4/
CD8 enumeration; complete blood
count; creatinine; erythrocyte sedi-
➤ Depending on the results of this pro- mentation rate; gentamicin; hepati-
cedure, additional testing may be tis serology; HIV-1/HIV-2 serology;
performed to evaluate or monitor immunofixation electrophoresis; im-
progression of the disease process munoglobulins A, G, and M; protein
and determine the need for a change fraction electrophoresis; total pro-
in therapy. Evaluate test results in tein; tobramycin; and urinalysis.
MUMPS SEROLOGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: N/A.
REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative or less
than a fourfold increase in titer.
DESCRIPTION & RATIONALE: Mumps inflammation of the testes, ovaries,

serology is done to determine the and pancreas. The presence of im-
presence of mumps antibody, indicat- munoglobulin M (IgM) antibodies
ing exposure to or active presence of indicates acute infection. The pres-
mumps. Mumps, also known as par- ence of IgG antibodies indicates cur-
otitis, is an infectious viral disease of rent or past infection. ■
the parotid glands caused by a myx-
ovirus that is transmitted by direct INDICATIONS:
contact with or droplets spread from • Determine resistance to or protection
the saliva of an infected person. The against the mumps virus by a positive
reaction, or susceptibility to mumps by
incubation period averages 3 weeks.
a negative reaction
Virus can be shed in saliva for 2 weeks
after infection and in urine for • Document immunity
2 weeks after the onset of symptoms. • Evaluate mumps-like diseases and dif-
Complications of infection include ferentiate between these and actual
aseptic meningitis, encephalitis, and mumps
Mumps Serology 965
RESULT ➤ There are no food, fluid, or medica-

Positive findings in: Past or current direction.
mumps infection.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that the test is pendix A. Positively identify the pa-
used to confirm acute infection with tient, and label the appropriate tubes
or immunity to the mumps virus. with the corresponding patient
plaints, including a list of known lection. Perform a venipuncture;
accordingly. Obtain a history of exposure dressing over the puncture site.
sure.
➤ Obtain a history of the patient’s im- the laboratory for processing and
mune system as well as results of analysis.
laboratory tests, refer to the Immune
by the appropriate health care practi-
System table.
tioner.
these products so that their effects pressure bandage in place, or replace
can be taken into consideration with a plastic bandage.
when reviewing results. ➤ Instruct the patient in isolation pre-
➤ Review the procedure with the pa- cautions during the time of commu-
tient. Inform the patient that several nicability or contagion.
tests may be necessary to confirm ➤ Emphasize that the patient must re-
diagnosis. Any individual positive turn to have a convalescent blood
result should be repeated in 7 to 14 sample taken in 7 to 14 days.
days to monitor a change in titer.
Inform the patient that specimen ➤ Inform the patient that the presence
collection takes approximately 5 to of mumps antibodies ensures life-
10 minutes. Address concerns about long immunity.
pain related to the procedure. ➤ A written report of the examination
Explain to the patient that there may will be sent to the requesting health
be some discomfort during the care practitioner, who will discuss
venipuncture. the results with the patient.
➤ Reinforce information given by the procedure, additional testing may be

patient’s health care provider regard- performed to evaluate or monitor
ing further testing, treatment, or progression of the disease process
referral to another health care pro- and determine the need for a change
vider. Answer any questions or in therapy. Evaluate test results in
MYOCARDIAL INFARCT SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: PYP cardiac scan, infarct scan, pyrophosphate

cardiac scan, acute myocardial infarction scan.
AREA OF APPLICATION: Heart, chest/thorax.

CONTRAST: Intravenous contrast medium.
DESCRIPTION & RATIONALE: Tech- radionuclide uptake that appear in 12

netium-99m stannous pyrophosphate hours at the earliest.
(PYP) scanning, also known as myo- PYP uptake usually takes place 24
cardial infarct imaging, reveals the to 72 hours after MI, and the radionu-
presence of myocardial perfusion and clide remains detectable for approxi-
the extent of myocardial infarction mately 10 to 14 days after the MI.
(MI). This procedure can distinguish PYP uptake is proportional to the
new from old infarcts when a patient blood flow to the affected area; with
has had abnormal electrocardiograms large areas of necrosis, PYP uptake
(ECGs) and cardiac enzymes have may be maximal around the periphery
returned to normal. PYP uptake by of a necrotic area, with little uptake
acutely infarcted tissue may be related being detectable in the poorly per-
to the influx of calcium through dam- fused center. Most of the PYP is con-
aged cell membranes, which accompa- centrated in regions that have 20% to
nies myocardial necrosis; that is, the 40% of the normal blood flow.
radionuclide may be binding to cal- Single-photon emission computed
cium phosphates or to hydroxyapatite. tomography (SPECT) can be used
The PYP in these damaged cells can to visualize the heart from multiple
be viewed as spots of increased angles and planes, enabling areas of
Myocardial Infarct Scan 967
MI to be viewed with greater accuracy the risk of radiation exposure to the

fetus
and resolution. This technique re-
moves overlying structures that may • Patients with hypersensitivity to the
confuse interpretation of the results. radionuclide
With the availability of assays of tro-
ponins, myocardial infarct imaging Factors that may
has become less important in the diag-
nosis of acute MI. ■
INDICATIONS: status
• Aid in the diagnosis of (or confirm
and locate) acute MI when ECG and • Metallic objects within the examina-
enzyme testing do not provide a diag- tion field (e.g., jewelry, earrings, and/or
nosis dental amalgams), which may inhibit
• Aid in the diagnosis of perioperative MI unclear images
• Differentiate between a new and old • Improper adjustment of the radi-
infarction ographic equipment to accommodate
• Evaluate possible reinfarction or exten- overexposure or underexposure and
sion of the infarct poor-quality study
• Obtain baseline information about in- • Patients who are very obese, who
farction before cardiac surgery may exceed the weight limit for the
equipment
RESULT • Incorrect positioning of the patient,
Normal Findings:
• Normal coronary blood flow and tissue
perfusion, with no PYP localization in • Other nuclear scans done within the
the myocardium previous 24 to 48 hours
• No uptake above background activity • Conditions such as chest wall trauma,
in the myocardium (note: when PYP cardiac trauma, or recent cardioversion
uptake is present, it is graded in rela- procedure
tion to adjacent rib activity) • Myocarditis
Abnormal Findings: • Pericarditis
• MI, indicated by increased PYP uptake • Left ventricular aneurysm
in the myocardium
• Metastasis
CRITICAL VALUES: N/A • Valvular and coronary artery calcifica-
tions
INTERFERING FACTORS: • Cardiac neoplasms
This procedure is • Aneurysms
• Patients who are pregnant or suspected Other considerations:
of being pregnant, unless the potential • Improper injection of the radionuclide
benefits of the procedure far outweigh may allow the tracer to seep deep into
the muscle tissue, producing erroneous is performed in a nuclear medicine

hot spots. department, usually by a technolo-
gist and support staff, and takes ap-
• Consultation with a health care practi- proximately 30 to 60 minutes. Inform
tioner should occur before the proce- the patient that the technologist will
dure for radiation safety concerns administer an intravenous injection
regarding younger patients or patients of the radionuclide and that he or she
who are lactating. will need to return 2 to 3 hours later
for the scan.
• Risks associated with radiologic overex- ➤ Sensitivity to cultural and social
posure can result from frequent x-ray issues, as well as concern for mod-
procedures. Personnel in the room with esty, is important in providing psy-
the patient should wear a protective chological support before, during,
lead apron, stand behind a shield, or and after the procedure.
leave the area while the examination is ➤ Instruct the patient to fast for 4
being done. Badges that reveal the level hours, refrain from smoking for 4 to
of exposure to radiation should be 6 hours, and withhold medications
worn by persons working in the area for 24 hours before the procedure.
where the examination is being done. ➤ Instruct the patient to remove den-
hairpins, credit cards, and other me-
tallic objects.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest: ➤ Ensure that the patient has complied
➤ Inform the patient that the procedure tions and other pretesting prepara-
assesses blood flow to the heart. tions. Ensure that the patient has
➤ Obtain a history of the patient’s com- removed all external metallic objects
plaints and symptoms, including a (jewelry, dentures, etc.) prior to the
list of known allergens. procedure.
➤ Obtain a history of the patient’s car- ➤ Have emergency equipment readily
diovascular system, as well as available.
results of previously performed labo- ➤ Patients are given a gown, robe, and
ratory tests, surgical procedures, foot coverings to wear and instructed
and diagnostic procedures. For re- to void prior to the procedure.
lated diagnostic tests, refer to the
Cardiovascular System table. ➤ Instruct the patient to cooperate fully
➤ Record the date of the last menstrual patient to lie very still during the pro-
period and determine the possibil- cedure because movement will pro-
ity of pregnancy in perimenopausal duce unclear images.
women.
➤ Obtain a list of the patient’s current follow the general guidelines in Ap-
medications. pendix A.
➤ Review the procedure with the pa- ➤ Place the patient in a supine position
tient. Address concerns about pain on a flat table with foam wedges
related to the procedure. Explain to to help maintain position and immo-
the patient that some pain may be bilization.
there may be moments of discom- ➤ Wear gloves during the radionuclide
fort. Explain the purpose of the test injection and while handling the pa-
and how the procedure is performed. tient’s urine.
Inform the patient that the procedure ➤ Imaging of the patient’s heart begin
Myocardial Infarct Scan 969
2 to 4 hours after injection of the after the procedure. Wash gloved

radionuclide. hands with soap and water before
➤ Images of the heart are taken from a removing gloves. Then wash hands
minimum of three angles: anterior, after the gloves are removed.
left anterior oblique, and left lateral. ➤ If a woman who is breast-feeding
In most circumstances, however, must have a nuclear scan, she
SPECT is done so that the heart can should not breast-feed the infant
be viewed from multiple angles and until the radionuclide has been elimi-
planes. nated. This could take as long as 3
➤ The results are recorded on film or in
a computerized system for recall and
postprocedure interpretation by the
Post-test: this procedure.
➤ Instruct the patient to resume nor- ➤ A written report of the examina-
mal activity and diet, unless other- tion will be completed by a health
wise indicated. care practitioner specializing in this
➤ If the patient must return for addi- branch of medicine. The report will
tional imaging, advise the patient to be sent to the requesting health care
rest in the interim and restrict diet to practitioner, who will discuss the re-
liquids before redistribution studies. sults with the patient.
➤ Advise patient to drink increased ➤ Reinforce information given by the
amounts of fluids for 24 to 48 hours patient’s health care provider regard-
to eliminate the radionuclide from ing further testing, treatment, or re-
the body, unless contraindicated. Tell ferral to another health care provider.
the patient that radionuclide is elimi- Answer any questions or address
nated from the body within 6 to 24 any concerns voiced by the patient
hours. or family.
➤ Observe the injection site for red-
ness, swelling, or hematoma.
➤ Observe patient for up to 60 minutes gression of the disease process and
after the study for a possible anaphy- determine the need for a change in
lactic reaction to the radionuclide, therapy. Evaluate test results in rela-
such as rash, tightening of throat, or tion to the patient’s symptoms and
difficulty breathing. other tests performed.
➤ Instruct the patient to flush the toilet
immediately after each voiding fol- Related diagnostic tests:
lowing the procedure, and to wash ➤ Related diagnostic tests include com-
hands meticulously with soap and puted tomography of the thorax,
water after each voiding for 24 hours echocardiography, electrocardiogram,
after the procedure. magnetic resonance imaging of
➤ Tell all caregivers to wear gloves the chest, and myocardial perfusion
when discarding urine for 24 hours scan.
MYOCARDIAL PERFUSION
HEART SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Thallium scan, sestamibi scan, stress thallium.

AREA OF APPLICATION: Heart, chest/thorax.
CONTRAST: Intravenous contrast medium.
DESCRIPTION & RATIONALE: Cardiac able in subsequent imaging. Compari-

scanning is a nuclear medicine study son of early stress images with images
that reveals clinical information about taken after 3 to 4 hours’ redistribution
coronary blood flow, ventricular size, (delayed images) enables differentia-
and cardiac function. Thallium-201 tion between normally perfused,
chloride rest or stress studies are used healthy myocardium (which is normal
to evaluate myocardial blood flow to at rest but ischemic on stress) and
assist in diagnosing or determining the infarcted myocardium.
risk for ischemic cardiac disease, coro- Technetium-99m agents such as ses-
nary artery disease (CAD), and tamibi (2-methoxyisobutylisonitrile)
myocardial infarction (MI). This pro- are delivered similarly to thallium-201
cedure is an alternative to angiography during myocardial perfusion imaging,
or cardiac catheterization in cases in but they are extracted to a lesser degree
which these procedures may pose a risk on the first pass through the heart and
to the patient. Thallium-201 is a are taken up by the mitochondria.
potassium analogue and is taken up by Over a short period, the radionuclide
myocardial cells proportional to blood concentrates in the heart to the same
flow to the cell and cell viability. degree as thallium-201. The advantage
During stress studies, the radionuclide to technetium-99m agents is that
is injected at peak exercise, after which immediate imaging is unnecessary be-
the patient continues to exercise for cause the radionuclide remains fixed to
several minutes. During exercise, areas the heart muscle for several hours. The
of heart muscle supplied by normal examination requires two separate
arteries increase their blood supply, as injections, one for the rest portion and
well as the supply of thallium-201 one for the stress portion of the proce-
delivery to the heart muscle, to a dure. These injections can take place
greater extent than regions of the heart on the same day or preferably over a 2-
muscle supplied by stenosed coronary day period. Examination quality is
arteries. This discrepancy in blood improved if the patient is given a light,
flow becomes apparent and quantifi- fatty meal after the radionuclide is
Myocardial Perfusion Heart Scan 971
injected to facilitate hepatobiliary • Evaluate the site of an old MI to deter-

mine obstruction to cardiac muscle
clearance of the radioactivity.
perfusion
If stress testing cannot be per-
formed by exercising, dipyridamole • Evaluate the effectiveness of medica-
(Persantine) or adenosine, a vasodilation regimen and balloon angioplasty
tor, can be administered orally or procedure on narrow coronary arteries
intravenously. A coronary vasodilator
RESULT
is administered before the thallium-
201, or other radionuclide, and the Normal Findings:
scanning procedure is then per- • Normal wall motion, coronary blood
formed. Vasodilators increase blood flow, tissue perfusion, and ventricular
flow in normal coronary arteries size and function
twofold to threefold without exercise,
and they reveal perfusion defects Abnormal Findings:
when blood flow is compromised • Abnormal stress and resting images,
by vessel pathology. Vasodilator- indicating previous MI
mediated myocardial perfusion scan- • Abnormal stress images with normal
ning is reserved for patients who are resting images, indicating transient
unable to participate in treadmill, ischemia
bicycle, or handgrip exercises for stress • Cardiac hypertrophy, indicated by
testing because of lung disease, neuro- increased radionuclide uptake in the
logic disorders (e.g., multiple sclerosis, myocardium
spinal cord injury), morbid obesity,
• Enlarged left ventricle
and orthopedic disorders (e.g., arthri-
tis, limb amputation). • Heart chamber disorder
Single-photon emission computed • Ventricular septal defects
tomography can be used to visualize
the heart from multiple angles and CRITICAL VALUES: N/A
planes, enabling areas of MI to be
viewed with greater accuracy and res-
olution. This technique removes over- This procedure is
lying structures that may confuse contraindicated for:
interpretation of the results. ■ • Patients who have taken sildenafil
(Viagra) within the previous 48
INDICATIONS: hours, as this test may require the use
• Aid in the diagnosis of CAD or risk for of nitrates (nitroglycerin) that can pre-
CAD cipitate life-threatening low blood
• Determine rest defects and reperfusion pressure
with delayed imaging in unstable • Patients with bleeding disorders
angina
• Evaluate the extent of CAD and deter- of being pregnant, unless the potential
mine cardiac function benefits of the procedure far outweigh
• Assess the function of collateral coro- the risk of radiation exposure to the
nary arteries fetus
• Evaluate bypass graft patency and gen- • Patients with hypersensitivity to the
eral cardiac status after surgery radionuclide
• Patients with left ventricular hypertro- which may produce poor visualization
phy, right and left bundle branch of the area to be examined
block, or hypokalemia, and patients
receiving cardiotonic therapy
• Patients with anginal pain at rest or which may inhibit organ visualization
patients with severe atherosclerotic and can produce unclear images
coronary vessels, in whom dipyri-
damole testing cannot be performed Other considerations:
• Patients with asthma, because chemical • Failure to follow dietary restrictions
stress with vasodilators can cause bron- before the procedure may cause the
chospasms procedure to be canceled or repeated.
Factors that may that allows the tracer to seep deep into
impair clear imaging: the muscle tissue produces erroneous
• Inability of the patient to cooperate or hot spots.
cause of age, significant pain, or mental • Inaccurate timing for imaging after
status radionuclide injection can affect the
results.
• Medications such as digitalis and quini-
dine, which can alter cardiac contractil-
ity; and nitrates, which can affect
cardiac performance
• Single-vessel disease, which can pro- who are lactating.
duce false-negative thallium-201 scan-
ning results
• Conditions such as chest wall or cardiac procedures. Personnel in the room with
trauma, angina that is difficult to con- the patient should wear a protective lead
trol, significant cardiac arrhythmias, apron, stand behind a shield, or leave
and recent cardioversion procedure the area while the examination is being
done. Personnel working in the area
• Suboptimal cardiac stress or patient where the examination is being done
exhaustion preventing maximum heart should wear badges that reveal their
rate testing level of exposure to radiation.
• Excessive eating or exercising between
initial and redistribution imaging
4 hours later, which produces false- Nursing Implications and
positive results Procedure ● ● ● ● ● ● ● ● ● ● ●
• Improper adjustment of the radiologic

equipment to accommodate obese or Pretest:
thin patients, which can cause overex- ➤ Inform the patient that the procedure
posure or underexposure and a poor- assesses blood flow to the heart.
quality study ➤ Obtain a history of the patient’s com-
• Patients who are very obese, who plaints and symptoms, including a
equipment ➤ Obtain a history of the patient’s
cardiovascular system, as well as
• Incorrect positioning of the patient, results of previously performed labo-
Myocardial Perfusion Heart Scan 973
ratory tests, surgical procedures, shoes (if treadmill exercise testing is

and diagnostic procedures. For to be performed), and emphasize the
related laboratory tests, refer to the importance of the patient reporting
Cardiovascular System table. fatigue, pain, or shortness of breath.
➤ Record the date of the last menstrual ➤ Instruct the patient to remove den-
period and determine the possibility tures, jewelry (including watches),
of pregnancy in perimenopausal hairpins, credit cards, and other
women. metallic objects in the area to be
examined.
the patient is taking, including anti- ➤ Make sure a written and informed
coagulant therapy, aspirin and other consent has been signed prior to the
salicylates, herbs, nutritional supple- procedure and before administering
ments, and nutraceuticals, especially any medications.
those known to affect coagulation ➤ This procedure may be terminated if
(see Appendix F). It is recommended chest pain, severe cardiac arrhyth-
that use be discontinued 14 days mias, or signs of a cerebrovascular
before surgical procedures. The re- accident occur.
questing health care practitioner and
patient regularly uses these products Intratest:
so that their effects can be taken ➤ Ensure that the patient has complied
into consideration when reviewing with dietary and medication restric-
results. tions and other pretesting prepara-
➤ Review the procedure with the pa- tions. Ensure that the patient has
tient. Address concerns about pain removed all external metallic objects
related to the procedure. Explain to (jewelry, dentures, etc.) prior to the
the patient that some pain may be procedure.
experienced during the test, or there ➤ Have emergency equipment readily
may be moments of discomfort. available.
is performed in a special depart- ➤ If the patient has a history of severe
ment, usually in a radiology or vascu- allergic reactions to any substance or
lar suite, by a health care practitioner drug, administer ordered prophylac-
and support staff, and takes approxi- tic steroids or antihistamines before
mately 30 to 60 minutes. the procedure. Use nonionic contrast
and after the procedure. ➤ Record baseline vital signs and
➤ Explain that an intravenous (IV) line may vary from facility to facility.
IV fluids, contrast medium, dye, or ➤ Instruct the patient to cooperate fully
sedatives. Usually normal saline is and to follow directions.
infused. ➤ Observe standard precautions, and
➤ Instruct the patient to fast for 4 follow the general guidelines in
hours, refrain from smoking for 4 to Appendix A.
6 hours, and withhold medications ➤ Establish IV fluid line for the injection
for 24 hours before the test. Instruct of emergency drugs and of sedatives.
the patient to avoid taking anticoagu- ➤ Place electrocardiographic (ECG)
lant medication or to reduce dosage electrodes on the patient for car-
as ordered prior to the procedure. diac monitoring. Establish baseline
➤ Instruct the patient to wear walking rhythm; determine if the patient has
ventricular arrhythmias. Monitor the ➤ Observe the needle/catheter inser-

patient’s blood pressure throughout tion site for bleeding, inflammation,
the procedure by using an automated or hematoma formation.
blood pressure machine. ➤ Instruct the patient to drink in-
➤ Assist the patient onto the treadmill creased amounts of fluids for 24 to
or bicycle ergometer and ask the 48 hours to eliminate the radionu-
patient to exercise to a calculated clide from the body, unless con-
80% to 85% of the maximum heart traindicated. Educate the patient that
rate, as determined by the protocol radionuclide is eliminated from the
selected. body within 6 to 24 hours.
➤ Wear gloves during the radionuclide ➤ Instruct the patient to flush the toilet
injection and while handling the pa- immediately after each voiding fol-
tient’s urine. lowing the procedure, and to wash
➤ Thallium-201 is injected 60 to 90 sec- hands meticulously with soap and
onds before exercise is terminated, water after each voiding for 24 hours
and imaging is done immediately in after the procedure.
the supine position and repeated in 4 ➤ Instruct all caregivers to wear gloves
hours. when discarding urine for 24 hours
➤ Patients who cannot exercise are after the procedure. Wash gloved
given dipyridamole 4 minutes before hands with soap and water before
thallium-201 is injected. removing gloves. Then wash hands
➤ Inform the patient that movement
during the resting procedure affects ➤ If a woman who is breast-feeding
the results and makes interpretation must have a nuclear scan, she
difficult. should not breast-feed the infant
until the radionuclide has been elimi-
➤ The results are recorded on film or in nated. This could take as long as 3
a computerized system for recall and days. She should be instructed to
postprocedure interpretation by the express the milk and discard it dur-
appropriate health care practitioner. ing the 3-day period to prevent ces-
Post-test:
➤ Instruct the patient to resume usual low-cholesterol, and low-sodium diet
diet, fluids, medications, or activity, should be consumed to reduce cur-
as directed by the health care practi- rent disease processes and/or de-
tioner. If the patient must return for crease risk of hypertension and
further thallium-201 imaging, advise coronary artery disease.
the patient to rest in the interim and ➤ No other radionuclide tests should
to restrict diet to liquids before redis- be scheduled for 24 to 48 hours after
tribution studies. this procedure.
➤ Monitor vital signs and ECG tracings ➤ A written report of the examina-
every 15 minutes for 60 minutes tion will be completed by a health
after the procedure. Compare with care practitioner specializing in this
baseline values. Protocols may vary branch of medicine. The report will
from facility to facility. be sent to the requesting health care
➤ Observe for delayed allergic reac- practitioner, who will discuss the
tions, such as rash, urticaria, tachy- results with the patient.
cardia, hyperpnea, hypertension, ➤ Recognize anxiety related to test re-
palpitations, nausea, or vomiting. sults, and be supportive of perceived
➤ Instruct the patient to immediately loss of independent function.
report symptoms such as fast heart Discuss the implications of abnormal
rate, difficulty breathing, skin rash, test results on the patient’s lifestyle.
itching or decreased urinary output. Provide teaching and information
Myoglobin 975

apy regimen. As appropriate, instruct ➤ Related diagnostic tests include com-
the patient in significant side effects puted tomography of the thorax,
and systemic reactions associated echocardiogram, electrocardiogra-
with the prescribed medication. phy, Holter monitoring, and magnetic
Encourage him or her to review cor- resonance imaging of the chest.
MYOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: MB.
Conventional & SI Units and isoenzymes, it does not indicate

5–70 g/dL the specific site involved. ■
INDICATIONS:
• Assist in predicting a flare-up of
polymyositis
DESCRIPTION & RATIONALE: Myo- • Estimate damage from skeletal muscle
globin is an oxygen-binding muscle injury or myocardial infarction
protein normally found in skeletal
and cardiac muscle. It is released into RESULT
the bloodstream after muscle damage
Increased in:
from ischemia, trauma, or inflamma-
tion. Although myoglobin testing is • Cardiac surgery
more sensitive than creatinine kinase • Cocaine use
• Exercise ceuticals. The requesting health care

• Malignant hyperthermia advised if the patient regularly uses
• Myocardial infarction can be taken into consideration
• Progressive muscular dystrophy when reviewing results.
• Renal failure patient. Inform the patient that spec-
• Rhabdomyolysis imen collection takes approximately
• Shock about pain related to the procedure.
• Thrombolytic therapy be some discomfort during the
venipuncture.
Decreased in: ➤ There are no food, fluid, or medica-
• Myasthenia gravis tion restrictions, unless by medical
direction.
• Presence of antibodies to myoglobin, as
seen in patients with polymyositis
Intratest:
• Rheumatoid arthritis ➤ If the patient has a history of severe
INTERFERING FACTORS: N/A ➤ Instruct the patient to cooperate fully
skeletal or myocardial muscle lection. Perform a venipuncture; col-
damage. lect the specimen in a 5-mL red- or
➤ Obtain a history of the patient’s com- tiger-top tube.
plaints, including a list of known al- ➤ Remove the needle, and apply a pres-
lergens (especially allergies or sure dressing over the puncture site.
sensitivities to latex), and inform the ➤ Promptly transport the specimen to
➤ Obtain a history of the patient’s car- ➤ The results are recorded manually
diovascular and musculoskeletal sys- or in a computerized system for re-
tem as well as results of previously call and postprocedure interpretation
performed laboratory tests, surgical by the appropriate health care practi-
procedures, and other diagnostic pro- tioner.
cedures. For related laboratory tests,
refer to the Cardiovascular and
Musculoskeletal System tables. Post-test:
➤ Obtain a list of medications the ➤ Observe venipuncture site for bleed-
Nerve Fiber Analysis 977
pressure bandage in place, or replace in therapy. Evaluate test results in

with a plastic bandage. relation to the patient’s symptoms
➤ A written report of the examination and other tests performed.
care practitioner, who will discuss Related laboratory tests:
the results with the patient. ➤ Related laboratory tests include
➤ Reinforce information given by the antiarrhythmic drugs, apolipoprotein
patient’s health care provider regard- A, apolipoprotein B, aspartate amino-
ing further testing, treatment, or re- transferase, atrial natriuretic peptide,
ferral to another health care provider. blood gases, B-type natriuretic pep-
Answer any questions or address tide, calcium (blood and ionized),
any concerns voiced by the patient cholesterol (total, HDL, and LDL),
or family. C-reactive protein, creatine kinase
and isoenzymes, glucose, glycated
➤ Depending on the results of this pro- hemoglobin, homocysteine, ketones,
cedure, additional testing may be lactate dehydrogenase and isoen-
performed to evaluate or monitor zymes, lipoprotein electrophoresis,
progression of the disease process magnesium, pericardial fluid, potas-
and determine the need for a change sium, triglycerides, and troponin.
NERVE FIBER ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: NFA.
CONTRAST: N/A.
DESCRIPTION & RATIONALE: There becomes larger. The thinning of the

are over 1 million ganglion nerve cells nerve fiber layer and the enlargement
in the retina of each eye. Each nerve of the nerve fiber cup are measure-
cell has a long fiber that travels through ments used to gauge the extent of dam-
the nerve fiber layer of the retina and age to the retina. Significant damage to
exits the eye through the optic nerve. the nerve fiber layer occurs before loss
The optic nerve is made up of all the of vision is noticed by the patient.
ganglion nerve fibers and connects the Damage can be caused by glaucoma or
eye to the brain for vision to occur. As by aging or occlusion of the vessels in
the ganglion cells die, the nerve fiber the retina. Ganglion cell loss due to
layer becomes thinner and an empty glaucoma begins in the periphery of
space in the optic nerve, called the cup, the retina, thereby first affecting
peripheral vision. This change in Nursing Implications and

vision can also be detected by visual Procedure ● ● ● ● ● ● ● ● ● ● ●
field testing. There are several different

techniques for measuring nerve fiber Pretest:
layer thickness. One of the most com- ➤ Inform the patient that the procedure
mon employs the use of a laser that measures the thickness of the retinal
emits polarizing light waves. The laser’s nerve fiber layer.
computer measures the change in ➤ Obtain a history of the patient’s
direction of alignment of the light complaints, including a list of known
allergens.
beam after it passes through the nerve
➤ Obtain a history of narrow-angle
fiber layer tissue. The amount of glaucoma. Obtain a history of known
change in polarization correlates to the or suspected visual impairment,
thickness of the retinal nerve fiber changes in visual acuity, and use of
layer. ■ glasses or contact lenses.
INDICATIONS: known or suspected vision loss,
• Assist in the diagnosis of eye diseases including type and cause; eye condi-
tions with treatment regimens; eye
• Determine retinal nerve fiber layer surgery; and other tests and proce-
thickness dures to assess and diagnose visual
deficit. For related diagnostic tests,
• Monitor the effects of various therapies refer to the table of tests associated
or the progression of conditions result- with the Ocular System.
ing in loss of vision ➤ Obtain a history of results of previ-
RESULT surgical procedures, and other diag-
nostic procedures.
Normal Findings:
• Normal nerve fiber layer thickness patient is taking, including herbs,
Abnormal Findings: ceuticals. The requesting health care
• Glaucoma or suspicion of glaucoma practitioner should be advised if the
• Ocular hypertension so that their effects can be taken
CRITICAL VALUES: N/A results.
INTERFERING FACTORS: tact lenses or glasses, as appropri-
the importance of keeping the eyes
open for the test.
• Inability of the patient to fixate on ➤ Review the procedure with the
focal point patient. Explain that the patient will
• Corneal disorder that prevents proper be requested to fixate the eyes dur-
alignment of the retinal nerve fibers ing the procedure. Address concerns
• Dense cataract that prevents visualiza- Explain to the patient that no pain will
tion of a clear nerve fiber image be experienced during the test, but
• Inability of the patient to cooperate or fort. Explain to the patient that some
remain still during the test because of discomfort may be experienced after
age, significant pain, or mental status the test when the numbness wears
Nerve Fiber Analysis 979
off from anesthetic drops admin- the appropriate health care practi-
stered prior to the test. Inform the tioner.
patient that a technician, optometrist,
or physician performs the test, and Post-test:
that to evaluate both eyes, the test
can take 10 to 15 minutes. ➤ A written report of the examina-
➤ There are no food, fluid, or medica- care practitioner specializing in this
tion restrictions, unless by medical branch of medicine. The report will
direction. be sent to the requesting health care
Intratest: results with the patient.
➤ Instruct the patient to cooperate ➤ Recognize anxiety related to test
fully and to follow directions. Ask the results, and be supportive of impaired
patient to remain still during the activity related to vision loss or per-
procedure because movement pro- ceived loss of driving privileges.
duces unreliable results. Discuss the implications of abnormal
➤ Seat the patient comfortably. Ins- test results on the patient’s lifestyle.
truct the patient to look straight Provide teaching and information
ahead, keeping the eyes open and regarding the clinical implications of
unblinking. the test results, as appropriate.
➤ Instill topical anesthetic in each eye, ➤ Reinforce information given by the
as ordered, and allow time for it to patient’s health care provider regard-
work. Topical anesthetic drops are ing further testing, treatment, or re-
placed in the eye with the patient ferral to another health care provider.
looking up and the solution directed Instruct the patient in the use of any
at the six o’clock position of the ordered medications, usually eye-
sclera (white of the eye) near the lim- drops. Explain the importance of
bus (grey, semitransparent area of adhering to the therapy regimen,
the eyeball where the cornea and especially since glaucoma does not
sclera meet). The dropper bottle present symptoms. Instruct the
should not touch the eyelashes. patient in both the ocular side effects
➤ The equipment used to perform the with the prescribed medication. En-
test determines whether dilation of courage him or her to review corre-
the pupils is required (OCT) or sponding literature provided by a
avoided (GDX). pharmacist. Answer any questions or
➤ Request that the patient look straight address any concerns voiced by the
ahead at a fixation light with the chin patient or family.
in the chin rest and forehead against ➤ Depending on the results of this pro-
the support bar. The patient should cedure, additional testing may be
be reminded not to move the eyes or performed to evaluate or monitor
blink the eyelids as the measure- progression of the disease process
ment is taken. The person perform- and determine the need for a change
ing the test can store baseline data in therapy. Evaluate test results in
or retrieve previous images from the relation to the patient’s symptoms
equipment. The equipment can cre- and other tests performed.
ate the mean image from current
and previous data, and its computer
can make a comparison against pre- Related diagnostic tests:
vious images. ➤ Related diagnostic tests include
➤ The results are recorded manually or fundus photography, gonioscopy,
in a computerized system for recall pachymetry, slit-lamp biomicroscopy,
and postprocedure interpretation by and visual field testing.
OSMOLALITY, BLOOD AND URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Osmo.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube; urine (5 mL)
from an unpreserved random specimen collected in a clean plastic collection
container.
REFERENCE VALUE: (Method: Freezing point depression)
SI Units
Serum 275–295 mOsm/kg 275–295 mmol/kg
Urine
Newborn 75–300 mOsm/kg 75–300 mmol/kg
Children 250–900 mOsm/kg 250–900 mmol/kg
and adults
DESCRIPTION & RATIONALE: Osmo- cles that contribute to osmolality are

lality refers to the number of particles sodium, chloride, bicarbonate, urea,
in solution; it is independent of parti- and glucose. Some of these substances
cle size, shape, and charge. Measure- are used in the following calculated
ment of osmotic concentration in estimate:
serum provides clinically useful infor-
Serum osmolality {[2 (Na)]
mation about water and dissolved-
[glucose/18] [BUN/2.8]}
particle transport across fluid com-
partment membranes. Osmolality is Measured osmolality is higher than
used to assist in the diagnosis of meta- the estimated value. The osmolal gap
bolic, renal, and endocrine disorders. is the difference between the meas-
The simultaneous determination of ured and calculated values and is
serum and urine osmolality provides normally 5 to 10 mOsm/kg. If the
the opportunity to compare values difference is greater than 15 mOsm/
between the two fluids. A normal kg, consider ethylene glycol, iso-
urine-to-serum ratio is approximately propanol, methanol, or ethanol toxic-
0.2 to 4.7 for random samples and ity. These substances behave like
greater than 3.0 for first-morning antifreeze, lowering the freezing point
samples (dehydration normally occurs in the blood, and provide mislead-
overnight). The major dissolved parti- ingly high results. ■
Osmolality, Blood and Urine 981
INDICATIONS • Urine:
Diabetes insipidus
Serum:
Hypernatremia
• Assist in the evaluation of antidiuretic
Hypokalemia
hormone (ADH) function
Primary polydipsia
• Assist in rapid screening for toxic sub-
stances, such as ethylene glycol, etha- CRITICAL VALUES: Serum:
nol, isopropanol, and methanol Less than 265 mOsm/kg
• Evaluate electrolyte and acid-base bal- Greater than 320 mOsm/kg
ance Note and immediately report to the
• Evaluate state of hydration increased or decreased values and related
Urine: symptoms.
• Evaluate concentrating ability of the Serious clinical conditions may be
kidneys associated with elevated or decreased
serum osmolality. The following condi-
• Evaluate diabetes insipidus tions are associated with elevated serum
• Evaluate neonatal patients with protein osmolality:
or glucose in the urine Respiratory arrest: 360 mOsm/kg
Stupor of hyperglycemia:
• Perform workup for renal disease 385 mOsm/kg
RESULT Grand mal seizures: 420 mOsm/kg
Death: greater than 420 mOsm/kg
Increased in: Symptoms of critically high levels
• Serum: include poor skin turgor, listlessness,
Azotemia acidosis (decreased pH), shock, seizures,
Dehydration coma, and cardiopulmonary arrest. Inter-
vention may include close monitoring
Diabetes insipidus
of electrolytes, administering intra-
Diabetic ketoacidosis venous fluids with the appropriate com-
Hypercalcemia position to shift water either into or
Hypernatremia out of the intravascular space as needed,
• Urine: monitoring cardiac signs, continuing
neurologic checks, and taking seizure pre-
Amyloidosis cautions.
Azotemia
Congestive heart failure INTERFERING FACTORS:
Dehydration • Drugs that may increase serum osmo-
Hyponatremia lality include citrates (as an anticoagu-
Syndrome of inappropriate lant), corticosteroids, ethylene glycol,
antidiuretic hormone production glycerin, inulin, ioxithalamic acid,
(SIADH) mannitol, and methoxyflurane.
Decreased in: • Drugs that may decrease serum
• Serum: osmolality include bendroflumethi-
azide, carbamazepine, chlorpromazine,
Adrenocorticoid insufficiency
chlorthalidone, cyclophosphamide,
Hyponatremia cyclothiazide, hydrochlorothiazide, lor-
SIADH cainide, methyclothiazide, and polythi-
Water intoxication azide.
• Drugs that may increase urine comfort during the venipuncture;

osmolality include anesthetic agents, there will be no discomfort during
chlorpropamide, cyclophosphamide, urine collection.
furosemide, mannitol, metolazone, ➤ Sensitivity to social and cultural
octreotide, phloridzin, and vincristine. issues, as well as concern for mod-
• Drugs that may decrease urine osmolal- chological support before, during,
ity include captopril, demeclocycline, and after the procedure.
glyburide, lithium, methoxyflurane, ➤ There are no food, fluid, or medica-
octreotide, tolazamide, and verapamil. tion restrictions, unless by medical
direction.

Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Direct the patient to breathe nor-
Pretest: movement during the venipuncture.
used to evaluate electrolyte and follow the general guidelines in
water balance. Appendix A. Positively identify the
➤ Obtain a history of the patient’s com- tubes or collection containers with
plaints, including a list of known the corresponding patient demo-
allergens (especially allergies or sen- graphics, date, and time of collection.
appropriate health care practitioner Blood:
accordingly.
➤ Obtain a history of the patient’s allergic reaction to latex, care should
endocrine and genitourinary sys- be taken to avoid the use of equip-
tems, as well as results of previously ment containing latex.
procedures, and other diagnostic ➤ Perform a venipuncture; collect the
procedures. For related laboratory specimen in a 5-mL red- or tiger-top
tests, refer to the Endocrine and tube.
Genitourinary System tables. ➤ Remove the needle, and apply a pres-
➤ Obtain a list of the medications the sure dressing over the puncture site.
Urine:
ceuticals. The requesting health care ➤ Provide a nonmetallic urinal, bedpan,
practitioner and laboratory should be or toilet-mounted collection device.
advised if the patient regularly uses ➤ Either a random specimen or a timed
these products so that their effects collection may be requested. For
can be taken into consideration timed specimens, a 12- or 24-hour
when reviewing results. time frame for urine collection may
➤ Review the procedure with the be ordered. Inform the patient that all
patient. Inform the patient that blood urine must be saved during that 12 or
specimen collection takes approxi- 24-hour period. Instruct the patient
mately 5 to 10 minutes; random not to void directly into the laboratory
urine collection takes approximately collection container. Instruct the
5 minutes and depends on the coop- patient to avoid defecating in the col-
eration of the patient. Urine speci- lection device and to keep toilet tis-
men collection may also be timed. sue out of the collection device to
Address concerns about pain related prevent contamination of the speci-
to the procedure. Explain to the men. Place a sign in the bathroom to
patient that there may be some dis- remind the patient to save all urine.
Osmolality, Blood and Urine 983
➤ Instruct the patient to void all urine patient for signs and symptoms
into the collection device and then to of fluid-volume excess related to ex-
pour the urine into the laboratory col- cess electrolyte intake, fluid-volume
lection container. Alternatively, the deficit related to active loss, or risk of
specimen can be left in the collection injury related to an alteration in body
device for a health care staff mem- chemistry. (For electrolyte-specific
ber to add to the laboratory collec- dietary references, see monographs
tion container. titled “Chloride,” “Potassium,” and
“Sodium.”)
➤ Increased osmolality may be associ-
➤ Instruct the male patient to (1) thor- ated with dehydration. Evaluate the
oughly wash his hands, (2) cleanse patient for signs and symptoms of
the meatus, (3) void a small amount dehydration. Dehydration is a signifi-
into the toilet, and (4) void directly cant and common finding in geriatric
into the specimen container. and other patients in whom renal
➤ Instruct the female patient to (1) function has deteriorated.
thoroughly wash her hands; (2) ➤ A written report of the examination
cleanse the labia from front to back; will be sent to the requesting health
(3) while keeping the labia separated, care practitioner, who will discuss
void a small amount into the toilet; the results with the patient.
and (4) without interrupting the urine ➤ Recognize anxiety related to test
stream, void directly into the speci- results. Discuss the implications of
men container. abnormal test results on the pa-
tient’s lifestyle. Provide teaching and
Indwelling catheter: information regarding the clinical
➤ Put on gloves. Empty drainage tube implications of the test results, as
of urine. It may be necessary to appropriate. Educate the patient
clamp off the catheter for 15 to 30 regarding access to counseling serv-
minutes before specimen collection. ices. Provide contact information, if
Cleanse specimen port with antisep- desired, for the National Kidney
tic swab, and then aspirate 5 mL of Foundation (http://www.kidney.org).
urine with a 21- to 25-gauge needle ➤ Reinforce information given by the
and syringe. Transfer urine to a ster- patient’s health care provider regard-
ile container. ing further testing, treatment, or re-
Blood or urine: Answer any questions or address
➤ Promptly transport the specimen to any concerns voiced by the patient
the laboratory for processing and or family.
analysis. ➤ Depending on the results of this pro-
➤ The results are recorded manually cedure, additional testing may be
or in a computerized system for performed to evaluate or monitor
recall and postprocedure interpreta- progression of the disease process
tion by the appropriate health care and determine the need for a change
practitioner. in therapy. Evaluate test results in
paper tape or other adhesive to hold ➤ Related laboratory tests include
pressure bandage in place, or replace antidiuretic hormone, ammonia,
with a plastic bandage. blood and urine urea nitrogen, blood
➤ Nutritional considerations: De- and urine creatinine, blood and urine
creased osmolality may be associ- electrolytes, ethanol, glucose, and
ated with overhydration. Observe the blood and urine ketones.
OSMOTIC FRAGILITY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Red blood cell osmotic fragility, OF.

SPECIMEN: Whole blood (1 mL) collected in a green-top (heparin) tube and
two peripheral blood smears.
REFERENCE VALUE: (Method: Spectrophotometry) Hemolysis begins at 0.5

w/v sodium chloride (NaCl) solution and is complete at 0.3 w/v NaCl solu-
tion. Results are compared to a normal curve.
• Iron-deficiency anemia
DESCRIPTION & RATIONALE: Osmo-
tic fragility (OF) is an indication of the • Liver disease
ability of red blood cells (RBCs) to • Reticulocytosis
take on water without lysing. In this
• Thalassemias
test, RBCs are placed in graded dilu-
tions of sodium chloride. Swelling of CRITICAL VALUES: N/A
the cells occurs at lower concentrations
of NaCl as they take on water in the INTERFERING FACTORS:
hypotonic solution. Thicker cells, such • Drugs that may increase osmotic
as spherocytes, have an increased OF; fragility include dapsone.
thinner cells have a decreased OF. ■
• Parasitic infestations, such as malaria,
may independently cause cell hemo-
INDICATIONS: Evaluate hemolytic ane- lysis.
mia
• Specimens should be submitted for
RESULT analysis immediately after collection.
Increased in:
• Acquired immune hemolytic anemias Nursing Implications and
• Hemolytic disease of the newborn Procedure ● ● ● ● ● ● ● ● ● ● ●
• Hereditary spherocytosis Pretest:

• Malaria ➤ Inform the patient that the test is pri-
• Pyruvate kinase deficiency marily used to assist in the diagnosis
of hereditary spherocytosis.
Decreased in: ➤ Obtain a history of the patient’s
• Asplenia complaints, including a list of known
• Hemoglobinopathies sitivities to latex), and inform the
Osmotic Fragility 985
appropriate health care practitioner collect the specimen in a 5-mL green-

accordingly. top tube.
➤ Obtain a history of the patient’s ➤ Remove the needle, and apply a pres-
hematopoietic system and results of sure dressing over the puncture site.
previously performed laboratory ➤ Promptly transport the specimen to
tests, surgical procedures, and other the laboratory for processing and
diagnostic procedures. For related analysis.
Hematopoietic System table. ➤ The results are recorded manually
these products so that their effects ➤ Observe venipuncture site for bleed-
can be taken into consideration ing or hematoma formation. Apply
when reviewing results. paper tape or other adhesive to hold
➤ Review the procedure with the pressure bandage in place, or replace
patient. Inform the patient that spec- with a plastic bandage.
imen collection takes approximately ➤ A written report of the examination
5 to 10 minutes. Address concerns will be sent to the requesting health
about pain related to the procedure. care practitioner, who will discuss
Explain to the patient that there may the results with the patient.
be some discomfort during the ➤ Reinforce information given by the
venipuncture. patient’s health care provider regard-
➤ There are no food, fluid, or medica- ing further testing, treatment, or re-
tion restrictions, unless by medical ferral to another health care provider.
direction. Answer any questions or address
or family.
Intratest:
➤ If the patient has a history of severe cedure, additional testing may be
allergic reaction to latex, care should performed to evaluate or monitor
be taken to avoid the use of equip- progression of the disease process
ment containing latex. and determine the need for a change
➤ Instruct the patient to cooperate fully in therapy. Evaluate test results in
and to follow directions. Direct the relation to the patient’s symptoms
patient to breathe normally and to and other tests performed.
follow the general guidelines in Ap- ➤ Related laboratory tests include
pendix A. Positively identify the complete blood count, glucose-6-
patient, and label the appropriate phosphate dehydrogenase, Ham’s
tubes with the corresponding patient test, hemoglobin electrophoresis,
demographics, date, and time of total iron, pyruvate kinase, and red
collection. Perform a venipuncture; blood cell morphology and inclusions.
OSTEOCALCIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Bone GLA protein, BGP.

SI Units
Age and Sex Conventional Units (Conventional Units 1)
Newborn 20–40 ng/mL 20–40 g/L
1–17 y 2.8–41 ng/mL 2.8–41 g/L
Adult
Male 3–13 ng/mL 3–13 g/L
Female
Premenopausal 0.4–8.2 ng/mL 0.4–8.2 g/L
Postmenopausal 1.5–11 ng/mL 1.5–11 g/L
DESCRIPTION & RATIONALE: Osteo- marker for bone matrix degradation

calcin is an important bone cell matrix and turnover. ■
protein and a sensitive marker in
bone metabolism. It is produced by INDICATIONS:
osteoblasts during the matrix mineral- • Assist in the diagnosis of bone cancer
ization phase of bone formation and is • Evaluate bone disease
the most abundant noncollagenous
bone cell protein. Synthesis of osteo- • Evaluate bone metabolism
calcin is dependent on vitamin K. • Monitor effectiveness of estrogen
Osteocalcin levels parallel alkaline replacement therapy
phosphatase levels. Osteocalcin levels
are affected by a number of factors, RESULT
including the hormone estrogen.
Assessment of osteocalcin levels per- Increased in:
mits indirect measurement of osteo- • Adolescents undergoing a growth spurt
blast activity and bone formation. • Chronic renal failure
Because it is released into the blood-
stream during bone resorption, there • Hyperthyroidism (primary and second-
is some question as to whether osteo- ary)
calcin might also be considered a • Metastatic skeletal disease
Osteocalcin 987
• Paget’s disease ceuticals. The requesting health care

• Renal osteodystrophy advised if the patient regularly uses
• Some patients with osteoporosis these products so that their effects
Decreased in:
• Growth hormone deficiency patient. Inform the patient that spec-
• Pregnancy imen collection takes approximately
• Primary biliary cirrhosis about pain related to the procedure.
venipuncture.
• Drugs that may increase calcitonin lev- tion restrictions, unless by medical
els include anticonvulsants, calcitriol, direction.
and estrogens.
Intratest:
• Drugs that may decrease calcitonin lev-
els include glucocorticoids. ➤ If the patient has a history of severe
• Recent radioactive scans or radiation be taken to avoid the use of equip-
within 1 week before the serum osteo- ment containing latex.
calcin test can interfere with test results ➤ Instruct the patient to cooperate fully
when radioimmunoassay is the test and to follow directions. Direct the
method. patient to breathe normally and to
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: demographics, date, and time of col-
used to evaluate bone disease. lect the specimen in a 5-mL red-top
tube.
plaints, including a list of known ➤ Remove the needle, and apply a pres-
allergens (especially allergies or sen- sure dressing over the puncture site.
sitivities to latex), and inform the ➤ Promptly transport the specimen to
musculoskeletal system and results or in a computerized system for recall
of previously performed laboratory and postprocedure interpretation by
tests, surgical procedures, and other the appropriate health care practi-
diagnostic procedures. For related tioner.
laboratory tests, refer to the Muscu-
loskeletal System table. Post-test:
➤ Note any recent procedures that can ➤ Observe venipuncture site for bleed-
➤ Obtain a list of the medications the paper tape or other adhesive to hold
patient is taking, including herbs, pressure bandage in place, or replace
nutritional supplements, and nutra- with a plastic bandage.
➤ Nutritional considerations: Increased intake can also negatively affect

osteocalcin levels may be associated calcium absorption, especially if it
with skeletal disease. Nutritional is combined with foods high in
therapy is indicated for individuals phosphorus. Vitamin D is synthe-
identified as being at high risk for sized by the skin and is also avail-
developing osteoporosis. Educate able in fortified dairy foods and cod
the patient regarding the National liver oil.
Osteoporosis Foundation’s guide- ➤ A written report of the examination
lines, which include a regular regi- will be sent to the requesting health
men of weight-bearing exercises, care practitioner, who will discuss
limited alcohol intake, avoidance the results with the patient.
of tobacco products, and adequate
dietary intake of vitamin D (400 ➤ Reinforce information given by the
to 800 IU/day) and calcium (120 patient’s health care provider regard-
mg/day). Dietary calcium can be ing further testing, treatment, or re-
obtained from animal or plant ferral to another health care provider.
sources. Milk and milk products, Answer any questions or address
sardines, clams, oysters, salmon, any concerns voiced by the patient
rhubarb, spinach, beet greens, broc- or family.
coli, kale, tofu, legumes, and fortified ➤ Depending on the results of this pro-
orange juice are high in calcium. Milk cedure, additional testing may be
and milk products also contain vita- performed to evaluate or monitor
min D and lactose, which assist cal- progression of the disease process
cium absorption. Cooked vegetables and determine the need for a change
yield more absorbable calcium than in therapy. Evaluate test results in
raw vegetables. Patients should be relation to the patient’s symptoms
informed of the substances that can and other tests performed.
inhibit calcium absorption by irre-
versibly binding to some of the cal- Related laboratory tests:
cium, making it unavailable for
absorption, such as oxalates, which ➤ Related laboratory tests include alka-
naturally occur in some vegetables; line phosphatase, calcium (blood
phytic acid, found in some cereals; and urine), collagen cross-linked N-
and insoluble dietary fiber (in exces- telopeptide, parathyroid hormone,
sive amounts). Excessive protein phosphorus, and vitamin D.
OTOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
AREA OF APPLICATION: Ears.
CONTRAST: N/A.
Otoscopy 989
crossing from front to back

DESCRIPTION & RATIONALE: This just under the upper edge,
noninvasive procedure is used to cone of light on the right side
inspect the external ear, auditory canal, at the 4 o’clock position; no
evidence of bulging, retraction,
and tympanic membrane. Otoscopy is
lusterless membrane, or obli-
an essential part of any general physical teration of the cone of light
examination, but is also done before
any other audiologic studies when Abnormal Findings:
symptoms of ear pain or hearing loss • Cerumen accumulation
are present. ■
• Ear trauma
INDICATIONS: • Foreign bodies
• Detect causes of deafness, obstruc-
tion, stenosis, or swelling of the pinna • Otitis externa
or canal causing a narrowing or closure • Otitis media
that prevents sound from entering
• Tympanic membrane perforation or
• Detect ear abnormalities during rou- rupture
tine physical examination
• Diagnose cause of ear pain CRITICAL VALUES: N/A
• Remove impacted cerumen (with a dull INTERFERING FACTORS:
ring curette) or foreign bodies (with a
forceps) that are obstructing the Factors that may impair the
entrance of sound waves into the ear results of the examination:
• Evaluate acute or chronic otitis media • Obstruction of the auditory canal with
and effectiveness of therapy in control- cerumen, dried drainage, or foreign
ling infections bodies that prevent introduction of the
otoscope
RESULT
Normal Findings:
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Normal structure and appearance of

the external ear, auditory canal, and Pretest:
tympanic membrane.
Pinna: funnel-shaped cartilagi-
is performed to investigate sus-
nous structure; no evidence of
pected ear disorders.
infection, pain, dermatitis with
swelling, redness, or itching ➤ Obtain a history of the patient’s
External auditory canal: S-shaped allergens.
canal lined with fine hairs, seb-
aceous and ceruminous glands; ➤ Obtain a history of the patient’s
no evidence of redness, lesions, known or suspected hearing loss,
edema, scaliness, pain, accumul- including type and cause; ear condi-
tions with treatment regimens; ear
ation of cerumen, drainage, or
surgery; and other tests and proce-
presence of foreign bodies dures to assess and diagnose audi-
Tympanic membrane: shallow, tory deficit. Obtain a history of the
circular cone that is shiny patient’s complaints of pain, itching,
and pearl gray in color, semi- drainage, deafness, or presence of
transparent whitish cord tympanotomy tube.
➤ Obtain a history of results of previ- age, and pull the pinna downward.
ously performed laboratory tests, Gently and slowly insert the specu-
surgical procedures, and other diag- lum into the ear canal downward and
nostic procedures. forward with the handle of the oto-
➤ Obtain a list of the medications the scope held downward. For the child,
patient is taking, especially antibiotic hold the handle upward while placing
regimen, as well as herbs, nutritional the edge of the hand holding the oto-
supplements, and nutraceuticals. The scope on the head to steady it during
requesting health care practitioner insertion. If the speculum resists
should be advised if the patient regu- insertion, withdraw and attach a
larly uses these products so that their smaller one.
effects can be taken into considera- ➤ Place an eye to the lens of the oto-
tion when reviewing results. scope, turn on the light source, and
➤ Review the procedure with the advance the speculum into the ear
patient. Inform the caregiver that he canal until the tympanic membrane
or she may need to restrain a child in is visible. Examine the posterior and
order to prevent damage to the ear if anterior membrane, cone of light,
the child cannot remain still. Address outer rim (annulus), umbo, handle of
concerns about pain related to the the malleus, folds, and pars tensa.
procedure. Explain to the patient that ➤ Culture any effusion with a sterile
no discomfort will be experienced swab and culture tube (see “Culture,
during the test. Inform the patient Bacterial, Ear,” monograph); or a
that a physician, nurse or health care health care practitioner will perform
practitioner specializing in this field needle aspiration from the middle
performs the test, and that to evalu- ear through the tympanic membrane
ate both ears, the test can take 5 to during the examination. Other proce-
10 minutes. dures such as cerumen and foreign
➤ Ensure that the external auditory body removal can also be performed.
canal is clear of impacted cerumen. ➤ Pneumatic otoscopy can be done to
determine tympanic membrane
Intratest: flexibility. This test permits the intro-
duction of air into the canal that
➤ Instruct the patient to cooperate fully reveals a reduction in movement of
and to follow directions. Ask the the membrane in otitis media and
patient to remain still during the pro- absence of movement in chronic oti-
cedure because movement pro- tis media.
➤ Administer ear drops or irrigation to for recall and postprocedure interpre-
prepare for cerumen removal, if tation by a health care professional
ordered. specializing in this field.
➤ Place adult patient in a sitting posi-
tion; place a child in a supine position Post-test:
on the caregiver’s lap. Request that
the patient remain very still during the ➤ Administer ear drops of a soothing
examination; a child can be restrained oil, and as ordered, if the canal is irri-
by the caregiver if needed. tated by removal of cerumen or for-
eign bodies.
➤ Assemble the otoscope with the
correct-size speculum to fit the size ➤ A written report of the examina-
of the patient’s ear and check the light tion will be completed by a health
source. For the adult, tilt the head care practitioner specializing in this
slightly away and, with the nondomi- branch of medicine. The report will
nant hand, pull the pinna upward and be sent to the requesting health care
backward. For a child, hold the head practitioner, who will discuss the
steady or have the caregiver hold the results with the patient.
child’s head steady, depending on the ➤ Recognize anxiety related to test
Ova and Parasites, Stool 991
results, and be supportive of impaired ➤ Depending on the results of this pro-

activity related to hearing loss. Dis- cedure, additional testing may be
cuss the implications of abnormal performed to evaluate or monitor
test results on the patient’s lifestyle. progression of the disease process
Provide teaching and information and determine the need for a change
regarding the clinical implications of in therapy. Evaluate test results in
the test results, as appropriate. relation to the patient’s symptoms
ing further testing, treatment, or re- Related diagnostic tests:
Answer any questions or address ➤ Related diagnostic tests include
any concerns voiced by the patient audiometry and bacterial culture of
or family. the ear.
OVA AND PARASITES, STOOL

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: O & P.
SPECIMEN: Stool collected in a clean plastic, tightly capped container.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination)
No presence of parasites, ova, or larvae.
• Blastocystis—Blastocystis hominis in-

DESCRIPTION & RATIONALE: This fection
test evaluates stool for the presence of
• Cryptosporidiosis—Cryptosporidium
intestinal parasites and their eggs. parvum infection
Some parasites are nonpathogenic;
others, such as protozoa and worms, • Enterobiasis—Enterobius vermicularis
can cause serious illness. ■ (pinworm) infection
• Giardiasis—Giardia lamblia infection
INDICATIONS: Assist in the diagnosis of
parasitic infestation • Hookworm disease—Ancylostoma duo-
denale, Necator americanus infection
RESULT • Isospora—Isospora belli infection
Positive findings in: • Schistosomiasis—Schistosoma haemato-
• Amebiasis—Entamoeba histolytica in- bium, Schistosoma japonicum, Schis-
fection tosoma mansoni infection
• Ascariasis—Ascaris lumbricoides in- • Strongyloidiasis—Strongyloides sterco-
fection ralis infection
• Tapeworm disease—Diphyllobothrium, ➤ Obtain a list of the medications the

Hymenolepiasis, Taenia saginata, Taenia patient is taking, including herbs,
solium infection nutritional supplements, and nutra-
• Trematode disease—Clonorchis sinensis, practitioner and laboratory should be
Fasciola hepatica, Fasciolopsis buski advised if the patient regularly uses
infection these products so their effects can
• Trichuriasis—Trichuris trichiura infec- reviewing results.
tion ➤ Review the procedure with the
patient. Instruct the patient on hand-
CRITICAL VALUES: N/A washing procedures, and inform the
patient that the infection may be
INTERFERING FACTORS: contagious. Warn the patient not to
• Failure to test a fresh specimen may contaminate the specimen with
yield a false-negative result. urine, toilet paper, or toilet water.
• Antimicrobial or antiamebic therapy to the procedure. Explain to the
within 10 days of test may yield a false- patient that there should be no dis-
negative result. comfort during the procedure.
• Failure to wait 1 week after a gastroin- ➤ Sensitivity to social and cultural
testinal study using barium or after lax- issues, as well as concern for mod-
ative use can affect test results. chological support before, during,
• Medications such as antacids, antibi- and after the procedure.
otics, antidiarrheal compounds, bis- ➤ Instruct the patient to avoid medica-
muth, castor oil, iron, magnesia, or tions that interfere with test results.
psyllium fiber (Metamucil) may inter- ➤ There are no food or fluid restric-
fere with analysis. tions, unless by medical direction.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Instruct the patient to cooperate fully
➤ Inform the patient that the test is pendix A. Positively identify the
used to assist in the diagnosis of par- patient, and label the appropriate col-
asitic infection. lection container with the correspon-
➤ Obtain a history of the patient’s com- ding patient demographics, date, and
plaints, including a list of known time of collection.
allergens, and inform the appropriate ➤ Collect a stool specimen directly into
health care practitioner accord- the container. If the patient is bedrid-
ingly. Document any travel to foreign den, use a clean bedpan and transfer
countries. the specimen into the container
➤ Obtain a history of the patient’s using a tongue depressor.
gastrointestinal and immune sys- ➤ Specimens to be examined for the
tems, and results of previously presence of pinworms are collected
performed laboratory tests, surgi- by the “Scotch tape” method in the
cal procedures, and other diagnostic morning before bathing or defeca-
procedures. For related laboratory tion. A small paddle with a piece of
tests, refer to the Gastrointestinal cellophane tape (sticky side facing
and Immune System tables. out) is pressed against the perianal
➤ Note any recent therapies that can area. The tape is placed in a collec-
interfere with test results. tion container and submitted to
Oxalate, Urine 993
determine if ova are present. Some- patient’s health care provider regard-
times adult worms are observed pro- ing further testing, treatment, or re-
truding from the rectum. ferral to another health care provider.
➤ Promptly transport the specimen to Educate the patient with positive
the laboratory for processing and findings on the transmission of the
analysis. parasite, as indicated. Warn the
patient that one negative result does
not rule out parasitic infestation and
that additional specimens may be
required. Answer any questions or
tioner.
patient or family.
results. Discuss the implications of and other tests performed.
abnormal test results on the pa-
tient’s lifestyle. Provide teaching and
information regarding the clinical Related laboratory tests:
implications of the test results, as ➤ Related laboratory tests include fecal
appropriate. analysis, immunoglobulin E, and
➤ Reinforce information given by the stool culture.
OXALATE, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

plastic collection container with hydrogen chloride (HCl) as a preservative.

0–40 mg/24 h 0–456 mol/24 h
• Primary hereditary hyperoxaluria (rare)

DESCRIPTION & RATIONALE: Oxalate
is derived from the metabolism of • Pyridoxine (vitamin B6) deficiency
oxalic acid, glycine, and ascorbic acid. • Sarcoidosis
Some individuals with malabsorption
disorders absorb and excrete abnor- Decreased in:
mally high amounts of oxalate, result- • Hypercalciuria
ing in hyperoxaluria. Hyperoxaluria • Renal failure
may be seen in patients who consume
large amounts of animal protein, cer- CRITICAL VALUES: N/A
tain fruits and vegetables, or mega-
doses of vitamin C (ascorbic acid). INTERFERING FACTORS:
Hyperoxaluria is also associated with • Drugs and vitamins that may increase
ethylene glycol poisoning (oxalic acid oxalate levels include methoxyflurane,
is used in cleaning and bleaching ascorbic acid, and calcium.
agents). Patients who absorb and • Drugs that may decrease oxalate levels
excrete large amounts of oxalate may include nifedipine and pyridoxine.
form calcium oxalate kidney stones. • Failure to follow dietary restrictions be-
Simultaneous measurement of serum fore the procedure may cause the pro-
and urine calcium is often requested. ■ cedure to be canceled or repeated.
INDICATIONS:
• Assist in the evaluation of patients with Nursing Implications and
ethylene glycol poisoning Procedure ● ● ● ● ● ● ● ● ● ● ●
• Assist in the evaluation of patients with

a history of kidney stones Pretest:
• Assist in the evaluation of patients with ➤ Inform the patient that the test is
used to identify patients at risk for
malabsorption syndromes or patients renal calculus formation, specifically
who have had jejunoileal bypass sur- calcium oxalate calculi. Hyperox-
gery aluria is also commonly observed in
patients with malabsorption condi-
RESULT tions.
Increased in: complaints, including a list of known
• Bacterial overgrowth allergens (especially allergies or sen-
• Biliary tract disease appropriate health care practitioner
• Bowel disease accordingly.
• Celiac disease ➤ Obtain a history of the patient’s gas-
trointestinal and genitourinary sys-
• Cirrhosis tems, as well as results of previously
• Diabetes procedures. For related laboratory
• Ethylene glycol poisoning and Genitourinary System tables.
• Ileal resection ➤ Obtain a list of the medications the
• Jejunal shunt patient is taking, including herbs,
nutritional supplements and nutra-
• Pancreatic disease ceuticals. The requesting health care
Oxalate, Urine 995
practitioner and laboratory should be ➤ If the patient has a history of severe

advised if the patient regularly uses allergic reaction to latex, care should
these products so that their effects be taken to avoid the use of equip-
can be taken into consideration ment containing latex.
when reviewing results. ➤ Instruct the patient to cooperate fully
➤ Review the procedure with the and to follow directions.
patient. Provide a nonmetallic urinal, ➤ Observe standard precautions, and
bedpan, or toilet-mounted collection follow the general guidelines in Ap-
device. Address concerns about pain pendix A. Positively identify the pa-
related to the procedure. Explain to tient, and label the appropriate tubes
the patient that there should be no with the corresponding patient
discomfort during the procedure. demographics, date, and time of col-
➤ Usually a 24-hour time frame for lection.
the patient that all urine must be Random specimen (collect
saved during that 24-hour period. in early morning):
directly into the laboratory collection
container. Instruct the patient to Clean-catch specimen:
avoid defecating in the collection ➤ Instruct the male patient to (1) thor-
device and to keep toilet tissue out oughly wash his hands, (2) cleanse
of the collection device to prevent the meatus, (3) void a small amount
contamination of the specimen. into the toilet, and (4) void directly
Place a sign in the bathroom to re- into the specimen container.
mind the patient to save all urine.
➤ Instruct the female patient to (1)
➤ Instruct the patient to void all urine thoroughly wash her hands; (2)
into the collection device and then to cleanse the labia from front to back;
pour the urine into the laboratory col- (3) while keeping the labia separated,
lection container. Alternatively, the void a small amount into the toilet;
specimen can be left in the collection and (4) without interrupting the urine
device for a health care staff mem- stream, void directly into the speci-
ber to add to the laboratory collec- men container.
tion container.
➤ Sensitivity to social and cultural Indwelling catheter:
issues, as well as concern for mod- ➤ Put on gloves. Empty drainage tube
esty, is important in providing psy- of urine. It may be necessary to
chological support before, during, clamp off the catheter for 15 to 30
and after the procedure. minutes before specimen collection.
➤ There are no fluid or medication Cleanse specimen port with antisep-
restrictions, unless by medical direc- tic swab, and then aspirate 5 mL of
tion. urine with a 21- to 25-gauge needle
➤ Calcium supplements, gelatin, rhu- and syringe. Transfer urine to a ster-
barb, spinach, strawberries, toma- ile container.
toes, and vitamin C should be
restricted for at least 24 hours before Timed specimen:
the test. High-protein meals should ➤ Obtain a clean 3-L urine specimen
also be avoided 24 hours before spec- container, toilet-mounted collection
imen collection. device, and plastic bag (for transport
Intratest: specimen must be refrigerated or
➤ Ensure that the patient has complied kept on ice throughout the entire
with dietary restrictions; assure that collection period. If an indwelling
restricted foods have been avoided urinary catheter is in place, the
for at least 24 hours prior to the drainage bag must be kept on ice.
procedure. ➤ Begin the test between 6 and 8 a.m.,
if possible. Collect first voiding and ation may be given to lessening

discard. Record the time the speci- dietary intake of oxalate if urine levels
men was discarded as the beginning are increased. Encourage patients
of the timed collection period. The with abnormal results to seek advice
next morning, ask the patient to void regarding dietary modifications from
at the same time the collection was a trained nutritionist. Magnesium
started and add this last voiding to supplementation may be recom-
the container. mended for patients with gastroin-
➤ If an indwelling catheter is in place, testinal disease to prevent the
replace the tubing and container sys- development of calcium oxalate kid-
tem at the start of the collection time. ney stones.
Keep the container system on ice ➤ A written report of the examination
during the collection period, or empty will be sent to the requesting health
the urine into a larger container peri- care practitioner, who will discuss
odically during the collection period; the results with the patient.
monitor to ensure continued drai- ➤ Recognize anxiety related to test
nage, and conclude the test the next results, and be supportive of fear of
morning at the same hour the collec- shortened life expectancy. Discuss
tion was begun. the implications of abnormal test
➤ At the conclusion of the test, com- results on the patient’s lifestyle.
pare the quantity of urine with the Provide teaching and information
urinary output record for the collec- regarding the clinical implications of
tion; if the specimen contains less the test results, as appropriate. Edu-
than what was recorded as output, cate the patient regarding access to
some urine may have been dis- counseling services.
carded, invalidating the test. ➤ Reinforce information given by the
➤ Include on the collection container’s patient’s health care provider regard-
label the amount of urine, test start ing further testing, treatment, or
and stop times, and ingestion of any referral to another health care pro-
foods or medications that can affect vider. Answer any questions or
test results. address any concerns voiced by the
patient or family.
General:
➤ Promptly transport the specimen to cedure, additional testing may be
the laboratory for processing and performed to evaluate or monitor
analysis. progression of the disease process
➤ The results are recorded manually and determine the need for a change
or in a computerized system for in therapy. Evaluate test results in
recall and postprocedure interpreta- relation to the patient’s symptoms
tion by the appropriate health care and other tests performed.
practitioner.
Post-test:
➤ Instruct the patient to resume usual serum and urine calcium, kidney
diet, as directed by the health care stone analysis, serum and urine mag-
practitioner. nesium, urinalysis, urine uric acid,
➤ Nutritional considerations: Consider- and vitamin C.
Pachymetry 997
PACHYMETRY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
CONTRAST: N/A.
• Determine corneal thickness in poten-

DESCRIPTION & RATIONALE: Pachy- tial refractive surgery candidates
metry is the measurement of the
• Monitor the effects of various therapies
thickness of the cornea using an ultra-
using eyedrops, laser, or filtering sur-
sound device called a pachymeter. gery
Refractive surgery procedures such as
LASIK remove tissue from the cornea.
Pachymetry is used to ensure that RESULT
there will be enough central corneal
Normal Findings:
tissue remaining after surgery to pre-
• 535 to 555
vent ectasia, or abnormal bowing, of
thin corneas. Also, recently published Abnormal Findings:
ophthalmology studies point to a
• Bullous keratopathy
correlation between increased risk of
glaucoma and decreased corneal thick- • Corneal rejection after penetrating ker-
ness. This correlation has influenced atoplasty
some health care practitioners to • Fuchs endothelial dystrophy
include pachymetry as a part of a reg-
ular eye health examination for • Glaucoma
patients who have a family history of
glaucoma or who are part of a high- CRITICAL VALUES: N/A
risk population. African Americans
have a higher incidence of glaucoma INTERFERING FACTORS:
than any other ethnic group. ■
INDICATIONS: results of the examination:
• Assist in the diagnosis of glaucoma • Inability of the patient to cooperate or
(note: the intraocular pressure in glau- remain still during the test because of
coma patients with a thin cornea, 530 age, significant pain, or mental status
or less, may be higher than in patients
whose corneal thickness is within nor- • Improper technique during application
mal limits) of the probe tip to the cornea
off from anesthetic drops admin-

Nursing Implications and stered prior to the test, or discomfort
Procedure ● ● ● ● ● ● ● ● ● ● ● may occur if too much pressure is
used during the test. Inform the
Pretest: patient that a technician, optometrist,
or physician performs the test, and
➤ Inform the patient that the procedure that to evaluate both eyes, the test
measures corneal thickness. can take 3 to 5 minutes.
plaints, including a list of known al- tion restrictions, unless by medical
lergens. direction.
➤ Obtain a history of narrow-angle
glaucoma. Obtain a history of known Intratest:
or suspected visual impairment, ➤ Instruct the patient to cooperate fully
changes in visual acuity, use of and to follow directions. Ask the
glasses or contact lenses. patient to remain still during the
➤ Obtain a history of the patient’s procedure because movement pro-
known or suspected vision loss, duces unreliable results.
including type and cause; eye condi- ➤ Seat the patient comfortably. In-
tions with treatment regimens; eye struct the patient to look straight
surgery; and other tests and proce- ahead, keeping the eyes open and
dures to assess and diagnose visual unblinking.
deficit. For related diagnostic tests,
➤ Instill topical anesthetic in each eye,
refer to the table of tests associated
as ordered, and allow time for it to
with the Ocular System.
work. Topical anesthetic drops are
➤ Obtain a history of results of previ- placed in the eye with the patient
ously performed laboratory tests, looking up and the solution directed
surgical procedures, and other diag- at the six o’clock position of the
nostic procedures. sclera (white of the eye) near the lim-
➤ Obtain a list of the medications the bus (grey, semitransparent area of
patient is taking, including herbs, the eyeball where the cornea and
nutritional supplements, and nutra- sclera meet). The dropper bottle
ceuticals. The requesting health care should not touch the eyelashes.
practitioner should be advised if the ➤ Request that the patient look straight
patient regularly uses these products ahead while the probe of the
so that their effects can be taken pachymeter is applied directly on the
into consideration when reviewing cornea of the eye. Take an average
results. of three readings for each eye.
Individual readings should be within
10 . Results on both eyes should be
tact lenses or glasses, as appropri-
similar.
the importance of keeping the eyes ➤ The results are recorded manually
open for the test. for recall and postprocedure interpre-
tation by the appropriate health care
practitioner.
patient. Explain that the patient will
be requested to fixate the eyes dur- Post-test:
ing the procedure. Address concerns
about pain related to the procedure. ➤ A written report of the examination
Explain to the patient that no pain will will be completed by a health care
be experienced during the test, but practitioner specializing in this
there may be moments of discom- branch of medicine. The report will
fort. Explain to the patient that some be sent to the requesting health care
discomfort may be experienced after practitioner, who will discuss the
the test when the numbness wears results with the patient.
Papanicolaou Smear 999
➤ Recognize anxiety related to test provider. Answer any questions or

results. Encourage the family to rec- address any concerns voiced by the
ognize and be supportive of impaired patient or family.
activity related to vision loss, per- ➤ Depending on the results of this pro-
ceived loss of driving privileges, or cedure, additional testing may be
the possibility of requiring corrective performed to evaluate or monitor
lenses (self-image). Discuss the im- progression of the disease process
plications of test results on the pa- and determine the need for a change
tient’s lifestyle. Reassure the patient in therapy. Evaluate test results in
regarding concerns related to their relation to the patient’s symptoms
impending cataract surgery. Provide and other tests performed.
teaching and information regarding
the clinical implications of the test
results, as appropriate. Related diagnostic tests:
➤ Reinforce information given by the ➤ Related diagnostic tests include
patient’s health care provider regard- fundus photography, gonioscopy,
ing further testing, treatment, or intraocular pressure, and visual field
referral to another health care testing.
PAPANICOLAOU SMEAR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Pap smear, cervical smear.

SPECIMEN: Cervical and endocervical cells.
REFERENCE VALUE: (Method: Microscopic examination of fixed and stained
smear) Reporting of Pap smear findings may follow one of several formats
and may vary from laboratory to laboratory. Simplified content of the two
most common formats for interpretation are listed in the table.
Bethesda System Description

Specimen type Conventional, liquid based or other
Specimen adequacy Satisfactory for evaluation—
(endocervical/transformation zone component
is described as present/absent along with
other quality indicators, e.g., partially
obscuring blood, inflammation)
Unsatisfactory for evaluation—either the
specimen is rejected and the reason given or
the specimen is processed and examined but
not evaluated for epithelial abnormalities and
the reason is given
Bethesda System Description

General categorization Negative for intraepithelial lesion or malignancy
Epithelial cell abnormality (abnormality is specified
in the interpretation section of the report)
Other comments
Automated review Indicates the case was examined by an
automated device and the results are listed
along with the name of the device
Ancillary testing Describes the test method and result
Interpretation/result Organisms—Trichomonas vaginalis, fungal
organisms consistent with Candida spp., shift
in flora suggestive of bacterial vaginosis,
bacteria morphologically consistent with
Actinomyces spp., cellular changes consistent
with Herpes simplex virus
Other nonneoplastic findings—reactive cellular
changes associated with inflammation,
radiation, intrauterine device; glandular cell
status post-hysterectomy; atrophy; endometrial
cells (in a woman of 40 years or greater)
Epithelial cell Squamous cell
abnormalities Atypical squamous cells—of undetermined
significance (ASC-US)
-cannot exclude HSIL (ASC-H)
Low grade squamous intraepithelial lesion
(LSIL)—encompassing: HPV/mild dysplasia/
CIN 1
High grade squamous intraepithelial lesion
(HSIL)—encompassing: moderate and severe
dysplasia, CIS/CIN 2 and CIN 3
–with features suspicious for invasion (if invasion
is suspected)
Squamous cell carcinoma
Glandular cell
Atypical—endocervical cells (NOS or specify
otherwise)
–endometrial cells (NOS or specify otherwise)
–glandular cells (NOS or specify otherwise)
Atypical—endocervical cells, favor neoplastic
–glandular cells – favor neoplastic
Endocervical carcinoma in situ
Adenocarcinoma—endocervical
–endometrial
–extrauterine
–not otherwise specified (NOS)
Other malignant neoplasms
Should be consistent with clinical followup
guidelines published by professional
Educational notes organizations with references included
and suggestions
DESCRIPTION & RATIONALE: The proved by the U.S. Food and Drug
Papanicolaou (Pap) smear is primarily Administration in 1996, is a tech-
used for the early detection of cervical nique that provides a uniform mono-
cancer. The interpretation of Pap layer of cells free of debris such as
smears is as heavily dependent on the blood and mucus. Computerized
collection and fixation technique as it scanning systems are also being used
is on the completeness and accuracy to reduce the number of smears that
of the clinical information provided require manual review by a cytotech-
with the specimen. The patient’s nologist or pathologist.
age, date of last menstrual period, par- There are now some alternatives to
ity, surgical status, postmenopausal cone biopsy and cryosurgery for
status, use of hormone therapy (in- the treatment of cervical dysplasia.
cluding use of oral contraceptives), Patients with abnormal Pap smear
history of radiation or chemotherapy, results may have a cervical loop elec-
history of abnormal vaginal bleeding, trosurgical excision procedure (LEEP)
and history of previous Pap smears are performed to remove or destroy
essential for proper interpretation. abnormal cervical tissue. In the LEEP
A Schiller’s test entails applying an procedure, a speculum is inserted into
iodine solution to the cervix. Normal the vagina, the cervix is numbed, and
cells pick up the iodine and stain brown. a special electrically charged wire loop
Abnormal cells do not pick up any color. is used to painlessly remove the suspi-
Improvements in specimen prepa- cious area. Postprocedure cramping
ration have added to the increased and bleeding can occur. Laser ablation
quality of screening procedures. The is another technique that can be
Cytyc ThinPrep PapTest (Cytyc Cor- employed for the precise removal of
poration, Boxborough, MA), ap- abnormal cervical tissue. ■
INDICATIONS: Decreased in: N/A

• Assist in the diagnosis of cervical dys-
plasia CRITICAL VALUES: N/A
• Assist in the diagnosis of endometriosis,
condyloma, and vaginal adenosis INTERFERING FACTORS:
• The smear should not be allowed to air
• Assist in the diagnosis of genital
dry before fixation.
infections (herpes, Candida spp.,
Trichomonas vaginalis, cytomegalo- • Lubricating jelly should not be used on
virus, Chlamydia, lymphogranuloma the speculum.
venereum, human papillomavirus, and • Improper collection site may result in
Actinomyces spp.) specimen rejection. Samples for cancer
• Assist in the diagnosis of primary and screening are obtained from the poste-
metastatic neoplasms rior vaginal fornix and from the cervix.
Samples for hormonal evaluation are
• Evaluate hormonal function
obtained from the vagina.
• Douching, sexual intercourse, using
RESULT tampons, or using vaginal medication
Positive findings in: (See table within 24 hours prior to specimen col-
[Bethesda system], presented earlier lection can interfere with the speci-
under “Reference Value”) men’s results.
• Collection of other specimens prior to the patient that there may be some
the collection of the Pap smear may be discomfort during the procedure.
cause for specimen rejection. Inform the patient that specimen col-
lection is performed by a health care
• Contamination with blood from sam- practitioner specializing in this proce-
ples collected during the patient’s men- dure and takes approximately 5 to 10
strual period may be cause for minutes.
specimen rejection. ➤ Sensitivity to social and cultural
Nursing Implications and chological support before, during,
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: tion restrictions, unless by medical
direction.
➤ Inform the patient that the test is pri- ➤ If the patient is taking vaginal antibi-
marily used to establish a histologic otic medication, testing should be
diagnosis of cervical and vaginal dis- delayed for 1 month after the treat-
ease and identify the presence of ment has been completed.
genital infections.
➤ Obtain a history of the patient’s com- consent has been signed prior to the
plaints, including a list of known procedure and before administering
allergens (especially allergies or sen- any medications.
accordingly.
cedure.
immune and reproductive systems
and results of previously performed ➤ Have the patient remove clothes
laboratory tests, surgical procedures, below the waist.
and other diagnostic procedures. For ➤ Instruct the patient to cooperate fully
related tests, refer to the Immune and to follow directions. Direct the
and Reproductive System tables. patient to breathe normally and to
➤ Record the date of the last menstrual avoid unnecessary movement during
of pregnancy in perimenopausal ➤ Observe standard precautions, and
women. follow the general guidelines in
➤ Note any recent procedures that can Appendix A. Positively identify the
interfere with test results. patient, and label the appropriate col-
lection containers with the correspon-
ding patient demographics, date and
time of collection, and site location.
ceuticals. The requesting health care ➤ Assist the patient into a lithotomy
practitioner and laboratory should be position on a gynecologic examina-
advised if the patient regularly uses tion table (with feet in stirrups).
these products so that their effects Drape the patient’s legs.
can be taken into consideration ➤ A plastic or metal speculum is
when reviewing results. inserted into the vagina and is opened
➤ Review the procedure with the to gently spread apart the vagina for
patient. Instruct the patient to avoid inspection of the cervix. The specu-
douching or sexual intercourse for 24 lum may be dipped in warm water to
hours before specimen collection. aid in comfortable insertion.
Verify that the patient is not menstru- ➤ After the speculum is properly posi-
ating. Address concerns about pain tioned, the cervical and vaginal spec-
related to the procedure. Explain to imens are obtained. A synthetic fiber
brush is inserted deep enough into practitioner specializing in this

the cervix to reach the endocervical branch of medicine. The report will
canal. The brush is then rotated one be sent to the requesting health care
turn and removed. The plastic or practitioner, who will discuss the
wooden spatula is used to lightly results with the patient.
scrape the cervix and vaginal wall. ➤ Recognize anxiety related to test
results, and offer support. Discuss
Conventional collection: the implications of abnormal test
➤ Both specimens that are on the brush Provide teaching and information
and spatula are then plated on the regarding the clinical implications of
glass slide. The brush specimen is the test results, as appropriate.
plated using a gentle rolling motion, Educate the patient regarding access
whereas the spatula specimen is to counseling services.
plated using a light gliding motion
across the slide. The specimens are ➤ Reinforce information given by the
immediately fixed to the slide with a patient’s health care provider regard-
liquid or spray containing 95% ing further testing, treatment, or
ethanol. The speculum is removed referral to another health care pro-
from the vagina. A pelvic and/or rec- vider. Inform the patient, as appropri-
tal exam is usually performed after ate, that repeat testing may be
specimen collection is completed. requested in the event of specimen
rejection or abnormal findings. Inform
the patient that non–sexually active
ThinPrep collection: women should begin yearly Pap
➤ The ThinPrep bottle lid is opened and smears at 18 years of age, and younger
removed, exposing the solution. The sexually active women should begin
brush and spatula specimens are yearly Pap smears earlier. Pap smears
then gently swished in the ThinPrep should be repeated more frequently
solution to remove the adhering if the results return abnormal. After a
cells. The brush and spatula are then hysterectomy, a vaginal cuff Pap
removed from the ThinPrep solution, smear is used to monitor the cells lin-
and the bottle lid is replaced and ing the terminal end of the vagina.
secured. Several guidelines differ in their rec-
ommendations on when to cease
Pap smear testing. Encourage
General: patients to discuss their Pap smear
➤ Place samples in properly labeled result history and women’s health
specimen container and promptly history with their health care provider
transport the specimen to the labo- to determine at what age testing may
ratory for processing and analysis. be terminated. Answer any questions
or address any concerns voiced by
➤ The results are recorded manually the patient or family.
and postprocedure interpretation by ➤ Depending on the results of this pro-
the appropriate health care practi- cedure, additional testing may be
Post-test: in therapy. Evaluate test results in
➤ Cleanse or allow the patient to relation to the patient’s symptoms
cleanse secretions or excess lubri- and other tests performed.
cant (if a pelvic and/or rectal exami-
nation is also performed) from the Related laboratory tests:
perineal area. Provide a sanitary pad ➤ Related laboratory tests include bac-
if cervical bleeding occurs. terial throat culture for gonorrhea,
➤ A written report of the examination cervical biopsy, and Chlamydia group
will be completed by a health care antibody.
PARATHYROID HORMONE: INTACT,

C-TERMINAL, AND N-TERMINAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Parathormone, PTH.

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Specimen
should be transported tightly capped and in an ice slurry.
SI Units
C-terminal
1–16 y 51–217 pg/mL 51–217 ng/L
Adults 50–330 pg/mL 50–330 ng/L
N-terminal
2–13 y 14–21 pg/mL 14–21 ng/L
Intact
Cord blood Less than 3 pg/mL Less than 3 ng/L
2–20 y 9–52 pg/mL 9–52 ng/L
DESCRIPTION & RATIONALE: Para- metabolites, causing increased cal-

thyroid hormone (PTH) is secreted by cium absorption in the small intes-
the parathyroid glands in response to tine. The net result of PTH action is
decreased levels of circulating calcium. maintenance of adequate serum cal-
PTH assists in the mobilization of calcium levels. In normal individuals,
cium from bone into the bloodstream, intact PTH has a circulating half-life
promoting renal tubular reabsorption of about 5 minutes. N-terminal PTH
of calcium and depression of phos- has a circulating half-life of about 2
phate reabsorption, thereby reducing minutes and is found in very small
calcium excretion and increasing quantities. Intact and N-terminal
phosphate excretion by the kidneys. PTH are the only biologically active
PTH also decreases the renal secretion forms of the hormone. Ninety percent
of hydrogen ions, which leads to of circulating PTH is composed of
increased renal excretion of bicarbon- inactive C-terminal and midregion
ate and chloride. PTH enhances renal fragments. PTH is cleared from the
production of active vitamin D body by the kidneys. ■
Parathyroid Hormone: Intact, C-Terminal, and N-Terminal 1005
INDICATIONS: INTERFERING FACTORS:

• Assist in the diagnosis of hyperparathy- • Drugs that may increase PTH levels
roidism include clodronate, dopamine, estro-
• Assist in the diagnosis of suspected sec- gen/progestin therapy, foscarnet,
ondary hyperparathyroidism due to furosemide, hydrocortisone, isoniazid,
chronic renal failure, malignant tumors lithium, octreotide, pamidronate, phos-
that produce ectopic PTH, and malab- phates, prednisone, tamoxifen, and ver-
sorption syndromes apamil.
• Detect incidental damage or inadver- • Drugs and vitamins that may decrease
tent removal of the parathyroid glands PTH levels include alfacalcidol, alu-
during thyroid or neck surgery minum hydroxide, calcitriol, cimeti-
dine (C-terminal only), diltiazem,
• Differentiate parathyroid and non- magnesium sulfate, pindolol, pred-
parathyroid causes of hypercalcemia nisone (intact), and vitamin D.
• Evaluate autoimmune destruction of • PTH levels are subject to diurnal varia-
the parathyroid glands tion, with highest levels occurring in
• Evaluate parathyroid response to altered the morning.
serum calcium levels, especially those • PTH levels should always be measured
that result from malignant processes, in conjunction with calcium for proper
leading to decreased PTH production interpretation.
• Evaluate source of altered calcium • Failure to follow dietary restrictions
metabolism before the procedure may cause the
RESULT
Increased in:
• Fluorosis Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Primary, secondary, or tertiary hyper-
parathyroidism Pretest:
• Pseudogout ➤ Inform the patient that the test is
• Pseudohypoparathyroidism used to assist in the diagnosis of
parathyroid disease and disorders of
• Spinal cord trauma calcium balance. It is also used to
• Zollinger-Ellison syndrome monitor patients undergoing renal
dialysis.
Decreased in: ➤ Obtain a history of the patient’s com-
• Autoimmune destruction of the plaints, including a list of known
parathyroids
• DiGeorge syndrome appropriate health care practitioner
accordingly.
• Hyperthyroidism
• Hypomagnesemia endocrine system and results of pre-
• Nonparathyroid hypercalcemia (in the viously performed laboratory tests,
absence of renal failure) surgical procedures, and other diag-
• Sarcoidosis ratory tests, refer to the Endocrine
• Secondary hypoparathyroidism due to System table.
surgery ➤ Obtain a list of the medications the
CRITICAL VALUES: N/A nutritional supplements, and nutra-
ceuticals. The requesting health care after collection. Information on the

practitioner and laboratory should be specimen label can be protected
advised if the patient regularly uses from water in the ice slurry if the
these products so that their effects specimen is first placed in a protec-
can be taken into consideration tive plastic bag.
when reviewing results. ➤ The results are recorded manually
➤ Review the procedure with the or in a computerized system for
patient. Early-morning specimen col- recall and postprocedure interpreta-
lection is recommended because of tion by the appropriate health care
the diurnal variation in PTH levels. practitioner.
Inform the patient that specimen col-
lection takes approximately 5 to 10 Post-test:
minutes. Address concerns about
pain related to the procedure. Ex- ➤ Observe venipuncture site for bleed-
plain to the patient that there may be ing or hematoma formation. Apply
some discomfort during the veni- paper tape or other adhesive to hold
puncture. pressure bandage in place, or replace
➤ The patient should fast for 12 hours with a plastic bandage.
before specimen collection. ➤ Instruct the patient to resume usual
➤ There are no fluid or medication diet, as directed by the health care
restrictions, unless by medical direc- practitioner.
tion. ➤ Nutritional considerations: Patients
➤ Prepare an ice slurry in a cup or plas- with abnormal parathyroid levels are
tic bag to have on hand for immedi- also likely to experience the effects
ate transport of the specimen to the of calcium level imbalances. Instruct
laboratory. the patient to report signs and symp-
toms of hypocalcemia and hypercal-
cemia to the health care practitioner.
Intratest: (For critical values, signs and symp-
➤ Ensure that the patient has com- toms of calcium imbalance, and
plied with dietary restrictions; assure nutritional information, see mono-
that food has been restricted for at graphs titled “Calcium.”)
least 12 hours prior to the procedure. ➤ A written report of the examination
ment containing latex. ➤ Reinforce information given by the
and to follow directions. Direct the ing further testing, treatment, or refer-
patient to breathe normally and to ral to another health care provider.
avoid unnecessary movement. Answer any questions or address
➤ Observe standard precautions, and or family.
demographics, date, and time of progression of the disease process
collection. Perform a venipuncture; and determine the need for a change
collect the specimen in a 5-mL red- in therapy. Evaluate test results in
top tube. relation to the patient’s symptoms
sure dressing over the puncture site.
➤ Promptly transport the specimen
to the laboratory for processing and ➤ Related laboratory tests include cal-
analysis. The sample should be cium (blood and ionized), blood and
placed in an ice slurry immediately urine phosphorus, and vitamin D.
Parathyroid Scan 1007
PARATHYROID SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Parathyroid scintiscan.

AREA OF APPLICATION: Parathyroid.
CONTRAST: Intravenous technetium-99m (Tc-99m) pertechnetate,
Tc-99m sestamibi, oral iodine-123, and thallium.
RESULT
DESCRIPTION & RATIONALE: Para-
thyroid scanning is performed to assist Normal Findings:
in the preoperative localization of • No areas of increased perfusion or
parathyroid adenomas in clinically uptake in the thyroid or parathyroid
proven primary hyperparathyroidism;
it is useful for distinguishing between Abnormal Findings:
intrinsic and extrinsic parathyroid • Intrinsic and extrinsic parathyroid ade-
adenomas. It is also performed after nomas
surgery to verify the presence of the
parathyroid gland in children, and it
is done after thyroidectomy as well.
The radionuclide is administered
10 to 20 minutes before the imaging This procedure is
is performed. The thyroid and sur- contraindicated for:
rounding tissues should be carefully • Patients who are pregnant or sus-
palpated. pected of being pregnant, unless the
Fine-needle aspiration biopsy guid- potential benefits of the procedure far
ed by ultrasound is occasionally neces- outweigh the risks to the fetus and
sary to differentiate thyroid pathology, mother
as well as pathology of other tissues,
Factors that may
from parathyroid neoplasia. ■ impair clear imaging:
INDICATIONS: remain still during the procedure be-
• Aid in the diagnosis of hyperparathy- cause of age, significant pain, or mental
roidism status
• Differentiate between extrinsic and • Ingestion of foods containing iodine
intrinsic parathyroid adenoma, but not (e.g., iodized salt) and medications
between benign and malignant condi- containing iodine (e.g., cough syrup,
tions potassium iodide, vitamins, Lugol’s
• Evaluate the parathyroid in patients solution, thyroid replacement medica-
with severe hypercalcemia or in patients tions), which can decrease uptake of
before parathyroidectomy the radionuclide
• Recent use of iodinated contrast ➤ Obtain a history of the patient’s

medium for radiographic studies or immune system, as well as results
recently performed nuclear medicine of previously performed diagnostic
procedures, which can affect the uptake procedures, surgical procedures,
and laboratory tests. For related
of the radionuclide diagnostic tests, refer to the
• Patients who are very obese, who Immune System table.
may exceed the weight limit for the ➤ Record the date of the last menstrual
equipment period and determine the possibility
• Incorrect positioning of the patient, women.
of the area to be examined ➤ Obtain a list of the medications the
patient is taking.
• Metallic objects within the examina- ➤ Determine whether the patient has
tion field (e.g., jewelry, body rings), had any recent intake of iodine.
and can produce unclear images patient. Address concerns about pain
Other considerations: the patient that some pain may be
• Improper injection of the radionuclide experienced during the test, and
that allows the tracer to seep deep into there may be moments of discom-
the muscle tissue produces erroneous fort. Explain the purpose of the test
hot spots. and how the procedure is per-
formed. Inform the patient that the
• Consultation with a health care practi- procedure is performed in a nuclear
tioner should occur before the proce- medicine department, usually by a
dure for radiation safety concerns technologist and support staff, and
regarding younger patients or patients takes approximately 30 to 60 min-
utes. Inform the patient that the
who are lactating. technologist will administer an intra-
• Risks associated with radiographic venous injection of the radionuclide
overexposure can result from frequent and that he or she will need to return
x-ray procedures. Personnel in the 2 to 3 hours later for the scan.
room with the patient should stand ➤ Record the date of the last menstrual
behind a shield or leave the area while period. Note any recent procedures
the examination is being done. that can interfere with test results,
Personnel working in the area where including examinations using iodine-
based contrast mediums or barium.
the examination is being done should
wear badges that reveal their level of ➤ Ensure that the patient has not been
exposure to radiation. scheduled for more than one
radionuclide scan on the same day.
Multiple procedures on the same
day may interfere with interpretation
Nursing Implications and of results.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
➤ Inform the patient that the procedure chological support before, during,
assesses the parathyroid glands. and after the procedure.
plaints and symptoms, including a tion restrictions, unless by medical
list of known allergens. direction.
Parathyroid Scan 1009
➤ Instruct the patient to remove den- Post-test:

hairpins, credit cards, and other me- ➤ Assess injection site for bleeding,
tallic objects. hematoma formation, and inflamma-
tion. Apply warm soaks to promote
Intratest: comfort if a hematoma develops.
➤ Advise patient to drink increased
➤ Make sure jewelry, chains, and any amounts of fluids for 24 to 48 hours
other metallic objects have been to eliminate the radionuclide from the
removed from the neck area. body, unless contraindicated. Tell the
➤ Patients are given a gown, robe, and patient that radionuclide is eliminated
foot coverings to wear and instructed from the body within 6 to 24 hours.
to void prior to the procedure. ➤ Instruct the patient to flush the toilet
➤ Instruct the patient to cooperate fully immediately after each voiding fol-
and to follow directions. Instruct the lowing the procedure, and to wash
patient to remain still throughout the hands meticulously with soap and
procedure because movement pro- water after each voiding for 24 hours
duces unreliable results. after the procedure.
➤ Observe standard precautions, and ➤ Tell all caregivers to wear gloves
follow the general guidelines in when discarding urine for 24 hours
Appendix A. after the procedure. Wash gloved
hands with soap and water before
➤ Wear gloves during the radionuclide removing gloves. Then wash hands
injection and while handling the after the gloves are removed.
patient’s urine.
➤ Administer technetium-99m (Tc- will be completed by a health care
99m) pertechnetate intravenously practitioner specializing in this
before scanning. branch of medicine. The report will
➤ To scan the parathyroid gland, the be sent to the requesting health care
patient is placed in a supine position practitioner, who will discuss the
under a radionuclide gamma camera results with the patient.
15 minutes after the radionuclide ➤ Reinforce information given by the
injection. Imaging is performed over patient’s health care provider regard-
the anterior neck area. ing further testing, treatment, or re-
➤ With the patient in the same posi- ferral to another health care provider.
tion, Tc-99m sestamibi is injected, Answer any questions or address
and after 10 minutes a second image any concerns voiced by the patient
is obtained and stored in the com- or family.
puter. The computer subtracts the ➤ Depending on the results of this pro-
technetium-visualized thyroid struc- cedure, additional testing may be
tures from the thallium accumulation needed to evaluate or monitor pro-
in a parathyroid adenoma. gression of the disease process and
➤ Iodine-123 may be administered
orally in place of Tc-99m pertechne-
tate; the imaging sequence, as
described previously, is performed
24 hours later.
➤ The images are recorded on film
or stored electronically for recall ➤ Related diagnostic tests include
and postprocedure interpretation by computed tomography of the thorax
the appropriate health care practi- and magnetic resonance imaging of
tioner. the chest.
PARTIAL THROMBOPLASTIN
TIME, ACTIVATED
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: APTT.
SPECIMEN: Plasma (1 mL) collected in a completely filled blue-top (sodium
citrate) tube.
REFERENCE VALUE: (Method: Clot detection) 25 to 39 seconds. Reference

ranges vary with respect to the equipment and reagents used to perform the
assay.
DESCRIPTION & RATIONALE: The boplastin time (PTT). A comparison

activated partial thromboplastin time between the results of APTT and pro-
(APTT) coagulation test evaluates the thrombin time (PT) tests can allow
function of the intrinsic (factors XII, some inferences to be made that a fac-
XI, IX, and VIII) and common (factor deficiency exists. A normal APTT
tors V, X, II, and I) pathways of the with a prolonged PT can only occur
coagulation sequence, specifically the with factor VII deficiency. A pro-
intrinsic thromboplastin system. It longed APTT with a normal PT
represents the time required for a firm could indicate a deficiency in factors
fibrin clot to form after tissue throm- XII, XI, IX, VIII, and VIII:C (von
boplastin or phospholipid reagents Willebrand factor). Factor deficiencies
similar to thromboplastin and cal- can also be identified by correction or
cium are added to the specimen. The substitution studies using normal
APTT is abnormal in 90% of patients serum. These studies are easy to per-
with coagulation disorders and is use- form and are accomplished by adding
ful in monitoring the inactivation plasma from a normal patient to a
of factor II effect of heparin therapy. sample from a patient suspected to be
The test is prolonged when there is factor deficient. When the APTT is
a 30% to 40% deficiency in one of repeated and is corrected, or within
the factors required, or when factor the reference range, it can be assumed
inhibitors (e.g., antithrombin III, pro- that the prolonged APTT is caused by
tein C, or protein S) are present. The a factor deficiency. The administra-
APTT has additional activators, such tion of prophylactic low-dose heparin
as kaolin, Celite, or elegiac acid, that does not require serial monitoring of
more rapidly activate factor XII, mak- APTT. (For more information on fac-
ing this test faster and more reliably tor deficiencies, see monograph titled
reproducible than the partial throm- “Fibrinogen.”) ■
Partial Thromboplastin Time, Activated 1011
INDICATIONS: symptoms. Important signs to note are

• Detect congenital deficiencies in clot- prolonged bleeding, hematoma at the
ting factors, as seen in diseases such as puncture site, hemorrhage, blood in the
hemophilia A (factor VIII) and hemo- stool, bleeding gums, and shock. Moni-
philia B (factor IX) toring vital signs and neurologic changes
until values are within normal range is
• Evaluate response to anticoagulant indicated. Administration of protamine
therapy with heparin or coumarin sulfate may be requested.
derivatives
• Identify individuals who may be prone INTERFERING FACTORS:
to bleeding during surgical, obstetric, • Drugs and vitamins such as anistre-
dental, or invasive diagnostic proce- plase, antihistamines, chlorpromazine,
dures salicylates, and ascorbic acid may cause
prolonged APTT.
• Identify the possible cause of abnormal
bleeding, such as epistaxis, hematoma, • Anticoagulant therapy with heparin
gingival bleeding, hematuria, and men- will prolong the APTT.
orrhagia • Copper is a component of factor V, and
• Monitor the hemostatic effects of con- severe copper deficiencies may result in
ditions such as liver disease, protein prolonged APTT values.
deficiency, and fat malabsorption • Traumatic venipunctures can activate
the coagulation sequence by contami-
RESULT nation of the sample with tissue throm-
boplastin and can produce falsely
Prolonged in: shortened results.
• Afibrinogenemia
• Failure to fill the tube sufficiently to
• Circulating products of fibrin and fib- yield a proper blood-to-anticoagulant
rinogen degradation ratio invalidates the results and is rea-
• Disseminated intravascular coagulation son for specimen rejection.
• Factor deficiencies • Excessive agitation that causes sample

hemolysis can falsely shorten the APTT
• Hemodialysis patients because the hemolyzed cells activate
• Polycythemia plasma-clotting factors.
• Severe liver disease • Inadequate mixing of the tube can pro-
duce erroneous results.
• Vitamin K deficiency
• Specimens left unprocessed for longer
• Von Willebrand’s disease than 4 hours should be rejected for
analysis.
• High platelet count or inadequate cen-
Greater than 70 seconds.
trifugation will result in decreased val-
The requesting health care practitioner
ues.
should also be notified if the APTT is less
than 53 seconds in a patient receiving • Hematocrit greater than 55% may
heparin therapy. Low values indicate that cause falsely prolonged results because
the therapy is providing inadequate anti- of anticoagulant excess. The excess
coagulation. anticoagulant chelates the calcium
Note and immediately report to the reagent in the test system, making it
health care practitioner any critically unavailable to react properly with the
increased or decreased values and related patient sample.

Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest:
used to evaluate coagulation disor- patient to breathe normally and to
ders and monitor therapy. avoid unnecessary movement.
accordingly. demographics, date, and time of
➤ Obtain a history of the patient’s collection. Perform a venipuncture;
hematopoietic and hepatobiliary sys- collect the specimen in a 5-mL blue-
tems, history of any bleeding disor- top tube. Fill the tube completely.
ders, and results of previously Important note: Two different con-
performed laboratory tests (espe- centrations of sodium citrate preser-
cially bleeding time, complete blood vative are currently added to blue-top
count, PTT, platelets, and PT), surgi- tubes for coagulation studies: 3.2%
cal procedures, and other diagnostic and 3.8%. The Clinical and Laboratory
procedures. For related laboratory Standards Institute/CLSI (formerly
tests, refer to the Hematopoietic and the National Committee for Clinical
Hepatobiliary System tables. Laboratory Standards/NCCLS) guide-
line for sodium citrate is 3.2%.
➤ Obtain a list of the medications Laboratories establish reference
the patient is taking, including anti- ranges for coagulation testing based
coagulant therapy, acetylsalicylic on numerous factors, including
acid, herbs, nutritional supplements, sodium citrate concentration, test
and nutraceuticals, especially those equipment, and test reagents. It is
known to affect coagulation. It is rec- important to inquire from the labora-
ommended that use of these prod- tory which concentration it recom-
ucts be discontinued 14 days before mends, because each concentration
dental or surgical procedures. The will have its own specific reference
requesting health care practitioner range.
➤ When multiple specimens are
drawn, the blue-top tube should be
ucts so that their effects can
collected after sterile (i.e., blood cul-
ture) and red-top tubes. When coag-
reviewing results. If the patient is
ulation testing is the only work to be
receiving anticoagulant therapy, note
done, an extra red-top tube should
the time and amount of the last dose.
be collected before the blue-top tube
➤ Review the procedure with the to avoid contaminating the specimen
patient. Inform the patient that spec- with tissue thromboplastin.
analysis. The CLSI recommendation
for processed and unprocessed
specimens stored in unopened tubes
venipuncture.
is that testing should be completed
➤ There are no food, fluid, or medica- within 1 to 4 hours of collection.
Parvovirus B19 Immunoglobulin G and Immunoglobulin M Antibodies 1013
➤ The results are recorded manually will be sent to the requesting health
or in a computerized system for care practitioner, who will discuss
recall and postprocedure interpreta- the results with the patient.
tion by the appropriate health care ➤ Reinforce information given by the
practitioner. patient’s health care provider regard-
Post-test: ferral to another health care provider.
➤ Observe venipuncture site for bleed- any concerns voiced by the patient
ing or hematoma formation. Apply or family.
hold pressure bandage in place, or ➤ Depending on the results of this
replace with a plastic bandage. procedure, additional testing may
be performed to evaluate or moni-
➤ Instruct the patient to report severe tor progression of the disease pro-
bruising or bleeding from any areas cess and determine the need for a
of the skin or mucous membranes. change in therapy. Evaluate test
➤ Inform the patient with prolonged results in relation to the patient’s
APTT values of the importance of symptoms and other tests per-
taking precautions against bruising formed.
and bleeding, including the use of a
soft bristle toothbrush, use of an Related laboratory tests:
electric razor, avoidance of constipa-
tion, avoidance of acetylsalicylic acid ➤ Related laboratory tests include
and similar products, and avoidance antithrombin III, bleeding time, coag-
of intramuscular injections. ulation factors, complete blood
count, copper, fibrin degredation
➤ Inform the patient of the importance products, platelet count, protein
of periodic laboratory testing while C, protein S, prothrombin time and
taking an anticoagulant. International Normalized Ratio, and
➤ A written report of the examination vitamin K.
PARVOVIRUS B19 IMMUNOGLOBULIN G

AND IMMUNOGLOBULIN M
ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Negative Less than 0.8 CRITICAL VALUES: N/A

Equivocal 0.8–1.2
INTERFERING FACTORS: Immunocom-
promised patients may not develop suffi-
cient antibody to be detected.
DESCRIPTION & RATIONALE: Par- Nursing Implications and

vovirus B19, a single-stranded DNA
Procedure ● ● ● ● ● ● ● ● ● ● ●
virus transmitted by respiratory secre-
tions, is the only parvovirus known to Pretest:
infect humans. Its primary site of
replication is in red blood cell precur- used to assist in confirming past or
sors in the bone marrow. It is capable present parvovirus infection.
of causing disease along a wide spec- ➤ Obtain a history of the patient’s
trum ranging from a self-limited ery- complaints, including a list of known
thema (fifth disease) to bone marrow allergens (especially allergies or sen-
failure or aplastic crisis in patients sitivities to latex), and inform the
with sickle cell anemia, spherocytosis, accordingly.
or thalassemia. Fetal hydrops and
spontaneous abortion may also occur immune system and results of previ-
as a result of infection during preg- ously performed laboratory tests,
nancy. The incubation period is surgical procedures, and other diag-
approximately 1 week after exposure. nostic procedures. For related labo-
B19-specific antibodies appear in the System table.
serum approximately 3 days after the
onset of symptoms. The presence of patient is taking, including herbs,
immunoglobulin M (IgM) antibodies nutritional supplements, and nutra-
indicates acute infection. The pres- ceuticals. The requesting health care
ence of IgG antibodies indicates past practitioner and laboratory should be
infection and is believed to confer life- these products so that their effects
long immunity. Parvovirus can also be can be taken into consideration
detected by DNA hybridization using when reviewing results.
a polymerase chain reaction. ■ ➤ Review the procedure with the
INDICATIONS: Assist in establishing a imen collection takes approximately
5 to 10 minutes. Inform the patient
diagnosis of parvovirus B19 infection that a subsequent sample will be
required in 7 to 14 days. Address
RESULT concerns about pain related to the
Positive findings in: there may be some discomfort dur-
• Arthritis
• Erythema infectiosum (fifth disease) tion restrictions, unless by medical
direction.
• Erythrocyte aplasia
• Hydrops fetalis Intratest:
Negative findings in: N/A allergic reaction to latex, care should
Parvovirus B19 Immunoglobulin G and Immunoglobulin M Antibodies 1015
be taken to avoid the use of equip- impaired activity related to lack

ment containing latex. of neuromuscular control, perceived
➤ Instruct the patient to cooperate fully loss of independence, and fear of
and to follow directions. Direct the shortened life expectancy. Discuss
patient to breathe normally and to the implications of abnormal test
avoid unnecessary movement. results on the patient’s lifestyle.
➤ Observe standard precautions, and regarding the clinical implications of
follow the general guidelines in the test results, as appropriate.
Appendix A. Positively identify the Educate the patient regarding access
patient, and label the appropriate to counseling services. Provide con-
tubes with the corresponding patient tact information, if desired, for the
demographics, date, and time of col- Myasthenia Gravis Foundation of
lection. Perform a venipuncture; col- America (http://www.myasthenia.
lect the specimen in a 5-mL red- or org) and Muscular Dystrophy Associ-
tiger-top tube. ation (http://www.mdausa.org).
➤ Remove the needle, and apply a ➤ Reinforce information given by the
pressure dressing over the puncture patient’s health care provider regard-
site. ing further testing, treatment, or re-
➤ Promptly transport the specimen to ferral to another health care provider.
the laboratory for processing and Emphasize the need for the patient
analysis. to return to have a convalescent
blood sample taken in 7 to 14 days.
➤ The results are recorded manually Answer any questions or address
or in a computerized system for recall any concerns voiced by the patient
and postprocedure interpretation by or family.
tioner. ➤ Depending on the results of this pro-
will be sent to the requesting health ➤ Related laboratory tests include bone
care practitioner, who will discuss marrow biopsy, complete blood
the results with the patient. count, hemoglobin electrophoresis,
➤ Recognize anxiety related to test red blood cell morphology, and sickle
results, and be supportive of cell screen.
PERICARDIAL FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: None.
SPECIMEN: Pericardial fluid (5 mL) collected in a red- or green-top
(heparin) tube for glucose, a lavender-top (EDTA) tube for cell count, and
sterile containers for microbiology specimens; 200 to 500 mL of fluid in a
clear container for cytology. Ensure that there is an equal amount of fluid
relative to fixative in the container for cytology.
REFERENCE VALUE: (Method: Spectrophotometry for glucose; automated or

manual cell count, macroscopic examination of cultured organisms, and
microscopic examination of specimen for microbiology and cytology; micro-
scopic examination of cultured microorganisms)
Pericardial Fluid Reference Value

Appearance Clear
Color Pale yellow
Glucose Parallel serum values
Red blood cell count None seen
White blood cell count Less than 1000/mm3
Culture No growth
Gram stain No organisms seen
Cytology No abnormal cells seen
DESCRIPTION & RATIONALE: The tery of tests used to distinguish a tran-

heart is located within a protective sudate from an exudate. Transudates
membrane called the pericardium. The are effusions that form as a result of a
fluid between the pericardial mem- systemic disorder that disrupts the
branes is called serous fluid. Normally regulation of fluid balance, such as a
only a small amount of fluid is present suspected perforation. Exudates are
because the rates of fluid production caused by conditions involving the tis-
and absorption are about the same. sue of the membrane itself, such as an
Many abnormal conditions can result infection or malignancy. Fluid is with-
in the buildup of fluid within the drawn from the pericardium by nee-
pericardium. Specific tests are usually dle aspiration and tested as listed in
ordered in addition to a common bat- the previous and following tables. ■
Pericardial Fluid Analysis 1017
Characteristic Transudate Exudate

Appearance Clear Cloudy or turbid
Specific gravity Less than 1.015 Greater than 1.015
Total protein Less than 2.5 g/dL Greater than 3.0 g/dL
Fluid-to–serum Less than 0.5 Greater than 0.5
protein ratio
LDH Parallels serum value Less than 200 U/L
LDH ratio
Fluid cholesterol Less than 55 mg/dL Greater than 55 mg/dL
White blood cell count Less than 100/mm3 Greater than 1000/mm3
LDH lactate dehydrogenase.
INDICATIONS: Decreased in (condition/test

• Evaluate effusion of unknown etiology showing decreased result):
• Bacterial pericarditis (glucose)
• Investigate suspected hemorrhage,
immune disease, malignancy, or infec- • Malignancy (glucose)
tion • Rheumatoid disease or systemic lupus
erythematosus (glucose)
RESULT
CRITICAL VALUES:
Increased in (condition/test Note and immediately report to the
showing increased result): health care practitioner positive culture
• Bacterial pericarditis (red blood cell results, if ordered, and related symptoms.
[RBC] count, white blood cell [WBC]
count with a predominance of neu- INTERFERING FACTORS:
trophils) • Bloody fluid may be the result of a
traumatic tap.
• Hemorrhagic pericarditis (RBC count,
WBC count) • Unknown hyperglycemia or hypo-
glycemia may be misleading in the
• Malignancy (RBC count, abnormal comparison of fluid and serum glucose
cytology) levels. Therefore, it is advisable to
• Post–myocardial infarction syndrome, collect comparative serum samples a
also called Dressler’s syndrome (RBC few hours before performing pericar-
count, WBC count with a predomi- diocentesis.
nance of neutrophils) • Failure to follow dietary restrictions
• Rheumatoid disease or systemic lupus
erythematosus (RBC count, WBC
count)
• Tuberculous or fungal pericarditis Nursing Implications and
(RBC count, WBC count with a pre- Procedure ● ● ● ● ● ● ● ● ● ● ●
dominance of lymphocytes)
• Viral pericarditis (RBC count, WBC Pretest:
count with a predominance of neu- ➤ Inform the patient that the test is pri-
trophils) marily used to classify the type of
effusion being produced and identify has been anesthetized, a large nee-
the cause of its accumulation. dle will be inserted through the chest
➤ Obtain a history of the patient’s com- to obtain the fluid. Inform the patient
plaints, including a list of known that specimen collection is performed
allergens (especially allergies or sen- under sterile conditions by a health
sitivities to latex), and inform the care practitioner specializing in this
appropriate health care practitioner procedure. The procedure usually
accordingly. takes approximately 30 minutes to
complete.
diovascular and immune systems, ➤ Explain that an intravenous (IV) line
any bleeding disorders, and results will be inserted to allow infusion of
of previously performed laboratory IV fluids, antibiotics, anesthetics, and
tests (especially bleeding time, analgesics.
complete blood count, partial throm- ➤ Sensitivity to social and cultural
boplastin time, platelets, and pro- issues, as well as concern for mod-
thrombin time), surgical procedures, esty, is important in providing psy-
and other diagnostic procedures. For chological support before, during,
related laboratory tests, refer to the and after the procedure.
Cardiovascular and Immune System
➤ Food and fluids should be restricted
tables.
for 6 to 8 hours before the proce-
➤ Note any recent procedures that can dure, as directed by the health care
interfere with test results. practitioner, unless the procedure is
➤ Record the date of the last menstrual performed in an emergency situation
period and determine the possibility to correct pericarditis. The requesting
of pregnancy in perimenopausal health care practitioner may request
women. that anticoagulants and aspirin be
withheld. The amount of days to
withhold medication is dependent on
the type of anticoagulant.
acid, herbs, nutritional supplements, ➤ Make sure a written and informed
and nutraceuticals, especially those consent has been signed prior to the
known to affect coagulation. The re- procedure and before administering
questing health care practitioner and any medications.
patient regularly uses these products Intratest:
into consideration when reviewing ➤ Ensure that the patient has complied
results. with dietary and fluids restrictions;
➤ Review the procedure with the assure that food has been restricted
patient. Inform the patient that it for at least 6 to 8 hours prior to the
may be necessary to shave the site procedure.
before the procedure. Address con- ➤ Ensure that anticoagulant therapy
cerns about pain related to the pro- has been withheld for the appropri-
cedure. Explain that a sedative ate amount of days prior to the
and/or analgesia will be administered procedure. Notify health care practi-
to promote relaxation and reduce tioner if patient anticoagulant ther-
discomfort prior to needle insertion apy has not been withheld.
through the chest wall. Explain to the ➤ Have emergency equipment readily
patient that any discomfort with the available.
needle insertion will be minimized
with local anesthetics and systemic ➤ Have the patient void before the pro-
analgesics. Explain that the anes- cedure.
thetic injection may cause a stinging ➤ Have the patient remove clothes
sensation. Explain that, after the skin above the waist and put on a gown.
Pericardial Fluid Analysis 1019
➤ Instruct the patient to cooperate fully recall and postprocedure interpreta-

and to follow directions. Direct the tion by the appropriate health care
patient to breathe normally and to practitioner.
avoid unnecessary movement dur-
ing the local anesthetic and the pro- Post-test:
cedure.
diet and medications, as directed by
tinue to monitor throughout the pro-
facility to facility. ➤ Monitor vital signs and cardiac status
every 15 minutes for the first hour,
every 30 minutes for the next 2
hours, every hour for the next 4
hours, and every 4 hours for the next
24 hours. Take the patient’s tempera-
ture every 4 hours for 24 hours.
Monitor intake and output for 24
hours. Notify the health care practi-
location.
tioner if temperature is elevated.
➤ Establish an IV line to allow infusion Protocols may vary from facility to
of IV fluids, anesthetics, analgesics, facility.
or IV sedation. ➤ Observe the patient for signs of res-
➤ Assist the patient into a comfortable piratory and cardiac distress, such as
supine position with the head ele- shortness of breath, cyanosis, or
vated 45 to 60. rapid pulse.
➤ Prior to the administration of local ➤ Continue IV fluids until vital signs are
anesthesia, cleanse the site with an stable and the patient can resume
antiseptic solution, and drape the fluid intake independently.
area with sterile towels. The skin at ➤ Inform the patient that 1 hour or
the injection site is then anes- more of bed rest is required after the
thetized. procedure.
➤ The precordial (V) cardiac lead wire is ➤ Assess the puncture site for bleed-
attached to the cardiac needle with ing or drainage and signs of inflam-
an alligator clip. The cardiac needle is mation each time vital signs are
inserted just below and to the left taken and daily thereafter for several
of the breastbone, and fluid is re- days. Report to health care practi-
moved. tioner if bleeding is present.
➤ Monitor vital signs every 15 minutes ➤ Assess for nausea and pain.
for signs of hypovolemia or shock. Administer antiemetic and analgesic
Monitor electrocardiogram for nee- medications as needed and as
dle-tip positioning to indicate acciden- directed by the health care practi-
tal puncture of the right atrium. tioner.
➤ The needle is withdrawn, and slight ➤ Administer antibiotics, as ordered,
pressure is applied to the site. Apply and instruct the patient in the im-
a sterile dressing to the site. portance of completing the entire
➤ Monitor the patient for complications course of antibiotic therapy even if
related to the procedure (e.g., aller- no symptoms are present.
gic reaction, anaphylaxis). ➤ A written report of the examina-
➤ Place samples in properly labeled tion will be completed by a health
specimen container, and promptly care practitioner specializing in this
transport the specimen to the labo- branch of medicine. The report will
ratory for processing and analysis. be sent to the requesting health care
➤ The results are recorded manually practitioner, who will discuss the
or in a computerized system for results with the patient.

results, and offer support. Discuss and determine the need for a change
the implications of abnormal test in therapy. Evaluate test results in
results on the patient’s lifestyle. relation to the patient’s symptoms
Provide teaching and information re- and other tests performed.
garding the clinical implications of the
test results, as appropriate. Educate Related laboratory tests:
seling services, if appropriate. ➤ Related laboratory tests include
aspartate aminotransferase, atrial
➤ Reinforce information given by the natriuretic peptide, bacterial culture,
patient’s health care provider regard- blood gases, B-type natriuretic pep-
ing further testing, treatment, or re- tide, CA 15–3, CA 19–9, CA 125,
ferral to another health care provider. carcinoembryonic antigen, creatine
Answer any questions or address kinase and isoenzymes, 1-fetopro-
any concerns voiced by the patient tein, fungal culture, homocysteine,
or family. lactate dehydrogenase and isoen-
➤ Depending on the results of this zymes, magnesium, mycobacterial
procedure, additional testing may be culture, myoglobin, troponin, and viral
performed to evaluate or monitor culture.
PERITONEAL FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Ascites fluid analysis.w

SPECIMEN: Peritoneal fluid (5 mL) collected in a red- or green-top
(heparin) tube for amylase, glucose, and alkaline phosphatase; lavender-
top (EDTA) tube for cell count; sterile containers for microbiology speci-
mens; 200 to 500 mL of fluid in a clear container with anticoagulant for
cytology. Ensure that there is an equal amount of fluid relative to fixative
in the container for cytology.
REFERENCE VALUE: (Method: Spectrophotometry for glucose, amylase, and

alkaline phosphatase; automated or manual cell count, macroscopic examina-
tion of cultured organisms, and microscopic examination of specimen for
microbiology and cytology; microscopic examination of cultured microor-
ganisms)
Peritoneal Fluid Reference Value

Appearance Clear
Color Pale yellow
Amylase Parallel serum values
Peritoneal Fluid Reference Value

Alkaline phosphatase Parallel serum values
Red blood cell count Less than 100,000/mm3
White blood cell count Less than 300/mm3
Culture No growth
Acid-fast stain No organisms seen
DESCRIPTION & RATIONALE: The Transudates are effusions that form as

peritoneal cavity and organs within it a result of a systemic disorder that
are lined with a protective membrane. disrupts the regulation of fluid bal-
The fluid between the membranes is ance, such as a suspected perforation.
called serous fluid. Normally only a Exudates are caused by conditions
small amount of fluid is present involving the tissue of the membrane
because the rates of fluid production itself, such as an infection or malig-
and absorption are about the same. nancy. Fluid is withdrawn from the
Many abnormal conditions can result peritoneal cavity by needle aspiration
in the buildup of fluid within the and tested as listed in the previous and
peritoneal cavity. Specific tests are following tables. ■
usually ordered in addition to a com-
mon battery of tests used to distin- INDICATIONS:
guish a transudate from an exudate. • Evaluate ascites of unknown cause

protein ratio
LDH ratio
White blood cell Less than 100/mm3 Greater than 1000/mm3
count
LDH lactate dehydrogenase.
• Investigate suspected peritoneal rup- • Abdominal malignancy (red blood cell

ture, perforation, malignancy, or infec- [RBC] count, carcinoembryonic anti-
tion gen, abnormal cytology)
• Abdominal trauma (RBC count greater
RESULT than 100,000/mm3)
Increased in (condition/test • Ascites caused by cirrhosis (white blood
showing increased result): cell [WBC] count, neutrophils greater
1021
than 25% but less than 50%, absolute effusion being produced and identify
granulocyte count greater than the cause of its accumulation.
250/mm3) ➤ Obtain a history of the patient’s
• Bacterial peritonitis (WBC count, neu- allergens (especially allergies or sen-
trophils greater than 50%, absolute sitivities to latex), and inform the
granulocyte count greater than appropriate health care practitioner
250/mm3) accordingly.
• Peritoneal effusion due to gastric ➤ Obtain a history of the patient’s gas-
strangulation, perforation, or necrosis trointestinal and immune systems,
(amylase, ammonia, alkaline phos- any bleeding disorders, and results
phatase) of previously performed laboratory
tests (especially bleeding time,
• Peritoneal effusion due to pancreatitis, complete blood count, partial throm-
pancreatic trauma, or pancreatic boplastin time, platelets, and pro-
pseudocyst (amylase) thrombin time), surgical procedures,
• Rupture or perforation of urinary blad- related laboratory tests, refer to
der (ammonia, creatinine, urea) the Gastrointestinal and Immune
• Tuberculous effusion (elevated lym- System tables.
phocyte count, positive acid-fast bacil- ➤ Note any recent procedures that can
lus smear and culture [25% to 50% of interfere with test results.
cases]) ➤ Record the date of the last menstrual
Decreased in (condition/test of pregnancy in perimenopausal
showing decreased result): women.
• Abdominal malignancy (glucose) ➤ Obtain a list of the medications the
patient is taking, including anti-
• Tuberculous effusion (glucose) coagulant therapy, acetylsalicylic
CRITICAL VALUES: and nutraceuticals, especially those
Note and immediately report to the known to affect coagulation. The
health care practitioner positive culture requesting health care practitioner
results, if ordered, and related symptoms. and laboratory should be advised if
the patient regularly uses these
INTERFERING FACTORS: products so that their effects can
• Bloody fluids may result from a trau- be taken into consideration when
matic tap. reviewing results.
• Unknown hyperglycemia or hypo- ➤ Review the procedure with the
patient. If patient has ascites, obtain
glycemia may be misleading in the
weight and measure abdominal
comparison of fluid and serum glucose girth. Inform the patient that it may
levels. Therefore, it is advisable to be necessary to shave the site
collect comparative serum samples a before the procedure. Address con-
few hours before performing para- cerns about pain related to the pro-
centesis. cedure. Explain that a sedative and/
or analgesia will be administered to
promote relaxation and reduce dis-
Nursing Implications and comfort prior to needle insertion
Procedure ● ● ● ● ● ● ● ● ● ● ●
through the abdomen wall. Explain
to the patient that any discomfort
with the needle insertion will be min-
Pretest:
imized with local anesthetics and
➤ Inform the patient that the test is pri- systemic analgesics. Explain that the
marily used to classify the type of anesthetic injection may cause an
Peritoneal Fluid Analysis 1023
initial stinging sensation. Explain patient to breathe normally and to

that, after the skin has been anes- avoid unnecessary movement during
thetized, a large needle will be the local anesthetic and the proce-
inserted through the abdominal wall dure.
and a “popping” sensation may be ➤ Observe standard precautions, and
experienced as the needle pene- follow the general guidelines in
trates the peritoneum. Inform the pa- Appendix A. Positively identify the
tient that specimen collection is patient, and label the appropriate col-
performed under sterile conditions lection containers with the corre-
by a health care practitioner special- sponding patient demographics,
izing in this procedure. The proce- date and time of collection, and site
dure usually takes approximately 30 location.
minutes to complete.
➤ Record baseline vital signs and con-
➤ Explain that an intravenous (IV) line tinue to monitor throughout the pro-
will be inserted to allow infusion of cedure. Protocols may vary from
IV fluids, antibiotics, anesthetics, and facility to facility.
analgesics.
➤ Establish an IV line to allow infusion
➤ Sensitivity to social and cultural of IV fluids, anesthetics, analgesics,
issues, as well as concern for mod- or IV sedation.
➤ Assist the patient to a comfortable
seated position with feet and
back supported or in high Fowler’s
➤ There are no food or fluid restric- position.
tions, unless by medical direction. ➤ Prior to the administration of local
The requesting health care practi- anesthesia, shave and cleanse the
tioner may request that anticoagu- site with an antiseptic solution, and
lants and aspirin be withheld. The drape the area with sterile towels.
amount of days to withhold medica- The skin at the injection site is then
tion is dependent on the type of anti- anesthetized.
coagulant.
➤ The paracentesis needle is inserted
➤ Make sure a written and informed 1 to 2 inches below the umbilicus,
consent has been signed prior to the and fluid is removed. If lavage fluid is
procedure and before administering required (helpful if malignancy is sus-
any medications. pected), saline or Ringer’s lactate
can be infused via the needle over a
Intratest: 15- to 20-minute period before the
lavage fluid is removed. Monitor vital
➤ Ensure that anticoagulant therapy signs every 15 minutes for signs of
has been withheld for the appropri- hypovolemia or shock.
ate amount of days prior to the
➤ No more than 1500 to 2000 mL of
procedure. Notify the health care
fluid should be removed at a time,
practitioner if patient anticoagulant
even in the case of a therapeutic
therapy has not been withheld.
paracentesis, because of the risk of
➤ Have emergency equipment readily hypovolemia and shock.
available. ➤ The needle is withdrawn, and slight
➤ Have the patient void or catheterize pressure applied to the site. Apply a
the patient to avoid accidental punc- sterile dressing to the site.
ture of the bladder if he or she is ➤ Monitor the patient for complications
unable to void. related to the procedure (e.g., aller-
➤ Have the patient remove clothing gic reaction, anaphylaxis).
and change into a gown for the pro- ➤ Place samples in properly labeled
cedure. specimen container, and promptly
➤ Instruct the patient to cooperate fully transport the specimen to the labo-
and to follow directions. Direct the ratory for processing and analysis.
➤ The results are recorded manually ➤ Administer antibiotics, as ordered,

or in a computerized system for and instruct the patient in the impor-
recall and postprocedure interpreta- tance of completing the entire
tion by the appropriate health care course of antibiotic therapy even if
practitioner. no symptoms are present.
Post-test: will be completed by a health care
➤ Instruct the patient to resume usual practitioner specializing in this
medications, as directed by the branch of medicine. The report will
health care practitioner. be sent to the requesting health care
➤ Monitor vital signs every 15 minutes
for the first hour, every 30 minutes
for the next 2 hours, every hour for ➤ Recognize anxiety related to test re-
the next 4 hours, and every 4 hours sults, and offer support. Discuss the
for the next 24 hours. Take the implications of abnormal test results
patient’s temperature every 4 hours on the patient’s lifestyle. Provide
for 24 hours. Monitor intake and out- teaching and information regarding
put for 24 hours. Notify the health the clinical implications of the test
care practitioner if temperature is results, as appropriate. Educate the
elevated. Protocols may vary from patient regarding access to counsel-
facility to facility. ing services, if appropriate.
➤ Assess the puncture site for bleed- ➤ Reinforce information given by the
ing or drainage and signs of inflam- patient’s health care provider regard-
mation each time vital signs are ing further testing, treatment, or re-
taken and daily thereafter for several ferral to another health care provider.
days. Report to health care practi- Answer any questions or address
tioner if bleeding is present. any concerns voiced by the patient
➤ If a large amount of fluid was or family.
removed, obtain weight and meas- ➤ Depending on the results of this pro-
ure abdominal girth. cedure, additional testing may be
➤ Inform the patient that 1 hour or performed to evaluate or monitor
more of bed rest is required after the progression of the disease process
procedure. and determine the need for a change
➤ Instruct the patient to immediately relation to the patient’s symptoms
report severe abdominal pain (note: and other tests performed.
rigidity of abdominal muscles indi-
cates developing peritonitis). Report
to health care practitioner if abdomi- Related laboratory tests:
nal rigidity or pain is present. ➤ Related laboratory tests include bac-
➤ Assess for nausea and pain. Admin- terial culture, CA 15-3, CA 19-9, CA
ister antiemetic and analgesic med- 125, carcinoembryonic antigen, fun-
ications as needed and as directed gal culture, mycobacterial culture,
by the health care practitioner. and viral culture.
Phosphorus, Blood 1025
PHOSPHORUS, BLOOD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Inorganic phosphorus, phosphate, PO4.

SI Units
0–5 d 4.6–8.0 mg/dL 1.5–2.6 mmol/L
1–3 y 3.9–6.5 mg/dL 1.3–2.1 mmol/L
4–6 y 4.0–5.4 mg/dL 1.3–1.7 mmol/L
7–11 y 3.7–5.6 mg/dL 1.2–1.8 mmol/L
12–13 y 3.3–5.4 mg/dL 1.1–1.7 mmol/L
14–15 y 2.9–5.4 mg/dL 0.9–1.7 mmol/L
16–19 y 2.8–4.6 mg/dL 0.9–1.5 mmol/L
Adult 2.5–4.5 mg/dL 0.8–1.4 mmol/L
DESCRIPTION & RATIONALE: Phos- phorus are interrelated with respect to

phorus, in the form of phosphate, is absorption and metabolic function.
distributed throughout the body. They have an inverse relationship
Approximately 85% of the body’s with respect to concentration: serum
phosphorus is stored in bones; the phosphorus is increased when serum
remainder is found in cells and body calcium is decreased. Hyperphos-
fluids. It is the major intracellular phatemia can result in an infant fed
anion and plays a crucial role in cellu- only cow’s milk during the first few
lar metabolism, maintenance of cellu- weeks of life because of the combina-
lar membranes, and formation of tion of a high phosphorus content
bones and teeth. Phosphorus also in cow’s milk and the inability of
indirectly affects the release of oxygen infants’ kidneys to clear the excess
from hemoglobin by affecting the for- phosphorus. ■
mation of 2,3-bisphosphoglycerate.
Levels of phosphorus are dependent INDICATIONS:
on dietary intake. • Assist in establishing a diagnosis of
Phosphorus excretion is regulated hyperparathyroidism
by the kidneys. Calcium and phos- • Assist in the evaluation of renal failure
RESULT • Respiratory alkalosis

• Respiratory infections
Increased in:
• Acromegaly • Rickets
• Bone metastases • Salicylate poisoning
• Diabetic ketoacidosis • Severe burns
• Excessive levels of vitamin D • Severe vomiting and diarrhea
• Hyperthermia • Vitamin D deficiency
• Hypocalcemia
CRITICAL VALUES:
• Hypoparathyroidism Values less than 1.0 mg/dL may
• Lactic acidosis have significant effects on the
neuromuscular, gastrointestinal,
• Milk alkali syndrome cardiopulmonary, and skeletal
systems.
• Pseudohypoparathyroidism
• Pulmonary embolism health care practitioner any critically
• Renal failure
symptoms. Interventions including intra-
• Respiratory acidosis venous (IV) replacement therapy with
sodium or potassium phosphate may be
Decreased in: necessary. Close monitoring of both
• Acute gout phosphorus and calcium is important
during replacement therapy.
• Alcohol withdrawal
• Gram-negative bacterial septicemia INTERFERING FACTORS:
• Drugs that may increase phosphorus
• Growth hormone deficiency
levels include anabolic steroids, -
• Hyperalimentation therapy adrenergic blockers, ergocalciferol,
furosemide, hydrochlorothiazide, me-
• Hypercalcemia
thicillin (occurs with nephrotoxicity),
• Hyperinsulinism oral contraceptives, parathyroid ext-
ract, phosphates, sodium etidronate,
• Hyperparathyroidism
tetracycline (occurs with nephrotoxic-
• Hypokalemia ity), and vitamin D.
• Impaired renal absorption • Drugs that may decrease phosphorus
levels include acetazolamide, albuterol,
• Malabsorption syndromes
aluminum salts, amino acids (via IV
• Malnutrition hyperalimentation), anesthetic agents,
anticonvulsants, calcitonin, epineph-
• Osteomalacia
rine, fibrin hydrolysate, fructose, gluco-
• Parathyroid hormone–producing corticoids, glucose, insulin, mannitol,
tumors oral contraceptives, pamidronate, phe-
nothiazine, phytate, and plicamycin.
• Primary hyperparathyroidism
• Serum phosphorus levels are subject to
• Renal tubular acidosis
diurnal variation: They are highest in
• Renal tubular defects late morning and lowest in the evening;
Phosphorus, Blood 1027
therefore, serial samples should be col- patient. Inform the patient that spec-
lected at the same time of day for con- imen collection takes approximately
sistency in interpretation. 5 to 10 minutes. Address concerns
• Hemolysis will falsely increase phos- Explain to the patient that there may
phorus values. be some discomfort during the
venipuncture.
• Specimens should never be collected ➤ There are no food, fluid, or medica-
above an IV line because of the poten- tion restrictions, unless by medical
tial for dilution when the specimen and direction.
the IV solution combine in the collec-
tion container, thereby falsely decreas- Intratest:
ing the result. There is also the
potential of contaminating the sample ➤ If the patient has a history of severe
with the substance of interest, if it is allergic reaction to latex, care should
present in the IV solution, thereby be taken to avoid the use of equip-
falsely increasing the result.
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to assist in the general evalua- tubes with the corresponding patient
tion of multiple body systems. demographics, date, and time of col-
endocrine, gastrointestinal, geni- analysis.
tourinary, and musculoskeletal sys- ➤ The results are recorded manually or
tems, as well as results of previously in a computerized system for recall
performed laboratory tests, surgi- and postprocedure interpretation by
cal procedures, and other diagnostic the appropriate health care practi-
procedures. For related labora- tioner.
tory tests, refer to the Endocrine,
Gastrointestinal, Genitourinary, and
Musculoskeletal System tables. Post-test:
nutritional supplements, and nutra- paper tape or other adhesive to
ceuticals. The requesting health care hold pressure bandage in place, or
practitioner and laboratory should be replace with a plastic bandage.
advised if the patient regularly uses ➤ Nutritional considerations: Severe
these products so that their effects hypophosphatemia is common in
can be taken into consideration elderly patients or patients who have
when reviewing results. been hospitalized for long periods of
➤ Review the procedure with the time. Good dietary sources of phos-
phorus include meat, dairy products, Answer any questions or address

nuts, and legumes. any concerns voiced by the patient
➤ Nutritional considerations: To or family.
decrease phosphorus levels to nor- ➤ Depending on the results of this pro-
mal in the patient with hyperphos- cedure, additional testing may be
phatemia, dietary restriction may be performed to evaluate or monitor
recommended. Other interventions progression of the disease process
may include the administration of and determine the need for a change
phosphate binders or administration in therapy. Evaluate test results in
of calcitriol (the activated form of relation to the patient’s symptoms
vitamin D). and other tests performed.
care practitioner, who will discuss ➤ Related laboratory tests include calci-
the results with the patient. tonin, calcium, collagen cross-linked
➤ Reinforce information given by the N-telopeptides, growth hormone,
patient’s health care provider regard- kidney stone analysis, osteocalcin,
ing further testing, treatment, or re- parathyroid hormones, urine phos-
ferral to another health care provider. phorus, and vitamin D.
PHOSPHORUS, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Urine phosphate.

REFERENCE VALUE: (Method: Spectrophotometry) Reference values are

dependent on phosphorus and calcium intake. Phosphate excretion exhibits
diurnal variation and is significantly higher at night.

0.4–1.3 g/24 h 12.9–42.0 g/24 h
DESCRIPTION & RATIONALE: Phos- phosphorus is stored in bones; the

phorus, in the form of phosphate, is remainder is found in cells and body
distributed throughout the body. fluids. It is the major intracellular
Approximately 85% of the body’s anion and plays a crucial role in cellu-
Phosphorus, Urine 1029
lar metabolism, maintenance of cellu- INTERFERING FACTORS:

lar membranes, and formation of • Drugs and vitamins that can cause an
bones and teeth. Phosphorus also increase in urine phosphorus levels
indirectly affects the release of oxygen include acetazolamide, acetylsalicylic
from hemoglobin by affecting the for- acid, alanine, bismuth salts, calcitonin,
corticosteroids, dihydrotachysterol,
mation of 2,3-bisphosphoglycerate.
glycine, hydrochlorothiazide, metola-
Levels of phosphorus are dependent zone, parathyroid extract, parathyroid
on dietary intake. hormone, phosphates, tryptophan,
Analyzing urinary phosphorus lev- valine, and vitamin D.
els can provide important clues to the
• Drugs that can cause a decrease in urine
functioning of the kidneys and other
phosphorus levels include aluminum-
major organs. Tests for phosphorus in containing antacids.
urine usually involve timed urine col-
lections over a 12- or 24-hour period. • Urine phosphorus levels are subject to
Measurement of random specimens diurnal variation: Output is highest in
may also be requested. Children with the afternoon, which is why 24-hour
urine collections are recommended.
thalassemia may have normal phos-
phorus absorption but increased • All urine voided for the timed collec-
excretion, which may result in a phos- tion period must be included in the
phorus deficiency. ■ collection or else falsely decreased val-
ues may be obtained. Compare output
INDICATIONS: records with volume collected to verify
• Assist in the diagnosis of hyperparathy- that all voids were included in the col-
roidism lection.
• Assist in the evaluation of calcium and
phosphorus balance
• Assist in the evaluation of nephroli- Procedure ● ● ● ● ● ● ● ● ● ● ●
thiasis
• Assist in the evaluation of renal tubular Pretest:
disease ➤ Inform the patient that the test is
used to evaluate calcium and phos-
RESULT phorus balance.
Increased in: plaints, including a list of known
• Abuse of diuretics allergens (especially allergies or sen-
• Primary hyperparathyroidism appropriate health care practitioner
• Renal tubular acidosis accordingly.
• Vitamin D deficiency endocrine and genitourinary sys-
tems, as well as results results of pre-
Decreased in: viously performed laboratory tests,
• Hypoparathyroidism surgical procedures, and other diag-
• Pseudohypoparathyroidism tory tests, refer to the Endocrine and
• Vitamin D intoxication Genitourinary System tables.
CRITICAL VALUES: N/A patient is taking, including herbs,
nutritional supplements, and nutra- ➤ If the patient has a history of severe

ceuticals. The requesting health care allergic reaction to latex, care should
practitioner and laboratory should be be taken to avoid the use of equip-
advised if the patient regularly uses ment containing latex.
these products so that their effects ➤ Instruct the patient to cooperate fully
can be taken into consideration and to follow directions.
➤ Review the procedure with the pa- follow the general guidelines in Ap-
tient. Provide a nonmetallic urinal, pendix A. Positively identify the
bedpan, or toilet-mounted collection patient, and label the appropriate
device. Address concerns about pain tubes with the corresponding patient
related to the procedure. Explain to demographics, date, and time of col-
the patient that there should be no lection.
➤ Usually a 24-hour time frame for Random specimen (collect
urine collection is ordered. Inform in early morning):
saved during that 24-hour period. Clean-catch specimen:
Instruct the patient not to void di-
rectly into the laboratory collection ➤ Instruct the male patient to (1) thor-
container. Instruct the patient to oughly wash his hands, (2) cleanse
avoid defecating in the collection the meatus, (3) void a small amount
device and to keep toilet tissue out into the toilet, and (4) void directly
of the collection device to prevent into the specimen container.
contamination of the specimen. ➤ Instruct the female patient to (1)
Place a sign in the bathroom to thoroughly wash her hands; (2)
remind the patient to save all urine. cleanse the labia from front to back;
➤ Instruct the patient to void all urine (3) while keeping the labia separated,
into the collection device and then to void a small amount into the toilet;
pour the urine into the laboratory col- and (4) without interrupting the urine
lection container. Alternatively, the stream, void directly into the speci-
specimen can be left in the collection men container.
Indwelling catheter:
tion container. ➤ Put on gloves. Empty drainage tube
➤ Sensitivity to social and cultural of urine. It may be necessary to
issues, as well as concern for mod- clamp off the catheter for 15 to 30
esty, is important in providing psy- minutes before specimen collection.
chological support before, during, Cleanse specimen port with antisep-
and after the procedure. tic swab, and then aspirate 5 mL of
➤ Instruct the patient to avoid exces- and syringe. Transfer urine to a ster-
sive exercise and stress during the ile container.
24-hour collection of urine.
➤ There are no food, fluid, or medica- Timed specimen:
tion restrictions, unless by medical ➤ Obtain a clean 3-L urine specimen
direction. container, toilet-mounted collection
Intratest: of the specimen container). The
➤ Ensure that the patient has complied specimen must be refrigerated or
with activity restrictions and pretest- kept on ice throughout the entire
ing preparations; assure that exces- collection period. If an indwelling uri-
sive exercise and stress have been nary catheter is in place, the drain-
restricted during the 24-hour proce- age bag must be kept on ice.
dure. ➤ Begin the test between 6 and 8 a.m.,
Phosphorus, Urine 1031
if possible. Collect first voiding and phosphorus. Vitamin D is added to

discard. Record the time the speci- food products such as milk, cheese,
men was discarded as the beginning and orange juice. The recommended
of the timed collection period. The daily intake of vitamin D is 200 IU
next morning, ask the patient to void per day.
at the same time the collection was ➤ Increased urine phosphorus levels
started and add this last voiding to may be associated with the forma-
the container. tion of kidney stones. Educate the
➤ If an indwelling catheter is in place, patient, if appropriate, on the impor-
replace the tubing and container sys- tance of drinking a sufficient amount
tem at the start of the collection of water when kidney stones are
time. Keep the container system on suspected.
ice during the collection period, or ➤ A written report of the examination
empty the urine into a larger con- will be sent to the requesting health
tainer periodically during the collec- care practitioner, who will discuss
tion period; monitor to ensure the results with the patient.
the test the next morning at the ➤ Recognize anxiety related to test
same hour the collection was begun. results. Discuss the implications
of abnormal test results on the pa-
➤ At the conclusion of the test, com- tient’s lifestyle. Provide teaching and
pare the quantity of urine with the information regarding the clinical
urinary output record for the collec- implications of the test results, as
tion; if the specimen contains less appropriate.
some urine may have been dis- ➤ Reinforce information given by the
carded, invalidating the test. patient’s health care provider regard-
➤ Include on the collection container’s ferral to another health care provider.
label the amount of urine, test start Answer any questions or address
and stop times, and ingestion of any any concerns voiced by the patient
foods or medications that can affect or family.
test results.
General: procedure, additional testing may be
➤ The results are recorded manually or relation to the patient’s symptoms
in a computerized system for recall and other tests performed.
tioner.
➤ Related laboratory tests include cal-
Post-test: citonin, blood and urine calcium,
kidney stone analysis, parathyroid
➤ Nutritional considerations: Vitamin D hormone, blood phosphorus, and
is necessary for the body to absorb urinalysis.
PLASMINOGEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Profibrinolysin, PMG.

REFERENCE VALUE: (Method: Chromogenic substrate) 80% to 120% of nor-
mal for plasma.

DESCRIPTION & RATIONALE: Plas-
minogen is a plasma glycoprotein. It is INTERFERING FACTORS: Drugs that may
the circulating, inactive precursor to decrease plasminogen levels include
plasmin. Damaged tissues release a streptokinase and urokinase.
substance called plasminogen activator
that initiates the conversion of plas-
minogen to plasmin. Plasmin partici-
pates in fibrinolysis and is capable of
Procedure ● ● ● ● ● ● ● ● ● ● ●
degrading fibrin, factor I (fibrinogen),
factor V, and factor VIII. (For more Pretest:
information on fibrin degradation, see
monograph titled “Fibrinogen.”) ■
is used to evaluate thrombotic dis-
orders and monitor thrombolytic
INDICATIONS: Evaluate the level of cir- therapy.
culating plasminogen in patients with
thrombosis or disseminated intravascular ➤ Obtain a history of the patient’s com-
coagulation (DIC)
RESULT appropriate health care practitioner
accordingly.
Increased in:
• Pregnancy (late) ➤ Obtain a history of the patient’s he-
matopoietic system and results of
Decreased in: previously performed laboratory
• DIC
• Fibrinolytic therapy with tissue plas- laboratory tests, refer to the Hema-
minogen activators such as streptoki- topoietic System table.
nase or urokinase ➤ Obtain a list of the medications the
• Hereditary deficiency patient is taking, including herbs,
• Liver disease ceuticals. The requesting health care
• Neonatal hyaline membrane disease
• Postsurgical period these products so that their effects
Plasminogen 1033
can be taken into consideration ulation testing is the only work to be

when reviewing results. done, an extra red-top tube should
➤ Review the procedure with the pa- be collected before the blue-top tube
tient. Inform the patient that speci- to avoid contaminating the specimen
men collection takes approximately with tissue thromboplastin, which
5 to 10 minutes. Address concerns can falsely decrease values.
about pain related to the procedure. ➤ Remove the needle, and apply a
Explain to the patient that there may pressure dressing over the puncture
be some discomfort during the site.
venipuncture. ➤ Promptly transport the specimen to
➤ There are no food, fluid, or medica- the laboratory for processing and
tion restrictions, unless by medical analysis. The CLSI recommendation
direction. for processed and unprocessed spec-
imens stored in unopened tubes is
Intratest: that testing should be completed
within 1 to 4 hours of collection.
➤ If the patient has a history of severe ➤ The results are recorded manually or
allergic reaction to latex, care should in a computerized system for recall
be taken to avoid the use of equip- and postprocedure interpretation by
ment containing latex. the appropriate health care practi-
➤ Instruct the patient to cooperate fully tioner.
avoid unnecessary movement. Post-test:
➤ Observe standard precautions and ➤ Observe venipuncture site for bleed-
follow the general guidelines in Ap- ing or hematoma formation. Apply
pendix A. Positively identify the paper tape or other adhesive to hold
patient and label the appropriate pressure bandage in place, or replace
tubes with the corresponding patient with a plastic bandage.
lect the specimen in a 5-mL blue-top care practitioner, who will discuss
tube. Important note: Two different the results with the patient.
concentrations of sodium citrate pre-
servative are currently added to blue- ➤ Reinforce information given by the
top tubes for coagulation studies: patient’s health care provider regard-
3.2% and 3.8%. The Clinical and ing further testing, treatment, or re-
Laboratory Standards Institute/CLSI ferral to another health care provider.
(formerly the National Committee Answer any questions or address
for Clinical Laboratory Standards/ any concerns voiced by the patient
NCCLS) guideline for sodium citrate or family.
is 3.2%. Laboratories establish refer- ➤ Depending on the results of this pro-
ence ranges for coagulation testing cedure, additional testing may be
based on numerous factors, includ- performed to evaluate or monitor
ing sodium citrate concentration, progression of the disease process
test equipment, and test reagents. It and determine the need for a change
is important to inquire from the labo- in therapy. Evaluate test results in
ratory which concentration it recom- relation to the patient’s symptoms
mends, because each concentration and other tests performed.
will have its own specific reference
range.
➤ When multiple specimens are
drawn, the blue-top tube should be ➤ Related laboratory tests include co-
collected after sterile (i.e., blood cul- agulation factors, fibrin degradation
ture) and red-top tubes. When coag- products, and fibrinogen.
PLATELET ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Antiplatelet antibody; platelet-bound IgG/IgM,

direct and indirect.
SPECIMEN: Serum (1 mL) collected in a red-top tube for indirect immuno-

globulin G (IgG) antibody. Whole blood (7 mL) collected in lavender-top
(EDTA) tube for direct antibody.
REFERENCE VALUE: (Method: Solid-phase hemagglutination and flow

cytometry) Negative.
INDICATIONS:
DESCRIPTION & RATIONALE: Platelet • Assist in the detection of platelet
antibodies can be formed by autoim- alloimmune disorders
mune response, or they can be
• Determine platelet type for refractory
acquired in reaction to transfusion patients
products. Platelet autoantibodies are
immunoglobulins of autoimmune RESULT
origin (i.e., immunoglobulin G), and
they are present in various autoim- Increased in:
mune disorders, including thrombo- • Acquired immunodeficiency syndrome
cytopenias. Platelet alloantibodies
• Acute myeloid leukemia
develop in patients who become sensi-
tized to platelet antigens of transfused • Idiopathic thrombocytopenic purpura
blood. As a result, destruction of both • Immune complex diseases
donor and native platelets occurs
• Multiple blood transfusions
along with a shortened survival time
of platelets in the transfusion recipi- • Multiple myeloma
ent. The platelet antibody detection • Neonatal immune thrombocytopenia
test is also used for platelet typing,
which allows compatible platelets to • Paroxysmal hemoglobinuria
be transfused to patients with disor- • Rheumatoid arthritis
ders such as aplastic anemia and can- • Systemic lupus erythematosus
cer. Platelet typing decreases the
alloimmunization risk resulting from • Thrombocytopenias provoked by drugs
repeated transfusions from random (see monograph titled “Platelet Count”)
donors. Platelet typing may also pro- Decreased in: N/A
vide additional support for a diagnosis
of post-transfusional purpura. ■ CRITICAL VALUES: N/A
Platelet Antibodies 1035
INTERFERING FACTORS: Hemolyzed or Intratest:

clotted specimens will affect results.
Procedure ● ● ● ● ● ● ● ● ● ● ●
used to evaluate thrombocytopenia. ➤ Observe standard precautions, and
➤ Obtain a history of the patient’s com- follow the general guidelines in Ap-
plaints, including a list of known pendix A. Positively identify the
allergens (especially allergies or sen- patient, and label the appropriate
sitivities to latex), and inform the tubes with the corresponding patient
appropriate health care practitioner demographics, date, and time of col-
accordingly. lection. Perform a venipuncture; col-
➤ Obtain a history of the patient’s and a 7-mL lavender-top tube.
hematopoietic and immune sys-
tems, a history of any bleeding dis- ➤ Remove the needle, and apply a pres-
orders, and results of previously sure dressing over the puncture site.
performed laboratory tests (espe- ➤ Promptly transport the specimen to
cially bleeding time, complete blood the laboratory for processing and
count, partial thromboplastin time, analysis.
prothrombin time, and platelets), sur- ➤ The results are recorded manually
gical procedures, and other diagnos- or in a computerized system for recall
tic procedures. For related laboratory and postprocedure interpretation by
tests, refer to the Hematopoietic and the appropriate health care practi-
Immune System tables. tioner.
patient is taking, including include Post-test:
anticoagulant therapy, acetylsalicylic ➤ Observe venipuncture site for bleed-
acid, herbs, nutritional supplements, ing or hematoma formation. Apply
and nutraceuticals, especially those paper tape or other adhesive to hold
known to affect coagulation. It is rec- pressure bandage in place, or re-
ommended that use be discontinued place with a plastic bandage.
cedures. The requesting health care ➤ Note the patient’s response to plate-
practitioner and laboratory should be let transfusions.
advised if the patient regularly uses ➤ Instruct the patient to report severe
these products so that their effects bruising or bleeding from any areas
can be taken into consideration of the skin or mucous membranes.
when reviewing results. ➤ Inform the patient who has devel-
➤ Review the procedure with the pa- oped platelet antibodies of the
tient. Inform the patient that speci- importance of taking precautions
men collection takes approximately against bruising and bleeding, includ-
5 to 10 minutes. Address concerns ing the use of a soft bristle tooth-
about pain related to the procedure. brush, use of an electric razor,
Explain to the patient that there may avoidance of constipation, avoidance
be some discomfort during the of acetylsalicylic acid and similar
venipuncture. products, and avoidance of intramus-
➤ There are no food, fluid, or medica- cular injections.
tion restrictions, unless by medical ➤ A written report of the examination
direction. will be sent to the requesting health
care practitioner, who will discuss performed to evaluate or monitor

the results with the patient. progression of the disease process
➤ Reinforce information given by the and determine the need for a change
patient’s health care provider regard- in therapy. Evaluate test results in
ing further testing, treatment, or re- relation to the patient’s symptoms
ferral to another health care provider. and other tests performed.
or family. ➤ Related laboratory tests include
➤ Depending on the results of this pro- bleeding time, clot retraction, and
cedure, additional testing may be platelet count.
PLATELET COUNT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Thrombocytes.
SPECIMEN: Whole blood from one full lavender-top (EDTA) tube.
REFERENCE VALUE: (Method: Automated, computerized multichannel
analyzers that sort and size cells on the basis of either changes in electrical
impedance or light pulses as the cells pass in front of a laser)
Age Platelet Count* Units 106) MPV (fL)
1–5 y 217–497 103/L 217–497 109/L 7.2–10.0
or 217,000–497,000/mm3
or 217–497 103/mm3
Adult 150–450 103/L 150–450 109/L 7.0–10.2
or 150,000–400,000/mm3
or 150–400 103/mm3
Note: Platelet counts decrease with age.
*Conventional units.
MPV mean platelet volume.
DESCRIPTION & RATIONALE: Platelets (megakaryocytes). Platelets have an

are non-nucleated, cytoplasmic, essential function in coagulation,
round or oval disks formed by bud- hemostasis, and blood thrombus for-
ding off of large, multinucleated cells mation. Thrombocytosis is an increase
Platelet Count 1037
in platelet count. In reactive thrombo- in MPV indicates an increase in

cytosis, the increase is transient and platelet turnover. Therefore, in a nor-
short lived, and it usually does not mal patient the platelet count and
pose a health risk. One exception may MPV have an inverse relationship.
be reactive thrombocytosis occurring Abnormal platelet size may also indi-
after coronary bypass surgery. This cate the presence of a disorder. MPV
circumstance has been identified as an and platelet distribution width (PDW)
important risk factor for postoperative are both increased in idiopathic
infarction and thrombosis. The term thrombocytopenic purpura. MPV
thrombocythemia is used to describe is also increased in May-Hegglin
platelet increases associated with anomaly, Bernard-Soulier syndrome,
chronic myeloproliferative disorders; myeloproliferative disorders, hyper-
thrombocytopenia is used to describe thyroidism, and pre-eclampsia. MPV
platelet counts of less than 140 is decreased in Wiskott-Aldrich syn-
103/L. Decreased platelet counts drome, septic thrombocytopenia, and
occur whenever the body’s need for hypersplenism. ■
platelets exceeds the rate of platelet
production; this circumstance will INDICATIONS:
arise if production rate decreases or • Confirm an elevated platelet count
platelet loss increases. The severity of (thrombocytosis), which can cause in-
bleeding is related to platelet count as creased clotting
well as platelet function. Platelet • Confirm a low platelet count (throm-
counts can be within normal limits, bocytopenia), which can be associated
but the patient may exhibit signs of with bleeding
internal bleeding; this circumstance • Identify the possible cause of abnormal
usually indicates an anomaly in bleeding, such as epistaxis, hematoma,
platelet function. Abnormal scatter- gingival bleeding, hematuria, and men-
plot findings by automated cell coun- orrhagia
ters may indicate the need to review a • Provide screening as part of a complete
smear of peripheral blood for platelet blood count in a general physical exam-
estimate. Abnormally large or giant ination, especially upon admission to a
platelets may result in underestima- health care facility or before surgery
tion of automated counts by 30% to
50%. A large discrepancy between the RESULT
automated count and the estimate
requires that a manual count be per- Increased in:
formed. • Acute infections
The significance of platelet sizing is • After exercise (transient)
becoming more widely known, as
modern cell counters are capable of • Anemias (posthemorrhagic, hemolytic,
iron-deficiency)
reporting platelet indexes that are anal-
ogous to red blood cell (RBC) indices. • Chronic heart disease
Platelet size, reflected by mean platelet • Cirrhosis
volume (MPV), and cellular age are
inversely related; that is, younger • Essential thrombocythemia
platelets tend to be larger. An increase • Leukemias (chronic)
• Malignancies (carcinoma, Hodgkin’s, • Metastatic carcinoma

lymphomas)
• Myelofibrosis
• Pancreatitis (chronic)
Increased destruction in
• Polycythemia vera (as a result of increased
• Rebound recovery from thrombocy- loss/consumption):
topenia • Contact with foreign surfaces (dialysis
membranes, artificial organs, grafts,
• Rheumatic fever (acute) prosthetic devices)
• Rheumatoid arthritis • Disseminated intravascular coagulation
• Splenectomy (2 months postproce- • Extensive transfusion
dure)
• Severe hemorrhage
• Surgery (2 weeks postprocedure)
• Thrombotic thrombocytopenic pur-
• Trauma pura
• Tuberculosis • Uremia
• Ulcerative colitis
Increased destruction in (as a
Decreased in (as a result result of immune reaction):
of megakaryocytic • Antibody/human leukocyte antigen
hypoproliferation): reactions
• Alcohol toxicity • Hemolytic disease of the newborn (tar-
• Aplastic anemia get is platelets instead of RBCs)
• Congenital states (Fanconi’s syndrome, • Idiopathic thrombocytopenic purpura
May Hegglin anomaly, Bernard-Soulier • Refractory reaction to platelet trans-
syndrome, Wiskott-Aldrich syndrome, fusion
Gaucher’s disease, Chédiak-Higashi
syndrome) Increased destruction in
(as a result of immune
• Drug toxicity reaction secondary to infection):
• Prolonged hypoxia • Bacterial infections
• Burns
Decreased in (as a result of
ineffective thrombopoiesis): • Congenital infections (cytomega-
• Ethanol abuse without malnutrition lovirus, herpes, syphilis, toxoplasmosis)
• Iron-deficiency anemia • Histoplasmosis
• Megaloblastic anemia (B12/folate defi- • Malaria
ciency) • Rocky Mountain spotted fever
• Paroxysmal nocturnal hemoglobinuria
Increased destruction in
• Thrombopoietin deficiency (as a result of other causes):
• Viral infection • Radiation
• Splenomegaly caused by liver disease
Decreased in (as a result
of bone marrow replacement):
CRITICAL VALUES:
• Lymphoma Less than 50,000 103/L (or 50
• Granulomatous infections 103/mm3 or 50,000/mm3)
Platelet Count 1039
Greater than 1,000 103/L (or • Leaving the tourniquet in place for
1,000,000/mm3) longer than 60 seconds can affect the
Note and immediately report to the results.
• Traumatic venipunctures may lead to
erroneous results as a result of activa-
symptoms. Possible interventions for
tion of the coagulation sequence.
decreased platelet count may include
transfusion of platelets. • Failure to fill the tube sufficiently (i.e.,
tube less than three-quarters full) may
INTERFERING FACTORS: yield inadequate sample volume for
• Drugs that may decrease platelet counts automated analyzers and may be a rea-
include acetohexamide, acetophena- son for specimen rejection.
zine, amphotericin B, antazoline, anti-
convulsants, antimony compounds, • Hemolysis or clotted specimens are rea-
apronalide, arsenicals, azathioprine, sons for rejection.
barbiturates, benzene, busulfan, buta- • Complete blood count should be care-
perazine, chlordane, chlorophenothane, fully evaluated after transfusion or
chlortetracycline, dactinomycin, dex- acute blood loss because the value may
tromethorphan, diethylstilbestrol, appear to be normal.
ethinamate, ethoxzolamide, floxuri-
dine, hexachlorobenzene, hydantoin • A white blood cell count greater than
derivatives, hydroflumethiazide, hydro- 100,000/mm3, severe RBC fragmenta-
xychloroquine, iproniazid, mechlo- tion, and extraneous particles in the
rethamine, mefenamic acid, mepazine, fluid used to dilute the sample can alter
miconazole, mitomycin, nitrofuran- test results.
toin, novobiocin, nystatin, phenolph-
thalein, phenothiazine, pipamazine,
plicamycin, procarbazine, pyrazolo- Nursing Implications and
nes, streptomycin, sulfonamides, tetra- Procedure
cycline, thiabendazole, thiouracil,
tolazamide, tolazoline, tolbutamide, tri- Pretest:
fluoperazine, and urethane. ➤ Inform the patient that the test is
• Drugs that may increase platelet counts used to evaluate, diagnose, and mon-
include glucocorticoids. itor bleeding disorders.
• X-ray therapy may also decrease plate-
let counts. allergens (especially allergies or sen-
• The results of blood counts may vary sitivities to latex), and inform the
depending on the patient’s position. appropriate health care practitioner
Platelet counts can decrease when the accordingly.
patient is recumbent, as a result of ➤ Obtain a history of the patient’s he-
hemodilution, and can increase when matopoietic and immune systems, a
the patient rises, as a result of hemo- history of any bleeding disorders,
concentration. and results of previously performed
laboratory tests (especially bleeding
• Platelet counts normally increase under time, complete blood count, partial
a variety of stressors, such as high alti- thromboplastin time, prothrombin
tudes or strenuous exercise. time, and platelets), surgical proce-
dures, and other diagnostic proce-
• Platelet counts are normally decreased dures. For related laboratory tests,
before menstruation and during preg- refer to the Hematopoietic and
nancy. Immune System tables.
➤ Note any recent procedures that can at room temperature or within 24

interfere with test results. hours if stored at refrigerated tem-
➤ Obtain a list of the medications the perature. If it is anticipated the spec-
patient is taking, including antico- imen will not be analyzed within 4 to
agulant therapy, acetylsalicylic acid, 6 hours, two blood smears should be
herbs, nutritional supplements, and made immediately after the veni-
nutraceuticals, especially those puncture and submitted with the
known to affect coagulation. It is rec- blood sample.
ommended that use be discontinued ➤ Remove the needle, and apply a
14 days before dental or surgical pro- pressure dressing over the puncture
cedures. The requesting health care site.
advised if the patient regularly uses ➤ Promptly transport the specimen to
these products so that their effects the laboratory for processing and
can be taken into consideration analysis.
when reviewing results. ➤ The results are recorded manually or
patient. Inform the patient that spec- and postprocedure interpretation by
imen collection takes approximately the appropriate health care practi-
5 to 10 minutes. Address concerns tioner.
Explain to the patient that there may Post-test:
be some discomfort during the ➤ Observe venipuncture site for bleed-
venipuncture. ing or hematoma formation. Apply
➤ Sensitivity to social and cultural paper tape or other adhesive to hold
issues, as well as concern for mod- pressure bandage in place, or replace
esty, is important in providing psy- with a plastic bandage.
➤ Instruct the patient to report bleed-
ing from any areas of the skin or
➤ There are no food, fluid, or medica- mucous membranes.
direction. ➤ Inform the patient with a decreased
platelet count of the importance of
Intratest: taking precautions against bruising
and bleeding, including the use of a
➤ If the patient has a history of severe soft bristle toothbrush, use of an
allergic reaction to latex, care should electric razor, avoidance of constipa-
be taken to avoid the use of equip- tion, avoidance of acetylsalicylic acid
ment containing latex. and similar products, and avoidance
➤ Instruct the patient to cooperate fully of intramuscular injections.
and to follow directions. Direct the ➤ Inform the patient of the importance
patient to breathe normally and to of periodic laboratory testing if he or
avoid unnecessary movement. she is taking an anticoagulant.
➤ Observe standard precautions, and ➤ Nutritional considerations: Instruct
follow the general guidelines in patients to consume a variety of
Appendix A. Positively identify the foods within the basic food groups,
patient, and label the appropriate maintain a healthy weight, be physi-
tubes with the corresponding patient cally active, limit salt intake, limit
demographics, date, and time of alcohol intake, and be a nonsmoker.
collect the specimen in a 5-mL laven-
der-top tube. The specimen should
be mixed gently by inverting the tube
10 times. The specimen should be
analyzed within 6 hours when stored ➤ Recognize anxiety related to test
Plethysmography 1041
results. Discuss the implications of performed to evaluate or monitor

abnormal test results on the progression of the disease process
patient’s lifestyle. Provide teaching and determine the need for a change
and information regarding the clinical in therapy. Evaluate test results in
implications of the test results, as relation to the patient’s symptoms
appropriate. and other tests performed.
ing further testing, treatment, or re- ➤ Related laboratory tests include
ferral to another health care provider. antiarrhythmic drugs (quinidine),
Answer any questions or address bleeding time, clot retraction, com-
any concerns voiced by the patient plete blood count, platelet antibod-
or family. ies, RBC morphology and inclusions,
➤ Depending on the results of this pro- and white blood cell count and differ-
cedure, additional testing may be ential.
PLETHYSMOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Impedance plethysmography, PVR.

AREA OF APPLICATION: Veins, arteries, and lungs.
CONTRAST: Done without contrast.
DESCRIPTION & RATIONALE: Ple- parison of results. The test is per-

thysmography is a noninvasive diag- formed by applying a series of three
nostic manometric study used to blood pressure cuffs to the extremity.
measure changes in the size of blood The amplitude of each pulse wave is
vessels by determining volume then recorded.
changes in the blood vessels of the eye, Venous plethysmography, done with a
extremities, and neck; or to measure series of cuffs, measures changes in
gas volume changes in the lungs. venous capacity and outflow (volume
Arterial plethysmography assesses and rate of outflow); it is used to diag-
arterial circulation in an upper or nose a thrombotic condition that
lower limb; it is used to diagnose causes obstruction of the major veins
extremity arteriosclerotic disease and of the extremity. When the cuffs are
to rule out occlusive disease. The test applied to an extremity in patients
requires a normal extremity for com- with venous obstruction, no initial
Venous Plethysmography:
increase in leg volume is recorded
because the venous volume of the leg • Detect partial or total venous throm-
botic obstruction
cannot dissipate quickly.
Body plethysmography measures the • Determine valve competency in con-
total amount (volume) of air within junction with Doppler ultrasonogra-
the thorax, whether or not the air is in phy in the diagnosis of varicose veins
ventilatory communication with the
Body Plethysmography:
lung; the elasticity (compliance) of the
• Detect acute pulmonary disorders,
lungs; and the resistance to airflow in
such as atelectasis
the respiratory tree. It is used in con-
junction with pulmonary stress testing • Detect or determine the status of
and pulmonary function testing. chronic obstructive pulmonary disease
Impedance plethysmography is widely (COPD), such as emphysema, asthma,
or chronic bronchitis
used to detect acute deep vein throm-
bosis (DVT) of the leg, but it can also • Detect or determine the status of
be used in the arm, abdomen, neck, or restrictive pulmonary disease, such as
thorax. Doppler flow studies now are fibrosis
used to identify DVT, but ultrasound • Detect infectious pulmonary diseases,
studies are less accurate in examina- such as pneumonia
tions below the knee. ■ • Determine baseline pulmonary status
before pulmonary rehabilitation to
INDICATIONS determine potential therapeutic benefit
Arterial Plethysmography: • Differentiate between obstructive and
• Confirm suspected acute arterial restrictive pulmonary pathology
embolization Impedance Plethysmography:
• Detect vascular changes associated with • Act as a diagnostic screen for patients at
Raynaud’s phenomenon and disease risk for DVT
• Determine changes in toe or finger • Detect and evaluate DVT
pressures when ankle pressures are ele-
vated as a result of arterial calcifications • Evaluate degree of resolution of DVT
after treatment
• Determine the effect of trauma on the
arteries in an extremity • Evaluate patients with suspected pul-
monary embolism (most pulmonary
• Determine peripheral small-artery emboli are complications of DVT in
changes (ischemia) caused by diabetes, the leg)
and differentiate these changes from
neuropathy RESULT
• Evaluate suspected arterial occlusive Normal Findings:
disease • Arterial plethysmography:
• Locate and determine the degree of Normal arterial pulse waves: steep
arterial atherosclerotic obstruction and upslope, more gradual downs-
vessel patency in peripheral atheroscle- lope with narrow pointed peaks
rotic disease, as well as inflammatory Normal pressure: less than 20 mm
changes causing obliteration in the ves- Hg systolic difference between
sels in thromboangiitis obliterans the lower and upper extremities;
toe pressure greater than or because the nicotine constricts the

equal to 80% of ankle pres- arteries
sure, and finger pressure grea-
ter than or equal to 80% of • Alcohol consumption
wrist pressure
• Low cardiac output
• Venous plethysmography:
• Shock
Normal venous blood flow in the
extremities • Compression of pelvic veins (tumors or
Venous filling times greater than external compression by dressings)
20 seconds
• Environmental temperatures (hot or
• Body plethysmography: cold)
Thoracic gas volume: 2400 mL
• Arterial occlusion proximal to the
Compliance: 0.2 L/cm H2O extremity to be examined, which can
Airway resistance: 0.6 to 2.5 cm prevent blood flow to the limb
H2O/L per second
• Impedance plethysmography: Venous Plethysmography:
Sharp rise in volume with
temporary occlusion Factors that may impair
Rapid venous outflow with release
of the occlusion • Low environmental temperature or
cold extremity, which constricts the
Abnormal Findings:
vessels
• COPD, restrictive lung disease, lung • High anxiety level or muscle tenseness
infection, or atelectasis (body plethys-
mography) • Venous thrombotic occlusion proximal
to the extremity to be examined, which
• DVT (arterial, venous, or impedance can affect blood flow to the limb
plethysmography)
• Incompetent valves, thrombosis, or Body Plethysmography:
thrombotic obstruction in a major vein
in an extremity Factors that may impair
• Small-vessel diabetic changes • Inability of the patient to follow
• Vascular disease (Raynaud’s phenome- breathing instructions during the pro-
non) cedure
• Vascular trauma
Impedance Plethysmography:
CRITICAL VALUES: N/A Factors that may impair
INTERFERING FACTORS • Movement of the extremity during
electrical impedance recording, poor
Arterial Plethysmography: electrode contact, or nonlinear electri-
cal output, which can cause false-
positive impedance plethysmography
results
• Cigarette smoking 2 hours before the
study, which causes inaccurate results • Constricting clothing or bandages
tioning, and activity before and dur-

Nursing Implications and ing the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ For body plethysmography, record
the patient’s weight, height, and
Pretest: gender. Determine whether the
➤ Inform the patient that the test is patient is claustrophobic.
used to measure changes in blood ➤ Sensitivity to cultural and social
vessel size or changes in gas volume issues, as well as concern for mod-
in the lungs. esty, is important in providing psy-
diovascular system, including signs
and symptoms of vascular disorders, ➤ The patient should refrain from
known or suspected peripheral vas- smoking for 2 hours prior to the pro-
cular disease (for arterial and vascu- cedure.
lar plethysmography), known or ➤ There are no food, fluid, or medica-
suspected diseases of the pul- tion restrictions, unless by medical
monary system (for body plethys- direction.
mography), and signs or symptoms
of DVT or circulatory changes (for
impedance plethysmography), as
Intratest:
well as results of previously per- ➤ Ensure that the patient has refrained
formed diagnostic procedures, surgi- from smoking for 2 hours before the
cal procedures, and laboratory tests. procedure.
For related diagnostic tests, refer to
➤ Ask the patient to notify medical per-
the Cardiovascular System table.
sonnel if he or she has ill effects
➤ Record the date of the last menstrual or unexpected symptoms during
period and determine the possibility the test.
women.
➤ Obtain a list of the medications the to void prior to the procedure.
patient is taking. ➤ Obtain and record baseline vital signs.
➤ Review the procedure with the ➤ Observe standard precautions, and
patient. Explain the purpose of the follow the general guidelines in
test and how the procedure is per- Appendix A.
formed. Address concerns about
to the patient that no discomfort will Arterial plethysmography:
be experienced during the test. For ➤ Explain to the patient that cuffs are
body plethysmography, explain that applied to the extremity to measure
the procedure measures the amount and compare blood flow.
of air contained in the chest, the elas- ➤ Explain to the patient that it is essen-
ticity of the lungs, and the occur- tial to remain still during the proce-
rence of restrictive breathing in the dure.
bronchioles. Explain that there may
be some discomfort during insertion ➤ Place the patient in a semi-Fowler
of the nasoesophageal catheter if position on an examining table or
compliance testing is done. Inform in bed.
the patient that the procedure is ➤ Apply three blood pressure cuffs to
generally performed in a specialized the extremity and attach a pulse vol-
area or at the bedside, by a technol- ume recorder (plethysmograph),
ogist, and usually takes 30 to 60 which records the amplitude of each
minutes. pulse wave.
➤ Assess the patient’s ability to comply ➤ Inflate the cuffs to 65 mm Hg to
with directions given for rest, posi- measure the pulse waves of each
cuff. When compared with a normal ➤ For compliance testing, a double-

limb, these measurements deter- lumen nasoesophageal catheter is
mine the presence of arterial occlu- inserted, and the bag is inflated
sive disease. with air. Intraesophageal pressure is
recorded during normal breathing.
Venous plethysmography:
➤ Explain to the patient that cuffs are Impedance plethysmography:
applied to the extremity to measure ➤ Explain to the patient that cuffs are
and compare blood flow. applied to the extremity to measure
➤ Explain to the patient that it is essen- and compare blood flow.
tial to remain still during the pro- ➤ Place the patient on his or her back
cedure. with the leg being tested above the
➤ Place the patient in a semi-Fowler heart level.
position on an examining table or ➤ Flex the patient’s knee slightly, and
in bed. rotate the hips by shifting weight to
➤ Apply two blood pressure cuffs to the same side as the leg being
the extremity, one on the proximal tested.
part of the extremity (occlusion cuff) ➤ Apply conductive gel and electrodes
and the other on the distal part of to the legs, near the cuffs.
the extremity (recorder cuff). Attach
a third cuff to the pulse volume ➤ Apply a blood pressure cuff to the
recorder. thigh.
➤ Inflate the recorder cuff to 10 mm ➤ Inflate the pressure cuff attached to
Hg, and evaluate the effects of respi- the thigh temporarily to occlude
ration on venous volume: Absence venous return without interfering
of changes during respirations indi- with arterial blood flow. Expect the
cates venous thrombotic occlusion. blood volume in the other calf to
➤ Inflate the occlusion cuff to 50 mm increase.
Hg, and record venous volume on ➤ A tracing of changes in electrical
the pulse monitor. Deflate the occlu- impedance occurring during inflation
sion cuff after the highest volume and for 15 seconds after cuff defla-
is recorded in the recorder cuff. A tion is recorded.
delay in the return to preocclusion ➤ With DVT, blood volume increases
volume indicates venous thrombotic less than expected because the
occlusion. veins are already at capacity.
Body plethysmography:
Post-test:
➤ Place the patient in a sitting position
on a chair in the body box. Explain to ➤ Remove conductive gel and elec-
the patient that the cuffs are applied trodes, as applied.
to the extremities to measure and ➤ Instruct the patient to resume usual
compare blood flow. activity and diet, as directed by the
➤ Position a nose clip to prevent health care practitioner.
breathing through the nose, and con- ➤ Note severe ischemia, ulcers, and
nect a mouthpiece to a measuring pain of the extremity after arterial,
instrument. venous, or impedance plethysmogra-
➤ Ask the patient to breathe through phy, and handle the extremity gently.
the mouthpiece. ➤ Note respiratory pattern after body
➤ Close the door to the box, and record plethysmography, and allow the
the start time of the procedure. At patient time to resume a normal
the beginning of the study, ask the breathing pattern. Monitor vital signs
patient to pant rapidly and shallowly, every 15 minutes until they return to
without allowing the glottis to close. baseline levels.
➤ A written report of the examina- cedure, additional testing may be

tion will be completed by a health needed to evaluate or monitor pro-
care practitioner specializing in this gression of the disease process and
branch of medicine. The report will determine the need for a change in
be sent to the requesting health care therapy. Evaluate test results in rela-
practitioner, who will discuss the re- tion to the patient’s symptoms and
sults with the patient. other tests performed.
patient’s health care provider regard- Related diagnostic tests:
computed tomography angiography,
echocardiography, magnetic reso-
nance angiography, and ultrasound
or family.
arterial and venous Doppler of the
➤ Depending on the results of this pro- extremities.
PLEURAL FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Thoracentesis fluid analysis.

SPECIMEN: Pleural fluid (5 mL) collected in a green-top (heparin) tube for
amylase, cholesterol, glucose, lactate dehydrogenase (LDH), pH, protein,
and triglycerides; lavender-top (EDTA) tube for cell count; sterile containers
for microbiology specimens; 200 to 500 mL of fluid in a clear container
with anticoagulant for cytology. Ensure that there is an equal amount of fixa-
tive and fluid in the container for cytology.
REFERENCE VALUE: (Method: Spectrophotometry for amylase, cholesterol,

glucose, LDH, protein, and triglycerides; ion-selective electrode for pH;
automated or manual cell count; macroscopic and microscopic examination
of cultured microorganisms; microscopic examination of specimen for
microbiology and cytology.)
Pleural Fluid Reference Value

Appearance Clear
Color Pale yellow
Amylase Parallel serum values
Cholesterol Parallel serum values
LDH Less than 200 U/L
Pleural Fluid Analysis 1047
Pleural Fluid Reference Value

Fluid LDH–to–serum LDH ratio 0.6 or less
Protein 3.0 g/dL
Fluid protein–to–serum protein ratio 0.5 or less
Triglycerides Parallel serum values
pH 7.37–7.43
RBC count Less than 1000/mm3
WBC count Less than 1000/mm3
Culture No growth
LDH lactate dehydrogenase; RBC red blood cell; WBC white blood cell.
DESCRIPTION & RATIONALE: The tery of tests used to distinguish a tran-

pleural cavity and organs within it are sudate from an exudate. Transudates
lined with a protective membrane. are effusions that form as a result of a
The fluid between the membranes is systemic disorder that disrupts the
called serous fluid. Normally only a regulation of fluid balance, such as a
small amount of fluid is present suspected perforation. Exudates are
because the rates of fluid production caused by conditions involving the tis-
and absorption are about the same. sue of the membrane itself, such as an
Many abnormal conditions can result infection or malignancy. Fluid is with-
in the buildup of fluid within the drawn from the pleural cavity by nee-
pleural cavity. Specific tests are usually dle aspiration and tested as listed in
ordered in addition to a common bat- the previous and following tables. ■

Fluid protein–to–
serum protein ratio Less than 0.5 Greater than 0.5
Fluid LDH–to–serum
LDH ratio Less than 0.6 Greater than 0.6
WBC count Less than 100/mm3 Greater than 1000/mm3
LDH lactate dehydrogenase; WBC white blood cell.
INDICATIONS: RESULT:
• Differentiate transudates from exudates • Bacterial or tuberculous empyema: Red
blood cell (RBC) count 5000/mm3,
• Evaluate effusion of unknown cause
white blood cell (WBC) count 25,000
• Investigate suspected rupture, immune to 100,000/mm3 with a predominance
disease, malignancy, or infection of neutrophils, increased fluid protein–
to–serum protein ratio, increased fluid stain and culture, increased protein,
LDH–to–serum LDH ratio, decreased decreased glucose, pH less than 7.3
glucose, pH less than 7.3
• Rheumatoid disease: Normal RBC
• Chylous pleural effusion: Marked in- count, WBC count 1000 to 20,000/
crease in both triglycerides (two to mm3 with a predominance of either
three times serum level) and chylomi- lymphocytes or neutrophils, pH less
crons than 7.3, decreased glucose, increased
• Effusion caused by pneumonia: RBC fluid protein–to–serum protein ratio,
count less than 5000/mm3, WBC increased fluid LDH–to–serum LDH
count 5000 to 25,000/mm3 with a pre- ratio, increased immunoglobulins
dominance of neutrophils and some • Systemic lupus erythematosus: Similar
eosinophils, increased fluid protein– findings as with rheumatoid disease,
to–serum protein ratio, increased fluid except that glucose is usually not
LDH–to–serum LDH ratio, pH less decreased
than 7.4 (and decreased glucose if bac-
terial pneumonia) CRITICAL VALUES:
• Esophageal rupture: Significantly de- Note and immediately report to the
creased pH (6.0) and elevated amylase health care practitioner positive culture
results, if ordered, and related symptoms.
• Hemothorax: Bloody appearance, in-
creased RBC count, elevated hematocrit INTERFERING FACTORS:
• Malignancy: RBC count 1000 to
• Bloody fluids may be the result of a
100,000/mm3, WBC count 5000 to
traumatic tap.
10,000/mm3 with a predominance
of lymphocytes, abnormal cytology, • Unknown hyperglycemia or hypo-
increased fluid protein–to–serum pro- glycemia may be misleading in the
tein ratio, increased fluid LDH– comparison of fluid and serum glucose
to–serum LDH ratio, deceased glucose, levels. Therefore, it is advisable to col-
pH less than 7.3 lect comparative serum samples a few
• Pancreatitis: RBC count 1000 to hours before performing thoracentesis.
10,000/mm3, WBC count 5000 to
20,000/mm3 with a predominance of
neutrophils, pH greater than 7.3, Nursing Implications and
increased fluid protein–to–serum pro- Procedure ● ● ● ● ● ● ● ● ● ● ●
tein ratio, increased fluid LDH–to–

serum LDH ratio, increased amylase Pretest:
• Pulmonary infarction: RBC count ➤ Inform the patient that the test is pri-
10,000 to 100,000/mm3, WBC count marily used to classify the type of
5000 to 15,000/mm3 with a predomi- effusion being produced and identify
nance of neutrophils, pH greater than the cause of its accumulation.
7.3, normal glucose, increased fluid ➤ Obtain a history of the patient’s
protein–to–serum protein ratio, and complaints, including a list of known
increased fluid LDH–to–serum LDH allergens (especially allergies or sen-
ratio.
• Pulmonary tuberculosis: RBC count accordingly.
10,000/mm3, WBC count 5000 to ➤ Obtain a history of the patient’s
10,000/mm3 with a predominance of immune and reproductive systems,
lymphocytes, positive acid-fast bacillus any bleeding disorders, and results of
Pleural Fluid Analysis 1049
previously performed laboratory tests ➤ Explain that an intravenous (IV) line

(especially bleeding time, complete will be inserted to allow infusion of
blood count, partial thromboplastin IV fluids, antibiotics, anesthetics, and
time, platelets, and prothrombin analgesics.
time), surgical procedures, and other ➤ Sensitivity to social and cultural
diagnostic procedures. For related issues, as well as concern for mod-
laboratory tests, refer to the Immune esty, is important in providing psy-
and Reproductive System tables. chological support before, during,
➤ Note any recent procedures that can and after the procedure.
interfere with test results. ➤ There are no food or fluid restric-
➤ Record the date of the last menstrual tions, unless by medical direction.
period and determine the possibility The requesting health care practi-
of pregnancy in perimenopausal tioner may request that anticoagu-
women. lants and aspirin be withheld. The
amount of days to withhold medica-
➤ Obtain a list of medications the tion is dependent on the type of anti-
patient is taking, including anticoagulant.
acid, herbs, nutritional supplements, ➤ Make sure a written and informed
and nutraceuticals, especially those consent has been signed prior to the
known to affect coagulation. The procedure and before administering
requesting health care practitioner any medications.
the patient regularly uses these Intratest:
products so that their effects can be
➤ Ensure that anticoagulant therapy
taken into consideration when re-
has been withheld for the appropri-
viewing results.
ate amount of days prior to the pro-
➤ Review the procedure with the pa- cedure. Notify the health care
tient. Inform the patient that it may practitioner if patient anticoagulant
be necessary to shave the site therapy has not been withheld.
before the procedure. Discuss with
the patient that the requesting
available. Keep resuscitation equip-
health care practitioner may request
ment on hand in the case of respira-
that a cough suppressant be given
tory impairment or laryngospasm
before the thoracentesis. Address
concerns about pain related to the
procedure. Explain that a sedative ➤ Avoid using morphine sulfate in
and/or analgesia will be administered those with asthma or other pul-
to promote relaxation and reduce monary disease. This drug can fur-
discomfort prior to needle insertion ther exacerbate bronchospasms and
through the chest wall into the pleu- respiratory impairment.
ral space. Explain to the patient that ➤ Have the patient remove clothing
any discomfort with the needle and change into a gown for the pro-
insertion will be minimized with cedure.
local anesthetics and systemic
analgesics. Explain that the local ➤ Instruct the patient to cooperate fully
anesthetic injection may cause an and to follow directions. Direct the
initial stinging sensation. Meperidine patient to breathe normally and to
(Demerol) or morphine may be given avoid unnecessary movement dur-
as a sedative. Inform the patient that ing the local anesthetic and the pro-
the needle insertion is performed cedure.
under sterile conditions by a health ➤ Observe standard precautions, and
care practitioner specializing in this follow the general guidelines in
procedure. The procedure usually Appendix A. Positively identify the
takes about 20 minutes to complete. patient, and label the appropriate
collection containers with the corre- ➤ Observe the patient for signs of res-
sponding patient demographics, piratory distress or skin color changes.
date and time of collection, and site ➤ Observe the thoracentesis site
location. for bleeding, inflammation, or hema-
➤ Record baseline vital signs and con- toma formation each time vital signs
tinue to monitor throughout the pro- are taken and daily thereafter for sev-
cedure. Protocols may vary from eral days.
➤ Observe the patient for hemoptysis,
➤ Establish an IV line to allow infusion difficulty breathing, cough, air hun-
of IV fluids, anesthetics, analgesics, ger, pain, or absent breathing sounds
or IV sedation. over the affected area. Report to
➤ Assist the patient into a comfortable health care provider.
sitting or side-lying position. ➤ Inform the patient that 1 hour or
➤ Prior to the administration of local more of bed rest (lying on the unaf-
anesthesia, shave and cleanse the fected side) is required after the pro-
site with an antiseptic solution, and cedure. Elevate the patient’s head
drape the area with sterile towels. for comfort.
The skin at the injection site is then
➤ Evaluate the patient for symptoms
anesthetized.
➤ The thoracentesis needle is inserted, mothorax, such as dyspnea, tachyp-
and fluid is removed. nea, anxiety, decreased breathing
➤ The needle is withdrawn, and pres- sounds, or restlessness. Prepare the
sure is applied to the site with a patient for a chest x-ray, if ordered,
vaseline gauze. A pressure dressing to ensure that a pneumothorax has
is applied over the vaseline gauze. not occurred as a result of the pro-
➤ Monitor the patient for complications cedure.
related to the procedure (e.g., aller- ➤ Assess for nausea and pain. Admin-
gic reaction, anaphylaxis). ister antiemetic and analgesic med-
➤ Place samples in properly labeled ications as needed and as directed
specimen container, and promptly by the health care practitioner.
transport the specimen to the labo- ➤ Administer antibiotics, as ordered,
ratory for processing and analysis. and instruct the patient in the impor-
➤ The results are recorded manually tance of completing the entire
or in a computerized system for recall course of antibiotic therapy even if
and postprocedure interpretation by no symptoms are present.
the appropriate health care practi- ➤ A written report of the examina-
tioner. tion will be completed by a health
Post-test: branch of medicine. The report will
practitioner, who will discuss the re-
medications, as directed by the
sults with the patient.
➤ Monitor vital signs every 15 minutes ➤ Recognize anxiety related to test
for the first hour, every 30 minutes results, and offer support. Discuss
for the next 2 hours, every hour for the implications of abnormal test
the next 4 hours, and every 4 hours results on the patient’s lifestyle.
for the next 24 hours. Take the Provide teaching and information
patient’s temperature every 4 hours regarding the clinical implications
for 24 hours. Monitor intake and out- of the test results, as appropriate.
put for 24 hours. Notify the health Educate the patient regarding access
care practitioner if temperature is el- to counseling services, if appropriate.
evated. Protocols may vary from ➤ Reinforce information given by the
facility to facility. patient’s health care provider regard-
Porphyrins, Urine 1051
ing further testing, treatment, or rein therapy. Evaluate test results in

ferral to another health care provider. relation to the patient’s symptoms
Answer any questions or address and other tests performed.
or family. Related laboratory tests:
➤ Depending on the results of this pro- ➤ Related laboratory tests include bac-
cedure, additional testing may be terial culture, CA 15–3, CA 19–9, CA
performed to evaluate or monitor 125, carcinoembryonic antigen, fun-
progression of the disease process gal culture, mycobacterial culture,
and determine the need for a change and viral culture.
PORPHYRINS, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Coproporphyrin, porphobilinogen, urobilinogen,

and other porphyrins.

clean, amber-colored plastic collection container with sodium carbonate as a
preservative.
REFERENCE VALUE: (Method: Chromatography for uroporphyrins;

spectrophotometry for -aminolevulinic acid, urobilinogen, and
porphobilinogen)

Total porphyrins Less than 320 g/24 h
Coproporphyrin
Tetracarboxyl-
coproporphyrin
Male Less than 96 g/24 h Less than 147 nmol/24 h
Female Less than 60 g/24 h Less than 92 nmol/24 h
(Conversion Factor 1.43)
Uroporphyrins
Pentacarboxyl-
porphyrin


Hexacarboxyl-
porphyrin
Heptacarboxyl-
porphyrin
Porphobilinogen Less than 2.0 mg/24 h Less than 8.8 mol/24 h
(Conversion Factor 1)
Urobilinogen 0.5–4.0 EU/24 h 0.5–4.0 EU/24 h
-Aminolevulinic 1.5–7.5 mg/24 h 11.4–57.2 mol/24 h
acid
DESCRIPTION & RATIONALE: Por- resembling port wine. Porphobilino-

phyrins are produced during the syn- gen is excreted as a colorless com-
thesis of heme. If heme synthesis is pound. A color change may occur in
disturbed, these precursors accumu- an acidic sample containing porpho-
late and are excreted in the urine in bilinogen if the sample is exposed to
excessive amounts. Conditions pro- air for several hours. ■
ducing increased levels of heme pre-
cursors are called porphyrias. The two INDICATIONS:
main categories of genetically deter- • Assist in the diagnosis of congenital or
mined porphyrias are erythropoietic acquired porphyrias, characterized by
abdominal pain, tachycardia, emesis,
porphyrias, in which major abnormal-
fever, leukocytosis, and neurologic
ities occur in red blood cell chemistry, abnormalities
and hepatic porphyrias, in which
heme precursors are found in urine • Detect suspected lead poisoning, as
and feces. Erythropoietic and hepatic indicated by elevated porphyrins
porphyrias are rare. Acquired por-
RESULT
phyrias are characterized by greater
accumulation of precursors in urine Increased in:
and feces than in red blood cells. Lead • Acute hepatic porphyrias
poisoning is the most common cause • Congenital or acquired porphyrias
of acquired porphyrias. Porphyrins are
reddish fluorescent compounds. • Heavy metal, benzene, or carbon tetra-
Depending on the type of porphyrin chloride toxicity
present, the urine may be reddish, • Variegated porphyrias
Porphyrins, Urine 1053
Decreased in: N/A sitivities to latex), and inform the

CRITICAL VALUES: N/A accordingly.
INTERFERING FACTORS: hematopoietic system and results
• Drugs that may increase urine por- of previously performed labora-
phyrin levels include acriflavine, tory tests, surgical procedures, and
aminopyrine, ethoxazene, griseofulvin, other diagnostic procedures. For
hexachlorobenzene, oxytetracycline, related laboratory tests, refer to the
and sulfonmethane.
• Numerous drugs are suspected as patient is taking, including herbs,
potential initiators of acute attacks, but nutritional supplements, and nutra-
drugs classified as unsafe for high- ceuticals. The requesting health care
risk individuals include aminopyrine, practitioner and laboratory should be
aminoglutethimide, antipyrine, barbi- advised if the patient regularly uses
turates, N-butylscopolammoniumine
can be taken into consideration when
bromide, carbamazepine, carbromal, reviewing results.
chlorpropamide, danazol, dapsone,
diclofenac, diphenylhydantoin, ergot tient. Provide a nonmetallic urinal,
preparations, ethchlorvynol, ethina- bedpan, or toilet-mounted collection
mate, glutethimide, griseofulvin, N- device. Address concerns about pain
isopropyl meprobamate, mephenytoin, related to the procedure. Explain to
meprobamate, methyprylon, novo- the patient that there should be no
biocin, phenylbutazone, primidone, discomfort during the procedure.
pyrazolone preparations, succinimides, ➤ Usually a 24-hour time frame for
sulfonamide antibiotics, sulfonethyl- urine collection is ordered. Inform
methane, sulfonmethane, synthetic the patient that all urine must be
estrogens and progestins, tolazamide, saved during that 24-hour period.
tolbutamide, trimethadione, and val- Instruct the patient not to void
directly into the laboratory collection
proic acid. container. Instruct the patient to
• Exposure of the specimen to light can avoid defecating in the collection
falsely decrease values. device and to keep toilet tissue out
of the collection device to prevent
• Screening methods are not well stan- contamination of the specimen.
dardized and can produce false-negative Place a sign in the bathroom to re-
results. mind the patient to save all urine.
• Failure to collect all urine and store into the collection device and then to
specimen properly during the 24-hour pour the urine into the laboratory col-
test period will interfere with results. lection container. Alternatively, the
Nursing Implications and ber to add to the laboratory collec-
Procedure ● ● ● ● ● ● ● ● ● ● ●
tion container.
Pretest: issues, as well as concern for mod-
➤ Inform the patient that the test is chological support before, during,
used to evaluate porphyrias. and after the procedure.
plaints, including a list of known tion restrictions, unless by medical
Intratest: catheter is in place, the drainage bag

must be kept on ice.
➤ If the patient has a history of severe ➤ Begin the test between 6 and 8 a.m.,
allergic reaction to latex, care should if possible. Collect first voiding and
be taken to avoid the use of equip- discard. Record the time the speci-
ment containing latex. men was discarded as the beginning
➤ Instruct the patient to cooperate fully of the timed collection period. The
and to follow directions. next morning, ask the patient to void
➤ Observe standard precautions, and at the same time the collection was
follow the general guidelines in Ap- started and add this last voiding to
pendix A. Positively identify the pa- the container.
tient, and label the appropriate tubes ➤ If an indwelling catheter is in place,
with the corresponding patient replace the tubing and container sys-
demographics, date, and time of tem at the start of the collection
collection. time. Keep the container system on
ice during the collection period, or
Random specimen (collect empty the urine into a larger con-
in early morning):
tion period; monitor to ensure
Clean-catch specimen: the test the next morning at the
➤ Instruct the male patient to (1) thor- same hour the collection was begun.
oughly wash his hands, (2) cleanse ➤ At the conclusion of the test, com-
the meatus, (3) void a small amount pare the quantity of urine with the
into the toilet, and (4) void directly urinary output record for the collec-
into the specimen container. tion; if the specimen contains less
➤ Instruct the female patient to (1) than what was recorded as output,
thoroughly wash her hands; (2) some urine may have been dis-
cleanse the labia from front to back; carded, invalidating the test.
(3) while keeping the labia separated, ➤ Include on the collection container’s
void a small amount into the toilet; label the amount of urine, test start
and (4) without interrupting the urine and stop times, and ingestion of any
stream, void directly into the speci- foods or medications that can affect
men container. test results.
Indwelling catheter: General:
➤ Put on gloves. Empty drainage tube ➤ Promptly transport the specimen to
of urine. It may be necessary to the laboratory for processing and
clamp off the catheter for 15 to 30 analysis.
tic swab, and then aspirate 5 mL of
and syringe. Transfer urine to a ster-
tioner.
ile container.
Timed specimen: Post-test:
➤ Obtain a clean 3-L urine specimen ➤ A written report of the examination

container, toilet-mounted collection will be sent to the requesting health
device, and plastic bag (for transport care practitioner, who will discuss
of the specimen container). The spec- the results with the patient.
imen must be refrigerated or kept ➤ Recognize anxiety related to test
on ice throughout the entire collec- results. Discuss the implications of
tion period. If an indwelling urinary abnormal test results on the patient’s
Positron Emission Tomography, Brain 1055
lifestyle. Provide teaching and infor- cedure, additional testing may be

mation regarding the clinical impli- performed to evaluate or monitor
cations of the test results, as progression of the disease process
appropriate. and determine the need for a change
ing further testing, treatment, or re- and other tests performed.
Answer any questions or address Related laboratory tests:
any concerns voiced by the patient ➤ Related laboratory tests include in-
or family. clude -aminolevulinic acid, erythro-
➤ Depending on the results of this pro- cyte protoporphyrin, and lead.
POSITRON EMISSION
TOMOGRAPHY, BRAIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: PET scan of the brain.

CONTRAST: Intravenous radioactive material (fluorodeoxyglucose [FDG]).
DESCRIPTION & RATIONALE: Posi- because every cell uses glucose, the
tron emission tomography (PET) metabolic activity occurring in neuro-
combines the biochemical properties logic conditions can be measured.
of nuclear medicine with the accuracy There is little localization of FDG in
of computed tomography (CT). PET normal tissue, allowing rapid detec-
uses positron emissions from specific tion of abnormal disease states. The
radionuclides (oxygen, nitrogen, car- brain uses oxygen and glucose almost
bon, and fluorine) to produce detailed exclusively to meet its energy needs,
functional images within the body. and therefore the brain’s metabolism
After the radionuclide becomes con- has been studied widely with PET.
centrated in the brain, PET images of The positron radiopharmaceuticals
blood flow or metabolic processes at generally have short half-lives, ranging
the cellular level can be obtained. from a few seconds to a few hours,
Fluorine-18, in the form of fluo- and therefore they must be produced
rodeoxyglucose (FDG), is one of the in a cyclotron located near where the
more commonly used radionuclides. test is being done. The PET scanner
FDG is a glucose analogue, and translates the emissions from the
radioactivity as the positron combines • Evaluate Alzheimer’s disease and differ-

with the negative electrons from the entiate it from other causes of demen-
tia, as evidenced by decreased cerebral
tissues and forms gamma rays that can
flow and metabolism
be detected by the scanner. This infor-
mation is transmitted to the com- • Evaluate cranial tumors preoperatively
puter, which determines the location and postoperatively and determine
and its distribution and translates the stage and appropriate treatment or pro-
cedure
emissions as color-coded images for
viewing, quantitative measurements, • Identify cerebrovascular accident or
activity changes in relation to time, aneurysm, as evidenced by decreased
and three-dimensional computer- blood flow and oxygen use
aided analysis. Each radionuclide • Identify focal seizures, as evidenced by
tracer is designed to measure a specific decreased metabolism between seizures
body process, such as glucose meta-
bolism, blood flow, or brain tissue RESULT
perfusion. The radionuclide can be
Normal Findings:
administered intravenously or inhaled
as a gas. PET has had the greatest clin- • Normal patterns of tissue metabolism,
blood flow, and radionuclide distribu-
ical impact in patients with epilepsy,
tion
dementia, neurodegenerative diseases,
inflammation, cerebrovascular disease Abnormal Findings:
(indirectly), and brain tumors. • Alzheimer’s disease
The expense of the study and
the limited availability of radiophar- • Cerebral metastases
maceuticals limit the use of PET, • Cerebrovascular accident
even though it is more sensitive than
• Creutzfeldt-Jakob disease
traditional nuclear scanning and
single-photon emission computed • Dementia
tomography. Changes in reimburse- • Head trauma
ment and the advent of mobile tech-
• Huntington’s disease
nology have increased the availability
of this procedure in the community • Migraine
setting. ■ • Parkinson’s disease
• Schizophrenia
INDICATIONS:
• Detect Parkinson’s disease and • Seizure disorders
Huntington’s disease, as evidenced by • Tumors
decreased metabolism
• Determine the effectiveness of therapy, CRITICAL VALUES: N/A
as evidenced by biochemical activity of
normal and abnormal tissues INTERFERING FACTORS
• Determine physiologic changes in psy-
This procedure is
chosis and schizophrenia contraindicated for:
• Differentiate between tumor recur- • Patients who are pregnant or suspected
rence and radiation necrosis of being pregnant, unless the potential
benefits of the procedure far outweigh regarding younger patients or patients

the risks to the fetus and mother who are lactating.
• Risks associated with radiologic overex-
Factors that may
• Inability of the patient to cooperate or the patient should stand behind a shield
remain still during the procedure be- or leave the area while the examination
cause of age, significant pain, or mental is being done. Personnel working in the
status area where the examination is being
• Patients who are very obese, who done should wear badges that reveal
may exceed the weight limit for the their level of exposure to radiation.
equipment
which may produce poor visualization Nursing Implications and
of the area to be examined Procedure ● ● ● ● ● ● ● ● ● ● ●
• Drugs that alter glucose metabolism, Pretest:

such as tranquilizers or insulin, because
hypoglycemia can alter PET results
assesses blood flow to the brain and
• The use of alcohol, tobacco, or caffeine- brain tissue metabolism.
containing drinks at least 24 hours ➤ Obtain a history of the patient’s com-
before the study, because the effects of plaints and symptoms, including a
these substances would make it difficult list of known allergens.
to evaluate the patient’s true physio- ➤ Obtain a history of the patient’s mu-
logic state (e.g., alcohol is a vasconstric- sculoskeletal system, as well as
tor and would decrease blood flow to results of previously performed labo-
the target organ) ratory tests, surgical procedures,
• Metallic objects within the examina- related diagnostic tests, refer to the
tion field (e.g., jewelry, body rings), Musculoskeletal System table.
which may inhibit organ visualization ➤ Note any recent procedures that can
and can produce unclear images interfere with test results, including
Other considerations: contrast medium or barium.
• Failure to follow dietary restrictions ➤ Record the date of the last menstrual
before the procedure may cause the period and determine the possibil-
procedure to be canceled or repeated. ity of pregnancy in perimenopausal
women.
• Improper injection of the radionuclide ➤ Obtain a list of the medications the
that allows the tracer to seep deep into patient is taking, including anti-
the muscle tissue produces erroneous coagulant therapy, aspirin and other
hot spots. salicylates, herbs, nutritional supple-
ments, and nutraceuticals, especially
• False-positive findings may occur as a those known to affect coagula-
result of normal gastrointestinal tract tion (see Appendix F). It is recom-
uptake and uptake in areas of infection mended that use be discontinued 14
or inflammation. days before surgical procedures. The
• Consultation with a health care practi- and laboratory should be advised if
tioner should occur before the proce- the patient regularly uses these
dure for radiation safety concerns products so that their effects can be
taken into consideration when re- ➤ Have emergency equipment readily

viewing results. available.
➤ Review the procedure with the pa- ➤ Patients are given a gown, robe, and
tient. Address concerns about pain foot coverings to wear and instructed
related to the procedure. Explain to to void prior to the procedure.
the patient that some pain may be ➤ Instruct the patient to cooperate fully
experienced during the test, or there and to follow directions. Instruct the
may be moments of discomfort. patient to remain still throughout the
Reassure the patient that radioactive procedure because movement pro-
material poses minimal radioactive duces unreliable results
hazard because of its short half-life
and rarely produces side effects. ➤ Record baseline vital signs and as-
Inform the patient that the procedure sess neurologic status. Protocols
is performed in a special department, may vary from facility to facility.
usually in a radiology suite, by a ➤ Observe standard precautions, and
health care practitioner and support follow the general guidelines in Ap-
staff, and takes approximately 60 to pendix A.
120 minutes.
➤ The radionuclide is injected, and
➤ Sensitivity to social and cultural imaging is started 30 minutes later. If
issues, as well as concern for mod- comparative studies are indicated,
esty, is important in providing psy- additional injections may be needed.
chological support before, during, Patient is placed in a supine position
and after the procedure. on the table.
➤ The patient should restrict food for 4 ➤ The patient may be asked to perform
hours; restrict alcohol, nicotine, or different cognitive activities (e.g.,
caffeine-containing drinks for 24 reading) to measure changes in brain
hours; and withhold medications for activity during reasoning or remem-
24 hours before the test. Instruct the bering.
patient to avoid taking anticoagulant ➤ The patient may be blindfolded or
medication or to reduce dosage as asked to use earplugs to decrease
ordered prior to the procedure. auditory and visual stimuli.
➤ Instruct the patient to remove den- ➤ Wear gloves during the radionuclide
tures, jewelry (including watches), injection and while handling the pa-
hairpins, credit cards, and other me- tient’s urine.
tallic objects in the area to be exam-
ined. ➤ Monitor the patient for complica-
➤ Sometimes fluorodeoxyglucose (FDG) allergic reaction, anaphylaxis, bron-
examinations are done after blood chospasm).
has been drawn to determine circu-
lating blood glucose levels. If blood ➤ The results are recorded on film or in
glucose levels are high, insulin may a computerized system for recall and
be given. postprocedure interpretation by the
Intratest:
Post-test:
with dietary and medication restric- ➤ Instruct the patient to resume usual
tions and pretesting preparations; diet, fluids, medications, or activity,
assure that food and medications as directed by the health care practi-
have been restricted as directed tioner.
prior to the procedure. Ensure the ➤ Advise the patient to immediately
patient has removed all external me- report symptoms such as fast heart
tallic objects (jewelry, dentures, etc.) rate, difficulty breathing, skin rash,
prior to the procedure. itching, or decreased urinary output.
➤ Observe the needle/catheter insertion will be completed by a health

tion site for bleeding, inflammation, care practitioner specializing in this
or hematoma formation. branch of medicine. The report will
➤ Instruct the patient to apply cold be sent to the requesting health care
compresses to the puncture site, as practitioner, who will discuss the re-
needed, to reduce discomfort or sults with the patient.
edema. ➤ Recognize anxiety related to test re-
sults, and be supportive of perceived
➤ Instruct the patient to drink increased
loss of independent function. Dis-
amounts of fluids for 24 to 48 hours
cuss the implications of abnormal
to eliminate the radionuclide from
the body, unless contraindicated.
Educate the patient that radionuclide
is eliminated from the body within 6
to 24 hours.
➤ Instruct the patient to flush the toilet patient’s health care provider regard-
immediately after each voiding fol- ing further testing, treatment, or
lowing the procedure, and to wash referral to another health care pro-
hands meticulously with soap and vider. Answer any questions or ad-
water after each voiding for 24 hours dress any concerns voiced by the
after the procedure. patient or family.
➤ Instruct all caregivers to wear gloves ➤ Instruct the patient in the use of any
when discarding urine for 24 hours ordered medications. Explain the
after the procedure. Wash gloved importance of adhering to the ther-
hands with soap and water before apy regimen. As appropriate, instruct
removing gloves. Then wash hands the patient in significant side effects
after the gloves are removed. and systemic reactions associated
➤ If a woman who is breast-feeding with the prescribed medication.
must have a nuclear scan, she Encourage him or her to review cor-
should not breast-feed the infant responding literature provided by a
until the radionuclide has been elimi- pharmacist.
nated. This could take as long as 3 ➤ Depending on the results of this pro-
days. She should be instructed to cedure, additional testing may be
express the milk and discard it dur- needed to evaluate or monitor pro-
ing the 3-day period to prevent ces- gression of the disease process and
sation of milk production. determine the need for a change in
➤ Nutritional considerations: A low-fat, therapy. Evaluate test results in rela-
low-cholesterol, and low-sodium diet tion to the patient’s symptoms and
should be consumed to reduce cur- other tests performed.
rent disease processes and/or de-
crease risk of hypertension and Related diagnostic tests:
➤ No other radionuclide tests should computed tomography of the brain,
be scheduled for 24 to 48 hours after electroencephalogram, magnetic res-
this procedure. onance imaging of the brain, and ultra-
➤ A written report of the examina- sound arterial Doppler of the carotids.
POSITRON EMISSION
TOMOGRAPHY, HEART
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: PET scan of the heart.

AREA OF APPLICATION: Heart, chest/thorax, vascular system.
DESCRIPTION & RATIONALE: Posi- translates the emissions from the

tron emission tomography (PET) radioactivity as the positron combines
combines the biochemical properties with the negative electrons from the
of nuclear medicine with the accuracy tissues and forms gamma rays that can
of computed tomography (CT). PET be detected by the scanner. This infor-
uses positron emissions from specific mation is transmitted to the com-
radionuclides (oxygen, nitrogen, car- puter, which determines the location
bon, and fluorine) to produce detailed and its distribution and translates the
functional images within the body. emissions as color-coded images for
After the radionuclide becomes con- viewing, quantitative measurements,
centrated in the heart, PET images of activity changes in relation to time,
blood flow or metabolic processes at and three-dimensional computer-
the cellular level can be obtained. aided analysis. Each radionuclide
Fluorine-18, in the form of fluo- tracer is designed to measure a spe-
rodeoxyglucose (FDG), is one of the cific body process, such as glucose
more commonly used radionuclides. metabolism, blood flow, or tissue
FDG is a glucose analogue, and be- perfusion. The radionuclide can be
cause every cell uses glucose, the meta- administered intravenously or inhaled
bolic activity occurring in heart as a gas.
conditions such as myocardial viabil- The expense of the study and the
ity can be measured. There is little limited availability of radiopharma-
localization of FDG in normal tissue, ceuticals limit the use of PET, even
allowing rapid detection of abnormal though it is more sensitive than
disease states. traditional nuclear scanning and
The positron radiopharmaceuticals single-photon emission computed
generally have short half-lives, ranging tomography. Changes in reimburse-
from a few seconds to a few hours, ment and the advent of mobile tech-
and therefore they must be produced nology have increased the availability
in a cyclotron located near where the of this procedure in the community
test is being done. The PET scanner setting. ■
Positron Emission Tomography, Heart 1061
INDICATIONS: benefits of the procedure far outweigh

• Assess tissue permeability the risks to the fetus and mother
• Determine the effects of therapeutic • Patients with hypersensitivity to the
drugs on malfunctioning or diseased radionuclide
tissue
Factors that may
• Determine localization of areas of heart impair clear imaging:
metabolism • Inability of the patient to cooperate or
• Determine the presence of coronary ar- remain still during the procedure be-
tery disease, as evidenced by metabolic cause of age, significant pain, or mental
state during ischemia and after angina status
• Determine the size of heart infarcts • Patients who are very obese, who may
• Identify cerebrovascular accident or ment
aneurysm, as evidenced by decreasing
blood flow and oxygen use
RESULT
• Drugs that alter glucose metabolism,
Normal Findings: such as tranquilizers or insulin, because
• Normal patterns of tissue metabolism, hypoglycemia can alter PET results
blood flow, and radionuclide distribu- • The use of alcohol, tobacco, or caffeine-
tion containing drinks at least 24 hours
before the study, because the effects of
Abnormal Findings: these substances would make it difficult
• Chronic obstructive pulmonary disease to evaluate the patient’s true physiologic
state (e.g., alcohol is a vasconstrictor
• Decreased blood flow and decreased and would decrease blood flow to the
glucose concentration, indicating ne- target organ)
crotic, scarred tissue
• Enlarged left ventricle tion field (e.g., jewelry, body rings),
• Heart chamber disorder which may inhibit organ visualization
• Myocardial infarction, indicating in-
creased radionuclide uptake in the Other considerations:
myocardium • Failure to follow dietary restrictions be-
fore the procedure may cause the pro-
• Pulmonary edema
cedure to be canceled or repeated.
• Reduced blood flow but increased glu- • Improper injection of the radionuclide
cose concentration, indicating ischemia that allows the tracer to seep deep into
the muscle tissue produces erroneous
CRITICAL VALUES: N/A hot spots.
INTERFERING FACTORS: • False-positive findings may occur as a

result of normal gastrointestinal tract
This procedure is uptake and uptake in areas of infection
contraindicated for: or inflammation.
• Patients who are pregnant or suspected • Consultation with a health care practi-
of being pregnant, unless the potential tioner should occur before the proce-
dure for radiation safety concerns ➤ Review the procedure with the pa-
regarding younger patients or patients tient. Address concerns about pain
who are lactating. related to the procedure. Explain to
• Risks associated with radiologic overex- experienced during the test, or there
posure can result from frequent x-ray may be moments of discomfort. Re-
procedures. Personnel in the room with assure the patient that radioactive
the patient should stand behind a shield material poses minimal radioactive
or leave the area while the examination hazard because of its short half-life
is being done. Personnel working in the and rarely produces side effects.
area where the examination is being Inform the patient that the procedure
is performed in a special department,
done should wear badges that reveal usually in a radiology or vascular
their level of exposure to radiation. suite, by a health care practitioner
Nursing Implications and mately 60 to 120 minutes.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that the procedure and after the procedure.
assesses blood flow to the heart.
➤ The patient should restrict food for 4
➤ Obtain a history of the patient’s com- hours; restrict alcohol, nicotine, or
plaints and symptoms, including a caffeine-containing drinks for 24
list of known allergens. hours; and withhold medications for
➤ Obtain a history of the patient’s car- 24 hours before the test. Instruct the
diovascular system, as well as patient to avoid taking anticoagulant
results of previously performed labo- medication or to reduce dosage as
ratory tests, surgical procedures, ordered prior to the procedure.
and other diagnostic procedures. For ➤ Instruct the patient to remove den-
related diagnostic tests, refer to the tures, jewelry (including watches),
Cardiovascular System table. hairpins, credit cards, and other me-
➤ Note any recent procedures that can tallic objects in the area to be exam-
interfere with test results, includ- ined.
ing examinations using iodine-based ➤ Sometimes fluorodeoxyglucose (FDG)
contrast medium or barium. examinations are done after blood
➤ Record the date of the last menstrual has been drawn to determine circu-
period and determine the possibil- lating blood glucose levels. If blood
ity of pregnancy in perimenopausal glucose levels are high, insulin may
women. be given.
patient is taking, including anticoagu- Intratest:
lant therapy, aspirin and other ➤ Ensure that the patient has complied
salicylates, herbs, nutritional supple- with dietary and medication restric-
ments, and nutraceuticals, especially tions and pretesting preparations;
those known to affect coagula- assure that food and medications
tion (see Appendix F). It is recom- have been restricted as directed
mended that use be discontinued 14 prior to the procedure. Ensure the
days before surgical procedures. The patient has removed all external me-
requesting health care practitioner tallic objects (jewelry, dentures, etc.)
and laboratory should be advised if prior to the procedure.
the patient regularly uses these
products so that their effects can be ➤ Have emergency equipment readily
taken into consideration when re- available.
viewing results. ➤ Patients are given a gown, robe, and
Positron Emission Tomography, Heart 1063
foot coverings to wear and instructed ➤ Instruct the patient to drink in-
to void prior to the procedure. creased amounts of fluids for 24 to
➤ Instruct the patient to cooperate fully 48 hours to eliminate the radionu-
and to follow directions. Instruct the clide from the body, unless con-
patient to remain still throughout the traindicated. Educate the patient that
procedure because movement pro- radionuclide is eliminated from the
duces unreliable results. body within 6 to 24 hours.
➤ Record baseline vital signs and as- ➤ Instruct the patient to flush the toilet
sess neurologic status. Protocols immediately after each voiding fol-
may vary from facility to facility. lowing the procedure, and to wash
hands meticulously with soap and
➤ Observe standard precautions, and water after each voiding for 24 hours
follow the general guidelines in Ap- after the procedure.
pendix A.
➤ Instruct all caregivers to wear gloves
➤ The radionuclide is injected while the when discarding urine for 24 hours
patient is in the supine position; after the procedure. Wash gloved
imaging is done at periodic intervals, hands with soap and water before
and continuous scanning is done for removing gloves. Then wash hands
1 hour. If comparative studies are after the gloves are removed.
indicated, additional injections may
be needed. ➤ If a woman who is breast-feeding
must have a nuclear scan, she
➤ Wear gloves during the radionuclide should not breast-feed the infant
injection and while handling the pa- until the radionuclide has been elimi-
tient’s urine. nated. This could take as long as 3
➤ Monitor the patient for complica- days. She should be instructed to
tions related to the procedure (e.g., express the milk and discard it dur-
allergic reaction, anaphylaxis, bron- ing the 3-day period to prevent ces-
chospasm). sation of milk production.
➤ The results are recorded on film or in ➤ Nutritional considerations: A low-fat,
a computerized system for recall and low-cholesterol, and low-sodium diet
postprocedure interpretation by the should be consumed to reduce cur-
appropriate health care practitioner. rent disease processes and/or de-
crease risk of hypertension and
Post-test: coronary artery disease.
➤ Instruct the patient to resume usual be scheduled for 24 to 48 hours after
diet, fluids, medications, or activ- this procedure.
ity, as directed by the health care
practitioner. ➤ A written report of the examina-
➤ Observe for delayed allergic reac- care practitioner specializing in this
tions, such as rash, urticaria, tachy- branch of medicine. The report will
cardia, hyperpnea, hypertension, be sent to the requesting health care
palpitations, nausea, or vomiting. practitioner, who will discuss the re-
➤ Instruct the patient to immediately sults with the patient.
report symptoms such as fast heart ➤ Recognize anxiety related to test re-
rate, difficulty breathing, skin rash, sults, and be supportive of perceived
itching, or decreased urinary output. loss of independent function. Dis-
➤ Observe the needle/catheter inser- cuss the implications of abnormal
tion site for bleeding, inflammation, test results on the patient’s lifestyle.
or hematoma formation. Provide teaching and information
➤ Instruct the patient to apply cold regarding the clinical implications of
compresses to the puncture site, as the test results, as appropriate.
needed, to reduce discomfort or ➤ Reinforce information given by the
edema. patient’s health care provider regard-
ing further testing, treatment, or re- ➤ Depending on the results of this pro-
ferral to another health care provider. cedure, additional testing may be
Answer any questions or address needed to evaluate or monitor pro-
any concerns voiced by the patient gression of the disease process and
or family. determine the need for a change in
apy regimen. As appropriate, instruct Related diagnostic tests:
and systemic reactions associated ➤ Related diagnostic tests include
with the prescribed medication. computed tomography of the thorax,
Encourage him or her to review cor- echocardiogram, electrocardiography,
responding literature provided by a magnetic resonance imaging of the
pharmacist. chest, and myocardial perfusion scan.
POSITRON EMISSION
TOMOGRAPHY, PELVIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: PET scan of the pelvis.

DESCRIPTION & RATIONALE: Posi- and detection of metastases are the

tron emission tomography (PET) main reasons to do a pelvic PET scan.
combines the biochemical properties Fluorine-18, in the form of fluo-
of nuclear medicine with the accuracy rodeoxyglucose (FDG), is one of the
of computed tomography (CT). PET more commonly used radionuclides.
uses positron emissions from specific FDG is a glucose analogue, and
radionuclides (oxygen, nitrogen, car- because every cell uses glucose, the
bon, and fluorine) to produce detailed metabolic activity occurring in pelvic
functional images within the body. conditions such as colorectal cancer
After the radionuclide becomes con- can be measured. There is little local-
centrated in the pelvis, PET images of ization of FDG in normal tissue,
blood flow or metabolic processes at allowing rapid detection of abnormal
the cellular level can be obtained. disease states.
Colorectal tumor detection, tumor The positron radiopharmaceuticals
staging, evaluation of the effects of generally have short half-lives, ranging
therapy, detection of recurrent disease, from a few seconds to a few hours,
Positron Emission Tomography, Pelvis 1065
Abnormal Findings:
and therefore they must be produced
in a cyclotron located near where the • Focal uptake of the radionuclide in
pelvis
test is being done. The PET scanner
translates the emissions from the • Focal uptake in abnormal lymph nodes
radioactivity as the positron combines • Focal uptake in tumor
with the negative electrons from the • Focal uptake in metastases
tissues and forms gamma rays that can
be detected by the scanner. This infor- CRITICAL VALUES: N/A
mation is transmitted to the com-
puter, which determines the location
and its distribution and translates the This procedure is
emissions as color-coded images for contraindicated for:
viewing, quantitative measurements, • Patients who are pregnant or suspected
activity changes in relation to time, of being pregnant, unless the potential
and three-dimensional computer- benefits of the procedure far outweigh
aided analysis. Each radionuclide the risks to the fetus and mother
tracer is designed to measure a specific Factors that may
body process, such as glucose metabo- impair clear imaging:
lism, blood flow, or tissue perfusion. • Inability of the patient to cooperate
The expense of the study and the or remain still during the procedure
limited availability of radiopharmaceu- because of age, significant pain, or
ticals limit the use of PET, even though mental status
it is more sensitive than traditional • Incorrect positioning of the patient,
nuclear scanning and single-photon which may produce poor visualization
emission computed tomography. of the area to be examined
Changes in reimbursement and the • Patients who are very obese, who
advent of mobile technology have may exceed the weight limit for the
increased the availability of this proce- equipment
dure in the community setting. ■ • Drugs that alter glucose metabolism,
such as tranquilizers or insulin, because
INDICATIONS: hypoglycemia can alter PET results
• Determine the effects of therapy
• The use of alcohol, tobacco, or caffeine-
• Determine the presence of colorectal containing drinks at least 24 hours
cancer before the study, because the effects of
• Determine the presence of metastases these substances would make it difficult
of a cancerous tumor to evaluate the patient’s true physiologic
state (e.g., alcohol is a vasconstrictor
• Determine the recurrence of tumor or and would decrease blood flow to the
cancer target organ)
• Identify the site for biopsy • Metallic objects within the examina-
RESULT which may inhibit organ visualization
Normal Findings: and can produce unclear images
• Normal patterns of tissue metabolism, Other considerations:
blood flow, and radionuclide distri- • Failure to follow dietary restrictions
bution before the procedure may cause the
• No focal uptake of radionuclide procedure to be canceled or repeated.
• Improper injection of the radionuclide ➤ Obtain a list of the medications the

that allows the tracer to seep deep into patient is taking, including anticoa-
the muscle tissue produces erroneous gulant therapy, aspirin and other
hot spots. salicylates, herbs, nutritional supple-
ments, and nutraceuticals, especially
• False-positive findings may occur as a those known to affect coagulation
result of normal gastrointestinal tract (see Appendix F). It is recommended
uptake and uptake in areas of infection that use be discontinued 14 days
or inflammation. before surgical procedures. The
• Consultation with a health care practi- and laboratory should be advised if
tioner should occur before the proce- the patient regularly uses these
dure for radiation safety concerns products so that their effects can be
regarding younger patients or patients taken into consideration when re-
who are lactating. viewing results.
• Risks associated with radiologic overex- patient. Address concerns about pain
posure can result from frequent x-ray related to the procedure. Explain to
procedures. Personnel in the room with the patient that some pain may be
the patient should wear a protective experienced during the test, and
lead apron, stand behind a shield, or there may be moments of discom-
leave the area while the examination is fort. Explain the purpose of the test
being done. Personnel working in the and how the procedure is performed.
Reassure the patient that radioactive
material poses minimal radioactive
done should wear badges that reveal hazard because of its short half-life
their level of exposure to radiation. and rarely produces side effects.
is performed in a special department,
Nursing Implications and usually in a radiology suite, by a
Procedure ● ● ● ● ● ● ● ● ● ● ●
health care practitioner and support
staff, and takes approximately 30 to
Pretest: 60 minutes.
assesses the pelvis and its contents esty, is important in providing psy-
for abnormal organ function. chological support before, during,
plaints and symptoms, including a ➤ The patient should restrict food for 4
list of known allergens. hours; restrict alcohol, nicotine, or
➤ Obtain a history of the patient’s gas- caffeine-containing drinks for 24
trointestinal system, as well as hours; and withhold medications for
results of previously performed labo- 24 hours before the test. Instruct the
ratory tests, surgical procedures, patient to avoid taking anticoagulant
and other diagnostic procedures. For medication or to reduce dosage as
related diagnostic tests, refer to the ordered prior to the procedure.
Gastrointestinal System table. ➤ Instruct the patient to remove den-
➤ Note any recent procedures that can tures, jewelry (including watches),
interfere with test results, including hairpins, credit cards, and other
examinations using iodine-based metallic objects in the area to be
contrast medium or barium. examined.
➤ Record the date of the last menstrual ➤ Sometimes fluorodeoxyglucose (FDG)
period and determine the possibility examinations are done after blood
of pregnancy in perimenopausal has been drawn to determine circu-
women. lating blood glucose levels. If blood
Positron Emission Tomography, Pelvis 1067
glucose levels are high, insulin may Post-test:

be given.
Intratest: diet, fluids, medications, or activity,
➤ Ensure that the patient has complied as directed by the health care practi-
with dietary and medication restric- tioner.
tions and pretesting preparations; ➤ Observe for delayed allergic reac-
assure that food and medications tions, such as rash, urticaria, tachy-
have been restricted as directed cardia, hyperpnea, hypertension,
prior to the procedure. Ensure the palpitations, nausea, or vomiting.
patient has removed all external ➤ Instruct the patient to immediately
metallic objects (jewelry, dentures, report symptoms such as fast heart
etc.) prior to the procedure. rate, difficulty breathing, skin rash,
➤ Have emergency equipment readily itching, or decreased urinary output.
available. ➤ Observe the needle/catheter inser-
➤ Patients are given a gown, robe, and tion site for bleeding, inflammation,
foot coverings to wear and instructed or hematoma formation.
to void prior to the procedure. ➤ Instruct the patient to apply cold
➤ Instruct the patient to cooperate fully compresses to the puncture site, as
and to follow directions. Instruct the needed, to reduce discomfort or
patient to remain still throughout the edema.
procedure because movement pro- ➤ Instruct the patient to drink in-
duces unreliable results. creased amounts of fluids for 24 to
➤ Record baseline vital signs and 48 hours to eliminate the radionu-
assess neurologic status. Protocols clide from the body, unless con-
may vary from facility to facility. traindicated. Tell the patient that
➤ Observe standard precautions, and radionuclide is eliminated from the
follow the general guidelines in body within 6 to 24 hours.
Appendix A. ➤ Instruct the patient to flush the toilet
➤ The radionuclide is injected, and immediately after each voiding fol-
imaging is started after a 45-minute lowing the procedure, and to wash
delay. Continuous scanning may be hands meticulously with soap and
done for 1 hour after the patient is water after each voiding for 24 hours
placed in the supine position on a after the procedure.
scanning table. If comparative stud- ➤ Tell all caregivers to wear gloves
ies are indicated, additional injec- when discarding urine for 24 hours
tions of radionuclide may be needed. after the procedure. Wash gloved
➤ If required, the bladder may need to hands with soap and water before
be lavaged via a urinary catheter with removing gloves. Then wash hands
2 L of 0.9% saline solution to after the gloves are removed.
remove concentrated radionuclide. ➤ If a woman who is breast-feeding
➤ Wear gloves during the radionuclide must have a nuclear scan, she
injection and while handling the should not breast-feed the infant
patient’s urine. until the radionuclide has been elimi-
nated. This could take as long as 3
chospasm).
in a computerized system for recall ➤ No other radionuclide tests should
and postprocedure interpretation be scheduled for 24 to 48 hours after
by the appropriate health care prac- this procedure.
titioner. ➤ A written report of the examination
will be completed by a health care importance of adhering to the ther-

practitioner specializing in this apy regimen. As appropriate, instruct
branch of medicine. The report will the patient in significant side effects
be sent to the requesting health care and systemic reactions associated
practitioner, who will discuss the with the prescribed medication. En-
results with the patient. courage him or her to review corre-
➤ Recognize anxiety related to test sponding literature provided by a
results, and be supportive of per- pharmacist.
ceived loss of independent function. ➤ Depending on the results of this pro-
Discuss the implications of abnormal cedure, additional testing may be
test results on the patient’s lifestyle. needed to evaluate or monitor pro-
Provide teaching and information gression of the disease process and
regarding the clinical implications of determine the need for a change in
the test results, as appropriate. therapy. Evaluate test results in rela-
➤ Reinforce information given by the tion to the patient’s symptoms and
patient’s health care provider regard- other tests performed.
ferral to another health care provider. Related diagnostic tests:
Answer any questions or address ➤ Related diagnostic tests include
any concerns voiced by the patient computed tomography of the abdo-
or family. men; kidney, ureter, and bladder
➤ Instruct the patient in the use of any (KUB) study; and magnetic reso-
ordered medications. Explain the nance imaging of the abdomen.
POTASSIUM, BLOOD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Serum K.

mL) collected in green-top (heparin) tube is also acceptable.
Serum Conventional Units SI Units (Conventional Units 1)

Newborn 3.7–5.9 mEq/L 3.7–5.9 mmol/L
Infant 4.1–5.3 mEq/L 4.1–5.3 mmol/L
Child 3.4–4.7 mEq/L 3.4–4.7 mmol/L
Adult 3.5–5.0 mEq/L 3.5–5.0 mmol/L
Note: Serum values are 0.1 mmol/L higher than plasma values, and reference ranges
should be adjusted accordingly. It is important that serial measurements be collected
using the same type of collection container to reduce variability of results from collection
to collection.
Potassium, Blood 1069
Altered cellular metabolism:

DESCRIPTION & RATIONALE: Elec- Damaged red blood cells
trolytes dissociate into electrically (RBCs) release potassium into
charged ions when dissolved. Cations, the circulating fluid, resulting
in increased potassium levels.
including potassium, carry a positive
charge. Body fluids contain approxi- INDICATIONS:
mately equal numbers of anions and • Assess a known or suspected disorder
cations, although the nature of the associated with renal disease, glucose
ions and their mobility differs metabolism, trauma, or burns
between the intracellular and extracel-
• Assist in the evaluation of electrolyte
lular compartments. Both types of imbalances; this test is especially indi-
ions affect the electrical and osmolar cated in elderly patients, patients
functions of the body. Electrolyte receiving hyperalimentation supple-
quantities and the balance among ments, patients on hemodialysis, and
them are controlled by oxygen and patients with hypertension
carbon dioxide exchange in the lungs; • Evaluate cardiac arrhythmia to deter-
absorption, secretion, and excretion of mine whether altered potassium levels
many substances by the kidneys; and are contributing to the problem, espe-
secretion of regulatory hormones by cially during digitalis therapy, which
the endocrine glands. Potassium is the leads to ventricular irritability
most abundant intracellular cation. It • Evaluate the effects of drug therapy,
is essential for the transmission of especially diuretics
electrical impulses in cardiac and
• Evaluate the response to treatment for
skeletal muscle. It also functions in abnormal potassium levels
enzyme reactions that transform glu-
cose into energy and amino acids into • Monitor known or suspected acidosis,
proteins. Potassium helps maintain because potassium moves from RBCs
into the extracellular fluid in acidotic
acid-base equilibrium, and it has a sig-
states
nificant and inverse relationship to
pH: A decrease in pH of 0.1 increases • Routine screen of electrolytes in acute
the potassium level by 0.6 mEq/L. and chronic illness
Abnormal potassium levels can be
RESULT
caused by a number of contributing
factors, which can be categorized as Increased in:
follows: ■ • Acidosis
• Acute renal failure
Altered renal excretion: Normally,
80% to 90% of the body’s • Addison’s disease
potassium is filtered out through
• Asthma
the kidneys each day (the re-
mainder is excreted in sweat • Burns
and stool); renal disease can
result in abnormally high • Chronic interstitial nephritis
potassium levels. • Dehydration
Altered dietary intake: A severe • Dialysis
potassium deficiency can be
caused by an inadequate • Diet (excessive intake of salt substitutes
intake of dietary potassium. or of potassium salts in medications)
• Excessive theophylline administration • Intravenous (IV) therapy with inade-

quate potassium supplementation
• Exercise
• Hemolysis (massive) • Laxat

David - S Comprehensive Handbook of Laboratory Tests With Nur PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

David - S Comprehensive Handbook of Laboratory Tests With Nur PDF

Uploaded by

Copyright:

Available Formats

00Van Leewan(F)-FM 12/15/05 8:33 PM Page i

This page left intentionally blank.

Anne M. Van Leeuwen, MA, BS, MT (ASCP)

F. A. DAVIS COMPANY • PHILADELPHIA

Copyright © 2006 by F. A. Davis Company

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Lisa B. Deitch

Library of Congress Cataloging-in-Publication Data

Van Leeuwen, Anne M.

This page left intentionally blank.

-Aminolevulinic Acid vii

ABOUT THIS BOOK

viii About This Book

About This Book ix

• Obtain pertinent clinical, laboratory, dietary, and therapeutic history of

x About This Book

complexity; a summary chart that details suggested approaches to persons at various

This page left intentionally blank.

-Aminolevulinic Acid xiii

Connie J. Frisch, RN, MA Deborah Little, MSN, RN, CCRN, CNRN,

This page left intentionally blank.

ABOUT THIS BOOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

SYSTEM TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1387

Patient Preparation and Specimen Collection 1403

Potential Nursing Diagnoses Associated with Laboratory

Guidelines for Age-Specific Communication 1418

Transfusion Reactions: Laboratory Findings and Potential

Introduction to CLIA 1988 & 1992 1427

Standard Precautions (CDC Isolation Precautions) 1431

This page left intentionally blank.

DESCRIPTION & RATIONALE: Nor- moma. The relationship between the

2 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

CRITICAL VALUES: N/A ➤ Obtain a history of the patient’s mus-

Acid Phosphatase, Prostatic 3

ing or hematoma formation. Apply implications of the test results as

ACID PHOSPHATASE, PROSTATIC

SYNONYMS/ACRONYM: Prostatic acid phosphatase, o-phosphoric monoester

SPECIMEN: Serum (1 mL) collected in a red-top tube.

4 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

A swab with vaginal secretions may be submitted in the appropriate trans-

REFERENCE VALUE: (Method: Spectrophotometric)

Conventional & SI Units

effective treatment. Rising levels are

• Assist with differential diagnosis of

Acid Phosphatase, Prostatic 5

6 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

care practitioner, who will discuss guilt, depression, anger) as a victim

ADRENAL GLAND SCAN

SYNONYM/ACRONYM: Adrenal scintiscan.

DESCRIPTION & RATIONALE: This adenoma in primary aldosteronism

Adrenal Gland Scan 7

tory function of the adrenal cortex. • Adrenal tumor

8 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

➤ Make sure a written and informed

Adrenocorticotropic Hormone (and Challenge Tests) 9

➤ If a woman who is breast-feeding practitioner, who will discuss the

SYNONYM/ACRONYM: Corticotropin, ACTH.

10 Davis’s Comprehensive Handbook of Laboratory and Diagnostic Tests—with Nursing Implications

REFERENCE VALUE: (Method: Immunoradiometric assay)

Conventional SI Units (Conventional

ACTH Challenge Tests

ACTH (Cosyntropin) SI Units

SYNONYMS/ACRONYMS: CSF tau protein and -amyloid-42, AD.