Common Laboratory procedures:

Nursing Responsibilities and Implications

3 Phases of Diagnostic testing Pretest  Client preparation  Intra-test Intra specimen collection and VS monitoring  Post-test Post Monitoring and follow-up follownursing care


Related Nursing Diagnoses

 Anxiety  Fear  Impaired

physical

mobility  Deficient knowledge

BLOOD TESTS CBC  Hemoglobin, Hematocrit, WBC, RBC and platelet  Serum Electrolytes  Arterial blood gases  Blood Chemistry  Drug and Hormone Assay


Complete Blood Count

 

Specimen: Venous blood Pretest: Pretest: obtain syringe, tourniquet, vial with appropriate anticoagulant Intratest: Cubital vein commonly used for venipuncture Post-test: Post-test: direct pressure and observe for bleeding, label vial

Normal values for CBC

   

RBC (M) 4.7-6.1/ (F) 4.2-5.4 4.74.2Hgb (M) 14-18/ (F) 12-16 mg/dL 1412Hct (M) 42-52/ (F) 33-47 % 4233WBC 5-10,000 cells/cubic cm 5Differential count  Neutrophils- 55- 70% Neutrophils- 55 Lymphocytes- 20-40% Lymphocytes- 20 Monocytes- 2-5% Monocytes Eosinophils- 1-4% EosinophilsPlatelets 150,000-400,000 150,000-

Table. 11.2

CBC
Normal WBC count Increased WBC (Leukocytosis) Increased Neutrophils Increased Lymphocytes 5-10,000 cell/cm3 More than 10, 000 ACUTE bacterial infection CHRONIC bacterial infection VIRAL infection PARASITIC infection

Increased Eosinophils

Serum Electrolytes
 

    

Specimen: venous blood Pretest/Intratest/Post-testPretest/Intratest/Post-test- same Commonly ordered: Sodium- 135Sodium- 135-145 mEq/L Potassium- 3.5Potassium- 3.5-5.0 mEq/L Chloride- 95Chloride- 95-105 mEq/L MagnesiumMagnesium- 1.3 to 2.1 mEq/L CalciumCalcium- 8 to 10 mg/dL

Serum Electrolytes Problems can be  Hyper if increased  Hypo if decreased

Blood Chemistry
  

 

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

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

Blood Chemistry
Enzymes/acids Uric acid SGOT/SGPT Purpose Gout detection Liver function test

Rheumatoid factor For Rheumatoid arthritis AntiAnti-DNA antibody SLE diagnosis CKCK-MB, LDH and Troponin Identifies Cardiac damage or muscle damage

Blood Chemistry
Coagulation studies Purpose
PT
12-16 seconds 12-

Measures the effectiveness of Warfarin The BEST single screening test for coagulation disorders

PTT
60-70 seconds 60-

aPTT
30-40 seconds 30-

Bleeding time
1-9 minutes

Same as PTT, measures effectiveness of HEPARIN (more specific than PTT) Measures Platelet function

Blood Chemistry
Others
ESR (erythrocyte sedimentation rate) 10-20 mm/hour 10-

Purpose
Measures the rate at which the RBCs settle out of the antianti-coagulated blood Elevates in inflammation auto immune diseases

Blood lipids Cholesterol= 150-200 mg/dL 150Triglycerides= 140-200 mg/dL 140-

To detect hyperlipidemia

Diabetes Mellitus

DIAGNOSTIC CRITERIA FBS equal to or greater than 126 mg/dL (7.0mmol/L) (Normal 8 hour FBS- 80-109 FBS- 80mg/dL)

Diabetes Mellitus

DIAGNOSTIC CRITERIA OGTT value 1 and 2 hours postpostprandial equal to or greater than 200 mg/dL  Normal OGTT 1 and 2 hours post-prandialpost-prandial- is 140 mg/dL

Diabetes Mellitus

DIAGNOSTIC CRITERIA RBS of equal to or greater than 200 mg/dL PLUS the

3 Ps

Diabetes Mellitus

DIAGNOSTIC CRITERIA Glycosylated hemoglobin (HbA1c) is a monitoring test to assess the adherence to diabetic medication

Arterial Blood Gases

 

Specimen: arterial blood Pretest: Pretest: obtain syringe with heparin, rubber stopper, container with ice Intratest: Intratest: usual site-radial siteartery, perform Allens test Post-test: Post-test: Apply direct pressure on site for 5-10 5minutes, send specimen with occluded needle on ice

Normal ABG values pH 7.35-7.45 7.35 pCO2 35-45 mmHg 35 paO2 8080-100 mmHg  HCO3 2222-26 mEq/L  Base excess -2 to +2  O2 sat 95-98% 95

ABG interpretation
Value pH paO2 SaO2 paCO2 HCO3 Normal 7.35-7.45 95-100 mmHg 9595-98% 9535-45 mmHg 22-26 mEq/L
Respiratory >45 Metabolic <22 Respiratory <35 Metabolic >26

Acidosis

Alkalosis

Below 7.35 Above 7.45

Urine Analysis Specimens  Clean-voided urine for Cleanroutine urinalysis  Clean-catch or midstream Cleanurine for urine culture  Suprapubic and catheterized urine for urine culture

Routine Urinalysis
 

  

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

Urine Culture: Normal is <100,000



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

Special Urine Collection



Infants  Special urine bag  Or cut a hole of the diaper (front for the boy, middle for the girl) pulling out through the hole the special bag Children  May use potty chair or bedpan  Give another vial to play with, allow parent to assist Elderly  Assistance may be required

TimedTimed-urine collection
  

Collection of ALL urine voided over a specified time Refrigerated or with preservative Pretest: Specimen container with preservative, receptacle for collection, a post sign Intratest: At the start of collection, have patient void and discard the urine At the end of collection period, instruct to completely void and save the urine Post test: Documentation

Catheter specimen

Sterile urine  Insert needle of the syringe through a drainage port  Only done with the rubber catheter not the plastic, silastic or silicone catheter.  Intratest: Clamp catheter x 30 mins Intratest: if no urine  Wipe area where needle will be inserted  30-45 angle, 3 ml for culture 30-45  Post-test : Unclamp catheter after Postcollection

Stool Analysis Occult Blood GUAIAC test  Steatorrhea  Ova/Parasites  Bacteria  Viruses


General Nursing consideration for stool collection



Pretest: Pretest: Determine purpose/s, obtain gloves, container and tongue blade Intratest:  Instruct to defecate in clean bed pan  Void before collection  Do not discard tissue in bedpan  Obtain 2.5 (1 inch) formed stool  15-30 ml of liquid stool 15Post-test: Post-test: prompt delivery

Occult Blood: Guaiac Test

  

Detect the presence of enzyme: Peroxidase (+) blue color positive guaiac Restrict intake of red meats, some medications and Vitamin C for 3-7 3days

FALSE (+): red meat, raw fruits and vegetables especially radish, turnip, melon and horseradish; meds like aspirin, NSAIDS, iron and anticoagulants
FALSE (-): Vitamin C, ingested 250 (mg per day from any source

Sputum Analysis
   

For Culture and sensitivity For sputum cytology For sputum AFB For monitoring of the effectiveness of therapy

Sputum examination
 

Pretest: Morning specimen is collected Intratest:  Mouthwash with plain water  Deeply inhale x 2 then cough  Wear gloves in collecting specimen  Expectorate needed- 1-2 Tbsp neededor 15-30 ml 15Post-test: Post-test: oral care and prompt delivery to lab

VISUALIZATION PROCEDURES Invasive procedures are direct methods and need CONSENT  Non-invasive procedures Nonare indirect methods and may need written consent in some instances


Visualization procedures They can be:



Radiographic procedures Scopic procedures

GIT Visualization
Barium Swallow- UGIS Swallow Pretest: written consent, NPO the night  Intratest: administer barium orally, then followed by X-ray X Post-test: Laxative for Postconstipation, increased fluids, assess for intestinal obstruction , warn that stool is light colored!


GIT Visualization
Barium Enema- LGIS Enema Pretest: Informed consent, NPO the night, Enema the morning  Intratest: Position on LEFT side, administer enema, then XXray follow  Post-test: Cleansing enema , PostLaxative for constipation, assess for intestinal obstruction


GIT Visualization
Esophagogastroscopy  Pretest: Informed consent, NPO for 8 hours, warn that gag reflex is abolished  Intratest: Position on LEFT side during scope insertion  Post-test: NPO until gag Postreturns. Monitor for complications

GIT Visualization


Anoscopy, proctoscopy, proctosigmoidoscopy, colonoscopy Pretest: Consent, NPO, and enema administration the morning Intratest: Position on the LEFT side during scope insertion PostPost-test: Monitor for complications

Gallbladder
   

Oral cholescystogram PTC ERCP Ultrasound

IV Cholecystogram


  

X-ray visualization of the gallbladder after administration of contrast media intravenously PrePre-test: Allergy to iodine and seaseafoods IntraIntra-test: ensure patent IV line PostPost-test: increase fluid intake to flush out the dye, Assess for delayed hypersensitivity reaction to the dye like chills and N/V

Oral Cholecystogram


X-ray visualization of the gallbladder after administration of contrast media Done 10 hours after ingestion of contrast tablets Done to determine the patency of biliary duct

Endoscopic retrograde cholangiopancreatography



Examination where a flexible endoscope is inserted into the mouth and via the common bile duct and pancreatic duct to visualize the structures Iodinated dye can also be injected after for the x-ray xprocedure

Endoscopic retrograde cholangiopancreatography



PrePre-test: consent, NPO for 12 hours, Allergy to sea-foods, seaAtropine sulfate IntraIntra-test: Gag reflex is abolished, Position on LEFT side PostPost-test: NPO until gag reflex returns, Position side lying and monitor for perforation and hemorrhage

Percutaneous Transhepatic Cholangiogram



Under fluoroscopy, the bile duct is entered percutaneously and injected with a dye to observe filling of hepatic and biliary ducts

Ultrasound of the liver, gallbladder and pancreas

  

Consent MAY be needed Place patient on NPO!!! Laxative may be given to decrease the bowel gas

Urinary Visualization
NonNon-invasive: KUB, IVP, Ultrasound  Pretest: Elicit allergy to iodine and seafood, NPO after midnight  Intra-test: IV iodinated Dye is Intraadministered then X-ray is Xtaken  Post-test: Increase fluids to Postflush the dye. Documentation, VS monitoring

Urinary Visualization


Invasive: retrograde cystourethrogram Pretest: Elicit allergy to iodine and seafood IntraIntra-test: catheter is inserted with dye is administered then X-ray is taken as patient voids PostPost-test: Increase fluids to flush the dye. Documentation, VS monitoring

Pulmonary visualization


Invasive: Bronchoscopy, laryngoscopy NonNon-invasive: CXR and Scan

Bronchoscopy


Purpose: Diagnostic and therapeutic Pretest: Consent, NPO, client teaching, anti-anxiety drugs antiIntratest: Intratest: gag reflex is abolished, instruct to remain still during procedure, FOWLER or SUPINE Post-test: Post-test: NPO until gag reflex returns, monitor patient for complication like perforation/bleed

Pulmonary function test



Test to determine lung volumes and capacities

LUNG VOLUMES
 

1. Tidal volume TV 2. Inspiratory Reserve VolumeVolumeIRV 3. Expiratory Reserve VolumeVolumeERV 4. Residual volume- RV volume-

LUNG CAPACITIES
Lung volume + another lung volume  1. Inspiratory Capacity- IC Capacity 2. Functional Residual CapacityCapacityFRC  3. Vital capacity- VC capacity 4. Total Lung capacity- TLC capacity-

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

Pulmonary "Volumes
3. Expiratory Reserve Volume  -amount of air that can still be expired by forceful expiration after the end of a normal tidal expiration  -about 1100ml 4. Residual Volume  -volume of air still remaining in the lungs after the most forceful expiration, averages about 1200ml

Pulmonary "Capacities:"
1. Inspiratory Capacity  -equals TV + IRV, about 3500ml  -amount of air that a person can breathe beginning at the normal expiratory level & distending his lungs to maximum amount 2. Functional Residual Capacity  -equals ERV + RV  -about amount of air remaining in the lungs at the end of normal expiration, about 2300ml

Pulmonary "Capacities:"
3. Vital Capacity

-equals IRV + TV + ERV or 1C + ERV, about 4600ml  -maximum amount of air that a person can expel from the lungs after filling the lungs to their maximum extent & expiring to the maximum extent 4. Total Lung Capacity  -maximum volume to which the lungs can be expanded with the greatest possible effort  -volume of air in the lungs at this level is equal to FRC (2300ml) in young adult


Cardiac Visualization
 Invasive:

angiography. Cardiac catheterization  Non-invasive: ECG, NonEchocardiography, Stress ECG

The Cardiovascular System LABORATORY PROCEDURES

ECHOCARDIOGRAM  Non-invasive test that Nonstudies the structural and functional changes of the heart with the use of ultrasound  No special preparation is needed

2 D-echocardiogram D-

Angiography


 

Pretest: informed consent, allergy to dyes, seafood and iodine Intratest: Monitor VS PostPost-test: maintain pressure dressing over puncture site Immobilize for 6 hours

Cardiac Catheterization
 

  

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

Myelography


 

Radiographic examination of the spinal column and subsubarachnoid space to help diagnose back pain causes PrePre-test: Consent, NPO, allergy to seafoods IntraIntra-test: like LT PostPost-test: supine for 12 hours

Arthroscopy


 

Insertion of fiber optic scope into the joint to visualize it, perform biopsy Performed under OR condition After care: Dressing over the puncture site for 24 hours to prevent bleeding Limit activity for several days (7 usually)

Arthrogram


X-ray visualization of the joint after introduction of contrast medium PrePre-test: consent, allergy to seafoods PostPost-test: Dressing over puncture site and limit joint activity

Electromyelography


 

Records the electrical activity in muscles at rest and during involuntary and electrical stimulation Detects disorders such as MG, MS and Parkinsons Explain the use of electrode inserted into the muscles Mild discomfort may be experienced About 45 minutes for one muscle

CT scan
 Painless,

nonnon-invasive, xxray procedure  Mechanism: distinguish density of tissues

MRI
  

Painless, non-invasive, no radiation nonCreates a magnetic field Contraindications:  (+) pacemaker  (+) metal prosthesis Client teaching:  Lie still during the procedure for 6060-90 minutes  Earplugs to reduce noise discomfort  Claustrophobia  No radiation

ASPIRATION AND BIOSPY Aspiration: Aspiration: withdrawal of fluid  Biopsy: removal and exam Biopsy: of tissue  Invasive procedure needs INFORMED CONSENT


Lumbar Puncture
  

Withdrawal of CSF from the arachnoid space Purpose: diagnostic and therapeutic To obtain specimen, relieve pressure and inject medication Pretest: consent, empty bladder

Lumbar Puncture


IntraIntra-test: Site used-between usedL4/L5  Position- flexion of the trunk PositionPostPost-test: Flat on bed (8-12 (8hours)  Offer fluids to 3 Liters  Oral analgesic for headache  Monitor bleeding, swelling and changes in neurologic status

Abdominal Paracentesis
  

Withdrawal of fluid from the peritoneal space Purpose: diagnostic and therapeutic Pretest: consent, empty bladder
Position: sitting  Site: midway between the umbilicus and symphysis


Abdominal Paracentesis


Intratest: 1,500 ml maximum amount collected at one time, Monitor VS Post-test: Post-test: monitor VS, bleeding complication


Measure abdominal girth and weight

Thoracentesis
Removal of fluid from the pleural space  Purpose: Diagnostic and therapeutic  Pretest: Consent, teach to avoid coughing  Position: sitting with arms above head


Thoracentesis


IntraIntra-test: Support and observation PostPost-test: Assess VS  Position Post-procedure: lie Poston the UNAFFECTED SIDE with head elevated 30 x 30 30 minutes to facilitate expansion of the affected lungs

Bone marrow Biopsy

  

Removal of specimen of bone marrow Purpose: diagnostic Pretest: Pretest: consent, teach that procedure is painful
Site: POSTERIOR SUPERIOR ILIAC CREST (adult); PROXIMAL TIBIA (pedia)  Position: prone or lateral


Bone marrow Biopsy



Intratest: Monitor, maintain pressure dressing over punctured site X 10 mins PostPost-test: Asses for discomfort, administer prescribed pain meds

Liver Biopsy  Liver tissue obtained for diagnostic purpose  Pretest: consent, administer Vitamin K, monitor bleeding parameters, NPO 2 hours before procedure  Position: Supine or semisemi-fowlers with upper right quadrant of abdomen exposed

Liver Biopsy


Intra-test: Intra-test: Monitor VS  Take few deep inhalation and exhalation and hold final breath in exhalation x 10 seconds as needle is injected PostPost-test: monitor VS, bleeding  Position post-procedure: postRIGHT side-lying with sidefolded towel/pillow under biopsy site for 4-6 hours 4-

Papanicolau Smear
  

Done as screening test for cervical cancer, for culture PrePre-test: no coitus for 2-3 2days, no menstrual bleeding IntraIntra-test: Lithotomy, speculum with water for lubrication, specimen obtained for cervix and vagina PostPost-test: monitor for bleeding

The Cardiovascular System LABORATORY PROCEDURES

ELECTROCARDIOGRAM (ECG)  A non-invasive nonprocedure that evaluates the electrical activity of the heart  Electrodes and wires are attached to the patient

What the waves represent?



P wave= Atrial Depolarization QRS= Ventricular Depolarization T wave= Ventricular REPOLARIZATION

LABORATORY PROCEDURES

CVP  The CVP is the pressure within the SVC  Reflects the pressure under which blood is returned to the SVC and right atrium

LABORATORY PROCEDURES

CVP  Normal CVP is 0 to 8 mmHg/ 4-10 cm H2O

LABORATORY PROCEDURES Measuring CVP  1. Position the client supine with bed elevated at 45 degrees (CBQ)  2. Position the zero point of the CVP line at the level of the right atrium. Usually this is at the MAL, 4th ICS  3. Instruct the client to be relaxed and avoid coughing and straining.

Tubes
   

Levine Salem Sump tube Gastrostomy tube Jejunostomy tube

Drainage
   

Penrose Drain Hemovac Pleuravac JacksonJackson-Pratt

Asked in the local boards

 DRE  Snellens

chart  Webers test  Rinnes test

DRE


Position: Left Lateral or Sims position with upper leg acutely flexed. Females can also be examined in lithotomy Ask client to BEAR DOWN  To accentuate rectal fissure, prolapse ,polyps  To relax the anal sphincter

Snellens Chart: test for visual acuity 20 ft or 6 m distance  3 readings: L, R and Both eyes  Report: 20/ xxx  Numerator: denotes the distance from the chart


Snellens Chart: test for visual acuity

 Denominator

denotes the distance from which the normal eye can read the chart  20/60: the person can see at 20 feet, what a normal person can see at 60 feet.

Webers test


Test for lateralization and bone conduction Tuning fork is placed on top of head NORMAL: sound is heard in BOTH ears, localized at the center of the head: WEBER NEGATIVE

Webers test


Sound is heard BETTER in the affected ear: Bone conductive hearing loss Sound is heard only or better on the NORMAL ear: Sensorineural heating loss ABNORMAL: WEBER POSITIVE

Rinnes Test


Test for AIR and BONE conduction Tuning fork is initially placed on the mastoid process until no vibration is heard Tuning fork is now placed in front of the ear until sound disappears

Rinnes Test
 Air

conduction is LONGER than bone conduction is POSITIVE

 Normal

Rinnes

Rinnes Test


CONDUCTIVE HEARING LOSS:  Bone conduction is GREATER than or equal to the AIR conduction  Abnormal is NEGATIVE RINNEs

Rinnes Test


SENSORINEURAL HEARING LOSS:  No bone conduction and air conduction vibration can be assessed  NEGATIVE RINNEs

Weber

Rinnes

Rinnes

FAILING TO PREPARE IS PREPARING TO FAIL