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Friday, October 26, 2007

Common Laboratory Procedures:: Medical Surgical Nursing :: Review For Nursing Licensure Examination

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Common Laboratory Procedures:: Medical Surgical Nursing :: Review For Nursing Licensure Examination Slide Transcript
Slide 1: Common Laboratory procedures: Nursing Responsibilities and Implications

Slide 2: 3 Phases of Diagnostic testing Pretest   Client preparation  Intra-test  specimen collection and VS monitoring  Post-test  Monitoring and follow-up nursing care

Slide 3: Related Nursing Diagnoses  Anxiety  Fear  Impaired physical mobility  Deficient knowledge

Slide 5: BLOOD TESTS CBC   Hemoglobin, Hematocrit, WBC, RBC and platelet  Serum Electrolytes  Arterial blood gases  Blood Chemistry  Drug and Hormone Assay

Slide 6: Complete Blood Count Specimen: Venous blood  Pretest: obtain syringe,  tourniquet, vial with appropriate anticoagulant Intratest: Cubital vein  commonly used for venipuncture Post-test: direct pressure and  observe for bleeding, label vial

Slide 7: Normal values for CBC RBC (M) 4.7-6.1/ (F) 4.2-5.4  Hgb (M) 14-18/ (F) 12-16 mg/dL  Hct (M) 42-52/ (F) 33-47 %  WBC 5-10,000 cells/cubic cm  Differential count  Neutrophils- 55- 70%  Lymphocytes- 20-40%  Monocytes- 2-5%  Eosinophils- 1-4% Platelets 150,000-400,000 

Slide 9: Table. 11.2

Slide 11: CBC Normal WBC count 5-10,000 cell/cm3 Increased WBC More than 10, 000 (Leukocytosis) Increased Neutrophils ACUTE bacterial infection Increased Lymphocytes CHRONIC bacterial infection VIRAL infection Increased Eosinophils PARASITIC infection

Slide 12: Serum Electrolytes Specimen: venous blood  Pretest/Intratest/Post-test- same  Commonly ordered: Sodium- 135-145 mEq/L  Potassium- 3.5-5.0 mEq/L  Chloride- 95-105 mEq/L  Magnesium- 1.3 to 2.1 mEq/L  Calcium- 8 to 10 mg/dL 

Slide 13: Serum Electrolytes Problems can be  Hyper if increased  Hypo if decreased

Slide 14: Blood Chemistry Specimen: Venous blood, serum  Pretest/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

Slide 15: Blood Chemistry Normal values for : Creatinine: 0.7 to 1.4 mg/dL BUN: 10-20 mg/dL Creatinine clearance: 1.67 to 2.5 mL/s Serum uric acid: 2.5 to 8 mg/dL Blood osmolality= 250 to 290 mOsm/L

Slide 16: Blood Chemistry Enzymes/acids Purpose Uric acid Gout detection SGOT/SGPT Liver function test Rheumatoid factor For Rheumatoid arthritis Anti-DNA antibody SLE diagnosis CK-MB, LDH and Identifies Cardiac Troponin damage or muscle damage

Slide 17: Blood Chemistry Coagulation studies Purpose PT Measures the effectiveness of Warfarin 12-16 seconds PTT The BEST single screening test for coagulation disorders 60-70 seconds aPTT Same as PTT, measures effectiveness of HEPARIN 30-40 seconds (more specific than PTT) Bleeding time Measures Platelet function 1-9 minutes

Slide 18: Blood Chemistry Others Purpose ESR (erythrocyte Measures the rate at which sedimentation rate) the RBCs settle out of the anti-coagulated blood 10-20 mm/hour Elevates in inflammation auto immune diseases Blood lipids To detect hyperlipidemia Cholesterol= 150-200 mg/dL Triglycerides= 140-200 mg/dL

Slide 19: Diabetes Mellitus DIAGNOSTIC CRITERIA FBS equal to or greater than 126 mg/dL (7.0mmol/L) (Normal 8 hour FBS- 80-109 mg/dL)

Slide 20: Diabetes Mellitus DIAGNOSTIC CRITERIA OGTT value 1 and 2 hours post- prandial equal to or greater than 200 mg/dL  Normal OGTT 1 and 2 hours post-prandial- is 140 mg/dL

Slide 21: Diabetes Mellitus DIAGNOSTIC CRITERIA RBS of equal to or greater than 200 mg/dL PLUS the 3 P’s

Slide 22: Diabetes Mellitus DIAGNOSTIC CRITERIA Glycosylated hemoglobin (HbA1c) is a monitoring test to assess the adherence to diabetic medication

Slide 23: Arterial Blood Gases Specimen: arterial blood  Pretest: obtain syringe with  heparin, rubber stopper, container with ice Intratest: usual site-radial  artery, perform Allen’s test Post-test: Apply direct  pressure on site for 5-10 minutes, send specimen with occluded needle on ice

Slide 24: Normal ABG values pH 7.35-7.45   pCO2 35-45 mmHg  paO2 80-100 mmHg  HCO3 22-26 mEq/L  Base excess -2 to +2  O2 sat 95-98%

Slide 25: ABG interpretation Value Normal Acidosis Alkalosis pH 7.35-7.45 Below 7.35 Above 7.45 paO2 95-100 mmHg SaO2 95-98% Respiratory Respiratory paCO2 35-45 mmHg >45 <35 Metabolic Metabolic HCO3 22-26 mEq/L <22 >26

Slide 27: Urine Analysis Specimens  Clean-voided urine for routine urinalysis  Clean-catch or midstream urine for urine culture  Suprapubic and catheterized urine for urine culture

Slide 28: Routine Urinalysis Specimen: Clean voided  Pretest: give clean vial and  instruct to void directly into the specimen bottle Intratest: Allow a 10 ml collection  Post-test: prompt delivery to  laboratory *First voided urine in a.m. is highly  concentrated, more uniform concentration and with more acidic pH

Slide 29: Urine Culture: Normal is <100,000 Specimen: clean catch,  midstream or catheterized urine Pretest: Instruct to wash and dry  genitalia/perineum with soap and water. (M)- circular motion, (F)- front to back direction Intratest: Midstream urine, 30-60  ml Post-test: Cap and label, prompt  delivery and documentation

Slide 30: 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

Slide 31: Timed-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 

Slide 32: 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 if no urine  Wipe area where needle will be inserted  30-45° angle, 3 ml for culture  Post-test : Unclamp catheter after collection

Slide 34: Stool Analysis Occult Blood GUAIAC test   Steatorrhea  Ova/Parasites  Bacteria  Viruses

Slide 35: General Nursing consideration for stool collection 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 Post-test: prompt delivery 

Slide 36: 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 days 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

Slide 38: Sputum Analysis For Culture and sensitivity  For sputum cytology  For sputum AFB  For monitoring of the  effectiveness of therapy

Slide 39: 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 or 15-30 ml Post-test: oral care and prompt  delivery to lab

Slide 41: VISUALIZATION PROCEDURES Invasive procedures are  direct methods and need CONSENT  Non-invasive procedures are indirect methods and may need written consent in some instances

Slide 42: Visualization procedures They can be: Radiographic procedures  “Scopic” procedures 

Slide 44: GIT Visualization Barium Swallow- UGIS   Pretest: written consent, NPO the night  Intratest: administer barium orally, then followed by X-ray  Post-test: Laxative for constipation, increased fluids, assess for intestinal obstruction , warn that stool is light colored!

Slide 47: GIT Visualization Barium Enema- LGIS   Pretest: Informed consent, NPO the night, Enema the morning  Intratest: Position on LEFT side, administer enema, then X-ray follow  Post-test: Cleansing enema , Laxative for constipation, assess for intestinal obstruction

Slide 49: 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 returns. Monitor for complications

Slide 51: GIT Visualization Anoscopy, proctoscopy,  proctosigmoidoscopy, colonoscopy Pretest: Consent, NPO, and  enema administration the morning Intratest: Position on the LEFT  side during scope insertion Post-test: Monitor for  complications

Slide 54: Gallbladder Oral cholescystogram  PTC  ERCP  Ultrasound 

Slide 55: IV Cholecystogram X-ray visualization of the  gallbladder after administration of contrast media intravenously Pre-test: Allergy to iodine and sea-  foods Intra-test: ensure patent IV line  Post-test: increase fluid intake to  flush out the dye, Assess for delayed hypersensitivity reaction to the dye like chills and N/V

Slide 57: 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

Slide 60: 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 procedure

Slide 61: Endoscopic retrograde cholangiopancreatography Pre-test: consent, NPO for 12  hours, Allergy to sea-foods, Atropine sulfate Intra-test: Gag reflex is  abolished, Position on LEFT side Post-test: NPO until gag  reflex returns, Position side lying and monitor for perforation and hemorrhage

Slide 65: Percutaneous Transhepatic Cholangiogram Under fluoroscopy, the bile duct  is entered percutaneously and injected with a dye to observe filling of hepatic and biliary ducts

Slide 67: Ultrasound of the liver, gallbladder and pancreas Consent MAY be needed  Place patient on NPO!!!  Laxative may be given to  decrease the bowel gas

Slide 69: Urinary Visualization Non-invasive: KUB, IVP, Ultrasound  Pretest: Elicit allergy to iodine and seafood, NPO after midnight  Intra-test: IV iodinated Dye is administered then X-ray is taken  Post-test: Increase fluids to flush the dye. Documentation, VS monitoring

Slide 72: Urinary Visualization Invasive: retrograde  cystourethrogram Pretest: Elicit allergy to iodine  and seafood Intra-test: catheter is inserted  with dye is administered then X-ray is taken as patient voids Post-test: Increase fluids to  flush the dye. Documentation, VS monitoring

Slide 75: Pulmonary visualization Invasive: Bronchoscopy,  laryngoscopy Non-invasive: CXR and Scan 

Slide 76: Bronchoscopy Purpose: Diagnostic and  therapeutic Pretest: Consent, NPO, client  teaching, anti-anxiety drugs Intratest: gag reflex is abolished,  instruct to remain still during procedure, FOWLER or SUPINE Post-test: NPO until gag reflex  returns, monitor patient for complication like perforation/bleed

Slide 79: Pulmonary function test Test to determine lung volumes  and capacities

Slide 82: LUNG VOLUMES 1. Tidal volume – TV  2. Inspiratory Reserve Volume-  IRV 3. Expiratory Reserve Volume-  ERV 4. Residual volume- RV 

Slide 83: LUNG CAPACITIES Lung volume + another lung volume  1. Inspiratory Capacity- IC  2. Functional Residual Capacity- FRC  3. Vital capacity- VC  4. Total Lung capacity- TLC

Slide 84: 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

Slide 85: 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

Slide 86: 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

Slide 87: 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

Slide 89: Cardiac Visualization  Invasive:angiography. Cardiac catheterization  Non-invasive: ECG, Echocardiography, Stress ECG

Slide 90: The Cardiovascular System LABORATORY PROCEDURES ECHOCARDIOGRAM  Non-invasive test that studies the structural and functional changes of the heart with the use of ultrasound  No special preparation is needed

Slide 91: 2 D-echocardiogram

Slide 92: Angiography Pretest: informed consent,  allergy to dyes, seafood and iodine Intratest: Monitor VS  Post-test: maintain pressure  dressing over puncture site Immobilize for 6 hours 

Slide 95: Cardiac Catheterization Introduction of catheter into heart  chambers Pretest: informed consent, allergy  to dyes, seafood and iodine, NPO 8-12 hours Intra-test: Empty bladder, Monitor  VS, explain palpitations Post-test: maintain pressure  dressing over puncture site Immobilize for 6-8 hours with  extremity straight

Slide 97: Myelography Radiographic examination of the  spinal column and sub- arachnoid space to help diagnose back pain causes Pre-test: Consent, NPO, allergy  to seafoods Intra-test: like LT  Post-test: supine for 12 hours 

Slide 99: 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)

Slide 101: Arthrogram X-ray visualization of the joint  after introduction of contrast medium Pre-test: consent, allergy to  seafoods Post-test: Dressing over  puncture site and limit joint activity

Slide 103: Electromyelography Records the electrical activity in  muscles at rest and during involuntary and electrical stimulation Detects disorders such as MG, MS  and Parkinson’s Explain the use of electrode inserted  into the muscles Mild discomfort may be experienced  About 45 minutes for one muscle 

Slide 106: CT scan  Painless, non-invasive, x- ray procedure  Mechanism: distinguish density of tissues

Slide 108: MRI Painless, non-invasive, no radiation  Creates a magnetic field  Contraindications:   (+) pacemaker  (+) metal prosthesis Client teaching:   Lie still during the procedure for 60-90 minutes  Earplugs to reduce noise discomfort  Claustrophobia  No radiation

Slide 113: ASPIRATION AND BIOSPY Aspiration: withdrawal of  fluid  Biopsy: removal and exam of tissue  Invasive procedure needs INFORMED CONSENT

Slide 114: 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

Slide 115: Lumbar Puncture Intra-test: Site used-between  L4/L5  Position- flexion of the trunk Post-test: Flat on bed (8-12  hours)  Offer fluids to 3 Liters  Oral analgesic for headache  Monitor bleeding, swelling and changes in neurologic status

Slide 118: 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

Slide 119: Abdominal Paracentesis Intratest: 1,500 ml maximum  amount collected at one time, Monitor VS Post-test: monitor VS,  bleeding complication Measure abdominal girth and  weight

Slide 121: Thoracentesis Removal of fluid from the  pleural space  Purpose: Diagnostic and therapeutic  Pretest: Consent, teach to avoid coughing  Position: sitting with arms above head

Slide 122: Thoracentesis Intra-test: Support and  observation Post-test: Assess VS   Position Post-procedure: lie on the UNAFFECTED SIDE with head elevated 30° x 30 minutes to facilitate expansion of the affected lungs

Slide 125: Bone marrow Biopsy Removal of specimen of bone  marrow Purpose: diagnostic  Pretest: consent, teach that  procedure is painful Site: POSTERIOR SUPERIOR  ILIAC CREST (adult); PROXIMAL TIBIA (pedia)  Position: prone or lateral

Slide 126: Bone marrow Biopsy Intratest: Monitor, maintain  pressure dressing over punctured site X 10 mins Post-test: Asses for  discomfort, administer prescribed pain meds

Slide 127: Liver Biopsy  Liver tissue obtained for diagnostic purpose  Pretest: consent, administer Vitamin K, monitor bleeding parameters, NPO 2 hours before procedure  Position: Supine or semi- fowlers with upper right quadrant of abdomen exposed

Slide 128: Liver Biopsy Intra-test: Monitor VS   Take few deep inhalation and exhalation and hold final breath in exhalation x 10 seconds as needle is injected Post-test: monitor VS,  bleeding  Position post-procedure: RIGHT side-lying with folded towel/pillow under biopsy site for 4-6 hours

Slide 129: Papanicolau Smear Done as screening test for  cervical cancer, for culture Pre-test: no coitus for 2-3  days, no menstrual bleeding Intra-test: Lithotomy,  speculum with water for lubrication, specimen obtained for cervix and vagina Post-test: monitor for  bleeding

Slide 131: The Cardiovascular System LABORATORY PROCEDURES ELECTROCARDIOGRAM (ECG)  A non-invasive procedure that evaluates the electrical activity of the heart  Electrodes and wires are attached to the patient

Slide 135: What the waves represent? P wave= Atrial Depolarization  QRS= Ventricular Depolarization  T wave= Ventricular REPOLARIZATION 

Slide 137: 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

Slide 138: LABORATORY PROCEDURES CVP  Normal CVP is 0 to 8 mmHg/ 4-10 cm H2O

Slide 139: 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.

Slide 142: Tubes Levine  Salem Sump tube  Gastrostomy tube  Jejunostomy tube 

Slide 146: Drainage Penrose Drain  Hemovac  Pleuravac  Jackson-Pratt 

Slide 150: Asked in the local boards  DRE  Snellen’s chart  Weber’s test  Rinnes’ test

Slide 151: DRE Position: Left Lateral or Sim’s  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

Slide 152: Snellen’s 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

Slide 154: Snellen’s 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.

Slide 155: Weber’s 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

Slide 156: Weber’s 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

Slide 157: Rinne’s 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

Slide 158: Rinne’s Test  Air conduction is LONGER than bone conduction  Normal is POSITIVE Rinne’s

Slide 159: Rinne’s Test CONDUCTIVE HEARING  LOSS:  Bone conduction is GREATER than or equal to the AIR conduction  Abnormal is NEGATIVE RINNEs

Slide 160: Rinne’s Test SENSORINEURAL  HEARING LOSS:  No bone conduction and air conduction vibration can be assessed  NEGATIVE RINNEs

Slide 161: Weber

Slide 162: Rinne’s

Slide 163: Rinne’s


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