Diagnostics For Nursing Reviewees

Cardio

(1) ECG/EKG- records electric conduction of heart

Types: (a) Resting ECG: secure electrodes, remain still, reassure pt. will not receive electric shock

(b) Holter Monitoring- portable ambulatory ECG monitoring (24 hrs): secure electrodes, continue normal activity, maintain a log of activities & note s/s

(c) Stress Test- multi-lead ECG monitoring during controlled and supervised exercise, usu. on treadmill or stationary bike: consent signed, light meal 1-2 hrs before exam or fasting for 4hrs, [ (-) caffeine, ROH, smoking], comfortable clothing, rubber shoes, secure electrodes, obtain baseline B/P & resting ECG, instruct pt. to exercise as instructed [report pain, weakness, SOB or other s/s], monitor B/P & ECG cont. record @ intervals w/ any s/s or changes in V/S esp. cardiac rhythm

(2) Echocardiography (2D Echo)-U/S of heart evaluate structure, FXN of heart chambers & valves: fast for 6hrs, remain still, secure electrodes for ECG, monitor B/P, reassure no pain or electric shocks rather the lubricant placed on skin will be cool, cleanse lubricant from pt’s chest, cont. fasting for 4hrs after study

(a) Transesophageal Echocardiography (TEE)- transducer thru esophagus: Throat is anesthetized before transducer insertion, ECG & B/P monitoring

*for2D-Echo w/ pharmacologic stress testing(Adenosine, dipyridamole, dobutamine) IV for sedation is started before study

(3) Phonocardiography-graphic recording of heart sounds: remain still, secure electrodes for ECG, and reassure no pain

No Postprocedure Nsg Care

(4) CT Scan-cross-sectional images of the chest, heart & great vessels: Explain procedure that pt. will lie on table while scanner rotates, contrast IV may be started (as in Cardiac Cath prep), remain still

(5) MRI-powerful magnetic field & computer-generated pics to image physiologic & anatomical properties: C/I in clients w/ pacemakers, metallic implants, prosthetic joints & orthodontic appliance, mild sedatives for claustrophobic pts., remain still

INVASIVE PROCEDURES:

1. Coronary Angio/Arteriography (Cardiac Cath)-physician injects dye into coronary arteries thru brachial or femoral artery, takes a series of X-Ray films to assess structure of arteries: consent signed, allergies of dye & shellfish, fast 8-12 hrs, will end <2hrs,>

2. Hemodynamic Monitoring:

1. Central Venous Pressure (CVP)-assess RIGHT VENTRICULAR FXN & venous blood return to the RIGHT SIDE of the heart: consent signed, skin prep, insertion to either external jugular, antecubutal or femoral vein, secure dry, air occlusive sterile dressing (Observe sterile technique); placement is confirmed thru X-Ray

• Increased CVP-hypervolemia

• Decreased CVP-hypovolemia

(b) Pulmonary Artery Pressure (PAP)- assess LEFT VENTRICULAR FXN via right side of heart & into pulmonary artery can also measure RV fxn or RA pressure, pulmonary systolic & diastolic pressure, mean pulmonary artery pressure & pulmonary artery wedge pressure. To evaluate medical interventions (to include effects of medications)

Complications of CVP/PAP:

• Infection

• Infarction (PAP)

• Pulmonary thromboembolism

• Catheter kinking

• Dysrhythmias

• Air Embolism

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Pulmo

1. Pulmonary FXN Test (PFT)- routinely used in pts. w/ chronic respiratory disorders, assess respiratory fxn & extent of dysfxn, measures lung volumes, ventilatory fxn & mechanics of breathing, diffusion & gas exchange, thru spirometer or spirometer w/ volume-collecting and recording device

2. Arterial Blood Gas (ABG)- measures blood pH & arterial O₂ & CO₂ thru radial, brachial, femoral artery or indwelling arterial cath blood extraction.

3. Pulse Oximetry- measures O₂ saturation of HGB

*Unreliable results in cardiac arrest pts & shock, when dyes (methylene blue) or vasoconstrictor meds have been used, severe anemia or high CO level.

4. Cultures- Nasal swabs, throat cultures, sputum studies

1. Sputum Exam- identify pathogenic organisms & malignant cells as well as hypersensitivity states & drug sensitivity: cleanse nose & throat, rinse mouth prior to expectoration, taken early morning specimen delivered to lab w/in 2 hrs

ENDOSCOPIC PROCEDURES ARE HIGHLY INVASIVE:

1. Bronchoscopy- direct inspection and exam of larynx, trachea & bronchi thru either a flexible fiberoptic bronchoscope or rigid bronchoscope: consent signed, remove dentures & other oral prosthesis, lidocaine anesthetic spray on pharynx, IV sedation may be started esp. for rigid bronchoscopy, ice chips & fluids when cough reflex is demonstrated, assess resp. status, observe s/s of hypoxia, hypotension, dysrhythmias, hempotysis & dyspnea-report promptly, pt shall not be discharge until cough reflex is adequate, report bleeding & SOB

Purpose:

• Examine tissues & collect secretions

• Biopsy & determine location & extent of pathology

• Determine if tumor can be surgically resected

• Diagnose bleeding sites

2. Thoracoscopy- pleural cavity is examined w/ endoscope, chest tube may be inserted and pleural cavity is drained by negative-pressure water-seal drainage: consent signed, IV sedation started, monitor for SOB (as in pneumothorax), chest tube in place and monitoring chest tube drainage system is essential, minor activity restrictions

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1. Thoracentesis- aspiration of pleural fluid or air for diagnostic or therapeutic purposes (medications instillation), needle biopsy may be performed at the same time: consent signed, assess for allergies to local anesthetics, IV sedation may be started, remain still, expect minimal discomfort and pressure sensation, position client either: straddling on chair w/ arms & head resting on the backrest of chair, sitting edge of bed w/ feet supported & arms & head on a padded over-the-bed table, lying on unaffected side w/ bed elevated 30-45degrees, skin prep (germicide solution), refrain coughing, apply pressure on small sterile dressing over puncture site, encourage bed rest, record amount of fluid, colour, viscosity; monitor SOB, chest asymmetry in movement, chest tightness, vertigo, faintness, uncontrollable cough; blood-tinged, frothy mucus, tachycardia & s/s of hypoxemia

2. Biopsy- excision of a small amount of tissue from pharynx, larynx, nasal passages, pleura & lungs: SAME AS ENDOSCOPY (Thora/broncho)

3. X-Ray/Roentgenogram: provide privacy w/ less body exposure & follow instructions during procedure

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­Gastro_x

1. Stool Exam- for consistency, color, occult blood, fecal urobilinogen, fat, nitrogen, parasites, pathogens, food residues & other substances: for quantitative24-72hr collection must be kept refrigerated until taken to lab, follow prescribed diet or refrain meds as instructed by MD (for special stool tests)

2. Abdominal U/S- high frequency sound waves are passed into internal body structures: fast for 8-12hrs to decrease amount of gas in the bowel, fat-free meal for gallbladder studies, barium studies should be performed after the test

3. Upper Gastrointestinal Tract Study (Upper GI Series)- x-ray of GI tract w/ ingested contrast agent (barium sulphate): low residue diet for several days, NPO after midnight before test, take laxatives as prescribed, no smoking the morning before exam, w/hold all med, assess for allergies of contrast agent; after procedure, increase fluids to evacuate stool & barium, monitor color of stools (barium appears clay-like), a laxative or enema may be needed.

4. Lower Gastrointestinal Tract Study- detect polyps, tumors & other lesions of large intestine, barium enema to visualize lower GI tract or w/ the use of water-soluble iodinated contrast agent: low residue diet 1-2days before test, clear liquid diet & laxative the night before, NPO after midnight, cleansing enema w/ clear returns the following morning, barium enemas should be before upper GI series, increase fluid intake to evacuate barium and as well as enema or laxative.

   • Enemas are C/I in pts. w/ inflammatory disease of colon

   • Barium enemas are C/I in pts. w/ s/s of perforation or obstruction instead water-soluble contrast study may be performed

   • Enemas and laxatives are C/I in pts. w/ active GI bleeding

   5. Gastric Analysis- yields info about the secretory activity of the gastric mucosa by NGT thru aspiration of gastric contents every 15 minutes of 1hr: NPO for 8-12hrs. PO meds w/held for 24-48hrs, smoking not allowed, NGT secured to the pt’s cheek & pt in semi-reclining position, label specimen

   6. Gastric Acid Stimulation Test- histamine or pentagastrin given per SQ to stimulate gastric secretions, specimen aspirated thru NGT every 15 minutes for 1hr: expect flushed feeling after administration of histamine/pentagastrin, monitor B/P & PR for hypotension, label specimens

   *Gastric Analysis, Gastric Stimulation Test may be in conjunction w/ Gastric pH monitoring

   ENDOSCOPIC PROCEDURES ARE HIGHLY INVASIVE: Lubrication necessary for GI endoscopy

   1. Upper Gastrointestinal Fibroscopy / Esophagogastroduodenoscopy- fibroscopy of the upper GI tract allows direct visualization through a lighted endoscope (gastroscope): consent signed, NPO for 6-12 hrs, spray or gargle local anesthetic, IV sedation started as ordered (medazolam-moderate sedation & relieves anxiety, atropine to decrease secretions, position pt on left side to facilitate saliva drainage and easy access; after procedure, position pt. in Simms position until awaken then Semi-Fowler’s, instruct not to eat or drink until gag reflex returns (1-2 hrs) then offer lozenges, saline gargles & oral analgesic-relieve throat discomfort, assess s/s of perforation i.e. pain, bleeding, difficulty swallowing & elevated temp., monitors pulse & B/P

   2. Anoscopy, Proctoscopy & Sigmoidoscopy- use of endoscope, anoscope-anus & lower rectum, proctoscope & sigmoidoscope-rectum & sigmoid colon: consent signed, no dietary restrictions, warm tap water/Fleet’s enema until clear, pt assumes position on left side w/ right leg bent & placed anteriorly (knee-chest at the edge of bed w/ back inclined at about 45degree angle for rigid endoscope); during procedure, monitor V/S, skin color, temp., pain tolerance & vagal response; after procedure, monitor for rectal bleeding & s/s of intestinal perforation i.e. fever, rectal drainage, abdominal distention & pain

   3. Fiberoptic Colonoscopy- inspection of the colon to the cecum, used for cancer screening and for surveillance in pts. w/ previous colon cancer or polyps, can removed visible polyps: consent signed, limit intake of liquids for 24-72hrs, cleansing of bowels (laxative for 2 nights before test, Fleet’s or saline enema till returns are clear-morning of test), start clear liquid diet at noon the day before test then ingest lavage solutions (intestinal lavage for optimal intestinal cleansing) @ 3-4 intervals, NPO after midnight (can take meds but w/ minimal water), position to left side, monitor V/S, O₂ saturation; assess color & temp. of skin, LOC, abdominal distention, vagal response & pain, assess RR due to sedation, supplemental O₂ should be used as necessary; after procedure, bed rest until fully alert; observe s/s of bowel perforation i.e. rectal bleeding, abdominal pain & distention, fever, focal peritoneal signs; if midazolam was used, pt is unable to recall verbal info. due to its amnesic effect-provide written instructions, report bleeding to MD

   4. Peritoneoscopy (Laparoscopy)- performed thru small incision of abdominal wall, biopsied may be taken, requires general anesthesia and decompression of stomach & bowel, usu. CO2 is insufflated into the peritoneal cavity to create more space for visualization, indicated to evaluate peritoneal disease, chronic abdominal pain, abdominal masses, gallbladder & liver disease: consent signed, IV sedation started, ensure safety during ambulation due to orthostatic hypotension after procedure, assess RR for resp. depression

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   Renal

   1. Urinalysis (U/A), Urine Culture & Sensitivity- provides info on kidney function & helps diagnose other diseases e.g. diabetes, identify bacteria & as well as their strains, identify appropriate antimicrobial therapy

   Evaluates:

   • Urine color

   • Urine clarity & odor

   • Urine pH & specific gravity

   • Urine RBCs, sediments, casts, crystals, pus & bacteria

   • Urine protein, ketones, glucose

2. KUB X-Ray- x-ray of abdomen or kidney, ureters & bladder to delineate size, shape & position, presence of calculi, cysts, tumors & kidney displacement: provide privacy w/ less body exposure

3. U/S: lower abdomen & genitalia exposed-provide privacy & minimal exposure, requires full bladder encourage fluid intake before testRetrograde Pyelography- catheters are advanced thru the ureters into the renal pelvis by means of cystoscopy, contrast agent injected, may be used before extracorporeal shock-wave lithotripsy: consent signed, allergies of dye & shellfish

ENDOSCOPIC PROCEDURES ARE HIGHLY INVASIVE: Lubrication necessary for GU endoscopy

2-way approach:

• Percutaneous

• Per Urethra (Lubrication necessary)

1. Cystoscopy- visualization of urethra, bladder, uretral orifices, prostatic urethra, renal pelvis w/ the use of a cystoscope, lidocaine to reduce discomfort, general anesthesia given: consent signed, NPO, explain procedure to pt & family for preparation & to allay fears, after procedure, assess RR for resp. depression, bed rest until fully alert, reduce/ relieve discomfort thru moist heat over lower abdomen, warm sitz baths, monitor for urine retention-intermittent catheterization may be necessary, monitor for UTI & obstruction (due to edema)

2. Brush Biopsy thru Cystoscope- cystoscope examination is first conducted followed by introduction of ureteral catheter, followed by biopsy brush passed thru the catheter, brushes back & forth to obtain cells, lidocaine to reduce discomfort, general anesthesia: consent signed, NPO, explain procedure to pt & family for preparation & to allay fears, after procedure, assess RR for resp. depression, bed rest until fully alert, expect hematuria w/in 24hrs & clearing after 24-48hrs, renal colic occasionally occurs yet responds to analgesics

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4. Kidney Biopsy- renal cortex tissue specimen taken thru either percutaneously (needle biopsy) or thru small flank incision: Obtain coagulation studies to check for bleeding tendencies, consent signed, fasting 6-8hrs, IV line established, U/A taken, for needle biopsy-pt. on prone position w/ sandbags under abdomen, instruct to hold breath while needle is inserted to prevent kidney from moving, for open biopsy-preparation similar to major abdomen surgery, pressure applied to biopsy site, bed rest for 6-8hrs kept in prone position

Reference: Brunner and Suddarth's Medical-Surgical Nursing 7th Edition