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Davis’s Comprehensive
Laboratory and Diagnostic
Test Handbook—with Nursing
Implications
Copyright © 2003 F.A. Davis Company
Davis’s Comprehensive
Laboratory and
Diagnostic Test
Handbook—with
Nursing Implications
Zoanne Burgess Schnell, PhD, RN
Anne M. Van Leeuwen, MA, BS, MT(ASCP)
Todd R. Kranpitz, MS, BS, NMT, ARRT
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
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 Canada
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.
ISBN 0-8036-1042-4
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Copyright © 2003 F.A. Davis Company
DEDICATION
T
o my parents, Eugene and Edith Burgess, whose love and nurturing gave me
confidence to pursue my goals. To my husband, Rich, and sons, Richard,
Patrick, and Shey, who have added immeasurable joy to my life and support
during work on “the book.” To my colleagues and friends for their interest and encour-
agement throughout the writing process. Especially to Dr. Rachel Pollow, whose use of
flow charts as a teaching tool inspired some of the activities suggested in the accom-
panying Instructor’s Guide and Student Workbook. To Anne and Todd, whose wit,
wisdom, and perseverance made this project happen and whose friendship I will always
cherish. To Lisa Deitch, Acquisitions Editor, who shared our vision of this book. And,
finally, to the patients, family members, students, and friends who have shared their
laboratory and diagnostic testing experiences, keeping me in touch with the “human”
side of it all.
Zoanne Burgess Schnell, PhD, RN
Professor
Department of Nursing, Food and Nutrition
Plattsburgh State University of New York
Plattsburgh, New York
v
Copyright © 2003 F.A. Davis Company
vi Dedication
To my wife, Mindy, who never once thought I could not succeed, and my son, Jake,
for their support throughout the entire project. I could not have done this without
them. To my coauthors, Zoanne and Anne, for their direction, endless commitment,
and organizational skills, but most of all for their friendship. To Lisa Deitch, for her
immeasurable faith in and support for this project, and to my friends and colleagues,
Fay and Dr. De Lise, for their encouragement and ongoing advice.
Todd R. Kranpitz, MS, BS, ARRT (R) (N), NM (NMTCB), ASCP (N)
Director of Imaging Services
King’s Daughters Medical Center
Ashland, Kentucky
Copyright © 2003 F.A. Davis Company
L
aboratory and diagnostic studies are essential components of a complete patient
assessment. Examined in conjunction with an individual’s history and physical
examination, laboratory and diagnostic data provide clues about health status.
Nurses are increasingly expected to integrate an understanding of laboratory and diag-
nostic procedures 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 responsibil-
ity 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
vii
Copyright © 2003 F.A. Davis Company
in this book relate to body systems can be found in tables at the front of the book. 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 cate-
gory 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 life span and across cultures; some-
times 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 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 encoun-
tered.
• Critical Values or findings that may be life-threatening or for which particular
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.
Copyright © 2003 F.A. Davis Company
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. A
summary list of nursing diagnoses associated with each phase of the testing procedure
is provided in the appendices for ease of reference.
Copyright © 2003 F.A. Davis Company
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 physical 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 collec-
tion 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 diagnostic data must be viewed with
thought and compassion, however, as well as with microscopes 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
interpretation of laboratory and diagnostic procedures and their outcomes. Just as
important, 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
Copyright © 2003 F.A. Davis Company
CONTENTS
DEDICATION .............................................. v
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
MONOGRAPHS ............................................ 1
APPENDIX A
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1097
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103
xiii
Copyright © 2003 F.A. Davis Company
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.
RESULT Pretest:
Increased in: ➤ Obtain a history of the patient’s
complaints, including a list of known
• Amyotrophic lateral sclerosis
allergens.
• MG (4.8 nmol/L indicates generalized ➤ Obtain a history of the patient’s
MG, 1.2 nmol/L indicates ocular MG, musculoskeletal system and results
and 0.9 nmol/L indicates remission) of previously performed tests and
1
Copyright © 2003 F.A. Davis Company
➤ Advise the patient that SSKI (120 meticulously wash hands with soap
mg/day) will be administered for 10 and water after each voiding for 72
days after the injection of the hours after the procedure.
radionuclide.
➤ Tell all caregivers to wear gloves
➤ A written report of the examination when discarding urine for 48 hours
will be completed by a physician after the procedure. Wash gloved
specializing in this branch of medi- hands with soap and water before
cine. The report will be sent to the removing gloves. Then wash hands
ordering provider, who will discuss after the gloves are removed.
this report with the patient.
➤ Evaluate test results in relation to
➤ Depending on the results of this the patient’s symptoms and other
procedure, additional testing may be tests performed. Related diagnos-
performed. tic tests include adrenal angiogra-
➤ Inform the patient to flush the toilet phy, CT, MRI, and positron emis-
immediately after each voiding sion tomography scans of the
following the procedure and to abdomen.
ADRENOCORTICOTROPIC HORMONE
(AND CHALLENGE TESTS)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Medication
Administered, Recommended
Procedure Adult Dosage Collection Times
zACTH stimulation, 250 µg cosyntropin IM 3 cortisol levels:
rapid test or IV bolus after baseline
overnight fast immediately before
bolus, 30 min after
bolus, and 60 min
after bolus
(Continued on the following page)
Copyright © 2003 F.A. Davis Company
Medication
Administered, Recommended
Procedure Adult Dosage Collection Times
Corticotropin-releasing IV dose of 1 µg/kg 3 cortisol and 3 ACTH
hormone (CRH) ovine CRH between levels: baseline
stimulation 9 a.m. and 8 p.m. before injection, 30
min after injection,
and 60 min after
injection
Dexamethasone Oral dose of 1 mg Collect cortisol at 8
suppression dexamethasone a.m. on the morning
(overnight) (Decadron) at 11 after the
p.m. dexamethasone
dose
Metyrapone Oral dose of 30 mg/kg Collect cortisol and
stimulation metyrapone with ACTH at 8 a.m. on
(overnight) snack at midnight the morning after
the metyrapone
dose
SI Units
(Conversion
Age Conventional Units Factor 0.22)
Cord blood 50–570 pg/mL 11–125 pmol/L
Newborn 10–185 pg/mL 2–41 pmol/L
Adult supine 9–52 pg/mL 2–11 pmol/L
specimen
collected in
morning 5–29 pg/mL 1–6 pmol/L
Women on oral
contraceptives
SI Units
(Conversion
Conventional Units Factor 27.6)
Dexamethasone Cortisol less than 3 Less than 83 nmol/L
Suppressed, µg/dL next day
Overnight Test
SI Units
(Conversion
Conventional Units Factor 0.22)
Metyrapone ACTH greater than Greater than 33
Stimulated, 150 pg/mL pmol/L
Overnight Test
SI Units
(Conversion
Conventional Units Factor 27.6)
Cortisol less than Less than 83 nmol/L
3 µg/dL next
day
ALANINE AMINOTRANSFERASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
(Conversion
Age Conventional Units Factor 0.017)
Newborn–1 y 13–45 U/L 0.22–0.77 µKat/L
2 y–adult
Male 10–40 U/L 0.17–0.68 µKat/L
Female 7–35 U/L 0.12–0.60 µKat/L
Alanine Aminotransferase 13
• Myocardial infarction
Pretest:
• Myositis
➤ Obtain a history of the patient’s
• Preeclampsia complaints, including a list of known
allergens.
• Shock (severe)
➤ Obtain a history of the patient’s
hepatobiliary system and results of
Decreased in: previously performed tests and
• Pyridoxal phosphate deficiency procedures. For related tests, refer
to the hepatobiliary system table.
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 ALT levels nutraceuticals. The requesting health
by causing cholestasis include care practitioner and laboratory
should be advised if the patient regu-
amitriptyline, anabolic steroids, andro-
larly uses these products so that their
gens, benzodiazepines, chlorothiazide, effects can be taken into considera-
chlorpropamide, dapsone, erythromy- tion when reviewing results.
cin, estrogens, ethionamide, gold
➤ There are no food, fluid, or medica-
salts, imipramine, mercaptopurine, tion restrictions unless by medical
nitrofurans, oral contraceptives, peni- direction.
cillins, phenothiazines, progesterone,
➤ Review the procedure with the
propoxyphene, sulfonamides, tamox- patient.
ifen, and tolbutamide.
➤ Inform the patient that specimen
• Drugs that may increase ALT levels by collection takes approximately 5 to
causing hepatocellular damage include 10 minutes.
acetaminophen (toxic), acetylsalicylic
acid, allopurinol, amiodarone, anabolic Intratest:
steroids, anticonvulsants, asparaginase, ➤ Direct the patient to breathe
azithromycin, bromocriptine, capto- normally and to avoid unnecessary
pril, cephalosporins, chloramphenicol, movement.
clindamycin, clofibrate, danazol, enflu- ➤ Observe standard precautions and
rane, ethambutol, ethionamide, fenofi- follow the general guidelines in
brate, fluconazole, fluoroquinolones, Appendix A. Perform a venipuncture,
foscarnet, gentamicin, indomethacin, and collect the specimen in a 5-mL
interferon, interleukin-2, levamisole, red- or tiger-top tube.
Copyright © 2003 F.A. Davis Company
SI Units
(Conversion
Age Conventional Units Factor 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
Copyright © 2003 F.A. Davis Company
Post-test:
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Observe venipuncture site for bleed-
ing or hematoma formation. Apply
Pretest: pressure bandage.
➤ Dietary recommendations may be
➤ Obtain a history of the patient’s indicated and vary depending on the
complaints, including a list of known severity of the condition. Ammonia
allergens. levels may be used to determine
➤ Obtain a history of the patient’s whether protein should be added to
gastrointestinal, genitourinary, and or reduced from the diet.
hepatobiliary system and results of ➤ Evaluate test results in relation to
previously performed tests and the patient’s symptoms and other
procedures. For related tests, refer tests performed. Related laboratory
to the gastrointestinal, genitourinary, tests include alanine aminotrans-
hepatobiliary system, and therapeu- ferase, alkaline phosphatase, ammo-
tic/toxicology tables. nia, aspartate aminotransferase,
➤ Obtain a list of the medications the bilirubin, electrolytes, γ-glutamyl
patient is taking, including herbs, nu- transpeptidase, hemoglobin, hema-
tritional supplements, and nutraceu- tocrit, hepatitis antibodies and anti-
ticals. The requesting health care gens, liver biopsy, osmolality, preal-
practitioner and laboratory should be bumin, protein, protein electro-
advised if the patient regularly uses phoresis, and smooth muscle anti-
these products so that their effects body.
Copyright © 2003 F.A. Davis Company
Aldolase 17
ALDOLASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: ALD.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Spectrophotometry)
SI Units
(Conversion
Age Conventional Units Factor 0.017)
Newborn–2 y 3.4–11.8 U/L 0.06–0.20 µKat/L
25 m–16 y 1.2–8.8 U/L 0.02–0.15 µKat/L
Adult Less than 7.4 U/L Less than 0.13 µKat/L
Post-test:
Pretest:
➤ Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s ing or hematoma formation. Apply
complaints, including a list of known pressure bandage.
allergens.
➤ Evaluate test results in relation to
➤ Obtain history of neuromuscular the patient’s symptoms and other
disorders, related treatments, and test results. Related laboratory tests
complaints of muscle fatigue or loss include alkaline phosphatase, anti-
of strength. mitochondrial antibody, aspartate
➤ Obtain a history of the patient’s aminotransferase, creatine kinase
hepatobiliary and musculoskeletal and isoenzymes, Jo-1 antibody,
system and results of previously lactate dehydrogenase and isoen-
performed tests and procedures. For zymes, liver biopsy, muscle biopsy,
related tests, refer to the hepatobil- and myoglobin.
Copyright © 2003 F.A. Davis Company
Aldosterone 19
ALDOSTERONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) or lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube is also acceptable.
SI Units
(Conversion
Age Conventional Units Factor 0.0277)
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
Supine 2–22 ng/dL 0.06–0.61 nmol/L
Upright 4–48 ng/dL 0.11–1.33 nmol/L
Adult
Supine 3–16 ng/dL 0.08–0.44 nmol/L
Upright 7–30 ng/dL 0.19–0.83 nmol/L
These values reflect a normal-sodium diet. Values for a low-sodium diet are three to
five times higher.
Aldosterone 21
Intratest:
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Ensure that the patient has complied
with dietary preparations and other
pretesting restrictions.
Pretest: ➤ Direct the patient to breathe
➤ Obtain a history of the patient’s normally and to avoid unnecessary
complaints, including a list of known movement.
allergens. ➤ Observe standard precautions and
➤ Obtain a history of known or follow the general guidelines in
suspected fluid or electrolyte imbal- Appendix A. Perform a venipuncture
ance, hypertension, renal function, after the patient has been in the
or stage of pregnancy. Note the upright (sitting or standing) position
amount of sodium ingested in the for 2 hours. If a supine specimen is
diet over the past 2 weeks. requested on an inpatient, the spec-
imen should be collected early in the
➤ Obtain a history of the patient’s
morning before rising. Collect the
endocrine and genitourinary system
specimen in a 5-mL red- or tiger-top
and results of previously performed
tube.
tests and procedures. For related
tests, refer to the endocrine and ➤ Label the specimen, and promptly
genitourinary system tables. transport it to the laboratory on ice.
Specify patient position (upright or
➤ Obtain a list of the medications the
supine) and exact source of speci-
patient is taking, including herbs, nu-
men (peripheral versus arterial).
tritional supplements, and nutraceu-
ticals. The requesting health care
practitioner and laboratory should be Post-test:
advised if the patient is regularly us-
ing these products so that their ef- ➤ Observe venipuncture site for bleed-
fects can be taken into consideration ing or hematoma formation. Apply
when reviewing results. pressure bandage.
➤ Note any recent procedures that can ➤ Instruct the patient to resume usual
interfere with test results. diet and medication as directed by
➤ The patient should be on a normal- the health care practitioner.
sodium diet (1 to 2 g of sodium per ➤ Instruct the patient to notify the
day) for 2 to 4 weeks before the test. health care practitioner of any signs
➤ Under medical direction, the patient and symptoms of dehydration or
should avoid diuretics, antihyperten- fluid overload related to elevated
sive drugs and herbals, and cyclic aldosterone levels or compromised
progestogens and estrogens for 2 to sodium regulatory mechanisms.
4 weeks before the test. ➤ Aldosterone levels are involved in
➤ Review the procedure with the the regulation of body fluid volume.
patient. Inform the patient that Educate patients about the impor-
multiple specimens may be tance of proper water balance.
required. Although there is no recommended
dietary allowance (RDA) for water,
➤ Inform the patient that the required adults need 1 mL/kcal per day.
position, supine/lying down or Infants need more water because
upright/sitting up, must be main- their basal metabolic heat produc-
tained for 2 hours before specimen tion is much higher than in adults.
collection. Tap water may also contain other
➤ Inform the patient that each speci- nutrients. Water-softening systems
men collection takes approximately replace minerals (e.g., calcium,
5 to 10 minutes. magnesium, iron) with sodium, so
Copyright © 2003 F.A. Davis Company
SI Units
Total Conventional (Conversion Bone Liver
ALP Units Factor 0.017) Fraction Fraction
1–5 y
Male 56–350 U/L 0.95–5.95 µKat/L 39–308 U/L Less than
8–101 U/L
Female 73–378 U/L 1.24–6.43 µKat/L 56–300 U/L Less than
8–53 U/L
6–7 y
Male 70–364 U/L 1.19–6.19 µKat/L 50–319 U/L Less than
8–76 U/L
Female 73–378 U/L 1.24–6.43 µKat/L 56–300 U/L Less than
8–53 U/L
8y
Male 70–364 U/L 1.19–6.19 µKat/L 50–258 U/L Less than
8–62 U/L
Female 98–448 U/L 1.67–7.62 µKat/L 78–353 U/L Less than
8–62 U/L
9–12 y
Male 112–476 U/L 1.90–8.09 µKat/L 78–339 U/L Less than
8–81 U/L
Female 98–448 U/L 1.67–7.62 µKat/L 78–353 U/L Less than
8–62 U/L
13 y
Male 112–476 U/L 1.90–8.09 µKat/L 78–389 U/L Less than
8–48 U/L
Female 56–350 U/L 0.95–5.95 µKat/L 28–252 U/L Less than
8–50 U/L
14 y
Male 112–476 U/L 1.90–8.09 µKat/L 78–389 U/L Less than
8–48 U/L
Female 56–266 U/L 0.95–4.52 µKat/L 31–190 U/L Less than
8–48 U/L
15 y
Male 70–378 U/L 1.19–6.43 µKat/L 48–311 U/L Less than
42–168 U/L 0.71–2.86 µKat/L 20–115 U/L 8–39 U/L
Female Less than
8–53 U/L
16 y
Male 70–378 U/L 1.19–6.43 µKat/L 48–311 U/L Less than
8–39 U/L
Female 28–126 U/L 0.48–2.14 µKat/L 14–87 U/L Less than
8–50 U/L
17 y
Male 56–238 U/L 0.95–4.05 µKat/L 34–190 U/L Less than
8–39 U/L
Female 28–126 U/L 0.48–2.14 µKat/L 17–84 U/L Less than
8–53 U/L
SI Units
Total Conventional (Conversion Bone Liver
ALP Units Factor 0.017) Fraction Fraction
18 y
Male 56–182 U/L 0.95–3.09 µKat/L 34–146 U/L Less than
8–39 U/L
Female 28–126 U/L 0.48–2.14 µKat/L 17–84 U/L Less than
8–53 U/L
19 y
Male 42–154 U/L 0.71–2.62 µKat/L 25–123 U/L Less than
8–39 U/L
Female 28–126 U/L 0.48–2.14 µKat/L 17–84 U/L Less than
8–53 U/L
20 y
Male 45–138 U/L 0.76–2.35 µKat/L 25–73 U/L Less than
8–48 U/L
Female 33–118 U/L 0.56–2.01 µKat/L 17–56 U/L Less than
8–50 U/L
Adult
Male 35–142 U/L 0.60–2.41 µKat/L 11–73 U/L 0–93 U/L
Female 25–125 U/L 0.42–2.12 µKat/L
• Drugs that may cause an overall ➤ Label the specimen, and promptly
decrease in ALP levels include calcitriol, transport it to the laboratory.
clodronate, clofibrate, cyclosporine,
etidronate, ipriflavone, norethisterone, Post-test:
oral contraceptives, pamidronate, ➤ Observe venipuncture site for bleed-
tamoxifen, theophylline, and ursodiol. ing or hematoma formation. Apply
• Hemolyzed specimens may cause pressure bandage.
falsely elevated results. ➤ Increased ALP levels may be associ-
ated with liver disease. Dietary
recommendations may be indicated
and vary depending on the severity
Nursing Implications and of the condition. A low-protein diet
Procedure ● ● ● ● ● ● ● ● ● ● ● may be in order if the patient’s liver
has lost the ability to process the
Pretest: end products of protein metabolism.
A diet of soft foods may be required
➤ Obtain a history of the patient’s if esophageal varices have devel-
complaints, including a list of known oped. Ammonia levels may be used
allergens. to determine whether protein
➤ Obtain a history of the patient’s should be added to or reduced from
hepatobiliary and musculoskeletal the diet. Patients should be encour-
system and results of previously aged to eat simple carbohydrates
performed tests and procedures. For and emulsified fats (as in homoge-
related tests, refer to the hepatobil- nized milk or eggs), as opposed
iary and musculoskeletal system to complex carbohydrates (e.g.,
tables. starch, fiber, and glycogen [animal
➤ Obtain a list of the medications the carbohydrates]) and complex fats,
patient is taking, including herbs, nu- which would require additional bile
tritional supplements, and nutraceu- to emulsify it so that it can be used.
ticals. The requesting health care The cirrhotic patient should be care-
practitioner and laboratory should be fully observed for the development
advised if the patient is regularly us- of ascites, in which case fluid and
ing these products so that their ef- electrolyte balance requires strict
fects can be taken into consideration attention.
when reviewing results. ➤ Evaluate test results in relation
➤ There are no food, fluid, or medica- to the patient’s symptoms and
tion restrictions unless by medical other tests performed. Related
direction. laboratory tests include acetamino-
phen, ammonia, alanine aminotrans-
➤ Review the procedure with the ferase, albumin, α1-antitrypsin, α1-
patient. antitrypsin phenotyping, ammonia,
➤ Inform the patient that specimen anti-DNA antibodies, antimitochon-
collection takes approximately 5 to drial antibodies, antinuclear antibod-
10 minutes. ies, anti–smooth muscle antibodies,
aspartate aminotransferase, bilirubin
Intratest: (total, direct, and indirect), bone
biopsy, calcium, ceruloplasmin,
➤ Direct the patient to breathe C3 complement, C4 complement,
normally and to avoid unnecessary copper, electrolytes, γ-glutamyl
movement. transpeptidase, hepatitis antigens
➤ Observe standard precautions and and antibodies, liver biopsy, magne-
follow the general guidelines in sium, parathyroid hormone, phos-
Appendix A. Perform a venipuncture, phorus, protein, protein electro-
and collect the specimen in a 5-mL phoresis, prothrombin time, salicy-
red- or tiger-top tube. late, vitamin D, and zinc.
Copyright © 2003 F.A. Davis Company
Allergen-Specific Immunoglobulin E 27
ALLERGEN-SPECIFIC
IMMUNOGLOBULIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Alternate Scoring
RAST Scoring Method (ASM): Increasing
Method Levels of Allergy Sensitivity
Specific IgE
Antibody Level kIU/L ASM Class ASM % Reference
Absent or
undetectable Less than 0.35 0 Less than 70
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 4 600–1999
17.50
5 2000–5999
6 Greater than 5999
ALVEOLAR/ARTERIAL GRADIENT
AND ARTERIAL/ALVEOLAR OXYGEN
RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
should always be transported to the ➤ Perform the Allen test (see mono-
laboratory as quickly as possible after graph titled “Blood Gases”).
collection. Delay in transport of the ➤ Inform the patient that specimen
sample or transportation without ice collection usually takes approxi-
may affect test results. mately 15 to 20 minutes.
Intratest:
Nursing Implications and ➤ Direct the patient to breathe
Procedure ● ● ● ● ● ● ● ● ● ● ●
normally and to avoid unnecessary
movement.
Pretest:
➤ Observe standard precautions and
➤ Obtain a history of the patient’s follow the general guidelines in
complaints, including a list of known Appendix A.
allergens. ➤ Perform an arterial puncture and
➤ Obtain a history of the patient’s collect the specimen in a hepar-
respiratory system and any bleeding inized syringe. There has been no
disorders as well as results of previ- difference in values noted when
ously performed tests and proce- samples are collected in plastic
dures, especially bleeding time, versus glass syringes.
coagulation time, complete blood ➤ Label the specimen, and promptly
count, platelets, partial thromboplas- transport it to the laboratory. The
tin time, and prothrombin time. For tightly capped sample should be
related tests, refer to the respiratory placed in an ice slurry immediately
system table. after collection. Information on the
➤ Obtain a list of medications the specimen label can be protected
patient is taking, including anticoag- from water in the ice slurry if the
ulants, acetylsalicylic acid, herbals, specimen is first placed in a protec-
and nutraceuticals; take particular tive plastic bag.
note of any products that are known
to affect coagulation. It is recom- Post-test:
mended that use of such products
be discontinued 14 days before ➤ Observe arterial puncture site for
dental or surgical procedures. The bleeding or hematoma formation.
requesting health care practitioner Apply pressure bandage.
and laboratory should be advised if
➤ Intervene appropriately for hypoxia
the patient regularly uses these
and ventilatory disturbances.
products so that their effects can be
taken into consideration when ➤ Evaluate test results in relation
reviewing results. to the patient’s symptoms and
➤ Note any recent procedures that can other tests performed. Related
interfere with test results. laboratory tests include allergen-
specific immunoglobulin E (IgE), 1-
➤ There are no food, fluid, or medica- antitrypsin, 1-antitrypsin phenotyp-
tion restrictions unless by medical ing, blood gases, D-dimer, elec-
direction. trolytes, eosinophil count, fibrino-
➤ Review the procedure with the gen, hypersensitivity pneumonitis,
patient. IgE, and theophylline.
Copyright © 2003 F.A. Davis Company
septic solution, and apply a small and frequently monitor body signs,
bandage. such as temperature and blood pres-
➤ Label the specimen, and promptly sure.
transport it to the laboratory. ➤ Observe the patient for neurologic
changes, such as altered level of
Post-test: consciousness, change in pupils,
reports of tingling or numbness, and
➤ Administer fluids, if permitted, to irritability.
replace lost CSF and help prevent or ➤ Recognize anxiety related to test
relieve headache, which is a side results. Provide teaching and infor-
effect of lumbar puncture. mation regarding the clinical impli-
➤ Position the patient flat, either on cations of the test results, as
the back or abdomen, although appropriate. Reassure family mem-
some health care practitioners allow bers and offer access to appropriate
30º elevation. Maintain this position counseling and other supportive
for 8 hours. Changing position is services.
acceptable as long as the body ➤ Evaluate test results in relation to
remains horizontal. the patient’s symptoms and other
➤ Check the puncture site for leakage, tests performed.
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
α-Amino-
α-Amino- n-butyric
Age Alanine β-Alanine Anserine adipic Acid Acid
Premature 212–504 0 — 0 14–52
Newborn– 131–710 0–10 0 0 8–24
1 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
Copyright © 2003 F.A. Davis Company
Cysta- Ethanol-
Age Carnosine Citrulline thionine Cystine amine
Premature — 20–87 5–10 15–70 —
Newborn– 0–19 10–45 0–3 17–98 0–115
1 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
Glutamic Homo-
Age Acid Glutamine Glycine Histidine cystine
Premature 107–276 248–850 298–602 72–134 3–20
Newborn–
1 mo 62–620 376–709 232–740 30–138 0
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
Phospho- Phospho-
Age ethanolamine serine Proline Sarcosine Serine
Premature 5–35 10–45 92–310 0 127–248
Newborn– 3–27 7–47 110–417 0–625 99–395
1 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– 46–492 90–329 0–60 55–147 86–190
1 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
Post-test:
Nursing Implications and
➤ Observe venipuncture site for bleed-
Procedure ● ● ● ● ● ● ● ● ● ● ●
ing or hematoma formation. Apply
pressure bandage.
Pretest:
➤ Instruct the patient to resume usual
➤ Obtain a history of the patient’s diet, as directed by the health care
complaints, including a list of known practitioner.
allergens. ➤ Instruct caregiver in special dietary
➤ Obtain a history of the patient’s modifications, as appropriate to treat
reproductive system as it relates to deficiency, or refer caregiver to a
genetic disease, as well as results of qualified nutritionist. Amino acids
previously performed tests and are classified as essential (i.e., must
procedures. For related tests, refer be present simultaneously in suffi-
to the reproductive system table. cient quantities); conditionally or
➤ Obtain a list of the medications the acquired essential (i.e., under certain
patient is taking, including herbs, stressful conditions, they become
nutritional supplements, and nutra- essential); and nonessential (i.e.,
ceuticals. The requesting health can be produced by the body,
care practitioner and laboratory when needed, if diet does not
should be advised if the patient provide them). Essential amino acids
regularly uses these products so include lysine, threonine, histidine,
that their effects can be taken into isoleucine, methionine, phenylala-
consideration when reviewing nine, tryptophan, and valine.
results. Conditionally essential amino acids
include cysteine, tyrosine, arginine,
➤ There are no fluid or medication citrulline, taurine, and carnitine.
restrictions unless by medical direc- Nonessential amino acids include
tion. alanine, glutamic acid, aspartic acid,
➤ Instruct the patient to fast for at glycine, serine, proline, glutamine,
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (10 mL) from a random or timed specimen collected in
a clean plastic collection container with hydrochloric acid as a preservative.
α-Amino-
α-Amino- n-butyric
Age Alanine β-Alanine Anserine adipic Acid Acid
Premature 1320–4040 1020–3500 — 70–460 50–710
Newborn–1 982–3055 25–288 0–3 0–180 8–65
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
Cysta- Ethanol-
Age Carnosine Citrulline thionine Cystine amine
Premature 260–370 240–1320 260–1160 480–1690 —
Newborn–1 97–665 27–181 16–147 212–668 840–3400
mo 203–635 22–180 33–470 68–710 0–2230
2 mo–2 y 72–402 10–99 0–26 25–125 0–530
2–18 y 10–90 8–50 20–50 43–210 0–520
Adult
Glutamic Homo-
Age Acid Glutamine Glycine Histidine cystine
Premature 380–3760 520–1700 7840–23,600 1240–7240 580–2230
Newborn–1 70–1058 393–1042 5749–16,423 908–2528 0–88
mo
2 mo–2 y 54–590 670–1562 3023–11,148 815–7090 6–67
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–1 10–125 40–440 125–390 78–195 270–1850
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
Phospho- Phospho-
Age ethanolamine serine Proline Sarcosine Serine
Premature 80–340 500–1690 1350–10,460 0 1680–6000
Newborn–1 0–155 150–339 370–2323 0–56 1444–3661
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
-Aminolevulinic Acid 43
-AMINOLEVULINIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: -ALA.
SPECIMEN: Urine (25 mL) from a timed specimen collected in a dark plas-
tic container with hydrochloric acid as a preservative.
cin, phenylbutazone, primidone, pyra- ➤ Instruct the patient to void all urine
zolone preparations, succinimides, into the collection device and then
sulfonamides, sulfonethylmethane, to pour the urine into the laboratory
sulfomethane, synthetic estrogens and collection container. Alternatively,
the specimen can be left in the
progestins, tolazamide, tolbutamide, collection device for a health care
trimethadione, and valproic acid. staff member to add to the labora-
tory collection container.
Ammonia 45
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.
from water in the ice slurry by first and emulsified fats (as in homoge-
placing the specimen in a protective nized milk or eggs), as opposed to
plastic bag. complex carbohydrates (e.g., starch,
fiber, and glycogen [animal carbohy-
Post-test: drates]) and complex fats, which
would require additional bile to
➤ Observe venipuncture site for bleed- emulsify it so that it could be used.
ing or hematoma formation. Apply The cirrhotic patient should be care-
pressure bandage. fully observed for the development
➤ Increased ammonia levels may be of ascites, in which case fluid and
associated with liver disease. electrolyte balance requires strict
Dietary recommendations may be attention.
indicated, depending on the severity ➤ Evaluate test results in relation
of the condition. A low-protein diet to the patient’s symptoms and
may be in order if the patient’s liver other tests performed. Related
has lost the ability to process the laboratory tests include acetamino-
end products of protein metabolism. phen, alanine aminotransferase,
A diet of soft foods may be required albumin, anion gap, aspartate
if esophageal varices have devel- aminotransferase, bilirubin, blood
oped. Ammonia levels may be used gases, calcium, complete blood
to determine whether protein count, electrolytes, glucose, lactic
should be added to or reduced from acid, ketones, osmolality, protein,
the diet. Patients should be encour- prothrombin time, urea nitrogen,
aged to eat simple carbohydrates and uric acid.
SYNONYM/ACRONYM: N/A.
SPECIMEN: Amniotic fluid (10 – 20 mL) collected in a clean amber glass or
plastic container.
• Determine the presence of fetal distress higher (3.5:1). (See monograph titled
in late-stage pregnancy “Lecithin/Sphingomyelin Ratio.”)
• Lamellar bodies are specialized alveolar
RESULT: cells in which lung surfactant is stored.
• Yellow, green, red, or brown fluid indi- They are approximately the size of
cates the presence of bilirubin, blood platelets. Their presence in sufficient
(fetal or maternal), or meconium, quantities is an indicator of fetal lung
which indicate fetal distress or death, maturity.
hemolytic disease, or growth retarda- • Elevated -fetoprotein levels and pres-
tion. ence of acetylcholinesterase indicates a
• Elevated bilirubin levels indicate fetal neural tube defect (see monograph
hemolytic disease or intestinal obstruc- titled “1-Fetoprotein”).
tion. Measurement of bilirubin is not
• Abnormal karyotype indicates genetic
usually performed before 20 to 24
abnormality (e.g., Tay-Sachs disease,
weeks’ gestation because no action can
mental retardation, chromosome or
be taken before then. The severity of
enzyme anomalies, and inherited
hemolytic disease is graded by optical
hemoglobinopathies). (See monograph
density (OD) zones: A value of 0.28 to
titled “Chromosome Analysis,
0.46 OD at 28 to 31 weeks’ gestation
Blood.”)
indicates mild hemolytic disease, which
probably will not affect the fetus; 0.47 • Elevated white blood cell count and
to 0.90 OD indicates a moderate effect positive leukocyte esterase are indica-
on the fetus; and 0.91 to 1.0 OD indi- tors of infection.
cates a significant effect on the fetus. A
trend of increasing values with serial
measurements may indicate the need CRITICAL VALUES: N/A
for intrauterine transfusion or early
delivery, depending on the fetal age. INTERFERING FACTORS:
After 32 to 33 weeks’ gestation, early • Bilirubin may be falsely elevated if
delivery is preferred over intrauterine maternal hemoglobin or meconium is
transfusion, because early delivery is present in the sample; fetal acidosis
more effective in providing the required may also lead to falsely elevated biliru-
care to the neonate. bin levels.
• Creatinine concentration greater than • Bilirubin may be falsely decreased if
2.0 mg/dL indicates fetal maturity (at the sample is exposed to light or if
36 to 37 weeks) if maternal creatinine amniotic fluid volume is excessive.
is also within the expected range. This
• Maternal serum creatinine should be
value should be interpreted in conjunc-
measured simultaneously for compari-
tion with other parameters evaluated in
son with amniotic fluid creatinine for
amniotic fluid and especially with the
proper interpretation. Even in circum-
L/S ratio because normal lung develop-
stances in which the maternal serum
ment depends on normal kidney devel-
value is normal, the results of the
opment.
amniotic fluid creatinine may be
• L/S ratio less than 2:1 and absence of misleading. A high fluid creatinine
phosphatidylglycerol at term indicate value in the fetus of a diabetic mother
fetal lung immaturity and possible may reflect the increased muscle mass
respiratory distress syndrome. The of a larger fetus. If the fetus is big, the
expected L/S ratio for the fetus of an creatinine may be high and the fetus
insulin-dependent diabetic mother is may still have immature kidneys.
Copyright © 2003 F.A. Davis Company
• Contamination of the sample with ➤ Note any recent procedures that can
blood or meconium or complications interfere with test results.
in pregnancy may yield inaccurate L/S ➤ There are no food, fluid, or medica-
ratios. tion restrictions unless by medical
direction.
• -Fetoprotein and acetylcholinesterase
➤ Review the procedure with the
may be falsely elevated if the sample is patient. Sensitivity to cultural and
contaminated with fetal blood. social issues and concern for
• Karyotyping cannot be performed modesty is important in providing
under the following conditions: (1) psychological support.
failure to promptly deliver samples for ➤ Explain the purpose of the study and
chromosomal analysis to the laboratory how the procedure is performed.
performing the test, or (2) improper Address concerns about pain related
to the procedure. Inform the patient
incubation of the sample, which causes that a health care practitioner
cellular death. performs the test, which takes 20 to
• Recent radioactive scans or radiation 30 minutes to complete.
within 1 week before the test can inter- ➤ Warn the patient that normal results
fere with test results when radioim- do not guarantee a normal fetus.
munoassay is the test method. ➤ Explain the necessity of remaining
still during the procedure.
• Amniocentesis is contraindicated in
women with a history of prema- ➤ Determine whether the patient has
an allergy to local anesthetics, and
ture labor or incompetent cervix. inform the health care practitioner
It is also contraindicated in the pres- accordingly.
ence of placenta previa or abruptio
➤ Obtain written and informed
placentae. consent before administering any
medications prior to the procedure.
Amylase 51
AMYLASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
Copyright © 2003 F.A. Davis Company
Amylase 53
(Conversion
Factor 0.073)
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.
ANGIOGRAPHY, ABDOMEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Angiography, Abdomen 57
Angiography, Abdomen 59
badges that reveal their level of expo- ➤ Obtain a history of the patient’s
sure to radiation. complaints, medication usage, and
known allergens.
➤ Obtain a history of the patient’s
Nursing Implications and abdominal organs and the results of
Procedure ● ● ● ● ● ● ● ● ● ● ●
previous performed tests, treat-
ment, surgeries, and procedures.
Pretest: For related tests, refer to the cardio-
vascular system table.
➤ Inform the patient that the proce- ➤ Ascertain recent coagulation times
dure will be performed by a physi- and other laboratory test results.
cian and will take 1 to 2 hours.
➤ Take baseline vital signs and assess
➤ Inform the patient that the proce- neurologic status.
dure will not be painful, but there
may be moments of discomfort. ➤ Complications of the procedure
include hemorrhage, infection at the
➤ Inform the patient that a burning and insertion site, cardiac arrhythmias,
flushing sensation may be felt and embolism caused by the inad-
throughout the body during injection vertent dislodgment of an athero-
of the contrast medium. After injec- sclerotic plaque.
tion of the contrast medium, the
patient may experience an urge to ➤ This procedure may be terminated if
cough, flushing, nausea, or a salty or chest pain, severe cardiac arrhyth-
metallic taste. mias, or signs of a cerebrovascular
accident occur.
➤ An informed consent needs to be
obtained and witnessed.
Intratest:
➤ Instruct the patient regarding the
importance of lying motionless ➤ Have emergency equipment readily
throughout the procedure. accessible.
➤ Instruct the patient to avoid taking ➤ If the patient has a history of
anticoagulant medication or to severe allergic reactions to any
reduce dosage as ordered before substance or drug, administer
undergoing the procedure. ordered prophylactic steroids or anti-
➤ Determine the date of last menstrual histamines before the procedure.
period and the possibility of preg- Use nonionic contrast medium for
nancy in perimenopausal women. the procedure.
➤ Patients receiving metformin ➤ Using a pen, mark the site of the
(Glucophage) for non–insulin- patient’s peripheral pulses before
dependent (type 2) diabetes should angiography; this allows quicker and
discontinue the drug on the day of more consistent assessment of the
the test and continue to withhold it pulses after the procedure.
for 48 hours after the test. Failure to ➤ Place electrocardiographic elec-
do so may result in lactic acidosis. trodes on the patient for cardiac
➤ Ensure that food has been restricted monitoring. Establish baseline
for at least 8 hours before the proce- rhythm; determine if the patient has
dure. ventricular arrhythmias.
➤ Instruct the patient to remove metal- ➤ Establish intravenous fluid line for
lic objects and valuables before the the injection of contrast medium,
test. emergency drugs, and sedatives.
➤ Obtain a history of known hypersen- ➤ Administer a mild sedative, as
sitivity to iodine, seafood, or ordered.
contrast medium from previous x-ray ➤ Place the patient in the supine posi-
procedures. tion on an x-ray table. Cleanse the
Copyright © 2003 F.A. Davis Company
selected vein, and cover with a ster- ➤ Instruct the patient to maintain bed
ile drape. rest for 4 to 6 hours after the proce-
➤ A local anesthetic is injected at the dure or as ordered, to resume previ-
site, and a small incision is made or ous diet, and to increase fluid intake
a needle inserted. The femoral artery to counteract the diuretic effects of
or vein is punctured and the the contrast medium.
guidewire inserted. The catheter is ➤ Advise the patient to immediately
inserted over the guidewire and report symptoms such as fast
threaded into the aorta and the spe- heart rate, difficulty breathing, skin
cific organ artery under fluoroscopy. rash, itching, or decreased urinary
➤ The contrast medium is injected, output.
and a rapid series of images is taken ➤ Observe the catheter insertion site
during and after the filling of the for bleeding, inflammation, or
vessels to be examined. Delayed hematoma formation.
images may be taken to examine ➤ Instruct the patient to apply cold
the vessels after time has elapsed compresses to the puncture site, as
and to monitor the venous phase of needed, to reduce discomfort or
the procedure. edema.
➤ Ask the patient to breathe deeply to ➤ Monitor for absence of pulse distal
relieve nausea. to catheter insertion site.
➤ Monitor the patient for complica- ➤ Assess neurologic status and vital
tions related to the contrast medium signs every 15 minutes or as
(e.g., allergic reaction, anaphylaxis, directed.
bronchospasm).
➤ Observe for a delayed allergic reac-
➤ The catheter is removed, and a pres- tion to contrast medium.
sure dressing is applied over the
puncture site. ➤ A written report of the examination
is completed by a physician who
➤ Assess extremities for signs of specializes in this branch of medi-
ischemia caused by a catheter- cine. The report is sent to the order-
induced thrombus. ing provider, who discusses the
results with the patient.
Post-test:
➤ Evaluate test results in relation to
➤ Instruct the patient to resume taking the patient’s symptoms and other
ordered medications that were tests performed. Related diagnostic
discontinued before the procedure. tests include computed tomography
Renal function should be assessed and magnetic resonance angiogra-
before metformin is restarted. phy.
ANGIOGRAPHY, ADRENAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Angiography, Adrenal 61
study
• Retained barium from a previous radi- Pretest:
ologic procedure ➤ Inform the patient that the proce-
dure will be performed by a physi-
• Metallic objects within the examina- cian and will take 1 to 2 hours.
tion field (e.g., jewelry, earrings, dental
➤ Inform the patient that the proce-
amalgams), which may inhibit organ
dure is not painful, but there may be
visualization and can produce unclear moments of discomfort.
images
➤ Inform the patient that a burning
• Improper adjustment of the radi- and flushing sensation may be felt
ographic equipment to accommodate throughout the body during the
obese or thin patients, which can cause injection of contrast medium. After
overexposure or underexposure and a the injection of the contrast
medium, the patient may experience
poor-quality study an urge to cough, flushing, nausea,
• Patients who are very obese, who may or a salty or metallic taste.
exceed the weight limit for the equip- ➤ An informed consent needs to be
ment obtained and witnessed.
➤ Instruct the patient regarding the
• Incorrect positioning of the patient, importance of lying motionless
which may produce poor visualization throughout the procedure.
of the area to be examined
➤ Instruct patient to avoid taking anti-
• Inability of the patient to cooperate or coagulant medication or to reduce
remain still during the procedure the dosage as ordered before under-
because of age, significant pain, or going the procedure.
mental status ➤ Patients receiving metformin
Copyright © 2003 F.A. Davis Company
Angiography, Adrenal 63
ANGIOGRAPHY, CORONARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Angiography, Coronary 65
Angiography, Coronary 67
➤ Instruct the patient to remove ➤ Place the patient in the supine posi-
dentures, metallic objects, and valu- tion on an x-ray table. Cleanse the
ables before the test. selected vein, and cover with a ster-
➤ Obtain a history of known hypersen- ile drape.
sitivity to iodine, seafood, or ➤ A local anesthetic is injected at the
contrast medium from previous x-ray site, and a small incision is made or
procedures. Also obtain a history of a needle inserted. The catheter is
ventricular arrhythmias or asthma. inserted into the femoral or brachial
For other related tests, refer to the artery for the left side of the heart
cardiovascular system table. and the femoral or anticubital vein
➤ Ascertain recent coagulation times for the right side of the heart under
and other laboratory tests as fluoroscopy. A rapid series of images
ordered. is obtained after the dye injection.
The table may be tilted in various
➤ Take baseline vital signs, and assess positions to facilitate different views
neurologic status. of the heart.
➤ Complications of this procedure ➤ Ask the patient to breathe deeply to
include cardiac arrhythmias, relieve nausea; to cough or breathe
reaction to the iodinated deeply to permit entry of the
contrast medium, bleeding, infec- catheter into the pulmonary artery;
tion, arterial thrombosis or embo- and to move the diaphragm in a
lism, pulmonary or cerebral embo- downward position, allowing clearer
lism, vascular perforation, renal visualization of the heart. Coughing
failure, and pneumothorax. can also correct some arrhythmias.
➤ This procedure may be terminated if ➤ Monitor the patient for complica-
chest pain, severe cardiac arrhyth- tions related to the contrast medium
mias, or signs of a cerebrovascular (e.g., allergic reaction, anaphylaxis,
accident occur. bronchospasm) or to catheterization
(e.g., arrhythmias, cardiac or vessel
Intratest: perforation).
➤ Have emergency equipment readily ➤ The catheter is removed, and a pres-
accessible. sure dressing is applied over the
➤ If the patient has a history of severe puncture site.
allergic reactions to any substance ➤ Assess extremities for signs of
or drug, administer ordered prophy- ischemia caused by a catheter-
lactic steroids or antihistamines induced thrombus.
before the procedure. Use nonionic
contrast medium for the procedure. Post-test:
➤ Ask the patient to remove his or her
clothes and put on a hospital gown. ➤ Instruct the patient to resume
taking ordered medications that
➤ Using a pen, mark the site of the were discontinued before the pro-
patient’s peripheral pulses before cedure. Renal function should be
angiography; this allows quicker and assessed before metformin is
more consistent assessment of the restarted.
pulses after the procedure.
➤ Instruct the patient to maintain bed
➤ Place electrocardiographic elec- rest for 6 to 8 hours after the proce-
trodes on the patient for cardiac dure or as ordered, to resume previ-
monitoring. Establish a baseline ous diet, and to increase fluid intake
rhythm; determine if the patient has to counteract the diuretic effects of
ventricular arrhythmias. contrast medium.
➤ Establish an intravenous fluid line for ➤ Advise the patient to immediately
the injection of contrast medium, report symptoms such as fast
emergency drugs, or sedatives. heart rate, difficulty breathing, skin
➤ Administer a mild sedative as rash, itching, or decreased urinary
ordered. output.
Copyright © 2003 F.A. Davis Company
ANGIOGRAPHY, MAGNETIC
RESONANCE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: MRA.
AREA OF APPLICATION: Vascular.
CONTRAST: Can be done with or without contrast (gadolinium).
which may produce poor visualization ➤ Tell the patient to expect to hear
of the area to be examined loud banging from the scanner
and possibly to see magneto-
• Metallic objects within the examina- phosphenes (flickering lights in the
tion field (e.g., jewelry or body rings), visual field); these will stop when
which may inhibit organ visualization the procedure is over.
and can produce unclear images ➤ Instruct the patient to take slow,
deep breaths if nausea occurs
Other considerations: during the procedure.
• Improper injection of the contrast ➤ Do not restrict food and fluids.
medium. If contrast medium is
allowed to seep deep into the muscle Intratest:
tissue, vascular visualization will be
impossible. ➤ Ask the patient to remove jewelry,
including watches, hairpins, and
other metallic objects, and credit
Nursing Implications and cards.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Ask the patient to void before the
procedure.
Pretest: ➤ Administer a sedative to a child or to
➤ Inform the patient that the test an uncooperative adult, as ordered.
permits assessment of the vascular ➤ Administer an antianxiety agent, as
system. ordered, if the patient has claustro-
➤ Inform the patient that the proce- phobia.
dure is performed in a special ➤ Place the patient in a supine position
department by a technologist and a on a flat table; use foam wedges to
physician and takes approximately help maintain position and immobi-
30 to 60 minutes. lization. Ask the patient to lie still
➤ Obtain a history of allergies or sensi- during the procedure because move-
tivities to contrast medium. ment produces unclear images, thus
affecting the results and making
➤ Obtain pertinent history of vascular interpretation difficult.
findings. For related tests, refer to
the cardiovascular system table. ➤ Supply earplugs to the patient to
block out the loud, banging sounds
➤ Ensure that the patient and staff
that occur during the test.
have removed all external metallic
objects before entering the scanning ➤ The table is moved into the scanner.
room. Instruct the patient to remain still.
The scanner makes noises as it
➤ Obtain a history of previous surger-
acquires images of the body. The
ies and determine if the patient has
patient may be asked to hold his or
ever had any device implanted into
her breath to facilitate visualization.
his or her body.
A number of images are taken.
➤ Inform the patient that intravenous These images are reconstructed by
contrast medium may be injected a computer and reviewed.
after the first series of images, with
➤ Administer the contrast medium, if
a second series of scans following.
ordered. A second series of images
➤ Inform the patient that the technolo- is obtained.
gist will place him or her in a supine
position on a flat table in a large
cylindrical scanner. Post-test:
➤ Ask the patient to lie still during ➤ A physician who specializes in this
the procedure because movement branch of medicine sends a written
produces unclear images. report to the ordering provider,
Copyright © 2003 F.A. Davis Company
Angiography, Pulmonary 71
who discusses the results with the tests performed. Related diagnos-
patient. tic tests include computed tomo-
➤ Evaluate test results in relation to graphy, angiogram, and Doppler
the patient’s symptoms and other ultrasound.
ANGIOGRAPHY, PULMONARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Angiography, Pulmonary 73
rest for 6 to 8 hours after the proce- ➤ A physician who specializes in this
dure or as ordered, to resume previ- branch of medicine sends a written
ous diet, and to increase fluid intake report to the ordering provider, who
to counteract the diuretic effects of discusses the results with the
contrast medium. patient.
➤ Advise the patient to immediately ➤ Evaluate test results in relation
report symptoms such as fast heart to patient’s symptoms and other
rate, difficulty breathing, skin rash, tests performed. Related diag-
itching, or decreased urinary output. nostic tests include chest radi-
➤ Observe the catheter insertion site ograph, electrocardiogram, lung
for bleeding, inflammation, or scan, computed tomography of
hematoma formation. the chest, echocardiogram, and
➤ Observe for a delayed allergic reac- magnetic resonance imaging of the
tion to contrast medium. chest.
ANGIOGRAPHY, RENAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Angiography, Renal 75
resulting from inadequate cleansing or badges that reveal their level of expo-
failure to restrict food intake before the sure to radiation.
study
• Retained barium from a previous radi-
ologic procedure Nursing Implications and
• Inability of the patient to cooperate or Procedure ● ● ● ● ● ● ● ● ● ● ●
Angiography, Renal 77
➤ Obtain a history of the patient’s selected vein, and cover with a ster-
complaints, medication usage, and ile drape.
known allergens. ➤ A local anesthetic is injected at the
➤ Obtain a history of the patient’s site, and a small incision is made or
renal system as well as tests and a needle inserted. The femoral artery
procedures previously performed. or vein is punctured and the
➤ Ascertain recent coagulation times guidewire inserted. The catheter is
and other laboratory tests as inserted over the guidewire and
ordered. For related tests, refer to threaded up into the aorta and into
the cardiovascular and genitouri- the renal arteries under fluoroscopy.
nary/renal systems tables. ➤ The contrast medium is injected,
➤ Take baseline vital signs and assess and a rapid series of images is taken
neurologic status. during and after the filling of the
vessels to be examined. Delayed
➤ Complications of the procedure images may be taken to examine
include hemorrhage, infection at the the vessels after time has elapsed
insertion site, cardiac arrhythmias, and to monitor the venous phase of
and embolism caused by the inad- the procedure.
vertent dislodgment of an athero-
➤ Ask the patient to breathe deeply to
sclerotic plaque.
relieve nausea.
➤ This procedure may be terminated if
➤ Monitor the patient for complica-
chest pain, severe cardiac arrhyth-
tions related to the contrast medium
mias, or signs of a cerebrovascular
(allergic reaction, anaphylaxis, bron-
accident occur.
chospasm).
➤ The catheter is removed, and a pres-
Intratest: sure dressing is applied over the
puncture site.
➤ Have emergency equipment readily
accessible. ➤ Assess extremities for signs of
ischemia caused by a catheter-
➤ If the patient has a history of severe induced thrombus.
allergic reactions to various
substances or drugs, administer
ordered prophylactic steroids or anti- Post-test:
histamines before the procedure.
➤ Instruct the patient to resume taking
Use nonionic contrast medium for
ordered medications that were
the procedure.
discontinued before the procedure.
➤ Using a pen, mark the site of the Renal function should be assessed
patient’s peripheral pulses before before metformin is restarted.
angiography; this allows quicker and ➤ Instruct the patient to maintain bed
more consistent assessment of the rest for 4 to 6 hours after the proce-
pulses after the procedure. dure or as ordered, to resume previ-
➤ Place electrocardiographic elec- ous diet, and to increase fluid intake
trodes on the patient for cardiac to counteract the diuretic effects of
monitoring. Establish baseline contrast medium.
rhythm; determine if the patient has ➤ Advise the patient to immediately
ventricular arrhythmias. report symptoms such as fast heart
➤ Establish intravenous fluid line for rate, difficulty breathing, skin rash,
the injection of contrast medium, itching, or decreased urinary output.
emergency drugs, and sedatives. ➤ Observe the catheter insertion site
➤ Administer a mild sedative as for bleeding, inflammation, or
ordered. hematoma formation.
➤ Place the patient in the supine posi- ➤ Instruct the patient to apply cold
tion on an x-ray table. Cleanse the compresses to the puncture site, as
Copyright © 2003 F.A. Davis Company
ANGIOTENSIN-CONVERTING
ENZYME
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Angiotensin-Converting Enzyme 79
Anion Gap 81
ANION GAP
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
DESCRIPTION: The anion gap is used into the serum as a result of cell
most frequently as a clinical indicator rupture. The anion gap is also widely
of metabolic acidosis. It does not used as a laboratory quality control
include measurement of important measure because low gaps usually
cations, such as calcium, potassium indicate a reagent, calibration, or
(usually), and magnesium; or anions, instrument error. ■
such as proteins, forms of phospho-
rus, sulfur, and organic acids. The INDICATIONS:
anion gap is calculated as follows: • Evaluate metabolic acidosis
(sodium [chloride + HCO3]) • Indicate the presence of a disturbance
Because HCO3 is not directly in electrolyte balance
measured on most multichannel • Indicate the need for laboratory instru-
chemistry analyzers, HCO3 is esti- ment recalibration or review of elec-
mated by substitution of total carbon trolyte reagent preparation and
dioxide value in the calculation. Some stability
laboratories may include potassium in
the calculation of anion gap. RESULT
Calculations including potassium can
Increased in:
be invalidated because minor
amounts of hemolysis can contribute • Dehydration (severe)
significant levels of potassium leaked • Excessive exercise
Copyright © 2003 F.A. Davis Company
Anion Gap 83
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
Peak: 1 h after dose
Quinidine gluconate Oral Trough: immediately before
next dose
Peak: 5 h after dose
Quinidine polygalac- Oral Trough: immediately before
turonate next dose
Peak: 2 h after dose
IV intravenous.
Copyright © 2003 F.A. Davis Company
Drug Therapeutic Volume of Protein
(Indication) Dose* SI Units Half-Life (h) Distribution (L/kg) Binding (%) Excretion
60–80% hepatic
* Conventional units.
CHF congestive heart failure.
Copyright © 2003 F.A. Davis Company
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 or hepatic impairment
Flecainide Renal or hepatic impairment, CHF
Lidocaine Hepatic impairment, CHF
Procainamide Renal impairment
Quinidine Hepatic impairment, CHF, elderly patients
changes in mental status, and visual include slurred speech, central nervous
disturbances (objects appear yellow or system depression, cardiovascular depres-
have halos around them). Possible inter- sion, convulsions, muscle twitches, and
ventions include discontinuing the possible coma. Possible interventions
medication, continuous electrocardio- include continuous ECG monitoring,
gram (ECG) monitoring (prolonged airway support, seizure precautions, and
P-R interval, widening QRS interval, hourly monitoring of temperature for
lengthening Q-Tc, and atrioventricular hyperthermia.
block), transcutaneous pacing, adminis-
tration of activated charcoal (if the Procainamide: Greater Than 12
patient has a gag reflex and central nerv-
ous system function), support and treat- g/mL; Procainamide
N-acetyl
ment of electrolyte disturbance, and Procainamide: Greater Than 30
administration of Digibind (digoxin 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.
tration of Digibind in patients with Possible interventions include airway
normal renal function (1 week or longer protection, emesis, gastric lavage, and
in patients with decreased renal func- administration of sodium lactate.
tion). Digibind cross-reacts in the
digoxin assay and may provide mislead-
ing elevations or decreases in values Quinidine: Greater Than 8 g/mL
depending on the particular assay in use Signs and symptoms of quinidine toxicity
by the laboratory. include ataxia, nausea, vomiting, diar-
rhea, respiratory system depression,
Disopyramide: Greater Than hypotension, syncope, anuria, arrhyth-
7 g/mL mias (heart block, widening of QRS and
Signs and symptoms of disopyramide Q-T intervals), asystole, hallucinations,
toxicity include prolonged Q-T interval, paresthesia, and irritability. Possible
ventricular tachycardia, hypotension, and interventions include airway support,
heart failure. Possible interventions emesis, gastric lavage, administration of
include discontinuing the medication, activated charcoal, administration of
airway support, and ECG and blood sodium lactate, and temporary transcuta-
pressure monitoring. neous or transvenous pacemaker.
• Drugs that may increase disopyramide glucose levels. It may also potentiate
levels or increase risk of toxicity the anticoagulating effects of warfarin.
include amiodarone and trolean-
• Long-term administration of pro-
domycin.
cainamide can cause false-positive
• Drugs that may decrease disopyramide antinuclear antibody results and devel-
levels include rifampin. opment of a lupus-like syndrome in
some patients.
• Drugs that may increase flecainide
levels or increase risk of toxicity • Quinidine may potentiate the effects of
include amiodarone and cimetidine. neuromuscular blocking medications
and warfarin anticoagulants.
• Drugs that may increase lidocaine
levels or increase risk of toxicity • Concomitant administration of quini-
include anticonvulsants, beta blockers, dine and digoxin can rapidly raise
cimetidine, metoprolol, nadolol, and digoxin to toxic levels. If both drugs
propranolol. are to be given together, the digoxin
level should be measured before the
• Drugs that may increase procainamide
first dose of quinidine and again in 4 to
levels or increase risk of toxicity
6 days.
include amiodarone, other antiarrhyth-
mics, cimetidine, ranitidine, and
trimethoprim.
Nursing Implications and
• Drugs that may increase quinidine Procedure ● ● ● ● ● ● ● ● ● ● ●
ANTIBIOTIC DRUGS—
AMINOGLYCOSIDES: AMIKACIN,
GENTAMICIN, TOBRAMYCIN;
TRICYCLIC GLYCOPEPTIDE:
VANCOMYCIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Route of Recommended
Antibiotic Type Administration Collection Time*
Aminoglycosides
Amikacin IV, IM Trough: immediately before
next dose
Peak: 30 min after 30-min IV
Gentamicin IV, IM Trough: immediately before
next dose
Peak: 30 min after 30-min IV
infusion
Tobramycin IV, IM Trough: immediately before
next dose
Peak: 30 min after 30-min IV
infusion
Tricyclic
glycopeptide
Vancomycin IV, PO Trough: immediately before
next dose
Peak: 2 h after dose
* Usually after fifth dose if given every 8 h or third dose if given every 12 h.
IV intravenous; IM intramuscular; PO by mouth.
Copyright © 2003 F.A. Davis Company
REFERENCE VALUE: (Method: Immunoassay)
Therapeutic Volume of Protein
Drug Dose* SI Units Half-Life (h) Distribution (L/kg) Binding (%) Excretion
(Conversion Factor 1.71)
Amikacin
Peak 20–30 g/mL 34–51 mol/L 4–8 0.4–1.3 50 90% renal
Trough 4–8 g/mL 7–14 mol/L
(Conversion Factor 2.09)
Gentamicin
Peak 6–10 g/mL 12–21 mol/L 4–8 0.4–1.3 50 90% renal
Trough Less than 2 Less than 4
g/mL mol/L
* Conventional units.
91
Copyright © 2003 F.A. Davis Company
RESULT
Level Result
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Amikacin Renal, hearing impairment
Gentamicin Renal, hearing impairment
Tobramycin Renal, hearing impairment
Vancomycin Renal, hearing impairment
Copyright © 2003 F.A. Davis Company
CRITICAL VALUES: The adverse these antibiotics are similar and include
effects of subtherapeutic levels are impor- loss of hearing and decreased renal func-
tant. Care should be taken to investigate tion. The most important intervention is
signs and symptoms of too little and too accurate therapeutic drug monitoring so
much medication. the medication can be discontinued
Signs and symptoms of toxic levels of before irreversible damage is done.
ANTIBODIES, ANTICYTOPLASMIC
NEUTROPHILIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Pretest:
Intratest:
➤ Obtain a history of the patient’s
complaints, including a list of known ➤ Direct the patient to breathe
allergens. normally and to avoid unnecessary
movement.
➤ Obtain a history of the patient’s gas-
trointestinal, genitourinary, hepato- ➤ Observe standard precautions and
biliary, immune, and musculoskele- follow the general guidelines in
tal system and results of previously Appendix A. Perform a venipuncture,
performed tests and procedures. For and collect the specimen in a 5-mL
related tests, refer to the gastroin- red-top tube.
testinal, genitourinary, hepatobiliary,
immune, and musculoskeletal sys- ➤ Label the specimen, and promptly
tem tables. transport it to the laboratory.
➤ Obtain a list of the medications the
patient is taking, including herbs, nu-
Post-test:
tritional supplements, and nutraceu-
ticals. 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 pressure bandage.
these products so that their effects
can be taken into consideration ➤ Evaluate test results in relation to the
when reviewing results. patient’s symptoms and other tests
performed. Related laboratory tests
➤ There are no food, fluid, or medica- include anti–glomerular basement
tion restrictions unless by medical membrane antibody, antimitochon-
direction. drial antibody, eosinophil count,
➤ Review the procedure with the kidney biopsy, rheumatoid factor, and
patient. urinalysis.
ANTIBODIES, ANTI–GLOMERULAR
BASEMENT MEMBRANE
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Post-test:
Pretest:
➤ Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s ing or hematoma formation. Apply
complaints, including a list of known pressure bandage.
allergens. ➤ Evaluate test results in relation to
➤ Obtain a history of the patient’s gen- the patient’s symptoms and other
itourinary, immune, and respiratory tests performed. Related laboratory
systems and results of previously tests include antineutrophilic cyto-
performed tests and procedures. For plasmic antibody, kidney biopsy,
related tests, refer to the genitouri- lung biopsy, and urinalysis.
Copyright © 2003 F.A. Davis Company
ANTIBODIES, ANTINUCLEAR,
ANTI-DNA, AND ANTICENTROMERE
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RESULT
Antibodies, Antiscleroderma 99
ANTIBODIES, ANTISCLERODERMA
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INDICATIONS: Pretest:
• Assist in the diagnosis of scleroderma
➤ Obtain a history of the patient’s
RESULT complaints, including a list of known
allergens.
Increased in: ➤ Obtain a history of the patient’s
Copyright © 2003 F.A. Davis Company
ANTIBODIES, ANTISPERM
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SYNONYMS/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Immunoassay)
ANTIBODIES, ANTISTREPTOLYSIN O
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ANTIBODIES, ANTITHYROGLOBULIN
AND ANTITHYROID PEROXIDASE
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ANTIBODIES, CARDIOLIPIN,
IMMUNOGLOBULIN G, AND
IMMUNOGLOBULIN M
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• Drug reactions
• Epilepsy Pretest:
ANTIBODIES, GLIADIN
(IMMUNOGLOBULIN G
AND IMMUNOGLOBULIN A)
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the clinical implications of the test have other related nutritional prob-
results, as appropriate. Educate the lems.
patient regarding access to appropri- ➤ Evaluate test results in relation
ate counseling services. to the patient’s symptoms and
➤ Encourage the patient with abnor- other tests performed. Related
mal findings to consult with a laboratory tests include albumin,
qualified nutritionist to plan a calcium, skin biopsy, D-xylose toler-
lactose- and gluten-free diet. This ance test, electrolytes, fecal analy-
dietary planning is complex because sis, fecal fat, folic acid, iron, and
patients are often malnourished and lactose tolerance test.
ANTIBODY, ANTIMITOCHONDRIAL
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SYNONYM/ACRONYM: AMA.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative or
titer less than 1:20.
RESULT Pretest:
➤ Obtain a history of the patient’s
Increased in: complaints, including a list of known
• PBC allergens.
➤ Obtain a history of the patient’s
• Hepatitis (alcoholic, viral) hepatobiliary and immune systems,
• Rheumatoid arthritis (occasionally) as well as results of previously
performed tests and procedures. For
• Systemic lupus erythematosus (occa- related tests, refer to the hepatobil-
sionally) iary and immune system tables.
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: ASMA.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative.
Copyright © 2003 F.A. Davis Company
ANTIBODY, Jo-1
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ANTICONVULSANT DRUGS:
CARBAMAZEPINE, ETHOSUXIMIDE,
PHENOBARBITAL, PHENYTOIN,
PRIMIDONE, VALPROIC ACID
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* Conventional units.
Copyright © 2003 F.A. Davis Company
ANTIDEOXYRIBONUCLEASE-B,
STREPTOCOCCAL
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INDICATIONS: Intratest:
• Investigate the presence of streptococ- ➤ Direct the patient to breathe
cal antibodies as a source of recent normally and to avoid unnecessary
infection movement.
➤ Observe standard precautions and
RESULT follow the general guidelines in Ap-
pendix A. Perform a venipuncture,
Increased in: and collect the specimen in a 5-mL
• Streptococcal infections (systemic) red-top tube.
➤ Label the specimen, and promptly
Decreased in: N/A transport it to the laboratory.
ANTIDEPRESSANT DRUGS:
AMITRYPTYLINE, NORTRIPTYLINE,
DIAZEPAM, DOXEPIN, IMIPRAMINE,
DESIPRAMINE
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Route of Recommended
Drug Administration Collection Time
Amitriptyline Oral Trough: immediately before next
dose (at steady state)
Nortriptyline Oral Trough: immediately before next
dose (at steady state)
Diazepam Oral Trough: immediately before next
dose (at steady state) or at a
consistent sampling time
Peak: 1–2 h after dose
Doxepin Oral Trough: immediately before next
dose (at steady state)
Imipramine Oral Trough: immediately before next
dose (at steady state)
Desipramine Oral Trough: immediately before next
dose (at steady state)
ous system depression, and seizure pre- advised if the patient regularly uses
cautions. Emetics are contraindicated. these products so that their effects
can be taken into consideration
Tricyclic Antidepressants: when reviewing results.
➤ There are no food, fluid, or medica-
• Amitryptyline: Greater than 500 tion restrictions unless by medical
ng/mL direction.
• Nortriptyline: Greater than 500 ➤ Review the procedure with the
ng/mL patient.
• Combined doxepin and desmethyldox- ➤ Inform the patient that specimen
collection takes approximately 5 to
epin: Greater than 500 ng/mL 10 minutes.
• Imipramine: Greater than 500 ng/mL
Intratest:
• Desipramine: Greater than 400 ng/mL
Signs and symptoms of tricyclic anti- ➤ Direct the patient to breathe
depressant toxicity include agitation, hal- normally and to avoid unnecessary
lucinations, confusion, seizures, arrhyth- movement.
mias, hyperthermia, flushing, dilation of ➤ Observe standard precautions and
the pupils, and possible coma. Possible follow the general guidelines in Ap-
interventions include administration of pendix A. Review dosing schedule to
activated charcoal; emesis; gastric lavage ensure that peak and trough speci-
with saline; administration of physostig- mens are ordered to be collected at
the appropriate time. Perform a
mine to counteract seizures, hyperten- venipuncture, and collect the speci-
sion, or respiratory depression; adminis- men in a 5-mL red-top tube.
tration of bicarbonate, propranolol,
➤ Label the specimen, and promptly
lidocaine, or phenytoin to counteract ar- transport it to the laboratory.
rhythmias; and electrocardiographic
monitoring.
Post-test:
INTERFERING FACTORS: Cyclic antide- ➤ Observe venipuncture site for bleed-
pressants may potentiate the effects of ing or hematoma formation. Apply
oral anticoagulants. pressure bandage.
➤ Explain to the patient the impor-
tance of following the medication
Nursing Implications and regimen and instructions regarding
Procedure ● ● ● ● ● ● ● ● ● ● ● food and drug interactions.
➤ Instruct the patient to immediately
Pretest: report any unusual sensations (e.g.,
severe headache, vomiting, sweat-
➤ Obtain a history of the patient’s ing, clammy skin, visual distur-
complaints, including a list of known bances) to the health care practi-
allergens. tioner. Blood pressure should be
➤ Review results of previously per- monitored regularly.
formed tests and procedures. For re- ➤ Instruct the patient to be prepared to
lated tests, refer to the hepatobiliary list to the pharmacist the other med-
system and therapeutic/toxicology ications he or she is already taking in
tables. the event that the requesting health
➤ Obtain a list of the medications the care practitioner prescribes a med-
patient is taking, including herbs, nu- ication.
tritional supplements, and nutraceu- ➤ Evaluate test results in relation to
ticals. The requesting health care the patient’s symptoms and other
practitioner and laboratory should be tests performed.
Copyright © 2003 F.A. Davis Company
ANTIDIURETIC HORMONE
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ANTIGENS/ANTIBODIES,
ANTI–EXTRACTABLE NUCLEAR
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Route of Recommended
Drug Administration Collection Time
Haloperidol Oral Peak: 3–6 h
Lithium Oral 12 h after dose
Volume of Protein
Therapeutic Half- Distribution Binding
Drug Dose* SI Units Life (h) (L/kg) (%) Excretion
(Conversion
Factor
2.66)
Haloperidol 5–20 ng/mL 13–53 nmo/L 15–40 18–30 90 Hepatic
(Conversion
Factor 1)
Lithium 0.6–1.2 mEq/L 0.6–1.2 mmol/L 18–24 0.7–1.0 0 Renal
*Conventional units.
ANTITHROMBIN III
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SI Units
Conventional Units (Conversion Factor 10)
Immunologic assay 21–30 mg/dL 210–300 mg/L
Copyright © 2003 F.A. Davis Company
SI Units
Conventional Units (Conversion Factor 0.01)
Functional assay 85–115% of standard 0.85–1.15
• Inflammation
Pretest:
• Menstruation
➤ Obtain a history of the patient’s
• Obstructive jaundice complaints, including a list of known
allergens.
• Renal transplant
➤ Obtain a history of the patient’s
• Vitamin K deficiency hematopoietic system and results of
previously performed tests and
Decreased in: procedures. For other related tests,
• Carcinoma refer to the hematopoietic system
table.
• Chronic liver failure
➤ Obtain a list of medications the pa-
• Cirrhosis tient is taking, including herbs, nutri-
tional supplements, and nutraceuti-
• Congenital deficiency cals. The requesting health care
practitioner and laboratory should be
• Disseminated intravascular coagula-
advised if the patient regularly uses
tion these products so that their effects
• Liver transplant or partial hepatectomy can be taken into consideration
when reviewing results.
• Nephrotic syndrome ➤ There are no food, fluid, or medica-
• Pulmonary embolism tion restrictions unless by medical
direction.
CRITICAL VALUES: N/A ➤ Review the procedure with the
patient.
INTERFERING FACTORS: ➤ Inform the patient that specimen
Copyright © 2003 F.A. Davis Company
1-ANTITRYPSIN AND
1-ANTITRYPSIN PHENOTYPING
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1-Antitrypsin
SI Units
(Conversion
Age Conventional Units Factor 0.01)
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
Apolipoprotein A 133
APOLIPOPROTEIN A
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SYNONYM/ACRONYM: Apo A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Immunonephelometry)
Copyright © 2003 F.A. Davis Company
SI Units
(Conversion
Sex/Age Conventional Units Factor 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
Apolipoprotein A 135
APOLIPOPROTEIN B
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SYNONYM/ACRONYM: Apo B.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Immunonephelometry)
SI Units
(Conversion
Age Conventional Units Factor 0.01)
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
Apolipoprotein B 137
ARTHROGRAM
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Arthrogram 139
Arthroscopy 141
ARTHROSCOPY
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SYNONYM/ACRONYM: N/A.
AREA OF APPLICATION: Joints.
CONTRAST: None.
• Synovitis
Nursing Implications and
• Torn cartilage Procedure ● ● ● ● ● ● ● ● ● ● ●
• Torn ligament
• Torn rotator cuff Pretest:
• Trapped synovium ➤ Inform the patient that the proce-
dure is generally performed under
local anesthesia in an endoscopy or
INTERFERING FACTORS surgical suite by a physician. The
procedure takes approximately 15 to
This procedure is contraindicated 45 minutes.
for:
➤ Instruct the patient not to eat or
• Patients with bleeding disorders, active drink 6 to 8 hours before the test.
arthritis, or cardiac conditions
➤ Obtain a history of allergies or sensi-
• Patients with joint infection or skin tivities to anesthetics, symptoms,
infection near proposed arthroscopic and use of analgesics, medications,
site and antibiotics. Obtain a history of
known or suspected musculoskele-
• Patients who have had an arthrogram tal or joint disorders and results of
within the last 14 days previously performed tests and pro-
cedures. For related tests, refer to
Factors that may impair clear the musculoskeletal system table.
imaging: ➤ An informed consent needs to be
• Inability of the patient to cooperate obtained and witnessed before
or remain still during the procedure administration of medications.
because of age, significant pain, or ➤ Determine previous abnormalities in
mental status laboratory test results, particularly
hematologic or coagulation tests.
• Metallic objects within the examina-
tion field (e.g., jewelry, earrings, dental ➤ Crutch walking should be taught
amalgams), which may inhibit organ before the procedure if it is antici-
pated postoperatively.
visualization and can produce unclear
images ➤ The joint area and areas 5 to 6 inches
above and below the joint are
• Improper adjustment of the radi- shaved and prepared for the proce-
ographic equipment to accommodate dure.
obese or thin patients, which can cause ➤ The patient is given a preprocedure
overexposure or underexposure and a sedative, as ordered.
poor-quality study
• Patients who are very obese, who may Intratest:
exceed the weight limit for the equip- ➤ Resuscitation equipment and patient
ment monitoring equipment must be avail-
able.
• Incorrect positioning of the patient,
which may produce poor visualization ➤ Have the patient remove dentures,
of the area to be examined contact lenses, eyeglasses, and
jewelry. Notify the physician if the
• Fibrous ankylosis of the joint prevent- patient has crownwork that could
ing effective use of the arthroscope affect the examination. Have the
patient remove clothing and change
• Joints with flexion of less than 50º into a gown for the procedure.
• Failure to follow dietary restrictions ➤ The extremity is scrubbed, elevated,
before the procedure may cause the and wrapped with an elastic band-
procedure to be canceled or repeated. age from the distal portion of the
Copyright © 2003 F.A. Davis Company
ASPARTATE AMINOTRANSPEPTIDASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
(Conversion
Age Conventional Units Factor 0.17)
Newborn 47–150 U/L 0.80–2.55 Kat/L
10 d–23 m 9–80 U/L 0.15–1.36 Kat/L
2–59 y
Male 15–40 U/L 0.26–0.68 Kat/L
Female 13–35 U/L 0.22–0.60 Kat/L
60–90 y
Male 19–48 U/L 0.32–0.82 Kat/L
Female 9–36 U/L 0.15–0.61 Kat/L
times normal):
Pretest:
• Cerebrovascular accident
➤ Obtain a history of the patient’s
• Cirrhosis, fatty liver complaints, including pain related to
• Delirium tremens ischemia or inflammation. Obtain a
list of known allergens.
• Hemolytic anemia ➤ Obtain a history of the patient’s car-
• Pericarditis diovascular and hepatobiliary sys-
tems, as well as results of previously
• Pulmonary infarction performed tests and procedures. For
related tests, refer to the cardiovas-
CRITICAL VALUES: N/A cular and hepatobiliary system ta-
bles.
INTERFERING FACTORS: ➤ Obtain a list of medications the pa-
• Drugs that may increase AST levels by tient is taking, including herbs, nutri-
causing cholestasis include amitripty- tional supplements, and nutraceuti-
line, anabolic steroids, androgens, cals. The requesting health care
practitioner and laboratory should be
benzodiazepines, chlorothiazide, chlor-
advised if the patient regularly uses
propamide, dapsone, erythromycin, these products so that their effects
estrogens, ethionamide, gold salts, can be taken into consideration
imipramine, mercaptopurine, nitrofu- when reviewing results.
rans, oral contraceptives, penicillins, ➤ There are no food, fluid, or medica-
phenothiazines, progesterone, pro- tion restrictions unless by medical
poxyphene, sulfonamides, tamoxifen, direction.
and tolbutamide.
➤ Review the procedure with the
• Drugs that may increase AST levels by patient.
causing hepatocellular damage include ➤ Inform the patient that specimen
acetaminophen (toxic), acetylsalicylic collection takes approximately 5 to
acid, allopurinol, amiodarone, anabolic 10 minutes.
steroids, anticonvulsants, asparaginase,
azithromycin, bromocriptine, capto- Intratest:
pril, cephalosporins, chloramphenicol, ➤ Direct the patient to breathe
clindamycin, clofibrate, danazol, enflu- normally and to avoid unnecessary
rane, ethambutol, ethionamide, fenofi- movement.
brate, fluconazole, fluoroquinolones, ➤ Observe standard precautions and
foscarnet, gentamicin, indomethacin, follow the general guidelines in Ap-
interferon, interleukin-2, levamisole, pendix A. Perform a venipuncture,
levodopa, lincomycin, low-molecular- and collect the specimen in a 5-mL
weight heparin, methyldopa, mono- red- or tiger-top tube. Handle the
amine oxidase inhibitors, naproxen, specimen gently to avoid hemolysis.
nifedipine, nitrofurans, oral contracep- ➤ Label the specimen, and promptly
tives, probenecid, procainamide, qui- transport it to the laboratory.
Copyright © 2003 F.A. Davis Company
INDICATIONS: Pretest:
• Assist in the confirmation of congestive ➤ Obtain a history of the patient’s
heart failure (CHF), as indicated by complaints, including a list of known
increased level allergens. Be alert to signs and
symptoms of altered cardiopul-
• Identify asymptomatic cardiac volume monary tissue perfusion related
overload, as indicated by increased to ventilation-perfusion imbalance,
level decreased cardiac output related to
altered muscle contractility, and fluid-
RESULT volume excess related to glomerular
filtration rate.
Increased in: ➤ Obtain a history of the patient’s
• Asymptomatic cardiac volume over- cardiovascular system and results of
load previously performed tests and
procedures. For related tests, refer
• CHF to the cardiovascular system table.
• Elevated cardiac filling pressure ➤ Obtain a list of medications the pa-
tient is taking, including herbs, nutri-
• Paroxysmal atrial tachycardia tional supplements, and nutraceuti-
cals. The requesting health care
Decreased in: N/A practitioner and laboratory should be
advised if the patient regularly uses
CRITICAL VALUES: N/A these products so that their effects
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: N/A.
Copyright © 2003 F.A. Davis Company
Ear
Nursing Implications and
Commonly identified organisms include
Escherichia coli, Proteus spp., Pseudomonas
Procedure ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
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.
➤ Instruct the patient not to touch the the diaphragmatic area and applica-
edge or inside of the container with tion of slight pressure. Another ap-
the hands or mouth. proach is to place a vaporizer or
➤ Review the procedure with the other humidifying device at the bed-
patient. side. After sufficient exposure to
adequate humidification, postural
➤ The time it takes to collect a proper drainage of the upper and middle
specimen varies according to the lung segments may be repeated be-
level of patient cooperation and the fore attempting to obtain the speci-
specimen collection site. men. Other methods may include
obtaining an order for an expecto-
Intratest: rant and administering it along with
➤ Ensure that the patient has complied additional water approximately 2
with dietary restrictions before bron- hours before attempting to obtain
choscopy. the specimen. In addition, chest per-
cussion and postural drainage of all
➤ Observe standard precautions and lung segments may be employed. If
follow the general guidelines in the patient is still unable to raise
Appendix A. sputum, the use of an ultrasonic
nebulizer (“induced sputum”) may
Bronchoscopy: be necessary and is usually per-
➤ Record baseline vital signs. The pa- formed by a respiratory therapist.
tient is positioned in relation to the
type of anesthesia being used. For Tracheal suctioning:
general anesthesia the patient is ➤ Obtain the necessary equipment,
placed in a supine position with the including a suction device, a suction
neck hyperextended. If local anes- kit, and a Lukens tube or in-line trap.
thesia is used, the patient is seated Position the patient with head
and the tongue and oropharynx are elevated as high as tolerated. Put on
sprayed and swabbed with anes- sterile gloves, with the dominant
thetic. The patient is then helped to hand maintained as sterile and the
a supine or side-lying position and nondominant hand as clean. Using
the bronchoscope is inserted. After the sterile hand, attach the suction
inspection, the samples are col- catheter to the rubber tubing of
lected from suspicious sites by the Lukens tube or in-line trap. Then
bronchial brush or biopsy forceps. attach the suction tubing to the male
adapter of the trap with the clean
Expectorated specimen: hand. Lubricate the suction catheter
➤ Request the patient to sit upright, with sterile saline. Tell nonintubated
with assistance and support (such as patients to protrude the tongue and
with an overbed table) as needed. take a deep breath as the suction
Ask the patient to take two or three catheter is passed through the
deep breaths and to cough deeply. nostril. When the catheter enters
Any sputum raised should be expec- the trachea, a reflex cough will be
torated directly into a sterile sputum stimulated; immediately advance
collection container. If the patient is the catheter into the trachea and
unable to produce the desired apply suction. Maintain suction for
amount of sputum, several strate- approximately 10 seconds and never
gies may be attempted. One ap- for longer than 15 seconds. Then
proach is to have the patient drink withdraw the catheter without
two glasses of water and then as- applying suction. Separate the
sume the positions for postural suction catheter and suction tubing
drainage of the upper and middle from the trap, and place the rubber
lung segments. Support for effective tubing over the male adapter to seal
coughing may be provided by place- the unit. For intubated patients or
ment of the hands or a pillow over those with a tracheostomy, the
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: N/A.
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 percent anaerobes and 1 to 4
percent aerobes. Normal flora present may include Bacteroides, Candida albi-
cans, Clostridium, Enterococcus, E. coli, Proteus, Pseudomonas, and
Staphylococcus aureus.
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (5 mL) collected in a sterile plastic collection container.
REFERENCE VALUE: (Method: Culture on selective and enriched media)
Negative: no growth.
Copyright © 2003 F.A. Davis Company
BARIUM ENEMA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Remove clothing and metallic
objects from the pelvic area.
Pretest: ➤ Provide patient with a gown with tie
closures and a robe to wear.
➤ Inform the patient about the
purpose of the procedure, and the ➤ If appropriate, remove any wires
need to have contrast medium connected to electrodes.
instilled into the rectum. The proce- ➤ Place the patient on the x-ray table in
dure is not painful, but the patient a supine position or have the patient
may experience cramping, abdomi- stand in front of an x-ray fluoroscopy
nal fullness, or an urge to defecate. screen.
➤ Obtain a history of the patient’s ➤ An initial image is taken. The patient
complaints and a list of any medica- is helped to a side-lying position
tions the patient is taking. (Sims’ position). A rectal tube is
➤ Obtain a history of the patient’s inserted into the anus while an
lower gastrointestinal system and attached balloon is inflated after it is
the results of previously performed situated against the anal sphincter.
tests, surgery, therapy, and proce- ➤ Barium is instilled into the colon and
dures. For related tests, refer to the then the movement is observed
gastrointestinal system table. through the colon by fluoroscopy.
➤ Determine patient’s allergies, includ- ➤ Images are taken at different angles
ing barium and latex. and positions to aid in the evaluation
➤ Assess for iodine allergy, including of the patient’s problem.
allergies to shellfish, if iodinated ➤ For patients with a colostomy, an in-
contrast medium is to be used. dwelling urinary catheter is inserted
Copyright © 2003 F.A. Davis Company
into the stoma and barium is admin- laxative and increase fluid intake
istered. (four glasses) to aid in elimination of
➤ The patient is returned to a position barium, unless contraindicated.
of comfort, and is placed on a ➤ Instruct the patient that stools will
bedpan or helped to the bathroom to be white or light in color for 2 to 3
expel the barium. days. If the patient is unable to elim-
➤ After the expulsion of the barium, an inate the barium, or if stools do not
additional film is taken of the intes- return to normal color, the patient
tine. should notify the physician.
➤ If a double-contrast barium enema ➤ Advise patients with a colostomy to
has been ordered, air is then instilled administer tap water colostomy irri-
in the intestine and additional films gation to aid in barium removal.
are taken. ➤ Carefully monitor the patient for
fatigue and fluid and electrolyte
Post-test: imbalance.
➤ Determine if the patient or patient’s
➤ Instruct the patient to resume food, family has any further questions or
fluids, and medications withheld concerns.
before the procedure.
➤ A physician specializing in this
➤ Inform the patient of the possible branch of medicine will send a report
need for further examinations to to the ordering health care provider
evaluate and determine the need for who will discuss the results with the
a change in therapy or progression patient.
of the disease process.
➤ Evaluate test results in relation to
➤ If iodine is used, monitor for reaction the patient’s symptoms and other
to iodinated contrast medium includ- tests performed. Related diagnostic
ing rash, urticaria, tachycardia, hy- tests include colonoscopy, as well as
perpnea, hypertension, or palpita- computed tomography and mag-
tions. netic resonance imaging of the ab-
➤ Instruct the patient to take a mild domen.
BARIUM SWALLOW
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
BIOPSY, BLADDER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Bladder tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal tissue or cells.
Copyright © 2003 F.A. Davis Company
BIOPSY, BONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Bone tissue.
REFERENCE VALUE: (Method: Microscopic study of bone samples) No
abnormal tissue or cells.
SYNONYM/ACRONYM: N/A.
SPECIMEN: Bone marrow aspirate, bone core biopsy, marrow and periph-
eral smears.
• Thrombocytopenia purpura
Pretest:
Increased M:E: ➤ Obtain a history of the patient’s
• Bone marrow failure complaints, including a list of known
allergens.
• Infections ➤ Obtain a history of the patient’s
• Leukemoid reactions hematopoietic and immune system
and any bleeding disorders, as well
• Myeloid leukemia as results of previously performed
tests and procedures, especially
Decreased M:E: bleeding time, clotting time, com-
plete blood count, partial thrombo-
• Anemias plastin time, platelets, and pro-
thrombin time. For related tests,
• Hepatic disease refer to the hematopoietic and im-
• Polycythemia vera mune system tables.
➤ Obtain a list of the medications the
• Posthemorrhagic hematopoiesis patient takes, including anticoagu-
lant therapy, acetylsalicylic acid,
Increased normoblasts: herbals, and nutraceuticals known to
• Anemias affect coagulation. These products
should be discontinued 14 days
• Chronic blood loss before dental or surgical procedures.
The requesting health care practi-
• Polycythemia vera tioner and laboratory should be
advised if the patient regularly uses
Decreased normoblasts: such products so their effect can
be taken into consideration when
• Aplastic anemia reviewing results.
• Folic acid or vitamin B12 deficiency ➤ Note any recent procedures that can
interfere with test results.
• Hemolytic anemia
➤ There are no food, fluid, or medica-
tion restrictions unless by medical
Increased eosinophils:
direction.
• Bone marrow cancer ➤ Review the procedure with the
patient. Sensitivity to cultural and
• Lymphadenoma
social issues, as well as concern for
• Myeloid leukemia modesty, is important in providing
psychological support. Explain that
CRITICAL VALUES: N/A discomfort of the puncture will be
minimized with local anesthetics
or systemic analgesics and that the
INTERFERING FACTORS: site may remain tender for several
• Recent blood transfusions, iron ther- weeks. For children, provide equip-
apy, or administration of cytotoxic ment and a doll with which to role-
agents may alter test results. play a simulated procedure. Inform
Copyright © 2003 F.A. Davis Company
the patient that bed rest for 10 to 30 aliquot of marrow withdrawn. The
minutes (depending on the test site) needle is removed and pressure
is required after the procedure. applied to the site. The aspirate is
➤ Assess if the patient has an allergy applied to slides, and when dry, a
to local anesthetics and inform the fixative is applied.
health care practitioner accordingly.
Needle biopsy:
➤ Obtain written and informed consent
before administering any medica- ➤ Record baseline vital signs. Local
tions prior to the procedure. anesthetic is introduced deeply
enough to include periosteum. A
➤ Explain that the test is done at the
cutting biopsy needle is introduced
bedside or in a treatment room by a
through a small skin incision and
health care practitioner and requires
bored into the marrow cavity. A core
about 20 minutes.
needle is introduced through the
cutting needle, and a plug of marrow
Intratest: is removed. The needles are with-
➤ Record baseline vital signs. drawn, and the specimen is placed
in a preservative solution. Pressure
➤ Observe standard precautions and is applied to the site for 5 to 10
follow the general guidelines in minutes, and a dressing is applied.
Appendix A.
➤ Label the specimen, and promptly
➤ Administer premedication pre- transport it to the laboratory.
scribed for pain or anxiety. Direct the
patient to breathe normally and to Post-test:
avoid unnecessary movement.
➤ Assist the patient to the desired ➤ After local anesthesia, monitor vital
position depending on the test site signs and compare with baseline
to be used. In young children, the values.
most frequently chosen site is the ➤ Advise the patient or caregiver to
proximal tibia. Vertebral bodies T10 keep ice on the site and not to
through L4 are preferred in older chil- remove the bandage for 24 hours.
dren. In adults, the sternum or iliac ➤ Instruct the patient to immediately
crests are the preferred sites. report any signs of infections or
➤ Place the patient in the prone, excessive bleeding.
sitting, or side-lying position for the ➤ Recognize anxiety related to test
vertebral bodies; the side-lying results and offer support. Provide
position for iliac crest or tibial sites; teaching and information regarding
or the supine position for the ster- the clinical implications of the test
num. results, as appropriate. Educate the
patient regarding access to counsel-
Needle aspiration: ing services.
➤ Prepare the skin with an antiseptic ➤ Evaluate test results in relation to
solution and drape the site. Record the patient’s symptoms and other
baseline vital signs. The health care tests performed. Related laboratory
practitioner will anesthetize the site tests include complete blood count,
with procaine or lidocaine, and then serum and urine immunofixation
insert a needle with stylet into the electrophoresis, leukocyte alkaline
marrow. The stylet is removed, a phosphatase, lymph node biopsy,
syringe attached, and a 0.5-mL and vitamin B12.
Copyright © 2003 F.A. Davis Company
BIOPSY, BREAST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Breast tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal cells or tissue.
BIOPSY, CERVICAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Cervical tissue.
REFERENCE VALUE: (Method: Microscopic examination of tissue cells) No
abnormal cells or tissue.
SYNONYM/ACRONYM: N/A.
SPECIMEN: Chorionic villus tissue.
REFERENCE VALUE: (Method: Tissue culture) Normal karyotype.
➤ There are no food, fluid, or medica- ate containers. Label indicating site
tion restrictions unless by medical location and promptly transport the
direction. specimen to the laboratory.
➤ Review the procedure with the
patient. Sensitivity to cultural and Post-test:
social issues, as well as concern for
modesty, is important in providing ➤ Monitor maternal and fetal vital
psychological support. signs and compare with baseline
values.
➤ Address concerns about pain related
to the procedure and that relaxation ➤ Observe for bleeding and instruct
and controlled breathing during the patient to immediately report exces-
procedure will aid in reducing sive bleeding, abdominal pain,
discomfort. temperature, or chills.
➤ Have the patient void before the ➤ Instruct the patient to expect a gray-
procedure. green vaginal discharge for several
days, to avoid strenuous activity for
➤ Warn the patient that normal results 8 to 24 hours, to avoid douching or
do not guarantee a normal fetus. intercourse for 2 weeks or as in-
Assure the patient that precautions structed by the health care practi-
to avoid injury to the fetus will be tioner, and to report excessive
taken by localizing the fetus with bleeding to the health care practi-
ultrasound. Inform the patient that tioner.
specimen collection takes approxi-
mately 10 to 15 minutes. ➤ Recognize anxiety related to test re-
sults and provide support. Provide
➤ Obtain written and informed teaching and information regarding
consent before administering any the clinical implications of the test
medications prior to the procedure. results, as appropriate. Encourage
family to seek counseling if con-
Intratest: cerned with pregnancy termination
➤ Position the patient in a lithotomy or to seek genetic counseling if
position on a gynecologic examina- chromosomal abnormality is deter-
tion table with feet in stirrups. Drape mined. Decisions regarding elective
the patient’s legs. abortion should take place in the
presence of both parents. Provide a
➤ Record maternal and fetal baseline nonjudgmental, nonthreatening at-
vital signs. mosphere for a discussion during
➤ Observe standard precautions and which risks of delivering an abnor-
follow the general guidelines in mal infant are discussed with op-
Appendix A. tions (termination of pregnancy or
➤ Cleanse the external genitalia with adoption). It is also important to dis-
an antiseptic solution. Direct the cuss problems the mother and fa-
patient to breathe normally and ther may experience (guilt, depres-
avoid unnecessary movement. sion, anger) if fetal abnormalities are
detected. Evaluate test results in re-
➤ The speculum is inserted and a lation to the patient’s symptoms and
suction catheter is inserted via the other tests performed. Related labo-
speculum to the biopsy site. A ratory tests include amniotic fluid
syringe is connected to the catheter analysis, -fetoprotein, chromosome
and the specimen is withdrawn. analysis, hexosaminidase A and B,
➤ Place the specimens in the appropri- and lecithin/sphingomyelin ratio.
Copyright © 2003 F.A. Davis Company
BIOPSY, INTESTINAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Intestinal tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal tissue or cells.
BIOPSY, KIDNEY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
BIOPSY, LIVER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Liver tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal cells or tissue.
RESULT
Nursing Implications and
Positive findings in: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Benign tumor
Pretest:
• Cancer
➤ Obtain a history of the patient’s
• Cholesterol ester storage disease complaints especially fatigue and
• Cirrhosis pain related to inflammation and
swelling of the liver.
• Galactosemia ➤ Obtain a list of known allergens.
• Hemochromatosis ➤ Obtain a history of the patient’s
Copyright © 2003 F.A. Davis Company
then every 2 hours for 4 hours, and results and offer support. Provide
as ordered. Take temperature every teaching and information regarding
4 hours for 24 hours. the clinical implications of the test
➤ After local anesthesia, monitor vital results, as appropriate. Educate the
signs and compare with baseline patient regarding access to counsel-
values. ing services.
➤ After percutaneous biopsy, instruct ➤ Evaluate test results in relation to the
the patient to stay in bed lying on patient’s symptoms and other tests
the affected side for at least 2 hours performed. Related laboratory tests
with a pillow or rolled towel under include alanine aminotransferase,
the site to prevent bleeding. The albumin, alkaline phosphatase, 1-
patient will also need to remain on antitrypsin/phenotyping, ammonia,
bed rest for 24 hours. amylase, antimitochondrial antibody,
anti–smooth muscle antibody, aspar-
➤ Instruct the patient in the care and tate aminotransferase, bilirubin,
assessment of the site, observe for bilirubin fractions, cholesterol, coagu-
bleeding, hematoma formation, bile lation factor assays, complete blood
leakage, and inflammation. Note any count, copper, -glutamyl transpepti-
pleuritic pain, persistent right shoul- dase, infectious mononucleosis
der pain, or abdominal pain. screen, lipase, prothrombin time,
➤ Recognize anxiety related to test and urinalysis.
BIOPSY, LUNG
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Lymph node tissue or cells.
Copyright © 2003 F.A. Davis Company
BIOPSY, MUSCLE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Muscle tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal tissue or cells.
BIOPSY, PROSTATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Prostate tissue.
REFERENCE VALUE: (Method: Microscopic examination of tissue cells) No
abnormal cells or tissue.
which malignant cells can seed normal sent before administering any med-
tissue. ications prior to the procedure.
➤ In certain cases prophylactic antibi-
otics may be administered before or
after the procedure.
Nursing Implications and
➤ Have the patient void before the
Procedure ● ● ● ● ● ● ● ● ● ● ●
procedure. Administer enemas if
ordered.
Pretest:
➤ Inform the patient that specimen
➤ Obtain a history of the patient’s collection will be performed by a
complaints, including a list of known health care practitioner. The speci-
allergens. men collection takes approximately
➤ Obtain a history of the patient’s 20 to 30 minutes.
immune and reproductive systems,
any bleeding disorders, and results Intratest:
of previously performed tests and
procedures, especially bleeding ➤ Direct the patient to breathe
time, clotting time, complete blood normally and to avoid unnecessary
count, partial thromboplastin time, movement.
platelets, and prothrombin time. For ➤ Observe standard precautions and
related tests, refer to the immune follow the general guidelines in
and reproductive system tables. Appendix A.
➤ Obtain a list of the medications the ➤ Record baseline vital signs.
patient is taking, including anticoag-
ulant therapy, acetylsalicylic acid, Transurethral approach:
herbs, and nutraceuticals known to
affect coagulation. These products ➤ Position patient on a urologic exam-
should be discontinued 14 days ination table with the feet in stir-
before dental or surgical procedures. rups. Clean external genitalia with
The requesting health care practi- antiseptic solution. Local anesthetic
tioner and laboratory should be is administered into the urethra
advised if the patient regularly uses and the endoscope is inserted.
these products so their effects can The tissue is excised with a cutting
be taken into consideration when loop and is placed in formalin solu-
reviewing results. tion.
➤ There are no food, fluid, or medica- Transrectal approach:
tion restrictions unless by medical
direction. ➤ Assist the patient into a Sims’ posi-
tion. A rectal examination is
➤ Review the procedure with the
performed to locate suspicious
patient. Sensitivity to cultural and
nodules. A biopsy needle guide is
social issues, as well as concern for
placed at the biopsy site, and the
modesty is important in providing
biopsy needle is inserted through
psychological support.
the needle guide. The cells are aspi-
➤ Address concerns about pain related rated, the needle is withdrawn, and
to the procedure. Explain that a local the sample is placed in formalin
anesthetic will be administered solution.
before the procedure and that some
discomfort during and after the Perineal approach:
procedure may be experienced.
➤ Position the patient in a jackknife or
➤ Assess if the patient has an allergy lithotomy position. Clean the per-
to local anesthetics, and inform the ineum with an antiseptic solution,
health care practitioner accordingly. administer the local anesthetic, and
➤ Obtain written and informed con- protect the biopsy site with sterile
Copyright © 2003 F.A. Davis Company
drapes. A small incision is made and rectal pain or bleeding, blood in the
the sample is removed by needle urine, or fever.
biopsy or biopsy punch.
➤ Administer analgesics and antibiotics
➤ Apply digital pressure to the biopsy as ordered, and instruct the patient in
site. If there is no bleeding, place a the importance of completing the
sterile dressing on the biopsy site. entire course of antibiotic therapy,
➤ Place tissue samples in formalin even if no symptoms are present.
solution. Label the specimen, indi- ➤ Recognize anxiety related to test
cating site location, and promptly results and provide support. Provide
transport it to the laboratory. teaching and information regarding
the test results, as appropriate.
Post-test: Counsel the patient, as appropriate,
that sexual dysfunction related to
➤ After local anesthesia, monitor vital
altered body function, drugs, or radi-
signs and compare with baseline
ation may occur. Educate the patient
values.
regarding access to counseling ser-
➤ Monitor urinary output and voiding vices, as appropriate.
pattern for 24 hours. Observe ap-
pearance of urine. ➤ Evaluate test results in relation to
the patient’s symptoms and other
➤ If the perineal approach was used, tests performed. Related labora-
observe biopsy site for bleeding or tory tests include prostate-specific
drainage. antigen and prostatic acid phos-
➤ Instruct the patient to report any phatase.
BIOPSY, SKIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Skin tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal tissue or cells.
DESCRIPTION: Skin biopsy is the exci- by any of these four ways: curettage,
sion of a tissue sample from suspicious shaving, excision, or punch. ■
skin lesions. The microscopic analysis
can determine cell morphology and INDICATIONS:
the presence of tissue abnormalities. • Assist in the diagnosis of keratoses,
This test assists in confirming the diag- warts, moles, keloids, fibromas, cysts,
nosis of malignant or benign skin or inflamed lesions
lesions. A skin biopsy can be obtained • Assist in the diagnosis of skin cancer
Copyright © 2003 F.A. Davis Company
BIOPSY, THYROID
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SYNONYM/ACRONYM: N/A.
SPECIMEN: Thyroid gland tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal cells or tissue.
Copyright © 2003 F.A. Davis Company
BLEEDING TIME
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➤ Evaluate test results in relation to the Related laboratory tests include clot
patient’s symptoms and other tests. retraction and platelet count.
BLOOD GASES
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REFERENCE VALUE: (Method: Selective electrodes for pH, pCO2 and pO2)
Arterial Venous
SI Units mmol/L SI Units mmol/L
tCO2 (Conversion Factor 1) (Conversion Factor 1)
Birth, cord, 13–22 mEq/L 14–22 mEq/L
full term
Adult/child 22–29 mEq/L 25–30 mEq/L
airways in any patient. Monitoring being weaned from ventilators. Blood gas
pO2 from blood gases is especially values are used to determine acid-base
appropriate under such circum- status, the type of imbalance, and the
stances. ■ degree of compensation as summarized
in the following section. Restoration of
INDICATIONS: pH to near-normal values is referred to as
This group of tests is used to assess condi- fully compensated balance. When pH
tions such as asthma, chronic obstructive values are moving in the same direction
pulmonary disease (COPD), embolism (i.e., increasing or decreasing) as the
(e.g., fatty or other embolism) during pCO2 or HCO3, the imbalance is meta-
coronary arterial bypass surgery, and bolic. When the pH values are moving in
hypoxia. It is also used to assist in the the opposite direction from the pCO2
diagnosis of respiratory failure, which is or HCO3, the imbalance is caused by
defined as a pO2 less than 50 mm Hg respiratory disturbances. To remember
and pCO2 greater than 50 mm Hg. this concept, the following mnemonic
Blood gases can be valuable in the can be useful: MeTRO Metabolic
management of patients on ventilators or Together, Respiratory Opposite.
Arterial Blood
Gas Parameter Less Than Greater Than
pH 7.20 7.60
HCO3 10 mmol/L 40 mmol/L
pCO2 20 mm Hg 55 mm Hg
pO2 45 mm Hg
CRITICAL VALUES: Signs and symp- and jaundice. Complications from dis-
toms of blood transfusion reaction range seminated intravascular coagulation
from mildly febrile to anaphylactic and (DIC) may also occur.
may include chills, dyspnea, fever, Possible interventions in mildly febrile
headache, nausea, vomiting, palpitations reactions would include slowing the rate
and tachycardia, chest or back pain, ap- of infusion, then verifying and compar-
prehension, flushing, hives, angioedema, ing patient identification, transfusion
diarrhea, hypotension, oliguria, hemo- requisition, and blood bag label. The
globinuria, renal failure, sepsis, shock, patient should be monitored closely for
Copyright © 2003 F.A. Davis Company
Intratest:
Nursing Implications and ➤ Ensure that the patient has complied
Procedure ● ● ● ● ● ● ● ● ● ● ●
with dietary preparations and other
pretesting restrictions.
Pretest: ➤ Ensure that emergency equipment
➤ Determine the date of the last is readily available during the proce-
menstrual period and the possibility dure.
of pregnancy in perimenopausal ➤ Have the patient remove all jewelry,
women. put on a hospital gown, and then
➤ Inform the patient that the test void.
permits assessment of the pump ➤ The patient is placed at rest in the
action of the heart. supine position on the scanning
➤ Inform the patient that the proce- table.
dure is performed in a special ➤ Expose the chest and attach the
department by a technologist and ECG leads.
Copyright © 2003 F.A. Davis Company
• Monitor changes in BMD due to tion field (e.g., jewelry, earrings, and/or
medical problems or therapeutic inter- dental amalgams), which may inhibit
vention organ visualization and can produce
• Determine a possible cause of amenor- unclear images
rhea • Improper adjustment of the radi-
• Evaluate bone demineralization associ- ographic equipment to accommodate
ated with chronic renal failure obese or thin patients, which can cause
overexposure or underexposure and
• Evaluate bone demineralization associ- poor-quality study
ated with immobilization
• Patients who are very obese, who may
RESULT: exceed the weight limit for the equip-
• T-score estimates the actual fracture ment
risk compared to young adults.
• Incorrect positioning of the patient,
• Normal bone mass is designated as a T- which may produce poor visualization
score value not less than 1. of the area to be examined
• Osteoporosis is defined as a BMD T-
Other considerations:
score value less than 2.5.
• The use of anticonvulsant drugs, cyto-
• Low bone mass or osteopenia has T- toxic drugs, tamoxifen, glucocorticoid,
scores from 1 to 2.5. lithium, or heparin, as well as increased
• Fracture risk increases as BMD alcohol intake, increased aluminum
declines from young-normal levels levels, excessive thyroxin, renal dialysis,
(low T-scores). or smoking, may affect the test results
by either increasing or decreasing the
• Low Z-scores in older adults can be
bone mineral content.
misleading because low BMD is very
common. • Consultation with a physician should
• Z-scores estimate fracture risk occur before the procedure for radia-
compared to others of the same age tion safety concerns regarding infants
(versus young-normal adults). of patients who are lactating.
• Risks associated with radiographic
INTERFERING FACTORS (OR FACTORS overexposure can result from frequent
ASSOCIATED WITH INCREASED RISK OF x-ray procedures. Personnel in the
OSTEOPOROSIS): room with the patient should wear a
protective lead apron, stand behind a
This procedure is contraindicated shield, or leave the area while the
for: examination is being done. Badges that
• Patients who are pregnant or suspected reveal the level of exposure to radiation
of being pregnant, unless the potential should be worn by persons working in
benefits of the procedure far outweigh the area where the examination is being
the risks to the fetus and mother. done.
complications including back pain, ➤ Inform the patient that the test
height loss, and kyphosis. usually takes 15 minutes.
➤ Limited activity may result including
difficulty bending and reaching. Intratest:
➤ Patient may have poor self-esteem ➤ Clothing is not usually removed
resulting from the cosmetic effects unless it contains metal or other
of kyphosis. items that would interfere with the
➤ Potential restricted lung function test.
may result from fractures. ➤ Patients may want to wear a gown
➤ Fractures may alter abdominal and robe, depending on the area to
anatomy, resulting in constipation, be examined.
pain, distention, and diminished ➤ Remove all metal objects from the
appetite. area to be examined.
➤ Potential for a restricted lifestyle ➤ Recognize anxiety related to the
may result in depression and other testing process.
psychological symptoms.
➤ Direct the patient to breathe
➤ Possible increased dependency on normally and to avoid unnecessary
family for basic care may occur. movement.
Pretest:
Post-test:
➤ Obtain a history of the patient’s
complaints. ➤ Compare new BMD values with
previous value(s) to determine
➤ Obtain a list of the medications the response to medical condition or
patient is taking. treatment.
➤ Obtain a history of the patient’s ➤ Post-test instructions should in-
bone mineral status, as well as clude instructions for adequate
results of previously performed intake of calcium and vitamin D,
tests and procedures. For related weight-bearing exercise, and avoid-
tests, refer to the musculoskeletal ance of tobacco use and alcohol
system table. abuse.
➤ Review the procedure with the ➤ Determine if the patient or family
patient. members have any further ques-
➤ Make special note of age, previous tions or concerns.
fractures, thinness, smoking, family ➤ A physician specializing in this
history, fall risk, alcohol and coffee branch of medicine will send a report
intake, age of menopause, and to the ordering health care provider
calcium intake. who will discuss the results with the
➤ Determine date of last menstrual patient.
period and possibility of pregnancy ➤ Evaluate test results in relation to
in perimenopausal women. the patient’s symptoms and other
➤ There are no food, fluid, or medica- tests performed. Related tests
tion restrictions unless by medical include bone CT, magnetic reso-
direction. nance imaging, and x-rays.
Copyright © 2003 F.A. Davis Company
BONE SCAN
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DESCRIPTION: This nuclear medicine tive. A gamma camera detects the radi-
scan assists in diagnosing and deter- ation emitted from the injected
mining the extent of primary and radioactive material. Whole body or
metastatic bone disease and bone representative images of the skeletal
trauma, and monitors the progression system can be obtained. ■
of degenerative disorders. Abnormali-
ties are identified by scanning 1 to 3 INDICATIONS:
hours after the intravenous injection of • Determine the cause of unexplained
a radionuclide such as technetium- bone or joint pain
99m methylene diphosphonate. Areas • Assess degenerative joint changes or
of increased uptake and activity on the acute septic arthritis
bone scan represent abnormalities • Confirm temporomandibular joint
unless they occur in normal areas of derangement
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 sarcoma, chondrosarcoma, Ewing’s
cranial sutures in children. The sarcoma, metastatic malignant tumors)
radionuclide mimics calcium physio-
logically and therefore localizes in • Aid in the diagnosis of benign tumors
or cysts
bone with an intensity proportional to
the degree of metabolic activity. • Aid in the diagnosis of osteomyelitis
Gallium, magnetic resonance imaging • Aid in the detection of traumatic or
(MRI), or white blood cell scanning stress fractures
can follow a bone scan to obtain a more
• Evaluate the healing process following
sensitive study if acute inflammatory
fracture, especially if an underlying
conditions such as osteomyelitis or bone disease is present
septic arthritis are suspected. In addi-
tion, bone scan can detect fractures in • Aid in the diagnosis of metabolic bone
patients who continue to have pain, diseases
even though x-rays have proved nega- • Detect Legg-Calvé-Perthes disease
Copyright © 2003 F.A. Davis Company
• Evaluate prosthetic joints for infection, • Metallic objects within the examina-
loosening, dislocation, or breakage tion field (e.g., jewelry, earrings, and/or
• Evaluate tumor response to radiation dental amalgams), which may inhibit
or chemotherapy organ visualization and can produce
unclear images.
• Identify appropriate site for bone
biopsy, lesion excision, or débridement • Improper adjustment of the radi-
ographic equipment to accommodate
• Assess suspected child abuse obese or thin patients, which can cause
overexposure or underexposure and
RESULT poor-quality study.
Normal Findings: • Patients who are very obese, who may
• No abnormalities, as indicated by exceed the weight limit for the equip-
homogeneous and symmetric distribu- ment.
tion of the radionuclide throughout all • Incorrect positioning of the patient,
skeletal structures which may produce poor visualization
of the area to be examined.
Abnormal Findings:
• Bone necrosis • Retained barium from a previous radi-
ologic procedure may affect the image.
• Degenerative arthritis
• A distended bladder may obscure
• Fracture pelvic detail.
• Legg-Calvé-Perthes disease • Other nuclear scans done within the
previous 24 to 48 hours may alter
• Metastatic bone neoplasm
image.
• Osteomyelitis
Other considerations:
• Paget’s disease
• The existence of multiple myeloma or
• Primary metastatic bone tumors thyroid cancer can result in a false-
• Renal osteodystrophy negative scan for bone abnormalities.
• Improper injection of the radionuclide
• Rheumatoid arthritis
may allow the tracer to seep deep into
the muscle tissue, producing erroneous
INTERFERING FACTORS hot spots.
This procedure is contraindicated • Consultation with a physician should
for: occur before the procedure for radia-
• Patients who are pregnant or suspected tion safety concerns regarding infants
of being pregnant, unless the potential of patients who are lactating.
benefits of the procedure far outweigh
• Risks associated with radiographic
the risks to the fetus and mother.
overexposure can result from frequent
Factors that may impair clear
x-ray procedures. Personnel in the
imaging: room with the patient should wear a
protective lead apron, stand behind a
• Inability of the patient to cooperate or shield, or leave the area while the
remain still during the procedure examination is being done. Badges that
because of age, significant pain, or reveal the level of exposure to radiation
mental status. should be worn by persons working in
Copyright © 2003 F.A. Davis Company
the area where the examination is being metallic objects. Have the patient
done. put on a hospital gown.
➤ Ask patient to void before the proce-
dure.
Nursing Implications and ➤ Place the patient in a supine position
Procedure ● ● ● ● ● ● ● ● ● ● ●
on a flat table with foam wedges to
help maintain position and immobi-
Pretest: lization. The radionuclide is adminis-
tered intravenously with images
➤ Inform the patient that the bone taken every 3 seconds for the first
scan can detect bone disease before minute over the area to be exam-
the disease can be detected with ined. This will evaluate the blood
plain film x-rays. flow to the area. A blood pool image
➤ Inform the patient that the proce- is then obtained over the area to be
dure is performed by a technologist examined (usually taking 2 to 3
in a special nuclear medicine depart- minutes). A 2- to 3-hour delay is
ment. The procedure usually takes required between the injection and
approximately 60 minutes. the actual bone scan to improve
tumor imaging.
➤ Obtain a history of the patient’s
complaints including a list of known ➤ After the delay that allows the
allergens. radionuclide to be taken up by the
bones, multiple images are obtained
➤ Obtain a history of the patient’s over the complete skeleton. A large
musculoskeletal system, as well as field-of-view camera is used to cover
results of previously performed the whole area. Delayed views may
tests, treatments, therapies, and be taken up to 24 hours after the
surgical procedures. For related injection.
tests, refer to the musculoskeletal
system table. ➤ The patient may be imaged by single
photon emission computed tomog-
➤ Obtain a list of the patient’s current raphy (SPECT) techniques to further
medications. clarify areas of suspicious radionu-
➤ Determine date of last menstrual clide localization.
period and possibility of pregnancy
in perimenopausal women.
Post-test:
➤ Inform the patient that the technolo-
gist will administer an intravenous ➤ Unless otherwise indicated, instruct
injection of the radionuclide and that the patient to resume normal activ-
he or she will need to return 2 to ity, medications, and diet.
3 hours later for the scan. ➤ Unless contraindicated, advise
➤ After the injection, the patient patient to drink increased amounts
should be encouraged to increase of fluids for 24 to 48 hours to elimi-
fluid intake and continue normal nate the radionuclide from the body.
physical activity. Tell the patient that radionuclide is
➤ Instruct the patient to lie very still eliminated from the body within 24
during the procedure because move- to 48 hours.
ment will produce unclear images. ➤ A physician specializing in this
➤ Sedate children who are unable to lie branch of medicine will send a report
still. to the ordering health care provider,
who will discuss the results with the
➤ Fasting before the scan is not patient.
required unless indicated otherwise.
➤ If a woman who is breastfeeding
Intratest: must have a nuclear scan, she
should not breastfeed the infant until
➤ Ask patient to remove jewelry, the radionuclide has been elimi-
including watches, and any other nated. This could take as long as 3
Copyright © 2003 F.A. Davis Company
Bronchoscopy 241
BRONCHOSCOPY
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Bronchoscopy 243
C-PEPTIDE
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C-Peptide 245
Pretest: Post-test:
➤ Obtain a history of the patient’s ➤ Observe venipuncture site for bleed-
complaints, including a list of known ing or hematoma formation. Apply
allergens. pressure bandage.
➤ Obtain a history of the patient’s ➤ Instruct the patient to resume usual
endocrine system and results of diet as directed by the health care
previously performed tests and practitioner.
procedures. For related tests, refer
to the endocrine system table. ➤ Abnormal C-peptide levels may be
associated with diabetes. Instruct
➤ Obtain a list of the medications the the diabetic patient, as appropriate,
patient is taking, including herbs, nu- in nutritional management of the
tritional supplements, and nutraceu- disease. Patients who adhere to
ticals. The requesting health care dietary recommendations report a
practitioner and laboratory should better general feeling of health,
be advised if the patient is regularly better weight management, greater
using these products so that their control of glucose and lipid values,
effects can be taken into considera- and improved use of insulin. There is
tion when reviewing results. no “diabetic diet”; however, there
➤ Note any recent procedures that can are many meal-planning approaches
interfere with test results. with nutritional goals endorsed by
➤ There are no fluid or medication the American Dietetic Association.
restrictions unless by medical direc- The nutritional requirements of each
tion. diabetic patient need to be deter-
mined individually with the appropri-
➤ The patient should fast for at least 10 ate health care professionals,
hours before specimen collection. particularly health care workers
➤ Review the procedure with the trained in nutrition.
patient. ➤ Instruct the patient and caregiver
➤ Inform the patient that specimen to report signs and symptoms of
collection takes approximately 5 to hypoglycemia (weakness, confu-
10 minutes. sion, diaphoresis, rapid pulse) or
hyperglycemia (thirst, polyuria,
Intratest: hunger, lethargy). Emphasize, as
appropriate, that good control of
➤ Direct the patient to breathe glucose levels delays the onset and
normally and to avoid unnecessary slows the progression of diabetic
movement. retinopathy, nephropathy, and
➤ Ensure that the patient has complied neuropathy.
with dietary preparations and other ➤ Evaluate test results in relation to
pretesting restrictions. the patient’s symptoms and other
➤ Observe standard precautions and tests performed. Related laboratory
follow the general guidelines in tests include cortisol, glucose,
Appendix A. Perform a venipuncture, glycated hemoglobin, glucose toler-
and collect the specimen in a 5-mL ance test, insulin, insulin antibodies,
red-top tube. and microalbumin.
Copyright © 2003 F.A. Davis Company
C-REACTIVE PROTEIN
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SYNONYM/ACRONYM: CRP.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: High-sensitivity immunoassay, nephelometry)
SI Units
Nephelometry Conventional Units (Conversion Factor 10)
Cord 1–35 g/dL 10–350 g/L
Adult 6.8–820 g/dL 68–8200 g/L
CA 125 249
CA 125
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CA 15-3
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CA 15-3 251
INDICATIONS: Monitor recurrent carci- ➤ Note any recent procedures that can
noma of the breast interfere with test results.
➤ There are no food, fluid, or medica-
RESULT tion restrictions unless by medical
direction.
Increased in: Recurrent carcinoma ➤ Review the procedure with the
of the breast patient.
➤ Inform the patient that specimen
Decreased in: Effective therapy or collection takes approximately 5 to
removal of the tumor 10 minutes.
Pretest: Post-test:
➤ Obtain a history of the patient’s ➤ Observe venipuncture site for bleed-
complaints, including a list of known ing or hematoma formation. Apply
allergens. pressure bandage.
➤ Obtain a history of the patient’s ➤ Recognize anxiety related to test
immune and reproductive systems, results and offer support. Provide
as well as results of previously teaching and information regarding
performed tests and procedures. For the clinical implications of the test
related tests, refer to the immune results, as appropriate. Educate the
and reproductive system tables. patient regarding access to counsel-
ing services.
➤ Obtain a list of the medications
the patient is taking, including ➤ Inform the patient that serial speci-
herbs, nutritional supplements, and mens may be requested at regular
nutraceuticals. Advise the request- intervals.
ing health care practitioner and labo- ➤ Evaluate test results in relation to
ratory if the patient regularly uses the patient’s symptoms and other
these products so that their effects tests performed. Related laboratory
can be taken into consideration tests include breast biopsy, carci-
when reviewing results. noembryonic antigen, and CA 125.
Copyright © 2003 F.A. Davis Company
CA 19-9
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Medication Recommended
Procedure Administered Collection Times
Calcium and Calcium, 2 mg/kg IV 4 calcitonin levels—baseline imme-
pentagastrin for 1 min, followed diately before bolus; and 1 min, 2
stimulation by pentagastrin min, and 5 min postbolus
0.5 g/kg 4 calcitonin levels—baseline imme-
Pentagastrin Pentagastrin, 0.5 diately before bolus; and 1.5 min,
stimulation g/kg IV push 2 min, and 5 min postbolus
Copyright © 2003 F.A. Davis Company
SI Units
Conventional Units (Conversion Factor 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
Male Less than 350 pg/mL Less than 350 ng/L
Female Less than 94 pg/mL Less than 94 ng/L
Maximum Response
After Pentagastrin
Stimulation
Male Less than 110 pg/mL Less than 110 ng/L
Female Less than 30 pg/mL Less than 30 ng/L
CALCIUM, IONIZED
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SYNONYM/ACRONYM: N/A.
SPECIMEN: Whole blood (1 mL) collected anaerobically in a heparinized
syringe. Serum (1 mL) collected in a red-top tube or plasma (1 mL)
collected in a green-top (heparin) tube is also acceptable. Specimen should
be transported tightly capped and in an ice slurry.
SI Units
Conventional Units (Conversion Factor 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
INDICATIONS: • Pseudohypoparathyroidism
• Detect ectopic parathyroid • Sepsis
hormone–producing neoplasms • Trauma
• Evaluate the effect of protein on • Vitamin D deficiency
calcium levels
• Identify individuals with hypocalcemia CRITICAL VALUES:
Less than 3.2 mg/dL
• Identify individuals with toxic levels of
vitamin D Greater than 6.4 mg/dL
Observe the patient for symptoms of
• Investigate suspected hyperparathy- critically decreased or elevated calcium
roidism levels. Hypocalcemia is evidenced by
• Monitor patients with renal failure convulsions, arrhythmias, changes in
or organ transplantation, in whom electrocardiogram (ECG) in the form of
secondary hyperparathyroidism may prolonged ST segment and Q-T interval,
be a complication facial spasms (positive Chvostek’s sign),
tetany, muscle cramps, numbness in
• Monitor patients with sepsis or magne- extremities, tingling, and muscle twitch-
sium deficiency ing (positive Trousseau’s sign). Possible
interventions include seizure precautions,
RESULT increased frequency of ECG monitoring,
and administration of calcium or magne-
Increased in: sium.
Severe hypercalcemia is manifested by
• Parathyroid hormone–producing neo-
polyuria, constipation, changes in ECG
plasms
(shortened ST segment), lethargy, muscle
• Hyperparathyroidism weakness, apathy, anorexia, headache,
and nausea, and ultimately may result in
• Vitamin D toxicity
coma. Possible interventions include the
administration of normal saline and
Decreased in:
diuretics to speed up excretion or admin-
• Burns istration of calcitonin or steroids to force
the circulating calcium into the cells.
• Hypoparathyroidism (primary)
• Magnesium deficiency INTERFERING FACTORS:
• Multiple organ failure • Drugs that may increase calcium levels
• Pancreatitis include antacids (some), calcitriol, and
lithium.
• The postdialysis period, as a result
of low-calcium dialysate administra- • Drugs that may decrease calcium levels
tion include calcitonin, citrates, foscarnet,
and pamidronate (initially).
• The post-transfusion period, as a result
of the use of citrated preservative • Calcium exhibits diurnal variation;
(calcium chelator) serial samples should be collected at
the same time of day for comparison.
• The postsurgical period (i.e., major
surgeries) • Venous hemostasis caused by
prolonged use of a tourniquet during
• Premature infants with hypoproteine- venipuncture can falsely elevate
mia and acidosis calcium levels.
Copyright © 2003 F.A. Davis Company
CALCIUM, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 0.25)
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
decreasing the result. There is also the ➤ Observe standard precautions and
potential of contaminating the sample follow the general guidelines in
with the substance in question, Appendix A. Perform a venipuncture,
contained in the IV solution, falsely and collect the specimen in a 5-mL
red- or tiger-top tube.
increasing the result.
➤ Label the specimen, and promptly
transport it to the laboratory.
Nursing Implications and Post-test:
Procedure ● ● ● ● ● ● ● ● ● ● ●
CALCIUM, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (5 mL) from an unpreserved random or timed specimen
collected in a clean plastic collection container.
SI Units
Age Conventional Units* (Conversion Factor 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.
nonfamilial)
Pretest:
• Hypoparathyroidism
➤ Obtain a history of the patient’s
• Hypothyroidism complaints, including a list of known
allergens.
• Malabsorption (celiac disease, tropical
sprue) ➤ Obtain a history of the patient’s
endocrine, genitourinary, and
• Malignant bone neoplasm musculoskeletal systems, as well as
results of previously performed
• Nephrosis and acute nephritis tests and procedures. For related
• Osteoblastic metastases tests, refer to the endocrine, geni-
tourinary, and musculoskeletal
• Osteomalacia system tables.
• Preeclampsia ➤ Obtain a list of the medications
the patient is taking, including
• Pseudohypoparathyroidism herbs, nutritional supplements, and
nutraceuticals. The requesting health
• Renal osteodystrophy care practitioner and laboratory
• Rickets should be advised if the patient
regularly uses these products so
• Vitamin D deficiency that their effects can be taken into
consideration when reviewing
results.
CRITICAL VALUES: N/A
➤ There are no fluid or medication
restrictions unless by medical direc-
INTERFERING FACTORS: tion.
• Drugs that can increase urine calcium ➤ Instruct the patient to follow a
levels include acetazolamide, ammo- normal calcium diet for at least 4
nium chloride, asparaginase, calci- days before test.
Copyright © 2003 F.A. Davis Company
➤ Review the procedure with the kept on ice throughout the collection
patient. Provide a nonmetallic urinal, period. If an indwelling urinary
bedpan, or toilet-mounted collection catheter is in place, the drainage bag
device. must be kept on ice.
➤ Usually a 24-hour time frame for ➤ Begin the test between 6 and 8
urine collection is ordered. Inform a.m., if possible. Collect first voiding
the patient that all urine must be and discard. Record the time the
saved during that 24-hour period. specimen was discarded as the
Instruct the patient not to void beginning of the timed collection
directly into the laboratory collection period. The next morning, ask the
container. Instruct the patient to patient to void at the same time the
avoid defecating in the collection collection was started, and add this
device and to keep toilet tissue out last voiding to the container.
of the collection device to prevent ➤ If an indwelling catheter is in place,
contamination of the specimen. replace the tubing and container
Place a sign in the bathroom to system at the start of the collection
remind the patient to save all urine. time. Keep the container system on
➤ Instruct the patient to void all urine ice during the collection period or
into the collection device and then to empty the urine into a larger
pour the urine into the laboratory container periodically during the
collection container. Alternatively collection period; monitor to ensure
the specimen can be left in the continued drainage, and conclude
collection device for a health care the test the next morning at the
staff member to add to the labora- same hour the collection began.
tory collection container. ➤ At the conclusion of the test,
compare the quantity of urine with
Intratest: the urinary output record for the
collection; if the specimen contains
➤ Ensure that the patient has complied less than the recorded output, some
with dietary preparations and other urine may have been discarded,
pretesting restrictions. invalidating the test.
➤ Observe standard precautions and ➤ Label the specimen, and promptly
follow the general guidelines in transport it to the laboratory. Include
Appendix A. on the label the amount of urine
Random specimen (collect in collected and test start and stop
times.
early morning):
➤ Obtain urine specimen in a properly Post-test:
labeled plastic collection container
and immediately transport urine. If ➤ Increased urine calcium levels may
an indwelling catheter is in place, it be associated with kidney stones.
may be necessary to clamp off the Educate the patient, if appropriate,
catheter for 15 to 30 minutes before as to the importance of drinking a
specimen collection. Cleanse speci- sufficient amount of water when
men port with antiseptic swab, and kidney stones are suspected.
then aspirate 5 mL of urine with a ➤ Evaluate test results in relation to
21- to 25-gauge needle and syringe. the patient’s symptoms and other
Transfer urine to a plastic container. tests performed. Related laboratory
tests include calcium, kidney stone
Timed specimen: analysis, magnesium, urine magne-
➤ Obtain a clean 3-L urine specimen sium, parathyroid hormone, urine
container, toilet-mounted collection oxalate, phosphorus, urine phospho-
device, and plastic bag (for transport rus, potassium, urine potassium,
of the specimen container). The uric acid, urine uric acid, urinalysis,
specimen must be refrigerated or and vitamin D.
Copyright © 2003 F.A. Davis Company
a device to strain the urine. The times more likely to develop stones
patient should be informed to trans- than females), and climate.
fer any particulate matter remaining ➤ Nutritional therapy is indicated for
in the strainer into the specimen individuals identified as being at high
collection container provided. risk for developing kidney stones.
Stones removed by the health care Educate the patient that diets rich in
practitioner should be placed in the protein, salt, and oxalates increase
appropriate collection container. the risk of stone formation.
➤ Label the specimen, and promptly Adequate fluid intake should be
transport it to the laboratory. encouraged.
➤ Follow-up testing of urine may be
Post-test: requested but usually not for 1
➤ Inform the patient with kidney month after the stones have passed
stones that the likelihood of recur- or been removed.
rence is high. Educate the patient ➤ Evaluate test results in relation to
regarding risk factors that contribute the patient’s symptoms and other
to the likelihood of kidney stone tests performed. Related laboratory
formation, including family history, tests include urine calcium, urine
osteoporosis, urinary tract infec- culture, creatinine clearance, urine
tions, gout, magnesium deficiency, magnesium, urine oxalate, urine
Crohn’s disease with prior resection, phosphorus, urine uric acid, and
age, gender (males are two to three urinalysis.
CARBON DIOXIDE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Conventional SI Units
Carbon Dioxide Units (Conversion Factor 1)
• Metabolic acidosis
Nursing Implications and
• Respiratory alkalosis Procedure ● ● ● ● ● ● ● ● ● ● ●
• Salicylate intoxication
• Starvation Pretest:
➤ Obtain a history of the patient’s
CRITICAL VALUES: complaints, including a list of known
Less than 15 mmol/L allergens.
Greater than 50 mmol/L ➤ Obtain a history of the patient’s
Observe the patient for signs and genitourinary and respiratory
symptoms of excessive or insufficient systems, as well as results of previ-
CO2 levels, and report these findings to a ously performed tests and proce-
health care practitioner. If the patient has dures. For related tests, refer to the
been vomiting for several days and is genitourinary and respiratory system
breathing shallowly, or if the patient has tables.
had gastric suctioning and is breathing ➤ Obtain a list of the medications
shallowly, this may indicate elevated the patient is taking, including
CO2 levels. Decreased CO2 levels are herbs, nutritional supplements, and
evidenced by deep, vigorous breathing nutraceuticals. The requesting health
and flushed skin. care practitioner and laboratory
should be advised if the patient
regularly uses these products so
INTERFERING FACTORS: that their effects can be taken into
• Drugs that may cause an increase in consideration when reviewing
tCO2 levels include acetylsalicylic acid, results.
aldosterone, bicarbonate, carbenicillin, ➤ There are no food, fluid, or medica-
carbenoxolone, corticosteroids, dexa- tion restrictions unless by medical
methasone, ethacrinic acid, laxatives direction.
(chronic abuse), and x-ray contrast ➤ Review the procedure with the
agents. patient.
• Drugs that may cause a decrease ➤ Inform the patient that specimen
in tCO2 levels include acetazola- collection takes approximately 5 to
mide, acetylsalicylic acid (initially), 10 minutes.
amiloride, ammonium chloride, fluo-
rides, metformin, methicillin, nitrofu-
Intratest:
rantoin, NSD 3004 (long-acting
carbonic anhydrase inhibitor), paralde- ➤ Direct the patient to breathe
hyde, tetracycline, triamterene, and normally and to avoid unnecessary
xylitol. movement.
• Prompt and proper specimen process- ➤ Instruct the patient to not clench and
ing, storage, and analysis are important unclench the fist during specimen
to achieve accurate results. The speci- collection.
men should be stored under anaerobic ➤ Observe standard precautions and
conditions after collection to prevent follow the general guidelines in
the diffusion of CO2 gas from the spec- Appendix A. Perform a venipuncture,
imen. Falsely decreased values result and collect the specimen in a 5-mL
from uncovered specimens. It is esti- red-, tiger-, or green-top tube.
mated that CO2 diffuses from the ➤ Label the specimen, and promptly
sample at the rate of 6 mmol/h. transport it to the laboratory.
Copyright © 2003 F.A. Davis Company
CARBOXYHEMOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Carboxyhemoglobin 271
CARCINOEMBRYONIC ANTIGEN
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SYNONYM/ACRONYM: CEA.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Plasma (1 mL)
collected in lavender-top (ethylenediaminetetra-acetic acid [EDTA]) tube is
also acceptable. Care must be taken to use the same type of collection
container if serial measurements are to be taken.
SI Units
Smoking Status Conventional Units (Conversion Factor 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
Pretest: Post-test:
➤ Obtain a history of the patient’s ➤ Observe venipuncture site for bleed-
complaints, including a list of known ing or hematoma formation. Apply
allergens. pressure bandage.
➤ Obtain a history of the patient’s ➤ Inform the patient that the test may
gastrointestinal, immune, and repro- be repeated monthly to monitor
ductive systems, as well as results response to therapy.
of previously performed tests and ➤ Recognize anxiety related to test
procedures. For related tests, refer results and offer support. Provide
to the gastrointestinal, immune, and teaching and information regarding
reproductive system tables. the clinical implications of the test
➤ Obtain a list of medications the results, as appropriate. Educate the
patient is taking, including herbs, patient regarding access to counsel-
nutritional supplements, and ing services.
nutraceuticals. The requesting health ➤ Instruct the patient in the impor-
care practitioner and laboratory tance of continuing scheduled ther-
should be advised if the patient apy or follow-up visits.
regularly uses these products so ➤ Evaluate test results in relation to
that their effects can be taken into the patient’s symptoms and other
consideration when reviewing tests performed. Related laboratory
results. tests include biopsy of suspicious
➤ Determine if the patient smokes, tissue, CA 15-3, and CA 19-9.
Copyright © 2003 F.A. Davis Company
CATECHOLAMINES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Catecholamines 275
CATECHOLAMINES, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
vanilla, walnuts, Chianti wine) can ➤ Review the procedure with the
produce elevated catecholamine levels. patient. Provide a nonmetallic urinal,
bedpan, or toilet-mounted collection
• Failure to collect all urine and store 24- device.
hour specimen properly will yield a ➤ Usually a 24-hour time frame for
falsely low result. urine collection is ordered. Inform
the patient that all urine over a 24-
hour period must be saved; if a
Nursing Implications and preservative has been added to the
container, instruct the patient not to
Procedure ● ● ● ● ● ● ● ● ● ● ●
discard the preservative. Instruct
the patient not to void directly into
Pretest: the laboratory collection container.
➤ Obtain a history of the patient’s Instruct the patient to avoid defecat-
complaints, including a list of known ing in the collection device and to
allergens. keep toilet tissue out of the collec-
tion device to prevent contamination
➤ Obtain a history of the patient’s of the specimen. Place a sign in the
endocrine system and results of bathroom as a reminder to save all
previously performed tests and urine.
procedures. For related tests, refer
to the endocrine system table. ➤ Instruct the patient to void all urine
into the collection device, then pour
➤ Obtain a list of medications the the urine into the laboratory collec-
patient is taking, including herbs, tion container. Alternatively the
nutritional supplements, and specimen can be left in the collec-
nutraceuticals. The requesting health tion device for a health care staff
care practitioner and laboratory member to add to the laboratory
should be advised if the patient collection container.
regularly uses these products so
that their effects can be taken into
Intratest:
consideration when reviewing
results. ➤ Ensure that the patient has complied
➤ There are no fluid restrictions unless with dietary preparations and other
by medical direction. pretesting restrictions.
Instruct the patient to: ➤ Instruct the patient to continue to
avoid excessive exercise and stress
➤ Follow a normal-sodium diet for 3
during the 24-hour collection of
days before testing.
urine.
➤ Abstain from smoking tobacco for
➤ Observe standard precautions and
24 hours before testing.
follow the general guidelines in
➤ Avoid consumption of foods high in Appendix A.
amines for 48 hours before testing.
➤ Avoid self-prescribed medications Timed specimen:
for 2 weeks before testing (espe- ➤ Obtain a clean 3-L urine specimen
cially appetite suppressants and cold container, toilet-mounted collection
and allergy medications, such as device, and plastic bag (for transport
nose drops, cough suppressants, of the specimen container). The
and bronchodilators). specimen must be refrigerated or
➤ Withhold health care practitioner– kept on ice throughout the collection
prescribed medication as directed period. If an indwelling urinary
(especially methyldopa, epinephrine, catheter is in place, the drainage bag
levodopa, and methenamine mande- must be kept on ice.
late). ➤ Begin the test between 6 and 8
➤ Fast from food and fluids for 10 to 12 a.m., if possible. Collect first voiding
hours before the test. and discard. Record the time the
Copyright © 2003 F.A. Davis Company
CD4/CD8 ENUMERATION
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
RBC red blood cell; VDRL Venereal Disease Research Laboratory; WBC white
blood cell.
• Assist in the diagnosis and differentia- • India ink preparation: meningitis due
tion of viral or bacterial meningitis or to C. neoformans
encephalitis
• Culture: encephalitis or meningitis due
• Assist in the diagnosis of diseases such to herpes simplex virus, S. pneumoniae,
as multiple sclerosis, autoimmune H. influenzae, N. meningitidis, C.
disorders, or degenerative brain disease neoformans
• Assist in the diagnosis of neurosyphilis • RBC count: hemorrhage
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
the CNS indicative of bacterial meningitis
• Monitor severe brain injuries Elevated WBC count with a
predominance of lymphocytes
indicative of viral, tubercular,
RESULT parasitic, or fungal meningitis;
Increases in: multiple sclerosis
Elevated WBC count with a
• Color and appearance: bloody— predominance of monocytes
hemorrhage; xanthochromic—old indicative of chronic bacterial
hemorrhage, red blood cell (RBC) meningitis, amebic meningitis,
breakdown, methemoglobin, bilirubin multiple sclerosis, toxoplasmosis
(greater than 6 mg/dL), increased Increased plasma cells indicative of
protein (greater than 150 mg/dL), acute viral infections, multiple
melanin (meningeal melanosarcoma), sclerosis, sarcoidosis, syphilitic
carotene (systemic carotenemia); meningoencephalitis, subacute
hazy—meningitis; pink to dark sclerosing panencephalitis,
yellow—aspiration of epidural fat; tubercular meningitis, parasitic
turbid—cells, microorganisms, pro- infections, Guillain-Barré
tein, fat, or contrast medium syndrome
Presence of eosinophils indicative
• Protein: meningitis, encephalitis of parasitic and fungal infections,
• Lactic acid: bacterial, tubercular, acute polyneuritis, idiopathic
fungal meningitis hypereosinophilic syndrome,
reaction to drugs or a shunt in
• Myelin basic protein: trauma, stroke, CSF
tumor, multiple sclerosis, subacute
sclerosing panencephalitis • VDRL: syphilis
• IgG and oligoclonal banding: multiple Positive findings in:
sclerosis, CNS syphilis, and subacute
sclerosing panencephalitis • Cytology: malignant cells
• Gram stain: meningitis due to Decreases in:
Streptococcus pneumoniae, Haemophilus
influenzae, Neisseria meningitidis, • Glucose: bacterial and tubercular
Cryptococcus neoformans meningitis
Copyright © 2003 F.A. Davis Company
tion the patient in the knee-chest vein for about 10 seconds. CSF pres-
position at the side of the bed. sure usually rises rapidly in response
Provide pillows to support the spine to the occlusion, and then returns to
or for the patient to grasp. The sitting the pretest level within 10 seconds
position is an alternative. In this posi- after the pressure is released.
tion, the patient must bend the neck Sluggish response may indicate CSF
and chest to the knees. obstruction.
➤ Observe standard precautions and ➤ Obtain four vials of spinal fluid in
follow the general guidelines in separate tubes (1 to 3 mL in each),
Appendix A. and label them numerically in the
➤ Prepare the site—usually between order they were filled.
L3 and L4, or between L4 and L5— ➤ A final pressure reading is taken, and
with povidone-iodine and drape the the needle is removed. Clean the
area. puncture site with an antiseptic solu-
➤ A local anesthetic is injected. Using tion and apply a small bandage.
sterile technique, the health care ➤ Label the specimen, and promptly
practitioner inserts the spinal needle transport it to the laboratory.
through the spinous processes of
the vertebrae and into the subarach-
noid space. The stylet is removed. If Post-test:
the needle is properly placed, CSF ➤ If permitted, administer fluids to
drips from the needle. replace lost CSF and help prevent or
➤ Attach the stopcock and manometer, relieve headache—a side effect of
and measure initial pressure. Normal lumbar puncture.
pressure for an adult in the lateral ➤ Position the patient flat, either on
recumbent position is 90 to 180 mm the back or abdomen; some health
H2O; normal pressure for a child care practitioners allow 30° eleva-
aged 8 years or younger is 10 to tion. Maintain position for 8 hours.
100 mm H2O. These values depend Changing position is acceptable as
on the body position and are long as the body remains horizontal.
different in a horizontal or sitting
position. ➤ Check the puncture site for leakage;
frequently monitor vital signs such
➤ CSF pressure may be elevated if the as temperature and blood pressure.
patient is anxious, holding his or her
breath, or tensing muscles. It may ➤ Observe the patient for neurological
also be elevated if the patient’s changes, such as altered level of
knees are flexed too firmly against consciousness, change in pupils,
the abdomen. CSF pressure may be reports of tingling or numbness, and
significantly elevated in patients irritability.
with intracranial tumors. If the initial ➤ Evaluate test results in relation to
pressure is elevated, the health the patient’s symptoms and other
care practitioner may perform tests performed. Related laboratory
Queckenstedt’s test. To perform this tests include complete blood count
test, apply pressure to the jugular and syphilis serology.
Copyright © 2003 F.A. Davis Company
Ceruloplasmin 287
CERULOPLASMIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 10)
Newborn–3 mo 5–18 mg/dL 50–180 mg/L
6–2 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
CHEST X-RAY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that no pain is ➤ Instruct the patient to inhale deeply,
associated with the study. to hold his or her breath while the x-
ray is taken, and then exhale after
Intratest: the film is taken.
➤ Instruct the patient to remove cloth- Post-test:
ing and metallic objects from the
waist up. ➤ Inform the patient of the possible
➤ Give the patient a gown and robe to need for additional chest x-rays to
wear. evaluate progression of the disease
process or to determine the need for
➤ Remove any wires connected to a change in therapy.
electrodes, if allowed.
➤ Determine if the patient or family
➤ Place patient in a standing, sitting, or members have any further ques-
recumbent position in front of the x- tions or concerns.
ray film holder.
➤ A physician sends a written report to
➤ For portable examinations, elevate the ordering health care provider,
the head of the bed to the high who discusses the results with the
Fowler’s position. patient.
➤ Have the patient place hands on ➤ Evaluate test results in relation to
hips, extend neck, and position the patient’s symptoms and other
shoulders forward. tests performed. Related diagnostic
➤ Position the chest with the left side tests include computed tomography
against the film holder for a lateral and magnetic resonance imaging of
view. the chest as well as a lung scan.
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Indirect fluorescent antibody, polymerase
chain reaction) Negative or less than fourfold increase in titer.
CHLORIDE, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cl.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
SI Units
Age Conventional Units (Conversion Factor 1)
Premature 95–110 mEq/L 95–110 mmol/L
0–30 d 98–113 mEq/L 98–113 mmol/L
2 mo–adult 97–107 mEq/L 97–107mmol/L
Copyright © 2003 F.A. Davis Company
above an intravenous (IV) line because movement. Instruct the patient not
of the potential for dilution when the to clench and unclench fist immedi-
specimen and the IV solution combine ately before or during specimen
in the collection container, falsely collection.
decreasing the result. There is also the ➤ Observe standard precautions and
potential of contaminating the sample follow the general guidelines in
with the substance of interest, Appendix A. Perform a venipuncture,
and collect the specimen in a 5-mL
contained in the IV solution, falsely red- or tiger-top tube.
increasing the result.
➤ Label the specimen, and promptly
transport it to the laboratory.
ride levels to avoid eating or drinking acid, which is essential for iron
anything containing sodium chloride absorption. In prolonged periods
salt. The patient or caregiver should of chloride deficit, iron-deficiency
also be encouraged to read food anemia could develop.
labels to determine which products ➤ Evaluate test results in relation to
are suitable for a low-sodium diet. the patient’s symptoms and other
➤ Instruct patients with low chloride tests performed. Related laboratory
levels that a decrease in iron absorp- tests include anion gap, carbon diox-
tion may occur as a result of less ide, potassium, sodium, and osmo-
chloride available to form gastric lality.
CHLORIDE, SWEAT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Conventional Units (Conversion Factor 1)
Normal 5–40 mEq/L 5–40 mmol/L
Intermediate 40–60 mEq/L 40–60 mmol/L
CHOLANGIOGRAPHY,
PERCUTANEOUS TRANSHEPATIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest:
➤ Administer sedatives, as ordered,
➤ Inform the patient about the before the test.
purpose of the procedure as well as
➤ Review the patient’s coagulation
the need to remain still and hold his
studies to determine if they are
or her breath for short periods of
within the normal range.
time.
➤ Administer a laxative, as ordered.
➤ Obtain a history of known or
suspected hypersensitivity to radio- ➤ Make sure clothing and metallic
graphic contrast medium, iodine, objects are removed from the
iodine-containing food, or shellfish. abdominal area.
➤ Obtain a history of the patient’s ➤ Give patient a gown and robe to
complaints. wear; ask patient to void before the
test begins.
➤ Obtain a history of the patient’s
biliary and abdominal systems and ➤ Remove any wires connected to
the results of previously performed electrodes, if allowed.
tests, treatments, surgeries, thera- ➤ Place patient on the fluoroscopy
pies, and procedures, especially table in a supine position.
blood urea nitrogen, creatinine, and
coagulation studies. For related ➤ A kidney, ureter, and bladder (KUB)
tests, refer to the gastrointestinal or plain film is taken to ensure that
and hepatobiliary system tables. no barium or stool will obscure visu-
alization of the biliary system.
➤ Assess date of last menstrual period
to ascertain possible pregnancy in ➤ An area over the abdominal wall is
perimenopausal women. anesthetized, and the needle is
inserted and advanced under fluoro-
➤ Type and screen the patient’s blood scopic guidance. Contrast medium
for possible transfusion. is injected when placement is
➤ Patients receiving metformin confirmed by the free flow of bile.
(Glucophage) for non–insulin- ➤ A specimen of bile may be sent to
dependent (type 2) diabetes should the laboratory for culture and cyto-
discontinue the drug on the day of logic analysis.
the test and continue to withhold it
for 48 hours after the test. Failure to ➤ X-ray exposures are made, and the
do so may result in lactic acidosis. results are processed as soon as
possible. Additional views may be
➤ Obtain a written, informed consent necessary to visualize the area in
for the procedure from the patient. question.
➤ The procedure lasts 60 minutes. ➤ At the end of the procedure, the
➤ Withhold food and fluids for 8 hours contrast medium is aspirated from
before the test. the biliary ducts, relieving pressure
➤ Inform the patient that there may be on the dilated ducts.
some abdominal discomfort from ➤ If an obstruction is found during the
the needle insertion; however, the procedure, a catheter is inserted into
area will have received prior anes- the bile duct to allow drainage of
thesia. bile.
Copyright © 2003 F.A. Davis Company
➤ Maintain pressure over the needle ➤ Advise the patient to watch for
insertion site for several hours if symptoms of infection, such as pain,
bleeding is persistent. fever, increased pulse rate, and
➤ Establish a closed and sterile muscle aches.
drainage system if a catheter is left ➤ Determine if the patient or family
in place. members have any further ques-
tions or concerns.
Post-test: ➤ A physician specializing in this
branch of medicine sends a written
➤ Monitor vital and neurological signs report to the ordering provider, who
until they return to preprocedure discusses the results with the
levels. patient.
➤ Instruct the patient to resume usual ➤ Inform the patient of the possible
diet and medications, as directed by need for further examinations to
the physician. Renal function should evaluate and determine the need for
be assessed before metformin is a change in therapy.
restarted.
➤ Evaluate test results in relation to
➤ Evaluate the patient for signs of the patient’s symptoms and other
hypersensitivity or reaction to tests performed. Related diagnostic
contrast medium, such as urticaria, tests include hepatobiliary scan,
headache, nausea, or vomiting. hepatobiliary ultrasound, computed
➤ Observe the puncture site for signs tomography and magnetic reso-
of bleeding, hematoma formation, nance imaging of the abdomen, and
ecchymosis, or leakage of bile. The KUB film.
physician should be informed if any
of these is present.
CHOLANGIOGRAPHY,
POSTOPERATIVE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Peritonitis may occur as a result of bile ➤ Restrict food and fluids 8 to 12 hours
extravasation. before the procedure.
➤ Note recent administration of
• Failure to follow dietary restrictions
barium because residual barium can
before the procedure may cause the obscure the organ to be examined.
procedure to be canceled or repeated.
➤ Ensure that a cleansing enema is
• Consultation with a physician should administered on the morning of
occur before the procedure for radia- the procedure, if ordered, and note
tion safety concerns regarding infants results.
of patients who are lactating.
Intratest:
• Risks associated with radiographic
overexposure can result from frequent ➤ Have the patient remove clothing
x-ray procedures. Personnel in the and metallic objects. Provide a gown
room with the patient should wear a with a tie closure.
protective lead apron, stand behind a ➤ Clamp the T-tube 24 hours before
shield, or leave the area while the and during the procedure, if ordered,
to help prevent air bubbles from
examination is being done. Badges that
entering the ducts.
reveal the level of exposure to radiation
should be worn by persons working in ➤ Have the patient void before the
procedure begins.
the area where the examination is being
done. ➤ An x-ray of the abdomen is obtained
to determine if any residual contrast
medium is present from previous
studies.
Nursing Implications and
➤ The patient is placed on an examina-
Procedure ● ● ● ● ● ● ● ● ● ● ●
tion table in the supine position.
➤ The area around the T-tube is draped;
Pretest:
the end of the T-tube is cleansed
➤ Explain to the patient the purpose of with 70% alcohol. If the T-tube site is
the study and how the procedure is inflamed and painful, a local anes-
performed. thetic (e.g., lidocaine) may be
injected around the site. A needle is
➤ Determine if the patient has aller-
inserted into the open end of the
gies or sensitivities to latex, anes-
T-tube, and the clamp is removed.
thetics, analgesics, antibiotics, or
iodine. ➤ Contrast medium is injected, and
fluoroscopy is performed to visualize
➤ Obtain a written, informed consent
contrast medium moving through
for the procedure from the patient.
the duct system.
➤ Obtain a history of suspected or ➤ The patient may feel a bloating
existing disease of the liver, gallblad- sensation in the upper right quadrant
der, and duct system. For related as the contrast medium is injected.
tests, refer to the hepatobiliary The tube is clamped, and films are
system table. taken of the right upper quadrant in
➤ Assess date of last menstrual period multiple positions. A delayed film
to ascertain possible pregnancy in may be taken 15 minutes later to
perimenopausal women. visualize passage of the contrast
➤ Explain that the procedure usually medium into the duodenum.
takes 30 to 60 minutes to complete ➤ For procedures done after surgery,
and generally is performed in the op- the T-tube is removed if findings are
erating room or the radiology suite normal; a dry, sterile dressing is
by a physician and support staff. applied to the site.
➤ Inform the patient that a flushed ➤ If retained calculi are identified, the
feeling may be experienced when T-tube is left in place for 4 to 6 weeks
the contrast medium is injected. until the tract surrounding the T-tube
Copyright © 2003 F.A. Davis Company
CHOLANGIOPANCREATOGRAPHY,
ENDOSCOPIC RETROGRADE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: ERCP.
AREA OF APPLICATION: Gallbladder, bile ducts, pancreatic ducts.
CONTRAST: Iodinated contrast medium.
be obtained from the bile and pancre- or duodenum, which can make locat-
atic ducts. ERCP is used in the ing the duodenal papilla difficult
diagnosis and follow-up of pancreatic • Barium remaining in the stomach or
disease. ■ bowel
➤ Restrict food and fluids 8 to 12 hours sphincter of Oddi at the papilla area
before the procedure. via the catheter as it is placed in the
➤ Note recent administration of area before the contrast medium is
barium because residual barium can injected.
obscure the organ to examined. ➤ When the catheter is in place,
contrast medium is injected into the
pancreatic and biliary ducts via the
Intratest: catheter, and fluoroscopic films are
➤ Have the patient put on a hospital taken. Biopsy specimens for cyto-
gown and void. logical analysis can be obtained
during the procedure.
➤ Administer ordered sedation.
➤ Place specimens in appropriate
➤ Insert an intravenous line for admin- containers, label them properly, and
istration of drugs, as needed. promptly transport them to the labo-
➤ An x-ray of the abdomen is obtained ratory.
to determine if any residual contrast
medium is present from previous
studies. Post-test:
➤ The oropharynx is sprayed or ➤ Tell the patient to expect some
swabbed with a topical local anes- throat soreness and possible
thetic. hoarseness. Advise the patient to
➤ The patient is placed on an exami- use warm gargles, lozenges, ice
nation table in the left lateral posi- packs to the neck, or cool fluids to
tion with the left arm behind the alleviate throat discomfort.
back and right hand at the side ➤ Monitor the patient for signs of
with the neck slightly flexed. A respiratory depression. Resus-
protective guard is inserted into citation equipment should be avail-
the mouth to cover the teeth. A able.
bite block can also be inserted to ➤ Observe the patient until the effects
maintain adequate opening of the of the sedation have worn off.
mouth.
➤ Inform the patient that any belching,
➤ The endoscope is passed through bloating, or flatulence is the result of
the mouth with a dental suction air insufflation.
device in place to drain secretions. A
side-viewing flexible, fiberoptic ➤ Emphasize that any severe pain,
endoscope is passed into the duode- fever, difficulty breathing, or expec-
num, and a small cannula is inserted toration of blood must be reported
into the duodenal papilla (ampulla of to the physician immediately.
Vater). ➤ Do not allow the patient to eat
➤ The patient is placed in the prone or drink until the gag reflex
position. The duodenal papilla is returns, after which the patient is
visualized and cannulated with a permitted to eat lightly for 12 to 24
catheter. Occasionally the patient hours.
can be turned slightly to the right ➤ Instruct the patient to resume
side to aid in visualization of the normal activity, medication, and diet
papilla. 24 hours after the examination, or as
➤ Intravenous glucagon or anticholiner- tolerated, unless otherwise indi-
gics can be administered to mini- cated.
mize duodenal spasm and to ➤ A physician specializing in this
facilitate visualization of the ampulla branch of medicine sends a written
of Vater. report to the ordering provider, who
➤ ERCP manometry can be done at discusses the results with the
this time to measure the pressure in patient.
the bile duct, pancreatic duct, and ➤ Inform the patient that an abnormal
Copyright © 2003 F.A. Davis Company
SI Units
HDLC Conventional Units (Conversion Factor 0.0259)
Birth 6–56 mg/dL 0.16–1.45 mmol/L
Children and 40–65 mg/dL 0.9–1.7 mmol/L
adults
SI Units
LDLC Conventional Units (Conversion Factor 0.0259)
Birth 20–56 mg/dL 0.52–1.45 mmol/L
5–19 y
Male 65–130 mg/dL 1.68–3.37 mmol/L
Female 65–140 mg/dL 1.68–3.63 mmol/L
20–29 y
Male 65–165 mg/dL 1.68–4.27 mmol/L
Female 55–160 mg/dL 1.42–4.14 mmol/L
30–44 y
Male 80–185 mg/dL 2.07–4.79 mmol/L
Female 70–175 mg/dL 1.81–4.53 mmol/L
Greater than 45 y
Male 90–185 mg/dL 2.33–4.79 mmol/L
Female 80–215 mg/dL 2.07–5.57 mmol/L
After age 10 years, values for African Americans are approximately 10 mg/dL higher
than in whites in the same age group.
Copyright © 2003 F.A. Davis Company
RESULT
LDLC Recommended Levels
Units SI Units
Risk Conventional (Conversion 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
• Exercise • A--lipoproteinemia
• Familial hyper--lipoproteinemia • Fish eye disease
• Alcoholism • Genetic predisposition or enzyme/
• Biliary cirrhosis cofactor deficiency
• Chronic hepatitis • Hypertriglyceridemia
Copyright © 2003 F.A. Davis Company
CHOLESTEROL, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
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 (Conversion Factor 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.
Intratest:
➤ Ensure that the patient has complied
Nursing Implications and with dietary preparations and other
Procedure ● ● ● ● ● ● ● ● ● ● ● pretesting restrictions.
➤ Direct the patient to breathe
Pretest: normally and to avoid unnecessary
➤ Obtain a history of the patient’s movement.
complaints, including a list of known ➤ Observe standard precautions and
allergens. follow the general guidelines in
➤ Obtain a history of the patient’s Appendix A. Perform a venipuncture,
cardiovascular, gastrointestinal, and collect the specimen in a 5-mL
hematopoietic, and hepatobiliary red- or tiger-top tube.
systems, as well as results of previ- ➤ Label the specimen, and promptly
ously performed tests and proce- transport it to the laboratory.
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: N/A.
SPECIMEN: Whole blood (2 mL) collected in green-top (sodium heparin)
tube.
Autosomal
Syndrome Chromosome Defect Features
Beckwith- Duplication 11p15 Macroglossia,
Wiedemann omphalocele, ear lobe
creases
Cat’s eye Trisomy 2q11 Anal atresia, coloboma
Cri du chat Deletion 5p Catlike cry, microcephaly,
hypertelorism, mental
retardation, retrognathia
Down’s 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
retardation, congenital
heart disease
Pallister-Killian Trisomy 12p Psychomotor delay,
sparse anterior scalp
hair, micrognathia,
hypotonia
Autosomal
Syndrome Chromosome Defect Features
Patau’s Trisomy 13 Microcephaly, cleft palate
or lip, polydactyly,
mental retardation,
congenital heart
disease
Warkam Mosaic trisomy 8 Malformed ears, bulbous
nose, deep palm
creases, absent or
hypoplastic patellae
Wolf-Hirschhorn Deletion 4p Microcephaly, growth
retardation, mental
retardation, carp mouth
CLOT RETRACTION
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Whole blood collected in a full 5-mL red-top tube.
REFERENCE VALUE: (Method: Macroscopic observation of sample) A
normal clot, gently separated from the side of the test tube and incubated at
37C, 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.
tube. Platelets play a major role in the • Prompt and proper specimen process-
clot retraction process. When platelets ing, storage, and analysis are important
are decreased or function is impaired, to achieve accurate results. Specimens
scant serum and a soft, plump, poorly received in the laboratory more than
demarcated clot form in the tube. In 1 hour after collection should be
rejected.
addition to normal platelets, clot
retraction depends on the contractile
protein thrombosthenin, magnesium,
Nursing Implications and
adenosine triphosphate (ATP), and
Procedure ● ● ● ● ● ● ● ● ● ● ●
pyruvate kinase. Clot retraction is also
influenced by hematocrit and by Pretest:
fibrinogen structure and concentra-
➤ Obtain a history of the patient’s
tion. ■ complaints, including a list of known
allergens.
INDICATIONS: ➤ Obtain a history of the patient’s
• Evaluate the adequacy of platelet func- hematopoietic system and results of
tion previously performed tests and
procedures. For related tests, refer
• Evaluate thrombocytopenia of to the hematopoietic system table.
unknown origin ➤ Obtain a list of medications the
patient is taking, including herbs,
• Investigate the possibility of nutritional supplements, and
Glanzmann’s disease nutraceuticals. The requesting health
• Investigate suspected abnormalities of care practitioner and laboratory
fibrinogen or fibrinolytic activity should be advised if the patient
regularly uses these products so
that their effects can be taken into
RESULT consideration when reviewing
results.
Increased in: N/A ➤ Note any recent procedures that can
interfere with test results.
Decreased in: Glanzmann’s throm- ➤ There are no food, fluid, or medica-
basthenia tion restrictions unless by medical
direction.
CRITICAL VALUES: N/A ➤ Review the procedure with the
patient.
INTERFERING FACTORS: ➤ Inform the patient that specimen
collection takes approximately 5 to
• Drugs that may produce a decreased 10 minutes.
result include apronalide, carbenicillin,
and plicamycin. Intratest:
• Platelet count less than 100,000/L, ➤ Direct the patient to breathe
acetylsalicylic acid therapy, altered normally and to avoid unnecessary
fibrinogen/fibrin structure, hypofi- movement.
brinogenemia, polycythemia or hemo- ➤ Observe standard precautions and
concentration, and multiple myeloma follow the general guidelines in
are conditions in which abnormal clot Appendix A. Perform a venipuncture,
retraction may occur, limiting the abil- and collect the specimen in a 5-mL
ity to form a valid assessment of red-top tube.
platelet function. ➤ Label the specimen, and promptly
Copyright © 2003 F.A. Davis Company
transport it to the laboratory within 1 may include the use of a soft bristle
hour of collection. toothbrush, use of an electric razor,
avoidance of constipation, avoidance
Post-test: of acetylsalicylic acid and similar
products, and avoidance of intra-
➤ Observe venipuncture site for bleed- muscular injections.
ing or hematoma formation. Apply ➤ Evaluate test results in relation to
pressure bandage. the patient’s symptoms and other
➤ Inform the patient with abnormal tests performed. Related labora-
clot retraction of the importance of tory tests include bleeding time,
taking precautions against bruising factor XIII, fibrinogen, and platelet
and bleeding. These precautions count.
COAGULATION FACTORS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Drugs that may increase factor V, VII, platelet and coagulation factor activa-
and X levels include anabolic steroids, tion.
fluoxymesterone, methandrostenolone,
• Incompletely filled tubes contaminated
nandrolone, oral contraceptives, and
with heparin or clotted specimens
oxymetholone.
must be rejected.
• Drugs that may decrease factor V levels
• Icteric or lipemic specimens interfere
include streptokinase.
with optical testing methods, produc-
• Drugs that may decrease factor VII ing erroneous results.
levels include asparaginase, acetylsali- • Incompletely filled collection tubes,
cylic acid, cefamandole, ceftriaxone, specimens contaminated with heparin,
dextran, dicumarol, gemfibrozil, oral clotted specimens, or unprocessed
contraceptives, and warfarin. specimens not delivered to the labora-
• Drugs that may increase factor VIII tory within 1 hour of collection should
levels include chlormadinone. be rejected.
• Drugs that may decrease factor VIII
levels include asparaginase. Nursing Implications and
• Drugs that may increase factor IX Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Review the procedure with the top tube to avoid contaminating the
patient. specimen with tissue thromboplas-
➤ Inform the patient that specimen tin.
collection takes approximately 5 to ➤ Label the specimen, and promptly
10 minutes. transport it to the laboratory. The
NCCLS recommendation for pro-
Intratest: cessed and unprocessed samples
stored in unopened tubes is that
➤ Direct the patient to breathe testing should be completed within
normally and to avoid unnecessary 1 to 4 hours of collection.
movement.
➤ Observe standard precautions and Post-test:
follow the general guidelines in
Appendix A. Perform a venipuncture, ➤ Observe venipuncture site for bleed-
and collect the specimen in a 5-mL ing or hematoma formation. Apply
blue-top tube. Important note: Two pressure bandage.
different concentrations of sodium ➤ Instruct the patient to report imme-
citrate preservative are currently diately any signs of unusual bleeding
added to blue-top tubes for coagula- or bruising.
tion studies: 3.2% and 3.8%. The
National Committee for Clinical ➤ Inform the patient with decreased
Laboratory Standards (NCCLS) factor levels of the importance of
guideline for sodium citrate is 3.2%. taking precautions against bruising
Laboratories establish reference and bleeding. These precautions
ranges for coagulation testing based may include the use of a soft bristle
on numerous factors, including toothbrush, use of an electric razor,
sodium citrate concentration, test avoidance of constipation, avoidance
equipment, and test reagents. It is of acetylsalicylic acid and similar
important to inquire from the labora- products, and avoidance of intra-
tory which concentration it recom- muscular injections.
mends, because each concentration ➤ Evaluate test results in relation to
will have its own specific reference the patient’s symptoms and other
range. When multiple specimens are tests performed. Related laboratory
drawn, the blue-top tube should be tests include alanine aminotrans-
collected after sterile (i.e., blood ferase, alkaline phosphatase, aspar-
culture) and red-top tubes. When tate aminotransferase, clot retrac-
coagulation testing is the only work tion, copper, plasminogen, protein C,
to be done, an extra red-top tube prothrombin time, activated partial
should be collected before the blue- thromboplastin time, and vitamin K.
• Prompt and proper specimen process- patient. Inform the patient that
ing, storage, and analysis are important multiple specimens may be
to achieve accurate results. Specimens required.
should always be transported to the ➤ Inform the patient that specimen
laboratory as quickly as possible after collection takes approximately 5 to
collection. The specimen must clot in a 10 minutes.
37C water bath for 1 hour before
separation. Refrigeration of the sample Intratest:
before serum separates from the RBCs ➤ Direct the patient to breathe
may falsely decrease the titer. normally and to avoid unnecessary
movement.
➤ Observe standard precautions and
Nursing Implications and follow the general guidelines in
Procedure ● ● ● ● ● ● ● ● ● ● ● Appendix A. Perform a venipuncture,
and collect the specimen in a 5-mL
Pretest: red-top tube.
➤ Obtain a history of the patient’s ➤ Inform the laboratory if the patient is
complaints, including a list of known receiving antibiotics.
allergens. ➤ Label the specimen, and promptly
➤ Obtain a history of the patient’s transport it to the laboratory.
immune and respiratory systems,
as well as results of previously Post-test:
performed tests and procedures. For
related tests, refer to the immune ➤ Observe venipuncture site for bleed-
and respiratory system tables. ing or hematoma formation. Apply
➤ Obtain a list of medications the pressure bandage.
patient is taking, including herbs, ➤ Instruct the patient to resume usual
nutritional supplements, and nutra- medication as directed by the health
ceuticals. The requesting health care care practitioner.
practitioner and laboratory should be ➤ Emphasize the need for the patient
advised if the patient regularly uses to return in 7 to 14 days for a conva-
these products so that their effects lescent blood sample.
can be taken into consideration
when reviewing results. ➤ Evaluate test results in relation to
the patient’s symptoms and other
➤ There are no food, fluid, or medica- tests performed. Related laboratory
tion restrictions (except antibiotics) tests include arterial/alveolar oxygen
unless by medical direction. ratio, blood gases, and complete
➤ Review the procedure with the blood count.
COLLAGEN CROSSLINKED
N-TELOPEPTIDE
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SYNONYM/ACRONYM: NTx.
Copyright © 2003 F.A. Davis Company
• Hyperparathyroidism Intratest:
• Osteomalacia ➤ Observe standard precautions and
follow the general guidelines in
• Osteoporosis Appendix A.
• Paget’s disease ➤ Instruct the patient to collect a
second-void morning specimen as
Decreased in: follows: (1) void and then drink a
glass of water; (2) wait 30 minutes,
• Effective therapy for osteoporosis and then try to void again.
➤ Label the specimen, and promptly
CRITICAL VALUES: N/A transport it to the laboratory.
COLONOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Colonoscopy 331
• Evaluate stools that show a positive bowel necrosis, toxic colitis, recent
occult blood test, lower-GI bleeding, bowel surgery, advanced pregnancy,
or change in bowel habits severe cardiac or pulmonary disease,
recent myocardial infarction, known or
• Assess GI function in a patient with a
suspected pulmonary embolus, and
personal or family history of colon
large abdominal aortic or iliac
cancer, polyps, or ulcerative colitis
aneurysm
RESULT • Patients who have had a colon anasto-
mosis within the past 14 to 21 days,
Normal Findings: because an anastomosis may break
down with gas insufflation
• Normal intestinal mucosa with no
abnormalities of structure, function, or
mucosal surface in the colon or termi- Factors that may impair clear
imaging:
nal ileum
• Inability of the patient to cooperate or
Abnormal Findings: remain still during the procedure
because of age, significant pain, or
• Bleeding sites
mental status
• Benign lesions
• Patients who are very obese, who may
• Bowel distention exceed the weight limit for the equip-
ment
• Bowel infection or inflammation
• Incorrect positioning of the patient,
• Colon cancer
which may produce poor visualization
• Crohn’s disease of the area to be examined
• Colitis • Strictures or other abnormalities
preventing passage of the scope
• Diverticula
• Barium swallow or upper GI series
• Foreign bodies
within the preceding 48 hours, which
• Hemorrhoids can hinder adequate visualization
• Polyps • Severe lower GI bleeding or the pres-
ence of feces, barium, blood, or blood
• Proctitis
clots, which can interfere with visuali-
• Tumors zation
• Vascular abnormalities
Other considerations:
CRITICAL VALUES: N/A • Failure to follow dietary restric-
tions before the procedure may cause
INTERFERING FACTORS: the procedure to be canceled or
repeated.
This procedure is contraindicated
for: • Bowel preparations that include
laxatives or enemas should be avoi-
• Patients with bleeding disorders or
ded in pregnant patients or patients
cardiac conditions
with inflammatory bowel disease,
• Patients with bowel perforation, acute unless specifically directed by a physi-
peritonitis, acute colitis, ischemic cian.
Copyright © 2003 F.A. Davis Company
Colposcopy 333
➤ At the end of the procedure, excess ➤ Inform the patient that belching,
air and secretions are aspirated bloating, or flatulence is the result of
through the scope, and the colono- air insufflation.
scope is removed.
➤ Emphasize that any severe pain,
➤ Gloves and gowns are worn by the fever, difficulty breathing, or GI
examiner throughout the procedure. bleeding must be reported to the
➤ Monitor the patient for signs of physician immediately.
respiratory depression. Resus- ➤ Resume normal activity, medication,
citation equipment should be avail- and diet 2 hours after the procedure
able. or as tolerated, unless otherwise
indicated.
Post-test:
➤ Encourage the patient to drink
➤ Monitor for any rectal bleeding. several glasses of water to help
Instruct the patient to expect slight replace fluids lost during the prepa-
rectal bleeding for 2 days after ration for the test.
removal of polyps or biopsy speci-
mens, but that an increasing amount ➤ A physician specializing in this
of bleeding or sustained bleeding branch of medicine sends a written
should be reported to the physician report to the ordering provider, who
immediately. discusses the results with the
patient.
➤ Observe the patient until the effects
of the sedation have worn off. ➤ Inform the patient that an abnormal
examination may indicate the need
➤ Observe the patient for indications
for further studies.
of chest pain, abdominal pain or
tenderness, or breathing problems. ➤ Evaluate test results in relation to
If these symptoms are present or the patient’s symptoms and other
increase in frequency or severity, the tests performed. Related diagnostic
change should be reported to a tests include barium enema and
physician immediately. proctosigmoidoscopy.
COLPOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Normal Findings:
Nursing Implications and
• Normal appearance of the vagina and
cervix Procedure ● ● ● ● ● ● ● ● ● ● ●
Colposcopy 335
COMPLEMENT C3 AND
COMPLEMENT C4
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 10)
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
Age Conventional Units (Conversion Factor 10)
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
Copyright © 2003 F.A. Davis Company
RESULT
• C3 and C4 • C3 and C4
Acute-phase reactions Hereditary deficiency
• C3 Liver disease
Amyloidosis SLE
Cancer • C3
Diabetes Chronic infection (bacterial,
Myocardial infarction parasitic, viral)
Pneumococcal pneumonia Post–membranoproliferative
Pregnancy glomerulonephritis
Rheumatic disease Post–streptococcal infection
Thyroiditis Rheumatic arthritis
Viral hepatitis
• C4
• C4 Angioedema (hereditary and
Certain malignancies acquired)
Copyright © 2003 F.A. Davis Company
COMPLEMENT, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CBC.
SPECIMEN: Whole blood from one full lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube or Microtainer. Whole blood from a green-top
(lithium or sodium heparin) tube may be submitted, but the following auto-
mated values may not be reported: white blood cell (WBC) count, WBC
differential, platelet count, and mean platelet volume.
Copyright © 2003 F.A. Davis Company
Hemoglobin
SI Units
Age Conventional Units (Conversion Factor 10)
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
SI Units
Age Conventional Units (%) (Conversion Factor 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.
Copyright © 2003 F.A. Davis Company
342
SI Units
(Conversion
Factor 109
Age cells/L) Neutrophils Lymphocytes Monocytes Eosinophils Basophils
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%
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%
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%
Copyright © 2003 F.A. Davis Company
Within
Morphology Normal 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
(Continued on the following page)
Copyright © 2003 F.A. Davis Company
Within
Morphology Normal 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
Within
Inclusions Normal Limits 1 2 3 4
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
Conventional SI Units
Age Units (Conversion Factor 106) MPV (fl)
1–5 y 217–497 10 /L/ mm
3 3
217–497 10 /L 9
7.2–10.0
Adult 150–450 103/L/ mm3 181–521 109/L 7.0–10.2
from infants, children, and adults for ➤ Label the specimen, and promptly
whom venipuncture may not be transport it to the laboratory.
feasible. The specimen should be
analyzed within 6 hours when stored
at room temperature or within 24
hours if stored at refrigerated Post-test:
temperature. If it is anticipated the
specimen will not be analyzed within ➤ Observe venipuncture site for bleed-
4 to 6 hours, two blood smears ing or hematoma formation. Apply
should be made immediately after pressure bandage.
the venipuncture and submitted
with the blood sample. Smears ➤ Evaluate test results in relation to
made from specimens older than 6 the patient’s symptoms and other
hours will contain an unacceptable tests performed. Related labora-
number of misleading artifactual tory tests include erythropoietin,
abnormalities of the RBCs, such as ferritin, iron/total iron-binding capac-
echinocytes and spherocytes as well ity, peripheral blood smear, and retic-
as necrobiotic WBCs. ulocyte count.
COMPUTED TOMOGRAPHY,
ABDOMEN
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COMPUTED TOMOGRAPHY,
ANGIOGRAPHY
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COMPUTED TOMOGRAPHY,
BILIARY TRACT AND LIVER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Administer sedative to a child or to
an uncooperative adult, as ordered.
Pretest: ➤ Administer antianxiety agent, as
ordered, if the patient is experienc-
➤ Inform the patient that the proce-
ing claustrophobia.
dure assesses the brain.
➤ Administer an antihistamine or
➤ Inform the patient that the proce-
steroid, as ordered by a physician,
dure is done in a radiology depart-
for patients with a known significant
ment or imaging center by a
allergic reaction to the IV contrast
technologist and a physician and
medium.
takes approximately 15 to 30
minutes. ➤ Place the patient in a supine position
on a flat table with foam wedges,
➤ Obtain a history of allergies or sensi-
which help maintain position
tivities to contrast medium or shell-
and immobilization. Ask the patient
fish.
to lie still during the procedure
➤ Obtain a list of medications the because movement produces
patient is taking. unclear images. Make sure jewelry,
➤ Obtain a history of the patient’s watches, chains, belts, and any other
neurological system and results of metallic objects have been removed.
previously performed tests, proce- ➤ As the table moves into the scanner,
dures, treatments, and surgeries on instruct the patient to remain still.
the brain and cerebrovascular The scanner makes noises as it
system. For related tests, refer to rotates around the body. The patient
the musculoskeletal and cardiovas- may be asked to take deep breaths
cular system tables. to facilitate visualization. A number
➤ Determine previous laboratory of images are taken. A computer
abnormalities, especially blood urea reconstructs these images so they
nitrogen (BUN) and creatinine, if can be reviewed.
contrast medium is to be used. ➤ Administer contrast medium if
➤ Determine date of last menstrual ordered, and obtain a second series
period and the possibility of preg- of images.
nancy in perimenopausal women.
➤ Ensure that results of blood tests Post-test:
are obtained and recorded before ➤ Instruct the patient to increase fluid
the procedure. intake to help eliminate the contrast
➤ Patients receiving metformin medium, if used.
Copyright © 2003 F.A. Davis Company
COMPUTED TOMOGRAPHY,
CARDIAC SCORING
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• If the score is between 101 and 400, a • Patients who are very obese, who may
significant amount of calcified plaque exceed the weight limit for the equip-
was found in the coronary arteries. ment
There is an increased risk of a future • Incorrect positioning of the patient,
Copyright © 2003 F.A. Davis Company
Pretest:
Post-test:
➤ Inform the patient that the proce-
dure assesses the coronary arteries. ➤ A physician specializing in this
branch of medicine sends a written
➤ Inform the patient that the proce- report to the ordering provider, who
dure is performed in a CT scanner by discusses the results with the
a technologist and takes approxi- patient.
mately 5 minutes.
➤ Evaluate test results in relation to
➤ Obtain a list of medications the the patient’s symptoms and other
patient is taking. tests performed. Related diagnostic
➤ Obtain a history of the patient’s tests include chest x-ray, coronary
respiratory and cardiac systems, angiogram, echocardiogram, electro-
as well as results of previously cardiogram, CT scan and magnetic
performed tests and procedures. resonance imaging of the chest, and
For related tests, refer to the respi- lung scan.
Copyright © 2003 F.A. Davis Company
COMPUTED TOMOGRAPHY,
COLONOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
COMPUTED TOMOGRAPHY,
PANCREAS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Patients who are very obese, who may dure is performed in a radiology
exceed the weight limit for the equip- department by a technologist and a
ment physician and takes approximately
30 minutes.
• Incorrect positioning of the patient, ➤ Obtain a history of allergies or sensi-
which may produce poor visualization tivities to contrast medium or shell-
of the area to be examined fish.
➤ Obtain a list of medications the
• Gas or feces in the gastrointestinal tract patient is taking.
resulting from inadequate cleansing or
failure to restrict food intake before the ➤ Obtain a history of the patient’s
abdominal system and organs, as
study well as results of previously
• Retained barium from a previous radi- performed tests, trauma, treat-
ments, surgeries, therapies, and
ologic procedure
procedures. For related tests, refer
• Metallic objects within the examina- to the hepatobiliary, endocrine, and
tion field (e.g., jewelry or body rings), gastrointestinal system tables.
which may inhibit organ visualization ➤ Determine previous laboratory
and can produce unclear images abnormalities, especially blood urea
nitrogen (BUN) and creatinine, if
contrast medium is to be used.
Other considerations: ➤ Determine date of last menstrual
period and the possibility of preg-
• Failure to follow dietary restrictions nancy in perimenopausal women.
before the procedure may cause the
➤ Ensure that results of blood tests
procedure to be canceled or repeated.
are obtained and recorded before
• Consultation with a physician should the procedure.
occur before the procedure for radia- ➤ Patients receiving metformin
tion safety concerns regarding infants (Glucophage) for non–insulin-
of patients who are lactating. dependent (type 2) diabetes should
discontinue the drug on the day
• Risks associated with radiographic of the test and continue to with-
overexposure can result from frequent hold it for 48 hours after the test.
x-ray procedures. Personnel in the Failure to do so may result in lactic
acidosis.
room with the patient should wear a
protective lead apron, stand behind a ➤ Inform the patient that he or she
shield, or leave the area while the may experience nausea, a feeling of
warmth, a salty or metallic taste, or
examination is being done. Personnel
a transient headache after injection.
working in the area where the exami- Instruct the patient to take slow,
nation is being done should wear deep breaths if this occurs.
badges that reveal their level of expo-
➤ Ensure that barium studies have
sure to radiation. been performed more than 2 days
before the scan.
➤ The patient may be asked to drink
approximately 450 mL of a dilute
Nursing Implications and barium solution (approximately 1%
Procedure ● ● ● ● ● ● ● ● ● ● ● barium) beginning 1 hour before the
examination. This is done to distin-
Pretest: guish gastrointestinal organs from
the pancreas.
➤ Inform the patient that the proce- ➤ Restrict food and fluids for 6 to
dure assesses the pancreas. 8 hours, if contrast medium is to
➤ Inform the patient that the proce- be given.
Copyright © 2003 F.A. Davis Company
Intratest: Post-test:
➤ Administer sedative to a child or to ➤ Instruct the patient to resume
an uncooperative adult, as ordered. normal activity, diet, and previous
➤ Administer antianxiety agent, as medications, unless otherwise indi-
ordered, if the patient is experienc- cated. Renal function should be
ing claustrophobia. assessed before metformin is
restarted.
➤ Administer an antihistamine or
➤ Instruct the patient to increase fluid
steroid, as ordered by a physician,
intake to help eliminate the contrast
for patients with a known significant
medium if used.
allergic reaction to the IV contrast
medium. ➤ Inform the patient that diarrhea may
occur after ingesting oral contrast
➤ Place the patient in a supine position
medium.
on a flat table with foam wedges
to help maintain position and ➤ Instruct the patient or caregiver to
immobilization. Ask the patient note change in urinary output after
to lie still during the procedure iodinated contrast medium adminis-
because movement produces tration in patients with impaired
unclear images. Make sure jewelry, renal function.
watches, chains, belts, and any ➤ Observe for delayed allergic reac-
other metallic objects have been tions, such as urticaria (hives),
removed. headache, nausea, or vomiting, if
➤ As the table moves into the scanner, contrast medium was used.
instruct the patient to remain still. ➤ A physician specializing in this
The scanner makes noises as it branch of medicine sends a written
rotates around the body. The patient report to the ordering provider, who
may be asked to take deep breaths discusses the results with the
to facilitate visualization. A number patient.
of images are taken. A computer ➤ Evaluate test results in relation to the
reconstructs these images so they patient’s symptoms and other tests
can be reviewed. performed. Related diagnostic tests
➤ Administer contrast medium, if include angiogram and magnetic
ordered, and obtain a second series resonance imaging of the abdomen
of images. and ultrasound of the pancreas.
COMPUTED TOMOGRAPHY,
PITUITARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
COMPUTED TOMOGRAPHY,
THORACIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Lymphomas
Pretest:
• Mycoplasma pneumonia
➤ Obtain a history of the patient’s
• Paroxysmal cold hemoglobinuria (idio- complaints, including a list of known
pathic or disease related) allergens.
• Passively acquired antibodies from ➤ Obtain a history of the patient’s
plasma products hematopoietic system as well as
results of previously performed
• Post–cardiac vascular surgery tests and procedures. For related
tests, refer to the hematopoietic
• Transfusion reactions (blood incom- system table.
patibility)
➤ Obtain a list of all medications the
patient is taking, including herbs,
Negative in: nutritional supplements, and nutra-
ceuticals. The requesting health care
• Samples in which sensitization of
practitioner and laboratory should be
erythrocytes has not occurred advised if the patient is regularly
using these products so that their
CRITICAL VALUES: N/A effects can be taken into considera-
tion when reviewing results.
INTERFERING FACTORS: ➤ There are no food, fluid, or medica-
• Drugs and substances that may cause a tion restrictions unless by medical
positive DAT include acetaminophen, direction.
aminosalicylic acid, aminopyrine, ➤ Review the procedure with the
ampicillin, antihistamines, aztreonam, patient. If a cord sample is to be
cephalosporins, chlorinated hydrocar- taken from a newborn, inform
parents that the sample will be
bon insecticides, chlorpromazine, obtained at the time of delivery and
chlorpropamide, cisplatin, clonidine, will not result in blood loss to the
dipyrone, ethosuximide, fenfluramine, infant.
hydralazine, hydrochlorothiazide, ➤ Inform the patient that specimen
ibuprofen, insulin, isoniazid, levodopa, collection takes approximately 5 to
mefenamic acid, melphalan, metha- 10 minutes.
done, methicillin, methyldopa,
moxalactam, penicillin, phenytoin, Intratest:
probenecid, procainamide, quinidine,
quinine, rifampin, streptomycin, ➤ Direct the patient to breathe
normally and to avoid unnecessary
stibophen, sulfonamides, and tetracy- movement.
cline.
➤ Observe standard precautions and
• Wharton’s jelly may cause a false- follow the general guidelines in
positive DAT. Appendix A. Perform a venipuncture,
and collect the specimen in a 5-mL
• Cold agglutinins and large amounts of red-top (serum) and lavender-top
paraproteins in the specimen may (whole blood) tube. Cord specimens
cause false-positive results. are obtained by inserting a needle
Copyright © 2003 F.A. Davis Company
attached to a syringe into the umbili- need for immediate exchange trans-
cal vein. The specimen is drawn into fusion of fresh whole blood that has
the syringe and gently expressed been typed and crossmatched with
into the appropriate collection mother’s serum.
container. ➤ Inform the postpartum patient of the
➤ Label the specimen, and promptly implications of positive test results
transport it to the laboratory. in cord blood. Prepare the newborn
for exchange transfusion, on medical
Post-test: direction.
➤ Evaluate test results in relation
➤ Observe venipuncture site for bleed- to the patient’s symptoms and
ing or hematoma formation. Apply other tests performed. Related
pressure bandage. laboratory tests include blood
➤ Note positive test results in cord group and type, bilirubin, Coombs’
blood of neonate; also assess indirect antiglobulin (IAT), Ham’s
newborn’s bilirubin and hematocrit test, haptoglobin, hematocrit, and
levels. Results may indicate the hemoglobin.
DESCRIPTION: The indirect anti- bate with reagent RBCs. The reagent
globulin test (IAT) detects and RBCs used are from group O donors
identifies unexpected circulating and have most of the clinically signif-
complement molecules or antibodies icant antigens present (D, C, E c, e,
in the patient’s serum. The first use of K, M, N, S, s, Fya, Fyb, Jka, and Jkb).
this test was for the detection and Antibodies present in the patient’s
identification of anti-D using an serum coat antigenic sites on the
indirect method. The test is now RBC membrane. The reagent cells
commonly used to screen a patient’s are washed with saline to remove
serum for the presence of antibodies any unbound antibody. Antihuman
that may react against transfused red globulin is added in the final step
blood cells (RBCs). During testing, of the test. If the patient’s serum
the patient’s serum is allowed to incu- contained antibodies, the antihuman
Copyright © 2003 F.A. Davis Company
Copper 395
COPPER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cu.
SPECIMEN: Serum (1 mL) collected in a royal blue–top, trace element–free
tube.
SI Units
Age Conventional Units (Conversion Factor 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.
INDICATIONS: • Burns
• Assist in establishing a diagnosis of • Chronic ischemic heart disease
Menkes’ disease • Cystic fibrosis
• Assist in establishing a diagnosis of • Dysproteinemia
Wilson’s disease
• Infants (especially premature infants)
• Monitor patients receiving long-term receiving milk deficient in copper
parenteral nutrition therapy
• Iron-deficiency anemias (some)
RESULT • Long-term total parenteral nutrition
• Malnutrition
Increased in:
• Menkes’ disease
• Anemias
• Malabsorption disorders (celiac
• Ankylosing spondylitis disease, tropical sprue)
• Biliary cirrhosis • Nephrotic syndrome
• Collagen diseases • Wilson’s disease
• Complications of renal dialysis
CRITICAL VALUES: N/A
• Hodgkin’s disease
• Infections
INTERFERING FACTORS:
• Drugs that may increase copper levels
• Inflammation
include anticonvulsants and oral
• Leukemia contraceptives.
• Malignant neoplasms • Drugs that may decrease copper levels
include citrates, penicillamine, and
• Myocardial infarction
valproic acid.
• Pellagra
• Excessive therapeutic intake of zinc
• Poisoning from copper-contaminated may interfere with intestinal absorp-
solutions or insecticides tion of copper.
Copyright © 2003 F.A. Davis Company
Medication Recommended
Procedure Administered Collection Times
ACTH Synthetic ACTH 3 cortisol levels—
stimulation (cosyntropin) IM or baseline
IV bolus immediately before
bolus, 30 min after
bolus, and 60 min
after bolus
CRH stimulation CRH 1 g/kg IV 9 a.m. 3 cortisol and ACTH
levels—baseline
before injection, 30
min after injection,
and 60 min after
injection
Dexamethasone Oral dose 8 a.m. after morning
suppression dexamethasone at collection of cortisol
(overnight) 11 p.m.
Metyrapone Oral dose of 8 a.m. after morning
stimulation metyrapone at collection of cortisol
(overnight) midnight and ACTH
ACTH adrenocorticotropic hormone; CRH corticotropin-releasing hormone; IM
intramuscular; IV intravenous.
If the adrenal glands are functioning decrease cortisol levels include barbitu-
normally, cortisol levels rise significantly rates, beclomethasone, betamethasone,
after administration of cosyntropin. clonidine, danazol, desoximetasone,
The metyrapone stimulation test is desoxycorticosterone, dexamethasone,
used to distinguish corticotropin- ephedrine, etomidate, fluocinolone,
dependent (pituitary Cushing’s disease ketoconazole, levodopa, lithium,
and ectopic Cushing’s disease) from methylprednisolone, metyrapone,
corticotropin-independent (carcinoma of midazolam, morphine, nitrous oxide,
the lung or thyroid) causes of increased oxazepam, phenytoin, ranitidine, and
cortisol levels. Metyrapone inhibits the trimipramine.
conversion of 11-deoxycortisol to corti-
• Test results are affected by the time this
sol. Cortisol levels should decrease to less
test is done because cortisol levels vary
than 3 g/dL if normal pituitary stimu-
diurnally.
lation by ACTH occurs after an oral dose
of metyrapone. Specimen collection and • Stress and excessive physical activity
administration of the medication are can produce elevated levels.
performed as with the overnight dexa-
• Normal values can be obtained in the
methasone test.
presence of partial pituitary deficiency.
Increased in: • The metyrapone stimulation test is
contraindicated in patients with
• Adrenal adenoma suspected adrenal insufficiency.
• Cushing’s syndrome • Metyrapone may cause gastroin-
• Ectopic ACTH production testinal distress and/or confu-
sion.
• Hyperglycemia
• Pregnancy
• Stress Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
Decreased in:
Pretest:
• Addison’s disease
➤ Obtain a history of the patient’s
• Adrenogenital syndrome complaints, including a list of known
allergens.
• Hypopituitarism
➤ Obtain a history of the patient’s
CRITICAL VALUES: N/A endocrine system as well as results
of previously performed tests and
INTERFERING FACTORS: procedures. For related tests, refer
to the endocrine system table.
• Drugs and substances that may ➤ Obtain a list of medications the
increase cortisol levels include amphet- patient is taking, including herbs,
amines, anticonvulsants, clomipra- nutritional supplements, and nutra-
mine, corticotropin, CRH, cortisone, ceuticals. The requesting health care
cyclic AMP, ether, fenfluramine, practitioner and laboratory should be
hydrocortisone, insulin, lithium, advised if the patient regularly uses
methadone, metoclopramide, nalox- these products so that their effects
can be taken into consideration
one, opiates, oral contraceptives, pred-
when reviewing results.
nisolone, ranitidine, spironolactone,
tetracosactrin, and vasopressin. ➤ There are no food, fluid, or medica-
tion restrictions unless by medical
• Drugs and substances that may direction.
Copyright © 2003 F.A. Davis Company
SI Units
Conventional Units (Conversion Factor 0.017)
Total CK
Newborn 3 adult values 3 adult values
Children and men 38–174 U/L 0.65–2.96 Kat/L
Children and
women 26–140 U/L 0.46–2.38 Kat/L
SI Units
Conventional Units (Conversion Factor 0.017)
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.
CREATININE, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
SI Units
Age Conventional Units (Conversion Factor 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
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (5 mL) from an unpreserved random or timed specimen
collected in a clean plastic collection container.
RESULT • Shock
• Urinary tract obstruction (e.g., from
Increased in: calculi)
• Acromegaly • Vegetarian diets
• Acute tubular necrosis
CRITICAL VALUES
• Carnivorous diets
• Congestive heart failure Degree of impairment:
• Dehydration Borderline: 62.5–80 mL/min/
1.73 m2
• Diabetes Slight: 52–62.5 mL/min/1.73 m2
• Exercise Mild: 42–52 mL/min/1.73 m2
• Exposure to nephrotoxic drugs and Moderate: 28–42 mL/min/1.73 m2
chemicals Marked: Less than 28 mL/min/
1.73 m2
• Gigantism
• Glomerulonephritis INTERFERING FACTORS:
• Hypothyroidism • Drugs that may increase urine creati-
nine levels include ascorbic acid, cefox-
• Infections
itin, cephalothin, corticosteroids,
• Neoplasms (bilateral renal) fluoxymesterone, levodopa, meth-
androstenolone, methotrexate, methyl-
• Nephrosclerosis
dopa, nitrofurans (including nitro-
• Polycystic kidney disease furazone), oxymetholone, phenolph-
thalein, and prednisone.
• Pyelonephritis
• Drugs that may increase urine creati-
• Renal artery atherosclerosis
nine clearance include enalapril, oral
• Renal artery obstruction contraceptives, prednisone, and
ramipril.
• Renal disease
• Drugs that may decrease urine creati-
• Renal vein thrombosis
nine levels include anabolic steroids,
• Shock and hypovolemia androgens, captopril, and thiazides.
• Tuberculosis • Drugs that may decrease the urine
Copyright © 2003 F.A. Davis Company
Cryoglobulin 411
CRYOGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cryo.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Visual observation for changes in appearance)
Negative.
RESULT
Primary
Identified Organism Specimen Source Condition
Mycobacterium avium Sputum, urine, Opportunistic
intracellulare CSF, semen, pulmonary infection
lymph nodes
M. fortuitum Surgical wound, Opportunistic infection
sputum, joint, (usually pulmonary)
bone, tissue
M. leprae Skin scrapings, CSF, Hansen’s disease
lymph nodes (leprosy)
M. kansasii Skin, joint, sputum, Pulmonary
lymph nodes tuberculosis
M. marinum Joint Granulomatous skin
lesions
M. tuberculosis Sputum, urine, CSF, Pulmonary
gastric washing tuberculosis
M. xenopi Sputum Pulmonary
tuberculosis
CSF cerebrospinal fluid.
INTERFERING FACTORS:
• Specimen collection after initiation of Nursing Implications and
treatment with antituberculosis drug Procedure ● ● ● ● ● ● ● ● ● ● ●
either the hands or a pillow over the tubing from the trap, and place the
diaphragmatic area and applying rubber tubing over the male adapter
slight pressure. Another approach is to seal the unit.
to place a vaporizer or other humidi- ➤ For intubated patients or patients
fying device at the bedside. with a tracheostomy, the previous
➤ After sufficient exposure to procedure is followed except that
adequate humidification, postural the suction catheter is passed
drainage of the upper and middle through the existing endotracheal
lung segments may be repeated or tracheostomy tube rather than
before attempting to obtain the through the nostril. The patient
specimen. Other methods may should be hyperoxygenated before
include obtaining an order for an and after the procedure in accor-
expectorant to be administered with dance with standard protocols for
additional water approximately 2 suctioning these patients.
hours before attempting to obtain ➤ Generally, a series of three to five
the specimen. Chest percussion and early morning sputum samples are
postural drainage of all lung collected in sterile containers. If
segments may also be employed. If leprosy is suspected, obtain a smear
the patient is still unable to raise from nasal scrapings or a biopsy
sputum, the use of an ultrasonic specimen from lesions in a sterile
nebulizer (“induced sputum”) may container. Label the specimen, and
be necessary; this is usually done by promptly transport it to the labora-
a respiratory therapist. tory. It is advisable to note antimi-
crobial therapy on the collection
Tracheal suctioning: container.
➤ Obtain the necessary equipment,
including a suction device, suction Post-test:
kit, and Lukens tube or in-line trap.
➤ Instruct the patient to resume usual
➤ Position the patient with head diet and medication as directed by
elevated as high as tolerated. the health care practitioner.
➤ Put on sterile gloves. Maintain the ➤ Instruct the patient to perform
dominant hand as sterile and the mouth care after the specimen has
nondominant hand as clean. been obtained. A cool beverage may
➤ Using the sterile hand, attach the aid in relieving throat irritation
suction catheter to the rubber tubing caused by coughing or suctioning.
of the Lukens tube or in-line trap. ➤ If a bronchoscopy was performed,
Then attach the suction tubing to the inform the patient to drink liquids or
male adapter of the trap with the eat food only after the gag reflex
clean hand. Lubricate the suction returns. Monitor vital signs and
catheter with sterile saline. compare with baseline values. The
➤ Tell nonintubated patients to patient may be placed in isolation
protrude the tongue and to take a pending results of the smear if
deep breath as the suction catheter tuberculosis is suspected.
is passed through the nostril. When ➤ Instruct the patient to notify some-
the catheter enters the trachea, a one immediately if he or she begins
reflex cough is stimulated; immedi- to have difficulty breathing or if
ately advance the catheter into bleeding occurs.
the trachea and apply suction.
Maintain suction for approximately ➤ Note the color, consistency, and
10 seconds, but never longer than 15 volume of the specimen collected.
seconds. Withdraw the catheter ➤ Observe the patient’s color and
without applying suction. Separate respiratory rate. Administer oxygen,
the suction catheter and suction as necessary.
Copyright © 2003 F.A. Davis Company
CULTURE, FUNGAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
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.
Hair:
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Fungi usually grow at the base of the
hair shaft. Infected hairs can be iden-
Pretest: tified by using a Wood’s lamp in a
darkened room. A Wood’s lamp
➤ Obtain a history of the patient’s provides rays of ultraviolet light at a
complaints, including a list of known wavelength of 366 nm, or 3660 Å.
allergens. Infected hairs fluoresce a bright
Copyright © 2003 F.A. Davis Company
yellow-green when exposed to light glass slide, and then the slide is
from the Wood’s lamp. Using tweez- covered and gently heated briefly.
ers, pluck hair from skin. The slide is examined under a micro-
scope for the presence of fungal
Nails: elements.
➤ Ideally, softened material from the ➤ Label the specimen, and promptly
nail bed is sampled from beneath transport it to the laboratory.
the nail plate. Alternatively, shavings
from the deeper portions of the nail
itself can be collected. Post-test:
➤ The potassium hydroxide (KOH) ➤ Evaluate test results in relation
test is used to indicate the pres- to the patient’s symptoms and
ence of mycelium, mycelial frag- other tests performed. Related tests
ments, spores, or budding yeast include relevant bacterial cultures,
cells. A portion of the specimen tissue biopsies, and body fluid
is mixed with 15% KOH on a analysis.
CULTURE, VIRAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine, semen, blood, body fluid, stool, tissue, or swabs from
the affected site.
CYSTOMETRY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Cystometry 423
Cystoscopy 425
CYSTOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Inflammation or infection
• Obstruction Pretest:
• Polyps ➤ Inform the patient that the proce-
dure is generally performed under
• Prostatic hypertrophy or hyperplasia general, spinal, or local anesthesia.
Copyright © 2003 F.A. Davis Company
Cystoscopy 427
➤ Inform the patient that the proce- ➤ Cleanse external genitalia with anti-
dure is performed by a physician in a septic solution. If local anesthetic is
special cystoscopy suite near or in used, it is instilled into the urethra
the operating room (or in a physi- and retained for 5 to 10 minutes. A
cian’s office) and takes approxi- penile clamp may be used for male
mately 30 to 60 minutes. patients to aid in retention of anes-
➤ Obtain a history of the patient’s thetic.
complaints. ➤ The physician inserts a cystoscope
➤ Obtain a history of the patient’s or a urethroscope to examine the
genitourinary system as well as urethra before cystoscopy. The
results of previously performed urethroscope has a sheath that may
tests and procedures for bleeding be left in place, and the cystoscope
disorders. For related tests, refer to is inserted through it, avoiding multi-
the genitourinary and renal system ple instrumentations.
tables. ➤ After insertion of the cystoscope, a
➤ Determine date of last menstrual sample of residual urine may be ob-
period and the possibility of preg- tained for culture or other analysis.
nancy in perimenopausal women. ➤ The bladder is irrigated via an
➤ Determine the patient’s allergies or irrigation system attached to the
sensitivities to anesthetics, anal- scope. The irrigant is usually sterile
gesics, or antibiotics. water, unless an isotonic solution,
➤ Assess hematologic status and such as mannitol, is used during
blood-clotting ability and urinalysis transurethral resection procedures.
findings for abnormalities. The irrigation fluid aids in bladder
visualization.
➤ Obtain a written, informed consent
for the procedure from the patient. ➤ If a prostatic tumor is found, a
biopsy specimen may be obtained
➤ Restrict food and fluids for 8 hours if by means of a cytology brush or
the patient is having general or biopsy forceps inserted through the
spinal anesthesia. For local anesthe- scope. If the tumor is small and
sia, allow only clear liquids 8 hours localized, it can be excised and fulgu-
before the procedure. rated. This procedure is termed
➤ Inform the patient that he or she transurethral resection of the blad-
may feel some sensation of pres- der. Polyps can also be identified
sure and/or having to void. and excised.
➤ Obtain and record the patient’s vital ➤ Ulcers or bleeding sites can be
signs. fulgurated using electrocautery.
➤ Review the procedure with the ➤ Renal calculi can be crushed and
patient. removed from the ureters and blad-
der.
Intratest: ➤ Ureteral catheters can be inserted
➤ Administer ordered preoperative via the scope to obtain urine
sedation. samples from each kidney for
comparative analysis and radi-
➤ Give the patient a gown and robe to ographic studies.
wear; ensure that the patient is
draped during the procedure to avoid ➤ Ureteral and urethral strictures can
unnecessary exposure. also be dilated during this proce-
dure.
➤ Position patient on the examination
table draped and with legs in stir- ➤ Upon completion of the examination
rups. If general or spinal anesthesia and related procedures, the cysto-
is to be used, it is administered scope is withdrawn.
before positioning the patient on the ➤ Place obtained specimens in proper
table. containers, label them properly, and
Copyright © 2003 F.A. Davis Company
CYSTOURETHROGRAPHY, VOIDING
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
CYTOLOGY, SPUTUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Sputum (10 to 15 mL) collected on 3 to 5 consecutive first-
morning, deep-cough expectorations.
CYTOLOGY, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (180 mL for an adult or at least 10 mL for a child)
collected in a clean wide-mouth plastic container.
tic swab, and then aspirate 5 mL of ile specimen container. Place a dry
urine with a 21- to 25-gauge needle sterile dressing over the site. Do not
and syringe. Transfer urine to a ster- collect urine from the pouch from
ile container. the patient with a urinary diversion
(e.g., ileal conduit). Instead perform
Urinary catheterization: catheterization through the stoma.
➤ Place female patient in lithotomy General:
position or male patient in supine
position. Using sterile technique, ➤ Label the specimen, and promptly
open the straight urinary catheteriza- transport it to the laboratory. If a
tion kit and perform urinary catheter- delay in transport is expected, add
ization. Place the retained urine in a an equal volume of 50% alcohol to
sterile specimen container. the specimen as a preservative.
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.
D-Dimer 439
D-DIMER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
will have its own specific reference processed and unprocessed sam-
range. ples stored in unopened tubes is
that testing should be completed
➤ When multiple specimens are
within 1 to 4 hours.
drawn, the blue-top tube should be
collected after sterile (i.e., blood
culture) and red-top tubes. When
Post-test:
coagulation testing is the only work ➤ Observe venipuncture site for bleed-
to be done, an extra red-top tube ing or hematoma formation. Apply
should be collected before the blue- pressure bandage.
top tube to avoid contaminating the
➤ Evaluate test results in relation to
specimen with tissue thromboplas-
the patient’s symptoms and other
tin, which can falsely decrease
tests performed. Related laboratory
values.
tests include fibrin split products,
➤ Label the specimen, and promptly fibrinogen, activated partial thrombo-
transport it to the laboratory. The plastin time, platelet count, and
NCCLS recommendation for prothrombin time.
SYNONYM/ACRONYM: N/A.
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.
gluten-induced enteropathy)
Pretest:
• Parasitic infestations (Giardia, schisto-
somiasis, hookworm) ➤ Obtain a history of the patient’s
complaints, including a list of known
• Radiation enteritis allergens.
Copyright © 2003 F.A. Davis Company
➤ Blood samples are collected 1 hour results and offer support to help the
postdose for pediatric patients and 2 patient and/or caregiver cope with
hours postdose for adults. the long-term implications of a
➤ Direct the patient to breathe chronic disorder and related lifestyle
normally and to avoid unnecessary changes. Provide teaching and infor-
movement. Perform a venipuncture, mation regarding the clinical impli-
and collect the specimen in a 5-mL cations of the test results, as
gray-top tube. appropriate. Educate the patient
regarding access to counseling serv-
➤ At the conclusion of the test, ices, as appropriate.
compare the quantity of urine with
the urinary output record for the ➤ Decreased D-xylose levels may be
collection; if the specimen contains associated with gastrointestinal
less than what was recorded as disease. Nutritional therapy may be
output, some urine may have been indicated in the presence of malab-
discarded, thus invalidating the test. sorption disorders. Encourage the
patient, as appropriate, to consult
➤ Label the specimen, and promptly with a qualified nutrition specialist to
transport it to the laboratory. Include plan a lactose- and gluten-free diet.
on the label the amount of urine, This dietary planning is complex
test start and stop times, and inges- because patients are often malnour-
tion of any foods or medications that ished and have related nutritional
could affect test results. problems.
Post-test: ➤ Evaluate test results in relation to
the patient’s symptoms and other
➤ Observe venipuncture site for bleed- tests performed. Related laboratory
ing or hematoma formation. Apply tests include sweat chloride, fecal
pressure bandage. analysis, fecal fat, intestinal biopsy,
➤ Recognize anxiety related to test and lactose tolerance.
DEHYDROEPIANDROSTERONE
SULFATE
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SYNONYM/ACRONYM: DHEAS.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in lavender-top (ethylenediaminetetra-acetic [EDTA]) tube is
also acceptable.
SI Units
Age Conventional Units (Conversion 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 g/dL 0.07–3.9 mol/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
Pretest: Post-test:
➤ Obtain a history of the patient’s ➤ Observe venipuncture site for bleed-
complaints, including a list of known ing or hematoma formation. Apply
allergens. pressure bandage.
➤ Obtain a history of the patient’s ➤ Evaluate test results in relation
endocrine system, as well as results to the patient’s symptoms and other
of previously performed tests and tests performed. Related labora-
procedures. For related tests, refer tory tests include ACTH, cortisol,
to the endocrine system table. prolactin, and testosterone.
Copyright © 2003 F.A. Davis Company
DRUGS OF ABUSE
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Amphetamines Ethanol
Barbiturates Opiates
Benzodiazepines Phencyclidine
Cannabinoids Tricyclic Antidepressants
Cocaine
RESULT: A urine screen merely identifies because of the risk of aspiration. Possible
the presence of these substances in urine: interventions include airway protection,
it does not indicate time of exposure, administration of oxygen, gastric lavage
amount used, quality of the source used, with water or saline (up to 24 hours after
or level of impairment. Positive screens ingestion), administration of activated
should be considered presumptive. charcoal, and monitoring CNS depres-
Drug-specific confirmatory methods sion.
should be used to investigate question- PCP intoxication causes a variety of
able results of a positive urine screen. symptoms depending on the stage of
intoxication. Stage I includes psychiatric
CRITICAL VALUES: The legal limit signs, muscle spasms, fever, tachycardia,
for ethanol intoxication varies from flushing, small pupils, salivation, nausea,
state to state, but in most states greater and vomiting. Stage II includes stupor,
than 100 mg/dL is considered impaired convulsions, hallucinations, increased
for driving. Levels greater than 300 heart rate, and increased blood pressure.
mg/dL are associated with amnesia, Stage III includes further increases of
vomiting, double vision, and hypother- heart rate and blood pressure that may
mia. Levels 400 to 700 mg/dL are associ- culminate in cardiac and respiratory fail-
ated with coma and may be fatal. ure. Possible interventions may include
Possible interventions for ethanol toxic- providing respiratory support, adminis-
ity include administration of tap water or tration of activated charcoal with a
3% sodium bicarbonate lavage, breath- cathartic such as sorbitol, gastric lavage
ing support, and hemodialysis (usually and suction, administration of intra-
indicated only if levels exceed 300 venous nutrition and electrolytes, and
mg/dL). acidification of the urine to promote
Barbiturate and benzodiazepine intox- PCP excretion.
ication causes central nervous system Cocaine intoxication causes short-
(CNS) depression, which may progress term symptoms of CNS stimulation,
to respiratory failure, hypotension, hypertension, tachypnea, mydriasis,
coma, and death. Do not induce emesis and tachycardia. Possible interventions
Copyright © 2003 F.A. Davis Company
include emesis (if orally ingested and if strong oxidizers can produce erroneous
the patient has a gag reflex and normal urine drug screen results.
CNS function), gastric lavage (if orally
• Ethanol is a volatile substance, and
ingested), whole bowel irrigation (if
specimens should be stored in a tightly
packs of the drug were ingested), airway
stoppered container to avoid falsely
protection, cardiac support, and adminis-
decreased values.
tration of diazepam or phenobarbital for
convulsions. The use of beta blockers is
contraindicated.
Amphetamine intoxication causes Nursing Implications and
psychoses, tremors, convulsions, insom- Procedure ● ● ● ● ● ● ● ● ● ● ●
ECHOCARDIOGRAPHY
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Echocardiography 451
• Myxoma
Nursing Implications and
• Pericardial effusion, tamponade, and Procedure ● ● ● ● ● ● ● ● ● ● ●
pericarditis
Pretest:
• Pulmonary hypertension
➤ Inform the patient that the proce-
• Pulmonary valve abnormalities dure assesses heart function.
• Septal defects ➤ Inform the patient that the proce-
dure is performed in a special
• Ventricular or atrial mural thrombi department by a technologist and
takes approximately 30 to 60
• Ventricular hypertrophy minutes, and that there is no risk of
radiation from the study.
CRITICAL VALUES: N/A ➤ Obtain a list of medications the
patient is taking.
INTERFERING FACTORS: ➤ Obtain pertinent history of previ-
ously performed cardiac tests and
Factors that may impair clear procedures, current cardiac condi-
imaging: tions or abnormalities, and therapy
received for cardiac condition. For
• Inability of the patient to cooperate related tests, refer to the cardiovas-
or remain still during the procedure cular system table.
because of age, significant pain, or
➤ Do not restrict food and fluids.
mental status
• Incorrect placement and movement of Intratest:
the transducer over the desired sites or ➤ Place the patient in a supine position
lack of skill in performing the proce- on a flat table with foam wedges to
dure help maintain position and immobi-
lization. Ask the patient to lie very
• Patient obesity, chest thickness, defor- still during the procedure because
mity, or other abnormality or trauma, movement will produce unclear
which can affect the transmission of images.
waves to and from the chest because of ➤ Patient movement during the proce-
increased space between the heart and dure will affect the results and make
transducer interpretation difficult.
• The presence of chronic obstructive ➤ Expose the chest, and attach the
pulmonary disease or use of mechani- electrocardiogram leads for simulta-
cal ventilation, which increases the air neous tracings, if desired.
between the heart and chest wall ➤ Apply conductive gel to the chest
(hyperinflation) and can attenuate the slightly to the left of the sternum.
ultrasound waves Place the transducer on the chest
surface along the left sternal border,
• The presence of arrhythmias the subxiphoid area, suprasternal
notch, and supraclavicular areas to
• Metallic objects within the examina- obtain views and tracings of the
tion field (e.g., jewelry or body rings), portions of the heart. Scan the areas
which may inhibit organ visualization by systematically moving the probe
and can produce unclear image in a perpendicular position to direct
the ultrasound waves to each part
• The presence of pleural effusion, peri- of the heart. These can be viewed
cardial fat pad, tumors around the immediately and recorded on
heart, clotted blood, or loculated effu- moving graph paper (M mode) or
sions videotape (two-dimensional).
Copyright © 2003 F.A. Davis Company
ECHOCARDIOGRAPHY,
TRANSESOPHAGEAL
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ELECTROCARDIOGRAM
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Electrocardiogram 457
Electrocardiogram 459
R
5 mm (0.2 sec)
PR (1 mm)
Segment
0.04
ST sec
Segment
PR Interval Q
S
QRS
Complex
QT Interval
ELECTROENCEPHALOGRAPHY
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Electroencephalography 461
Electromyography 463
ELECTROMYOGRAPHY
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Electromyography 465
Intratest: Post-test:
ELECTROMYOGRAPHY,
PELVIC FLOOR SPHINCTER
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DESCRIPTION: Pelvic floor sphincter ➤ Assure the patient that the pain is
minimal during the catheter inser-
electromyography, also known as
tion.
rectal electromyography, is performed
to measure electrical activity of the
external urinary sphincter. This Intratest:
procedure, often done in conjunction
➤ Ask the patient to void immediately
with cystometry and voiding before the test.
urethrography as part of a full ➤ Place the patient in a supine position
urodynamic study, helps to diagnose on the examining table and place a
neuromuscular dysfunction and drape over the patient, exposing the
incontinence. ■ perineal area.
➤ Two skin electrodes are positioned
INDICATIONS: Evaluate neuromuscular slightly to the left and right of the
dysfunction and incontinence perianal area and a grounding elec-
trode is placed on the thigh.
CRITICAL VALUES: N/A ➤ If needle electrodes are used,
they are inserted into the muscle
INTERFERING FACTORS: surrounding the urethra.
➤ Muscle activity signals are recorded
This procedure is contraindicated as waves, which are interpreted for
for: Patients who are pregnant or number and configurations in diag-
suspected of being pregnant, unless the nosing urinary abnormalities.
potential benefits of the procedure far ➤ An indwelling urinary catheter is
outweigh the risks to the fetus and inserted, and the bulbocavernosus
mother reflex is tested; the patient is
instructed to cough while the
Other considerations: Failure to catheter is gently pulled.
follow dietary restrictions before the ➤ Voluntary control is tested by
procedure may cause the procedure to requesting the patient to contract
be canceled or repeated. and relax the muscle. Electrical
activity is recorded during this
period of relaxation with the bladder
empty.
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ The bladder is filled with sterile
water at a rate of 100 mL/min while
Pretest: the electrical activity during filling is
recorded.
➤ Inform the patient that the proce- ➤ The catheter is removed; the patient
dure is performed in a special room is then placed in a position to
and takes about 30 minutes to void and is asked to urinate and
complete. empty the full bladder. This voluntary
➤ Obtain a history of previously urination is then recorded until
performed tests, procedures, treat- completed. The complete procedure
ments, and surgeries. For related includes recordings of electrical
tests, refer to the genitourinary and signals before, during, and at the
musculoskeletal systems tables. end of urination.
Copyright © 2003 F.A. Davis Company
ELECTRONEUROGRAPHY
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Electroneurography 469
➤ The time required for the impulse skin where the electrodes were
to travel from the stimulation site applied.
to the muscle contraction (total ➤ Monitor electrode sites for
latency) is recorded in milliseconds. hematoma or inflammation.
➤ Calculate the conduction velocity. ➤ If residual pain is noted after the
The conduction velocity is converted procedure, instruct the patient to
to meters per second and computed apply warm compresses and to take
using the following equation: analgesics, as ordered.
Conduction velocity ➤ Instruct the patient to resume
(in meters per normal activity, diet, and previous
second) medication use, unless otherwise
indicated.
[distance (in meters)]
➤ A physician specializing in this
[total latency – branch of medicine sends a written
distal latency] report to the ordering provider,
who discusses the results with the
patient.
Post-test:
➤ Evaluate test results in relation to
➤ When the procedure is complete, the patient’s symptoms and any
remove the electrodes and clean the related tests performed.
EOSINOPHIL COUNT
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ERYTHROCYTE
PROTOPORPHYRIN, FREE
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ERYTHROCYTE
SEDIMENTATION RATE
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Erythropoietin 477
ERYTHROPOIETIN
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SYNONYM/ACRONYM: EPO.
SPECIMEN: Serum (2 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay)
ESOPHAGEAL MANOMETRY
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➤ Have the patient put on a hospital drip into the catheter at about 10
gown and void. mL/min. Then hydrochloric acid is
➤ Place the patient on the examining allowed to drip into the catheter.
table, and spray the throat with local ➤ Pain experienced when the
anesthetic. hydrochloric acid is instilled deter-
➤ Wear gloves throughout the proce- mines the presence of an
dure. esophageal abnormality. If no pain is
experienced, symptoms are the
Esophageal manometry: result of some other condition.
ESOPHAGOGASTRODUODENOSCOPY
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Esophagogastroduodenoscopy 483
Estradiol 485
ESTRADIOL
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SYNONYM/ACRONYM: E2.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma
(1 mL) collected in green-top (heparin) tube is also acceptable.
SI Units (Conversion
Age Conventional Units Factor 3.67)
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
DESCRIPTION: Estrogens are hor- cortex and the testes. Only three
mones secreted in large amounts by types of estrogen are present in the
the ovaries and during pregnancy by blood in measurable amounts:
the placenta. Estradiol is also secreted estrone, estradiol, and estriol.
in minute amounts by the adrenal Estradiol is the most active of the
Copyright © 2003 F.A. Davis Company
chance of pregnancy
Pretest:
RESULT
➤ Obtain a history of the patient’s
Increased in: complaints, including a list of known
allergens.
• Adrenal tumors
➤ Obtain a history of the patient’s
• Estrogen-producing tumors endocrine and reproductive
• Feminization in children systems, as well as phase of
menstrual cycle and results of previ-
• Gynecomastia ously performed tests and proce-
• Hepatic cirrhosis dures. For related tests, refer to the
endocrine and reproductive system
• Hyperthyroidism tables.
➤ Obtain a list of the medications the
Decreased in: patient is taking, including herbs,
• Ovarian failure nutritional supplements, and nutra-
ceuticals. The requesting health care
• Primary and secondary hypogonadism
practitioner and laboratory should be
• Turner’s syndrome advised if the patient regularly uses
these products so that their effects
CRITICAL VALUES: N/A can be taken into consideration
when reviewing results.
INTERFERING FACTORS: ➤ There are no food, fluid, or medica-
• Drugs that may increase estradiol levels tion restrictions unless by medical
include cimetidine, clomiphene, dehy- direction.
droepiandrosterone, diazepam, estro- ➤ Review the procedure with the
gen/progestin therapy, ketoconazole, patient.
mifepristone (some patients with ➤ Inform the patient that specimen
meningiomas and not receiving any collection takes approximately 5 to
other drugs), nafarelin, nilutamide, 10 minutes.
Copyright © 2003 F.A. Davis Company
Intratest: Post-test:
➤ Direct the patient to breathe ➤ Observe venipuncture site for bleed-
normally and to avoid unnecessary ing or hematoma formation. Apply
movement. pressure bandage.
➤ Observe standard precautions and ➤ Evaluate test results in relation to
follow the general guidelines in the patient’s symptoms and other
Appendix A. Perform a venipuncture, tests performed. Related laboratory
and collect the specimen in a 5-mL tests include FSH, LH, proges-
red- or tiger-top tube. terone, and prolactin.
➤ Label the specimen, and promptly
transport it to the laboratory.
cord, as well as the results of previ- placed on the patient’s ears, and a
ously performed tests, surgeries, clicking noise stimulus is delivered
treatments, and procedures. For into one ear while a continuous tone
related tests, refer to the muscu- is delivered to the opposite ear.
loskeletal system table. Responses to the stimuli are
➤ Obtain a written, informed consent recorded as waveforms for analysis.
for the procedure from the patient.
Somatosensory evoked
➤ Ensure that the patient is able to
relax; report any extreme anxiety or potentials:
restlessness. ➤ Place the patient in a comfortable
➤ Ensure that hair is clean and free of position, and place the electrodes at
hair sprays, creams, or solutions. the nerve sites of the wrist, knee,
and ankle and on the scalp at the
➤ Obtain a list of the medications the
sensory cortex of the hemisphere
patient is taking including herbs,
on the opposite side (the electrode
nutritional supplements, and
that picks up the response and deliv-
nutraceuticals. The requesting health
ers it to the recorder). Additional
care practitioner and laboratory
electrodes can be positioned at the
should be advised if the patient
cervical or lumbar vertebrae for
regularly uses these products so
upper or lower limb stimulation. The
that their effects can be taken into
rate at which the electric shock stim-
consideration when reviewing
ulus is delivered to the nerve elec-
results.
trodes and travels to the brain is
➤ Remove any jewelry or metallic measured, computer analyzed, and
objects above the neck. recorded in waveforms for analysis.
➤ Assure the patient that there is no Both sides of the area being exam-
discomfort during the procedure, ined can be tested by switching the
and encourage relaxation. electrodes and repeating the proce-
dure.
Intratest:
Event-related potentials:
Visual evoked potentials: ➤ Place the patient in a sitting position
in a chair in a quiet room. Earphones
➤ Place the patient in a comfortable are placed on the patient’s ears
position about 1 m from the stimula- and auditory cues administered. The
tion source. Attach electrodes to the patient is asked to push a button
occipital and vertex lobe areas and a when the tones are recognized.
reference electrode to the ear. A Flashes of light are also used as
light-emitting stimulation or a visual cues, with the client pushing
checkerboard pattern is projected on a button when cues are noted.
a screen at a regulated speed. This Results are compared to normal EP
procedure is done for each eye (with waveforms for correct, incorrect, or
the opposite eye covered) as the absent responses.
patient looks at a dot on the screen
without any change in the gaze
Post-test:
while the stimuli are delivered. A
computer interprets the brain’s ➤ When the procedure is complete,
responses to the stimuli and records remove the electrodes and clean the
them in waveforms. skin where the electrodes were
applied.
Auditory evoked potentials:
➤ A physician specializing in this
➤ Place the patient in a comfortable branch of medicine sends a written
position, and place the electrodes on report to the ordering provider, who
the scalp at the vertex lobe area and discusses the results with the
on each earlobe. Earphones are patient.
Copyright © 2003 F.A. Davis Company
FECAL ANALYSIS
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SYNONYM/ACRONYM: N/A.
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)
FECAL FAT
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Method
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.
Intratest:
Pretest: ➤ Ensure that the patient has complied
➤ Obtain a history of the patient’s with dietary preparations and other
complaints that indicate a gastroin- pretesting restrictions.
testinal (GI) disorder—diarrhea ➤ Observe standard precautions and
Copyright © 2003 F.A. Davis Company
Ferritin 501
follow the general guidelines in sure the label includes the date of
Appendix A. collection and the start and stop
➤ Obtain the appropriate-sized speci- times.
men container, toilet-mounted
collection container to aid in speci- Post-test:
men collection, and plastic bag
for specimen transport. A large, ➤ Instruct the patient with abnormal
clean, preweighed container should values on the importance of fluid
be used for the timed test. A intake and proper diet specific to his
smaller, clean container can be used or her condition.
for the collection of the random ➤ Instruct the patient to resume his or
sample. her usual diet and medication as
➤ For the quantitative procedure, directed by the health care practi-
instruct the patient to collect each tioner.
stool and place it in the 500-mL ➤ Evaluate test results in relation to
container during the timed collection the patient’s symptoms and other
period. Keep the container refriger- tests performed. Related laboratory
ated in the plastic bag throughout tests include 1-antitrypsin/pheno-
the entire collection period. typing, complete blood count, D-
➤ Label the specimen, and promptly xylose tolerance test, and sweat
transport it to the laboratory. Make chloride.
FERRITIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Immunoassay)
SI Units
Age Conventional Units (Conversion Factor 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 10–120 ng/mL 10–120 g/L
than 40 y
Women 40 y and 12–263 ng/mL 12–263 g/L
older
Copyright © 2003 F.A. Davis Company
FETAL FIBRONECTIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: fFN.
SPECIMEN: Swab of vaginal secretions.
REFERENCE VALUE: (Method: Immunoassay) Negative.
1-Fetoprotein 505
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.
AFP
Fetus, first-trimester peak 200–400 mg/dL
Cord blood Less than 5 mg/dL
1-Fetoprotein 507
Multiple pregnancy
Pretest:
Polycystic kidneys
Underestimation of gestational age ➤ Obtain a history of the patient’s
complaints and known or suspected
• Men or nonpregnant women: malignancy. Obtain a list of known
Cirrhosis allergens.
Hepatic carcinoma ➤ Obtain a history of the patient’s
Hepatitis immune and reproductive systems,
gestational age, and results of previ-
Metastatic lesions involving the ously performed tests and proce-
liver dures. For related tests, refer to the
immune and reproductive system
Decreased in: tables.
• Pregnant women: ➤ Provide required information to
Down’s syndrome (trisomy 21) laboratory for triple-marker testing,
Edwards’s syndrome (trisomy 18) including maternal birth date,
weight, age, race, calculated gesta-
Fetal demise (undetected over a tional age, gestational age by
lengthy period of time) ultrasound, gestational date by phys-
Hydatidiform moles ical examination, first day of last
Copyright © 2003 F.A. Davis Company
• Drugs that may increase fibrin degra- ➤ There are no food, fluid, or medica-
dation product levels include heparin tion restrictions unless by medical
and fibrinolytic drugs such as strepto- direction.
kinase and urokinase. ➤ Review the procedure with the
patient.
• The presence of rheumatoid factor
➤ Inform the patient that specimen
may falsely elevate results with some collection takes approximately 5 to
test kits. 10 minutes.
• The test should not be ordered on
patients receiving heparin therapy. Intratest:
➤ Direct the patient to breathe
Nursing Implications and normally and to avoid unnecessary
movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Fibrinogen 511
FIBRINOGEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Factor I.
SPECIMEN: Plasma (1 mL) collected in blue top (sodium citrate) tube.
REFERENCE VALUE: (Method: Photo optical clot detection)
SI Units
Age Conventional Units (Conversion Factor 0.01)
Newborn 125–300 mg/dL 1.25–3.00 g/L
Adult 200–400 mg/dL 2.00–4.00 g/L
Folate 513
FOLATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 2.265)
Newborn–1 y 5–21 ng/mL 11–48 nmol/L
Adult Greater than 2.5 ng/mL Greater than 5.7 nmol/L
Copyright © 2003 F.A. Davis Company
FOLLICLE-STIMULATING HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Status Conventional Units (Conversion Factor 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
Copyright © 2003 F.A. Davis Company
Fructosamine 517
FRUCTOSAMINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Status Conventional Units (Conversion Factor 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
GALLIUM SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Gastric fluid collected in eight plastic tubes at 15-minute
intervals.
• PAO
Chronic gastritis Pretest:
Gastric cancers ➤ Obtain a history of the patient’s
Gastric polyps complaints, including a list of known
Gastric ulcer allergens.
Myxedema ➤ Obtain a history of the patient’s
Pernicious anemia gastrointestinal system as well as
results of previously performed
tests and procedures. For related
CRITICAL VALUES: N/A tests, refer to the gastrointestinal
system table.
INTERFERING FACTORS: ➤ Obtain a list of the medications
• Drugs that may increase gastric volume the patient is taking, including
include atropine, diazepam, ganglionic herbs, nutritional supplements, and
blocking agents, and insulin. nutraceuticals. The requesting health
care practitioner and laboratory
• Drugs and substances that may should be advised if the patient
increase gastric pH include caffeine, regularly uses these products so
calcium salts, corticotropin, ethanol, that their effects can be taken into
rauwolfia, reserpine, and tolazoline. consideration when reviewing
results.
• Drugs and substances that may
➤ Instruct the patient to fast from food
decrease gastric pH include atropine, after the evening meal the night
cimetidine, diazepam, famotidine, before the test and not to drink
ganglionic blocking agents, glucagon, water for 1 hour before the test. The
nizatidine, omeprazole, oxmetidine, patient should be instructed to
propranolol, prostaglandin 2, raniti- refrain from chewing gum or smok-
dine, and secretin. ing for at least 12 hours before the
test.
• Gastric intubation is contraindicated
➤ Drugs and substances that may
in patients with esophageal alter gastric secretions (e.g., alcohol,
varices, diverticula, stenosis, histamine, nicotine, adrenocorti-
malignant neoplasm of the esophagus, cotropic steroids, insulin, para-
aortic aneurysm, severe gastric hemor- sympathetic agents, belladonna
rhage, and congenital heart failure. alkaloids, anticholinergic drugs,
histamine receptor antagonists)
• The use of histamine diphosphate is should be restricted by medical
contraindicated in patients with direction for 72 hours before the
a history of asthma, paroxysmal test.
hypertension, urticaria, or other aller- ➤ Review the procedure with the
gic conditions. patient. Explain that some discom-
• Failure to follow dietary restrictions fort is experienced from insertion of
the nasogastric tube.
may result in stimulation of gastric
secretions. ➤ Obtain a written and informed
consent before administering any
• Exposure to the sight, smell, or medications prior to the procedure.
Copyright © 2003 F.A. Davis Company
➤ Inform the patient that specimen ➤ Using a constant but gentle suction,
collection takes approximately 60 to gastric contents are collected. Do
120 minutes. not use specimens obtained from
the first 15 to 30 minutes of suction-
Intratest: ing.
➤ Ensure that the patient has complied ➤ The gastric stimulant is adminis-
with dietary preparations and other tered, and the peak basal speci-
pretesting restrictions. mens are collected over a 60-
minute period as four 15-minute
➤ Ensure that the patient does not specimens.
have a history of asthma, paroxys-
mal hypertension, urticaria, or other ➤ Number the specimen tubes in the
allergic conditions if histamine order in which they were collected.
diphosphate is being considered for Label the specimen, including time
use in the test. of collection, and promptly transport
it to the laboratory.
➤ Direct the patient to breathe
normally and to avoid unnecessary
movement. Post-test:
➤ Record baseline vital signs.
➤ Instruct the patient to resume usual
➤ If the patient is wearing dentures, diet and medication as directed by
remove them. the health care practitioner.
➤ Observe standard precautions and ➤ Monitor vital signs and compare
follow the general guidelines in with baseline values.
Appendix A.
➤ Monitor for side effects of drugs
➤ Have the patient sit, or help the administered to induce gastric
patient recline on the left side. secretion (e.g., flushing, headache,
➤ A cold lubricated gastric (Levine) nasal stuffiness, dizziness, faint-
tube is inserted orally. Alternatively, ness, nausea).
if the patient has a hyperactive gag ➤ Evaluate test results in relation to
reflex, the tube can be inserted the patient’s symptoms and other
nasally. The tube must have a tests performed. Related laboratory
radiopaque tip. tests include complete blood count,
➤ Fluoroscopy or x-ray is used to folate, gastrin, intrinsic factor anti-
confirm proper position of the tube bodies, Helicobacter pylori, and
before the start of the test. vitamin B12.
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay)
Gastrin Level
SI Units
Age Conventional Units (Conversion Factor 1)
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
Stimulation Tests
Gastrin stimulation test No response or slight
with calcium or increase over
secretin baseline
on a flat table with foam wedges the patient that radionuclide is elimi-
to help maintain position and immo- nated from the body within 6 to 24
bilization. The radionuclide is admin- hours.
istered intravenously, and the
➤ Inform the patient to flush the
abdomen is scanned immediately
toilet immediately after each voiding
for 1 minute to screen for vascular
following the procedure and to wash
lesions that cause bleeding. Images
hands meticulously with soap and
are taken every 5 minutes for the
water after each voiding for 24 hours
next 60 minutes in the anterior,
after the procedure.
oblique, and lateral views, and a
postvoid anterior view is taken. ➤ Tell all caregivers to wear gloves
➤ If the patient is having major GI when discarding urine for 24 hours
bleeding, closely monitor vital signs after the procedure. Wash gloved
during the procedure. hands with soap and water before
removing gloves. Then wash hands
➤ Wear gloves during the radionuclide after the gloves are removed.
injection and while handling the
patient’s urine. ➤ A physician specializing in this
branch of medicine sends a written
Post-test: report to the ordering provider, who
discusses the results with the
➤ Evaluate the patient’s vital signs. patient.
➤ Instruct the patient to resume ➤ Evaluate test results in relation
normal activity, medications, and to the patient’s symptoms and
diet, unless otherwise indicated. other tests performed. Related
➤ Advise the patient to drink increased diagnostic tests include angiogra-
amounts of fluids for 24 to 48 hours phy, magnetic resonance imaging,
to eliminate the radionuclide from and computed tomography of the
the body, unless contraindicated. Tell abdomen.
GLUCAGON
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Plasma (1 mL) collected in chilled, lavender-top (ethylenedi-
aminetetra-acetic acid [EDTA]) tube. Specimen should be transported
tightly capped and in an ice slurry.
SI Unit
Age Conventional Units (Conversion Factor 1)
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
Copyright © 2003 F.A. Davis Company
Glucagon 535
Glucose 537
GLUCOSE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 0.0555)
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 75–110 mg/dL 4.2–6.1 mmol/L
60–90 y 80–115 mg/dL 4.7–6.4 mmol/L
Older than 75–120 mg/dL 4.2–6.7 mmol/L
90 y
2-Hour Postprandial
2-h Postprandial Less than 105 mg/dL Less than 5.8 mmol/L
Glucose 539
include abdominal pain, fatigue, muscle counts can lead to falsely decreased
cramps, nausea, vomiting, polyuria, and glucose values.
thirst. Possible interventions include
• Failure to follow dietary restrictions
subcutaneous or IV injection of insulin
before the fasting test can lead to falsely
with continuous glucose monitoring.
elevated glucose values.
INTERFERING FACTORS: • Administration of insulin or oral hypo-
• Drugs that may increase glucose glycemic agents within 8 hours of a
levels include acetazolamide, alanine, fasting blood glucose can lead to falsely
albuterol, anesthetic agents, antipyrine, decreased values.
atenolol, betamethasone, cefotaxime,
chlorpromazine, chlorprothixene, • Specimens should never be collected
clonidine, clorexolone, corticotropin, above an IV line because of the poten-
cortisone, cyclic AMP, cyclopropane, tial for dilution when the specimen
dexamethasone, dextroamphetamine, and the IV solution combine in the
diapamide, epinephrine, enflurane, collection container, falsely decreasing
ethacrynic acid, ether, fludrocorti- the result. There is also the potential of
sone, fluoxymesterone, furosemide, contaminating the sample with the
glucagon, glucocorticoids, homohar- substance of interest, contained in the
ringtonine, hydrochlorothiazide, IV solution, falsely increasing the
hydroxydione, isoniazid, maltose, result.
meperidine, meprednisone, methy-
clothiazide, metolazone, niacin,
nifedipine, nortriptyline, octreotide, Nursing Implications and
oral contraceptives, oxyphenbutazone, Procedure ● ● ● ● ● ● ● ● ● ● ●
GLUCOSE-6-PHOSPHATE
DEHYDROGENASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: G6PD.
SPECIMEN: Whole blood (1 mL) collected in a lavender-top (ethylenedi-
aminetetra-acetic acid [EDTA]) tube.
Copyright © 2003 F.A. Davis Company
SI Units
Conventional Units (Conversion Factor 0.0555)
Standard Oral
Tolerance
Fasting sample Less than 126 mg/dL Less than 7.0 mmol/L
2-hour sample Less than 200 mg/dL Less than 11.1 mmol/L
Standard Less than 141 mg/dL Less than 7.8 mmol/L
Gestational
Screen
Standard
Gestational
Tolerance
Fasting sample 75–104 mg/dL 4.2–5.8 mmol/L
1-hour sample 75–180 mg/dL 4.2–10.0 mmol/L
2-hour sample 75–164 mg/dL 4.2–9.1 mmol/L
3-hour sample 75–144 mg/dL 4.2–8.0 mmol/L
Plasma glucose values are reported to be 10–20% higher than serum values.
INDICATIONS: Hemochromatosis
• Evaluate abnormal fasting or postpran- Hyperlipidemia
dial blood glucose levels that do not
clearly indicate diabetes • Decreased glycogenesis:
Hyperthyroidism
• Evaluate glucose metabolism in
women of childbearing age, especially Infections
women who are pregnant and have Liver disease (severe)
(1) a history of previous fetal loss or Stress
birth of infants weighing 9 pounds or Pheochromocytoma
more, and/or (2) a family history of
diabetes Pregnancy
von Gierke disease
• Identify abnormal renal tubular func-
tion if glycosuria occurs without
hyperglycemia CRITICAL VALUES: N/A
• Identify impaired glucose metabolism
without overt diabetes
INTERFERING FACTORS:
• Drugs and substances that may
• Support the diagnosis of hyperthy- increase GTT values include acetylsali-
roidism and alcoholic liver disease, cylic acid, atenolol, bendroflumethi-
which are characterized by a sharp rise azide, clofibrate, fenfluramine, fluoxy-
in blood glucose followed by a decline mesterone, glyburide, guanethidine,
to subnormal levels lisinopril, methandrostenolone, meto-
prolol, nandrolone, niceritrol, nifedip-
RESULT ine, nitrendipine, norethisterone,
phenformin, phenobarbital, prazosin,
Tolerance increased in: terazosin, and caffeine.
• Decreased absorption of glucose: • Drugs and substances that may
Adrenal insufficiency (Addison’s decrease GTT values include acebu-
disease, hypopituitarism) tolol, beclomethasone, bendroflume-
Hypothyroidism thiazide, betamethasone, calcitonin,
Intestinal diseases, such as celiac catecholamines, chlorothiazide, chlor-
disease and tropical sprue promazine, chlorthalidone, cimetidine,
Whipple’s disease corticotropin, cortisone, danazol,
deflazacort, dexamethasone, diapa-
• Increased insulin secretion: mide, diethylstilbestrol, ethacrynic
Pancreatic islet cell tumor acid, fludrocortisone, furosemide,
glucagon, glucocorticosteroids, heroin,
Tolerance impaired in:
hydrochlorothiazide, mephenytoin,
• Increased absorption of glucose: mestranol, methadone, methandro-
Excessive intake of glucose stenolone, methylprednisolone, muzo-
Gastrectomy limine, niacin, nifedipine, norethin-
Gastroenterostomy drone, norethynodrel, oral contra-
Hyperthyroidism ceptives, paramethasone, perphena-
zine, phenolphthalein, phenothiazine,
Vagotomy
phenytoin, pindolol, prednisolone,
• Decreased usage of glucose: prednisone, propranolol, quinetha-
Central nervous system lesions zone, thiazides, triamcinolone,
Cushing’s syndrome triamterene, and verapamil.
Diabetes • The test should be performed on
Copyright © 2003 F.A. Davis Company
ambulatory patients. Impaired physical ➤ The patient should fast for at least 8
activity affects test results. to 12 hours before the standard oral
and standard gestational GTTs.
• Failure of the patient to ingest a diet ➤ Review the procedure with the
with sufficient carbohydrate content patient.
(e.g., 150 g/day) for at least 3 days ➤ Inform the patient that specimen
before the test can result in falsely collection takes approximately 5 to
decreased values. 10 minutes.
• Impaired physical activity can lead to
falsely increased values. Intratest:
➤ Ensure that the patient has complied
• Excessive physical activity before or with dietary preparations and other
during the test can lead to falsely pretesting restrictions.
decreased values.
➤ Direct the patient to breathe
• Smoking before or during the test can normally and to avoid unnecessary
lead to falsely increased values. movement.
➤ Observe standard precautions and
• The patient should not be under recent follow the general guidelines in
or current physiologic stress during Appendix A. Perform the venipunc-
the test. If the patient has had recent ture, and collect the specimen in a 5-
surgery (less than 2 weeks previously), mL gray-top tube.
an infectious disease, or a major illness
(e.g., myocardial infarction), the test Standard oral GTT:
should be delayed or rescheduled. ➤ The standard oral GTT takes 2 hours.
A fasting blood glucose is deter-
mined before administration of an
oral glucose load. If the fasting blood
Nursing Implications and glucose is less than 126 mg/dL, the
Procedure ● ● ● ● ● ● ● ● ● ● ●
patient is given an oral glucose load.
➤ An oral glucose load should not be
Pretest: administered before the value of the
➤ Obtain a history of the patient’s fasting specimen has been received.
complaints, including a list of known If the fasting blood glucose is
allergens. greater than 126 mg/dL, the glucola
is not administered and the test is
➤ Obtain a history of the patient’s canceled. The laboratory will follow
endocrine system as well as results its protocol as far as notifying the
of previously performed tests and patient of his or her glucose level
procedures. For related tests, refer and the reason why the test was
to the endocrine system table. canceled. The requesting health care
➤ Obtain a list of medications practitioner will then be issued a
the patient is taking, including report indicating the glucose level
herbs, nutritional supplements, and and the cancellation of the test. A
nutraceuticals. The requesting health fasting glucose greater than 126
care practitioner and laboratory mg/dL indicates diabetes; therefore
should be advised if the patient the glucola would never be adminis-
regularly uses these products so tered before allowing the requesting
that their effects can be taken into health care practitioner to evaluate
consideration when reviewing the clinical situation.
results. ➤ Adults receive 75 g and children
➤ There are no fluid or medication receive 1.75 g/kg ideal weight, not to
restrictions unless by medical direc- exceed 75 g. The glucose load
tion. should be consumed within 5
Copyright © 2003 F.A. Davis Company
minutes, and time 0 begins as soon specimen label. Do not wait until all
as the patient begins to ingest the specimens have been collected to
glucose load. A second specimen is transport.
collected at 2 hours, concluding the
test. The test is discontinued if the
Post-test:
patient vomits before all specimens
have been collected. ➤ Observe venipuncture site for bleed-
ing or hematoma formation. Apply
Standard gestational screen: pressure bandage.
➤ The standard gestational screen is ➤ Instruct the patient to resume usual
performed on pregnant women. If diet as directed by the health care
results from the screen are abnor- practitioner.
mal, a full gestational GTT is
➤ The nutritional needs of each
performed. The gestational screen
diabetic patient need to be deter-
does not require a fast. The patient
mined individually (especially during
is given a 50-g oral glucose load.
pregnancy) with the appropriate
The glucose load should be consu-
health care professionals, particu-
med within 5 minutes, and time
larly professionals trained in nutri-
0 begins as soon as the patient
tion. Patients who adhere to dietary
begins to ingest the glucose load.
recommendations report a better
One hour after ingestion, a speci-
general feeling of health, better
men is collected. The test is discon-
weight management, greater control
tinued if the patient vomits before
of glucose and lipid values, and
the 1-hour specimen has been
improved use of insulin. There is no
collected.
“diabetic diet”; however, many
Standard gestational GTT: meal-planning approaches with
nutritional goals are endorsed by the
➤ The standard gestational GTT takes American Dietetic Association. The
3 hours. A fasting blood glucose is nutritional needs of each diabetic
determined before administration of patient need to be determined
a 100-g oral glucose load. If the fast- individually with the appropriate
ing blood glucose is less than 200 health care professionals, particu-
mg/dL, the patient is given an oral larly professionals trained in nutri-
glucose load. tion.
➤ An oral glucose load should not be ➤ Impaired glucose tolerance may be
administered before the value of the associated with diabetes. Instruct
fasting specimen has been received. the patient and caregiver to report
If the fasting blood glucose is signs and symptoms of hypo-
greater than 126 mg/dL, the glucola glycemia (weakness, confusion,
is not administered and the test is diaphoresis, rapid pulse) or hyper-
canceled (see previous explanation). glycemia (thirst, polyuria, hunger,
➤ The glucose load should be lethargy).
consumed within 5 minutes, and ➤ Recognize anxiety related to test
time 0 begins as soon as the patient results and offer support. Provide
begins to ingest the glucose teaching and information regarding
load. Subsequent specimens are the clinical implications of the test
collected at 1, 2, and 3 hours, results, as appropriate. Emphasize,
concluding the test. The test is as appropriate, that good glycemic
discontinued if the patient vomits control delays the onset of and
before all specimens have been slows the progression of diabetic
collected. retinopathy, nephropathy, and
➤ Label the specimen, and promptly neuropathy. Educate the patient
transport it to the laboratory. You regarding access to counseling serv-
must note the collection time on the ices, as appropriate.
Copyright © 2003 F.A. Davis Company
-Glutamyltransferase 547
-GLUTAMYLTRANSFERASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Sex Conventional Units (Conversion Factor 0.017)
Male 1–94 U/L 0.02–1.6 Kat/L
Female 1–70 U/L 0.02–1.2 Kat/L
• Conditions that decrease red blood cell ➤ There are no food, fluid, or medica-
life span tion restrictions unless by medical
direction.
• Hemolytic anemia ➤ Review the procedure with the
• Pregnancy patient.
➤ Inform the patient that specimen
CRITICAL VALUES: N/A collection takes approximately 5 to
10 minutes.
INTERFERING FACTORS:
• Drugs that may increase glycated Intratest:
hemoglobin A1C values include
➤ Direct the patient to breathe
hydrochlorothiazide, indapamide, normally and to avoid unnecessary
insulin, morphine, propranolol, and movement.
sulfonylureas.
➤ Observe standard precautions and
• Drugs that may decrease glycated follow the general guidelines in
hemoglobin A1C values include carba- Appendix A. Perform a venipuncture,
mate, galactose, metformin, and salicy- and collect the specimen in a 5-mL
late. lavender-top tube.
➤ Label the specimen, and promptly
• Conditions involving abnormal hemo- transport it to the laboratory.
globins (hemoglobinopathies) affect
the reliability of glycated hemoglobin Post-test:
A1C values, causing (1) falsely increased
values, (2) falsely decreased values, or ➤ Observe venipuncture site for bleed-
(3) discrepancies in either direction ing or hematoma formation. Apply
depending on the method. pressure bandage.
➤ Increased glycated hemoglobin A1C
levels may be associated with
diabetes. Instruct the diabetic
Nursing Implications and patient, as appropriate, in nutritional
Procedure ● ● ● ● ● ● ● ● ● ● ● management of the disease.
Patients who adhere to dietary
Pretest: recommendations report a better
general feeling of health, better
➤ Obtain a history of the patient’s weight management, greater control
complaints, including a list of known of glucose and lipid values, and
allergens. improved use of insulin. There is no
➤ Obtain a history of the patient’s “diabetic diet”; however, many
endocrine system as well as results meal-planning approaches with
of previously performed tests and nutritional goals are endorsed by the
procedures. For related tests, refer American Dietetic Association. The
to the endocrine system table. nutritional needs of each diabetic
➤ Obtain a list of medications patient must be determined individ-
the patient is taking, including ually with the appropriate health
herbs, nutritional supplements, and care professionals, particularly
nutraceuticals. The requesting health professionals trained in nutrition.
care practitioner and laboratory ➤ Instruct the patient and caregiver to
should be advised if the patient report signs and symptoms of hypo-
regularly uses these products so glycemia (weakness, confusion,
that their effects can be taken into diaphoresis, rapid pulse) or hyper-
consideration when reviewing glycemia (thirst, polyuria, hunger,
results. lethargy).
Copyright © 2003 F.A. Davis Company
GRAM STAIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Blood, biopsy specimen, or body fluid as collected for culture.
REFERENCE VALUE: N/A.
RESULT
Acid Fast or
Gram Partial Acid
Positive Gram Negative 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 Enterobacter Proteus
(gram variable) Escherichia Pseudomonas
Peptostreptococcus Flavobacter Rickettsia
Propionibacterium Francisella Salmonella
Rhodococcus Fusobacterium Serratia
Staphylococcus Gardnerella Shigella
Streptococcus Haemophilus Vibrio
Note: Treponema species are classified as gram-negative spirochetes, but they are most
often visualized using dark-field or silver staining techniques.
➤ Obtain a history of the patient’s ➤ Inform the patient that the test helps
complaints, including a list of known identify organisms that cause infec-
allergens. tions.
➤ Obtain a history of the patient’s ➤ Review the procedure with the
gastrointestinal, genitourinary, im- patient.
mune, reproductive, and respiratory ➤ The time it takes to collect a proper
systems, as well as results of previ- specimen varies according to the
ously performed tests and proce- patient’s level of cooperation as well
dures. For related tests, refer to as the specimen collection site.
Copyright © 2003 F.A. Davis Company
Intratest: Post-test:
➤ Specific collection instructions are ➤ Evaluate test results in relation to
found in the associated culture the patient’s symptoms and other
monograph. tests performed. Related laboratory
➤ Label the specimen, and promptly tests include bacterial and viral
transport it to the laboratory. cultures.
Haptoglobin 559
HAPTOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 0.01)
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
SYNONYM/ACRONYM: H. pylori.
SPECIMEN: Serum (1 mL) collected in a plain red-top tube.
REFERENCE VALUE: (Method: Enzyme-linked immunosorbent assay
[ELISA]) Negative.
Intratest: Post-test:
HEMATOCRIT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Hematocrit
Hematocrit 563
Hematocrit 565
HEMOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Hgb.
SPECIMEN: Whole blood from one full lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube, Microtainer, or capillary. Whole blood from a
green-top (lithium or sodium heparin) tube may also be submitted.
SI Units
Age Conventional Units (Conversion Factor 10)
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
Hemoglobin 567
the right represents a decrease in the tration. The Hct should be within
affinity of Hgb for O2. Conditions three times the Hgb if the RBC popu-
that can cause a rightward shift lation is normal in size and shape.
include increased body temperature, The Hct plus six should approximate
increased 2,3-DPG levels, increased the first two figures of the RBC count
CO2 concentration, or decreased pH. within three (e.g., Hct is 40 percent;
Hgb levels are a direct reflection of therefore 40 6 46, and the RBC
the O2-combining capacity of the count should be 4.6 or in the range of
blood. It is the combination of heme 4.3–4.9). There are some cultural
and O2 that gives blood its character- variations in Hgb and Hct (H&H)
istic red color. RBC counts parallel values. After the first decade of life,
the O2-combining capacity of Hgb, the mean Hgb in African-Americans
but because some RBCs contain more is 0.5 to 1.0 g lower than in
Hgb than other cells, the relationship Caucasians. Mexican-Americans and
is not directly proportional. As CO2 Asian-Americans have higher Hgb
diffuses into RBCs, an enzyme called and H&H values than Caucasians. ■
carbonic anhydrase converts the CO2
into bicarbonate and hydrogen ions. INDICATIONS:
Hgb that is not bound to O2 • Detect hematologic disorder, neo-
combines with the free hydrogen plasm, or immunologic abnormality
ions, increasing pH. As this binding is • Determine the presence of hereditary
occurring, bicarbonate is leaving the hematologic abnormality
RBC in exchange for chloride ions. • Evaluate known or suspected anemia
(For additional information about the and related treatment, in combination
relationship between the respiratory with Hct
and renal components of this buffer
• Monitor blood loss and response to
system, see monograph titled “Blood blood replacement, in combination
Gases.”) with Hct
Hgb is included in the complete
blood count (CBC) and generally • Monitor the effects of physical or
emotional stress on the patient
performed with a hematocrit (Hct).
These levels parallel each other and • Monitor hematologic status during
are frequently used to evaluate pregnancy, in combination with Hct
anemia. Polycythemia is a term used in • Monitor the progression of nonhema-
conjunction with conditions resulting tologic disorders, such as chronic
from an abnormal increase in Hgb, obstructive pulmonary disease
Hct, and RBC count. Anemia is a (COPD), malabsorption syndromes,
term associated with conditions cancer, and renal disease
resulting from an abnormal decrease • Monitor response to drugs or
in Hgb, Hct, and RBC count. Results chemotherapy, and evaluate undesired
of the Hgb, Hct, and RBC count reactions to drugs that may cause
should be evaluated simultaneously blood dyscrasias
because the same underlying condi- • Provide screening as part of a CBC in a
tions affect this triad of tests similarly. general physical examination, espe-
The RBC count multiplied by three cially upon admission to a health care
should approximate the Hgb concen- facility or before surgery
Copyright © 2003 F.A. Davis Company
Hemoglobin 569
HEMOGLOBIN ELECTROPHORESIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A
SPECIMEN: Whole blood (1 mL) collected in a lavender-top (ethylenedi-
aminetetra-acetic acid [EDTA]) tube.
Hgb A
Adult Greater than 95%
Hgb A2
Adult 1.5–3.7%
(Continued on the following page)
Copyright © 2003 F.A. Davis Company
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%
Hemosiderin 573
HEMOSIDERIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
complaints, including a list of known oughly wash his hands, (2) cleanse
allergens. the meatus, (3) void a small amount
➤ Obtain a history of the patient’s into the toilet, and (4) void directly
hematopoietic system, especially a into the specimen container.
history of hemolytic anemia, as well ➤ Instruct the female patient to (1)
as results of previously performed thoroughly wash her hands; (2)
tests and procedures. For related cleanse the labia from front to back;
tests, refer to the hematopoietic (3) while keeping the labia sepa-
system table. rated, void a small amount into the
➤ Obtain a list of the medications toilet; and (4) without interrupting
the patient is taking, including the urine stream, void directly into
herbs, nutritional supplements, and the specimen container.
nutraceuticals. The requesting health
care practitioner and laboratory Indwelling catheter:
should be advised if the patient
➤ Put on gloves. Empty drainage tube
regularly uses these products so
of urine. It may be necessary to
that their effects can be taken
clamp off the catheter for 15 to 30
into consideration when reviewing
minutes before specimen collection.
results.
Cleanse specimen port with antisep-
➤ There are no food, fluid, or medica- tic swab, and then aspirate 5 mL of
tion restrictions unless by medical urine with a 21- to 25-gauge needle
direction. and syringe. Transfer urine to a
➤ Review the procedure with the collection container.
patient. ➤ Label the specimen, and promptly
➤ Inform the patient that specimen transport it to the laboratory.
collection takes approximately 5 to
10 minutes.
Post-test:
Intratest: ➤ Evaluate test results in relation to
the patient’s symptoms and other
➤ Observe standard precautions and
tests performed. Related laboratory
follow the general guidelines in
tests include bone marrow studies,
Appendix A.
complete blood count (CBC), iron/
total iron-binding capacity, ferritin,
Clean-catch specimen:
kidney biopsy, lead, and RBC
➤ Instruct the male patient to (1) thor- morphology.
HEPATITIS A ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
➤ There are no food, fluid, or medica- needle stick, perinatal period, sexual
tion restrictions unless by medical contact) for temporary, passive
direction. protection. Some studies have indi-
➤ Review the procedure with the cated that alpha interferon may be
patient. useful in the treatment of chronic
hepatitis.
➤ Inform the patient that specimen
collection takes approximately 5 to ➤ Counsel the patient and significant
10 minutes. contacts, as appropriate, that HBIG
immunization is available and has
Intratest: in fact become a requirement in
many places as part of childhood
➤ Direct the patient to breathe immunization and employee health
normally and to avoid unnecessary programs. Parents may choose to
movement. sign a waiver preventing their
➤ Observe standard precautions and newborns from receiving the
follow the general guidelines in vaccine; they may choose not to
Appendix A. Perform a venipuncture, vaccinate on the basis of philosophi-
and collect the specimen in a 5-mL cal, religious, or medical reasons.
red- or tiger-top tube. Vaccination regulations vary from
state to state.
➤ Label the specimen, and promptly
transport it to the laboratory. ➤ Inform the patient that positive find-
ings must be reported to local health
Post-test: department officials, who will ques-
tion him or her regarding sexual part-
➤ Observe venipuncture site for bleed- ners.
ing or hematoma formation. Apply ➤ Offer support, as appropriate, to
pressure bandage. patients who may be the victims of
➤ Dietary recommendations may be rape or other forms of sexual assault
indicated and will vary depending including children and elderly individ-
on the type and severity of the uals. Educate the patient regarding
condition. Elimination of alcohol access to counseling services. Pro-
ingestion and a diet optimized vide a nonjudgmental, nonthreaten-
for convalescence are commonly ing atmosphere for a discussion
included in the treatment plan. A during which the risks of sexually
high-calorie, high-protein, moderate- transmitted diseases are explained.
fat diet with a high fluid intake is It is also important to discuss the
often recommended for patients problems that the patient may expe-
with hepatitis. rience (e.g., guilt, depression, anger)
➤ Recognize patient anxiety related to if test results indicate the presence
test results and offer support. of hepatitis B antigen.
Provide teaching and information ➤ Evaluate test results in relation to
regarding the clinical implications of the patient’s symptoms and other
the test results, as appropriate. tests performed. Related laboratory
Counsel the patient, as appropriate, tests include alanine aminotrans-
regarding risk of transmission and ferase, alkaline phosphatase, aspar-
proper prophylaxis. Hepatitis B tate aminotransferase, bilirubin,
immune globulin (HBIG) vaccination liver biopsy, -glutamyl transpepti-
should be given immediately after dase, human immunodeficiency
situations in which there is a poten- virus (HIV) serology, and hepatitis C
tial for HBV exposure (e.g. accidental serology.
Copyright © 2003 F.A. Davis Company
HEPATITIS C ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
HEPATITIS D ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
➤ There are no food, fluid, or medica- fat diet with a high fluid intake is
tion restrictions unless by medical often recommended for patients
direction. with hepatitis.
➤ Review the procedure with the ➤ Recognize patient anxiety related
patient. to test results and offer support.
➤ Inform the patient that specimen Provide teaching and information
collection takes approximately 5 to regarding the clinical implications of
10 minutes. the test results, as appropriate.
Counsel the patient, as appropriate,
Intratest: regarding the risk of transmission
and proper prophylaxis. Hepatitis B
➤ Direct the patient to breathe immune globulin (HBIG) vaccination
normally and to avoid unnecessary should be given immediately after
movement. situations in which there is a poten-
➤ Observe standard precautions and tial for HBV exposure (e.g., acciden-
follow the general guidelines in tal needle stick, perinatal period,
Appendix A. Perform a venipuncture, sexual contact) for temporary,
and collect the specimen in a 5-mL passive protection. Counsel the
red- or tiger-top tube. patient and significant contacts, as
appropriate, that HBIG immunization
➤ Label the specimen, and promptly is available and has in fact become a
transport it to the laboratory. requirement in many places as part
of childhood immunization and
Post-test: employee health programs. Parents
➤ Observe venipuncture site for bleed- may choose to sign a waiver
ing or hematoma formation. Apply preventing their newborns from
pressure bandage. receiving the vaccine; they may
choose not to vaccinate on the
➤ Dietary recommendations may be basis of philosophical, religious, or
indicated and will vary depending medical reasons. Vaccination regula-
on the type and severity of the tions vary from state to state.
condition. Elimination of alcohol
ingestion and a diet optimized ➤ Evaluate test results in relation to
for convalescence are commonly the patient’s symptoms and other
included in the treatment plan. A tests performed. Related laboratory
high-calorie, high-protein, moderate- tests include hepatitis B serology.
HEPATOBILIARY SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Patients who are very obese, who may shield, or leave the area while the
exceed the weight limit for the equip- examination is being done. Personnel
ment working in the area where the exami-
nation is being done should wear
• Incorrect positioning of the patient, badges that reveal their level of expo-
which may produce poor visualization sure to radiation.
of the area to be examined
• Retained barium from a previous radi-
ologic procedure Nursing Implications and
• Metallic objects within the examina- Procedure ● ● ● ● ● ● ● ● ● ● ●
HER-2/NEU ONCOPROTEIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: c-erb-B2.
Copyright © 2003 F.A. Davis Company
HEXOSAMINIDASE A AND B
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
Copyright © 2003 F.A. Davis Company
Total SI Units
Hexosaminidase Conventional Units (Conversion Factor 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 1027 Greater than
homozygote nmol/h/mL 17.15 U/L
SI Units
Hexosaminidase A Conventional Units (Conversion Factor 0.0167)
Noncarrier 456–592 nmol/h/mL 7.2–9.88 U/L
Heterozygote 197–323 nmol/h/mL 3.3–5.39 U/L
Tay-Sachs 0 nmol/h/mL 0 U/L
homozygote
SI Units
Hexosaminidase B Conventional Units (Conversion Factor 0.0167)
Noncarrier 12–32 nmol/h/mL 0.2–0.54 U/L
Heterozygote 21–81 nmol/h/mL 0.35–1.35 U/L
Tay-Sachs Greater than Greater than 5.09 U/L
homozygote 305 nmol/h/mL
HOLTER MONITOR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
turn on the recorder. Tape all wires ➤ Advise the patient to immediately
to the chest, and place the belt report symptoms such as fast heart
or shoulder strap in the proper rate or difficulty breathing.
position.
➤ Compare the activity log and tape
recordings for changes during the
Post-test: monitoring period.
➤ Gently remove the tape and other ➤ A physician specializing in this
items securing the electrodes to the branch of medicine sends a written
patient. report to the ordering provider, who
➤ Instruct the patient to resume discusses the results with the
ordered medications that were patient.
discontinued before the procedure. ➤ Evaluate test results in relation
➤ Instruct the patient to resume to the patient’s symptoms and
pretest activities after the proce- other tests performed. Related
dure, or as ordered, and to resume tests include ECG and echocardio-
previous diet. gram.
HOMOCYSTEINE AND
METHYLMALONIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
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 (ethylenediaminetetra-acetic acid
[EDTA]) tube may be acceptable for the homocysteine measurement. The
laboratory should be consulted before specimen collection because specimen
type may be method dependent. Care must be taken to use the same type of
collection container if serial measurements are to be taken.
HOMOVANILLIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HVA.
SPECIMEN: Urine (10 mL) from a timed specimen collected in a clean plas-
tic collection container with 6N HCl as a preservative.
Intratest: Post-test:
➤ Ensure that the patient has complied ➤ Instruct the patient to resume usual
with dietary preparations and other medication as directed by the health
pretesting restrictions. care practitioner.
➤ Observe standard precautions and ➤ Evaluate test results in relation to
follow the general guidelines in the patient’s symptoms and other
Appendix A. Obtain a clean 3-L urine tests performed. Related labora-
specimen container, toilet-mounted tory tests include carcinoembryonic
collection device, and plastic bag antigen, catecholamines, urine cate-
(for transport of the specimen cholamines, metanephrines, and
container). The specimen must be vanillylmandelic acid.
Copyright © 2003 F.A. Davis Company
SI Units
Conventional Units (Conversion Factor 1)
Males and Less than 5 mIU/mL Less than 5 IU/L
nonpregnant
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
RESULT
Pretest:
Increased in:
➤ Obtain a history of the patient’s
• Choriocarcinoma complaints, including a list of known
allergens.
• Ectopic HCG-producing tumors
(stomach, lung, colon, pancreas, liver, ➤ Obtain a history of the patient’s
breast) endocrine, immune, and reproduc-
tive systems, as well as results of
• Erythroblastosis fetalis previously performed tests and
procedures. For related tests, refer
• Germ cell tumors (ovary and testes) to the endocrine, immune, and
• Hydatidiform mole reproductive system tables.
➤ Obtain a list of the medications the
• Islet cell tumors patient is taking, including herbs,
• Multiple gestation pregnancy nutritional supplements, and nutra-
ceuticals. The requesting health care
• Pregnancy practitioner and laboratory should be
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: HIV-1/HIV-2.
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: HLA-B27.
Copyright © 2003 F.A. Davis Company
Post-test:
Pretest: ➤ Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s ing or hematoma formation. Apply
complaints, including a list of known pressure bandage.
allergens. ➤ Warn the patient that false-positive
➤ Obtain a history of the patient’s results occur and that the absence
immune system, a history of of antibody does not guarantee
high-risk behaviors, and results of absence of infection, because the
previously performed tests and virus may be latent or not have
procedures. For related tests, refer produced detectable antibody at the
to the immune system table. time of testing.
➤ Obtain a list of the medications ➤ Recognize anxiety related to test
the patient is taking, including results and offer support. Provide
herbs, nutritional supplements, and teaching and information regarding
nutraceuticals. The requesting health the clinical implications of the test
care practitioner and laboratory results, as appropriate. Counsel the
should be advised if the patient patient, as appropriate, regarding
regularly uses these products so risk of transmission and proper
that their effects can be taken into prophylaxis, and reinforce the impor-
consideration when reviewing tance of strict adherence to the
results. treatment regime.
➤ There are no food, fluid, or medica- ➤ Inform the patient that the presence
tion restrictions unless by medical of HTLV-I/HTLV-II antibodies pre-
direction. cludes blood donation, but it does
not mean that leukemia or a neuro-
➤ Review the procedure with the logic disorder is present or will
patient. develop.
➤ Inform the patient that specimen ➤ Inform the patient that subsequent
collection takes approximately 5 to retesting may be necessary.
10 minutes.
➤ Evaluate test results in relation to
Intratest: the patient’s symptoms and other
tests performed. Related laboratory
➤ Direct the patient to breathe tests include complete blood count,
normally and to avoid unnecessary HIV-1/HIV-2, and hepatitis antigens
movement. and antibodies.
Copyright © 2003 F.A. Davis Company
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.
replace the tubing and container test start and stop times, and inges-
system at the start of the collection tion of any foods or medications that
time. Keep the container system on can affect test results.
ice during the collection period, or
empty the urine into a larger Post-test:
container periodically during the
collection period; monitor to ensure ➤ Instruct the patient to resume usual
continued drainage. Conclude the diet and medication as directed by
test the next morning at the same the requesting health care practi-
hour the collection was begun. tioner. Consideration may be given
to niacin supplementation and
➤ At the conclusion of the test, increased protein, if appropriate, for
compare the quantity of urine with patients with abnormal findings. In
the urinary output record for the some cases, the tumor may divert
collection; if the specimen contains dietary tryptophan to serotonin,
less than what was recorded as resulting in pellagra.
output, some urine may have been
➤ Evaluate test results in relation to
discarded, invalidating the test.
the patient’s symptoms and other
➤ Label the specimen, and promptly tests performed. A related labora-
transport it to the laboratory. Include tory test is biopsy of the affected
on the label the amount of urine, tissue.
HYPERSENSITIVITY PNEUMONITIS
SEROLOGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
test result does not rule out hypersen- regularly uses these products so
sitivity pneumonitis as a possible that their effects can be taken
into consideration when reviewing
diagnosis, nor does a positive test results.
result confirm the diagnosis. Also,
➤ There are no food, fluid, or medica-
individuals with a positive test result tion restrictions unless by medical
may not exhibit the typical symp- direction.
toms, and patients with severe symp- ➤ Review the procedure with the
toms may not have detectable levels of patient.
antibody while their disease is inac- ➤ Inform the patient that specimen
tive. To confirm the diagnosis, it is collection takes approximately 5 to
necessary to obtain a sputum culture 10 minutes.
and chest x-rays. ■
Intratest:
INDICATIONS: Assist in establishing a ➤ Direct the patient to breathe
diagnosis of hypersensitivity pneumonitis normally and to avoid unnecessary
in patients experiencing fever, chills, and movement.
dyspnea after repeated exposure to moist ➤ Observe standard precautions and
organic sources follow the general guidelines in
Appendix A. Perform a venipuncture
and collect the specimen in a 5-mL
RESULT red-top tube.
➤ Label the specimen, and promptly
Increased in: Hypersensitivity pneu- transport it to the laboratory.
monitis
Post-test:
CRITICAL VALUES: N/A ➤ Observe venipuncture site for bleed-
ing or hematoma formation. Apply
INTERFERING FACTORS: N/A pressure bandage.
➤ Positive test results may be associ-
ated with respiratory disease.
Nursing Implications and Malnutrition is commonly seen in
Procedure ● ● ● ● ● ● ● ● ● ● ●
patients with severe respiratory
disease for reasons including fatigue
Pretest: and lack of appetite. The importance
of following the prescribed diet
➤ Obtain a history of the patient’s should be stressed to the patient
complaints, including a list of known and/or caregiver.
allergens. ➤ Instruct the patient in preventive
➤ Obtain a history of the patient’s measures for protecting his or her
immune and respiratory systems, as lungs (e.g., avoid contact with
well as results of previously persons who have respiratory or
performed tests and procedures. For other infections, avoid use of
related tests, refer to the immune tobacco, avoid highly polluted areas
and respiratory system tables. as well as work environments with
➤ Obtain a list of the medications hazards such as fumes, dust, and
the patient is taking, including other respiratory pollutants).
herbs, nutritional supplements, and ➤ Instruct the patient in deep breath-
nutraceuticals. The requesting health ing and pursed-lip breathing to
care practitioner and laboratory enhance breathing patterns, as
should be advised if the patient appropriate.
Copyright © 2003 F.A. Davis Company
Hysterosalpingography 609
HYSTEROSALPINGOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Elderly and other patients who are • Risks associated with radiographic
chronically dehydrated before the overexposure can result from frequent
test, because of their risk of x-ray procedures. Personnel in the
contrast-induced renal failure. room with the patient should wear a
protective lead apron, stand behind a
• Patients who are in renal failure. shield, or leave the area while the
• Patients with menses, undiagnosed examination is being done. Personnel
vaginal bleeding, or pelvic inflamma- working in the area where the exami-
tory disease. nation is being done should wear
badges that reveal their level of expo-
• Young patients (17 years and younger), sure to radiation.
Copyright © 2003 F.A. Davis Company
Hysterosalpingography 611
Intratest:
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Ask the patient to void before the
procedure. Have the patient put on a
hospital gown.
Pretest:
➤ Ask the patient to lie still during
➤ Inform the patient that the proce- the procedure because movement
dure assesses the uterus and fallop- produces unclear images. Make
ian tubes and takes approximately sure jewelry, watches, chains, belts,
30 minutes. and any other metallic objects have
➤ Obtain a history of allergies or sensi- been removed.
tivities to contrast medium, shell- ➤ Remove any wires connected to
fish, or latex. electrodes, if allowed.
➤ Obtain a list of the medications the ➤ Administer enemas or suppositories
patient is taking. on the morning of the test, as
➤ Assess date of last menstrual period ordered.
and possibility of pregnancy in peri- ➤ Administer sedative, as ordered,
menopausal women. before the test.
➤ The procedure should be performed ➤ Place patient in a lithotomy position
2 to 5 days after menstruation ends. on the fluoroscopy table.
➤ Obtain a history of the patient’s ➤ A kidney, ureter, and bladder (KUB)
reproductive system and previously film is taken to ensure that no stool,
performed laboratory tests (espe- gas, or barium will obscure visualiza-
cially blood urea nitrogen and creati- tion of the uterus and fallopian
nine), surgeries, therapies, and tubes.
procedures. For related tests, refer
➤ A speculum is inserted into the
to the reproductive system table.
vagina, and contrast medium is
➤ Patients receiving metformin introduced into the uterus through
(Glucophage) for non–insulin- the cervix via a cannula, after which
dependent (type 2) diabetes should both fluoroscopic and radiographic
discontinue the drug on the day of films are taken.
the test and continue to withhold it
➤ The patient may experience tempo-
for 48 hours after the test. Failure to
rary sensations of nausea, dizziness,
do so may result in lactic acidosis.
bradycardia, or uterine cramping as
➤ Instruct the patient to take a laxative the contrast medium is instilled. The
or an enema the night before the patient may have shoulder pain
test, or as ordered. caused by subphrenic irritation from
➤ Restrict food and fluids for 8 hours the contrast medium as it leaks into
before the test. the peritoneal cavity.
➤ Explain to the patient that she may ➤ To take oblique views, the table may
feel menstrual-like cramping during be tilted or the patient may be asked
the procedure and shoulder pain to change position during the proce-
from subphrenic irritation from the dure.
contrast medium as it spills into the
peritoneal cavity. Post-test:
➤ Obtain a written, informed consent ➤ Direct the patient to resume usual
for the procedure from the patient. diet, activity, and medication, if
➤ Schedule barium and colonoscopy withheld and as directed by the
studies after completion of the physician. Renal function should
study, if ordered. be assessed before metformin is
➤ Wear gloves throughout the proce- restarted.
dure. ➤ Inform the patient of the possible
Copyright © 2003 F.A. Davis Company
IMMUNOFIXATION ELECTROPHORESIS,
SERUM 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.
ing test for light chains. IFE hematopoietic and immune sys-
has replaced immunoelectrophoresis tems, as well as results of previously
performed tests and procedures. As-
because it is more sensitive and easier sess whether the patient received
to interpret. ■ any vaccinations or immunizations
within the last 6 months or any
INDICATIONS: blood or blood components within
• Assist in the diagnosis of multiple the last 6 weeks. For related tests,
myeloma and amyloidosis refer to the hematopoietic and im-
mune system tables.
• Assist in the diagnosis of suspected ➤ Obtain a list of medications the
immunodeficiency patient is taking, including herbs,
• Assist in the diagnosis of suspected nutritional supplements, and nu-
immunoproliferative disorders, such as traceuticals. The requesting health
care practitioner and laboratory
multiple myeloma and Waldenström’s should be advised if the patient
macroglobulinemia regularly uses these products
• Identify biclonal or monoclonal so that their effects can be taken
gammopathies into consideration when reviewing
results.
• Identify cryoglobulinemia ➤ Note any recent procedures that can
• Monitor the effectiveness of chemo- interfere with test results.
therapy or radiation therapy ➤ There are no food, fluid, or medica-
tion restrictions unless by medical
RESULT: See monograph titled direction.
“Immunoglobulins A, D, G, and M.” ➤ Review the procedure with the
patient. Provide a nonmetallic urinal,
CRITICAL VALUES: N/A bedpan, or toilet-mounted collection
device.
INTERFERING FACTORS: ➤ Usually a 24-hour time frame for
• Drugs that may increase immunoglob- urine collection is ordered. Inform
the patient that all urine must be
ulin levels include asparaginase, cimeti- saved during that 24-hour period.
dine, and narcotics. Instruct the patient not to void
• Drugs that may decrease immunoglob- directly into the laboratory collection
ulin levels include dextran, oral contra- container. Instruct the patient to
avoid defecating in the collection
ceptives, phenytoin, and methylpred- device and to keep toilet tissue
nisolone (high doses). out of the collection device to
• Chemotherapy and radiation treat- prevent contamination of the speci-
ments may alter the width of the bands men. Place a sign in the bathroom
to remind the patient to save all
and make interpretation difficult. urine.
➤ Instruct the patient to void all urine
into the collection device and then to
Nursing Implications and pour the urine into the laboratory
Procedure ● ● ● ● ● ● ● ● ● ● ●
collection container. Alternatively
the specimen can be left in the
Pretest: collection device for a health care
staff member to add to the labora-
➤ Obtain a history of the patient’s tory collection container.
complaints, including a list of known ➤ Inform the patient that specimen
allergens. collection takes approximately 5 to
➤ Obtain a history of the patient’s 10 minutes.
Copyright © 2003 F.A. Davis Company
IMMUNOGLOBULIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: IgE.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Immunoassay)
SI Unit
Age Conventional Units (Conversion Factor 1)
Newborn Less than 12 IU/mL Less than 12 kIU/mL
Less than 1 y Less than 50 IU/mL Less than 50 kIU/mL
2–4 y Less than 100 IU/mL Less than 100 kIU/mL
5 y and older Less than 300 IU/m Less than 300 kIU/mL
Copyright © 2003 F.A. Davis Company
Immunoglobulin E 615
IMMUNOGLOBULINS A, D, G, AND M
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Immunoglobulin D
(Conversion Factor 10)
Newborn Greater than 2 mg/dL Greater than 20 mg/L
Adult Less than 15 mg/dL Less than 150 mg/L
Immunoglobulin G
(Conversion Factor 0.01)
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
(Conversion Factor 10)
Newborn Less than 25 mg/dL Less than 250 mg/L
1–9 mo 20–125 mg/dL 200–1250 mg/L
10–12 mo 40–150 mg/dL 400–1500 mg/L
2–8 y 45–200 mg/dL 450–2000 mg/L
9–12 y 50–250 mg/dL 500–2500 mg/L
Greater than 12 y 50–300 mg/dL 500–3000 mg/L
IMMUNOSUPPRESSANTS:
CYCLOSPORINE, METHOTREXATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Route of Recommended
Immunosuppressant Administration Collection Time
Cyclosporine Oral 12 hours after dose
Methotrexate Oral Varies according to dosing
protocol
Intramuscular Varies according to dosing
protocol
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay)
Glucose
Insulin 6.945 (Tolerance for
Insulin SI Units 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
INSULIN ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay) Less than 3 percent;
includes binding of human, beef, and pork insulin to antibodies in patient’s
serum.
Intratest:
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Direct the patient to breathe
normally and to avoid unnecessary
Pretest: movement.
➤ Observe standard precautions and
➤ Obtain a history of the patient’s follow the general guidelines in
complaints, including a list of known Appendix A. Perform a venipuncture,
allergens. and collect the specimen in a 5-mL
➤ Obtain a history of the patient’s en- red-top tube.
docrine and immune systems, as ➤ Label the specimen, and promptly
well as results of previously per- transport it to the laboratory.
formed tests and procedures. For re-
lated tests, refer to the endocrine
and immune system tables. Post-test:
➤ Obtain a list of medications the pa- ➤ Observe venipuncture site for bleed-
tient is taking, including herbs, nutri- ing or hematoma formation. Apply
tional supplements, and nutraceuti- pressure bandage.
cals. The requesting health care
practitioner and laboratory should be ➤ Instruct the patient and caregiver
advised if the patient is regularly us- to report signs and symptoms of
ing these products so that their ef- hypoglycemia (weakness, confu-
fects can be taken into consideration sion, diaphoresis, rapid pulse) or
when reviewing results. hyperglycemia (thirst, polyuria,
hunger, and lethargy).
➤ Note any recent procedures that can
interfere with test results. ➤ Emphasize, as appropriate, that
good glycemic control delays the
➤ There are no food, fluid, or medica- onset and slows the progression of
tion restrictions unless by medical diabetic retinopathy, nephropathy,
direction. and neuropathy.
➤ Review the procedure with the ➤ Evaluate test results in relation to
patient. the patient’s symptoms and other
➤ Inform the patient that specimen tests performed. Related laboratory
collection takes approximately 5 to tests include C-peptide, glucose,
10 minutes. and insulin.
INTRAVENOUS PYELOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Patients who are pregnant or suspected • Retained barium from a previous radi-
of being pregnant, unless the potential ologic procedure
benefits of the procedure far outweigh
• Gas or feces in the gastrointestinal tract
the risks to the fetus and mother.
resulting from inadequate cleansing or
• Elderly and other patients who are failure to restrict food intake before the
chronically dehydrated before study
the test, because of their risk of
• End-stage renal disease, which may
contrast-induced renal failure.
produce an examination of poor
• Patients who are in renal failure. quality
• Patients with renal insufficiency, indi-
cated by a blood urea nitrogen (BUN) Other considerations:
value greater than 40 mg/dL, because • Consultation with a physician should
contrast medium can complicate occur before the procedure for radia-
kidney function. tion safety concerns regarding infants
of patients who are lactating.
• Young patients (17 years old and
younger), unless the benefits of the x- • Risks associated with radiographic
ray diagnosis outweigh the risks of overexposure can result from frequent
exposure to high levels of radiation. x-ray procedures. Personnel in the
room with the patient should wear a
• Patients with multiple myeloma, who protective lead apron, stand behind a
may experience decreased kidney func- shield, or leave the area while the
tion subsequent to administration of examination is being done. Personnel
contrast medium. working in the area where the exami-
nation is being done should wear
Factors that may impair clear badges that reveal their level of expo-
imaging: sure to radiation.
• Inability of the patient to cooperate or
remain still during the procedure
because of age, significant pain, or
mental status Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: IF antibodies.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Plasma (1 mL)
collected in a lavender-top (ethylenediaminetetra-acetic acid) tube is also
acceptable.
INDICATIONS:
• Assist in the diagnosis of pernicious Nursing Implications and
anemia Procedure ● ● ● ● ● ● ● ● ● ● ●
Iron 633
IRON
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Fe.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Spectrophotometry)
SI Units
Age Conventional Units (Conversion Factor 0.179)
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
Copyright © 2003 F.A. Davis Company
Iron 635
affect the absorption of iron, enhanc- gastric acid. Phytic acids from
ing or decreasing absorption regard- cereals, tannins from tea and coffee,
less of the original content of oxalic acid from vegetables, and
the iron-containing dietary source. minerals such as copper, zinc, and
Consumption of large amounts of manganese interfere with iron
alcohol damages the intestine and absorption.
allows increased absorption of iron.
A high intake of calcium and ascor- ➤ Evaluate test results in relation to
bic acid also increases iron absorp- the patient’s symptoms and other
tion. Iron absorption after a meal tests performed. Related laboratory
is also increased by factors in tests include bone marrow biopsy,
meat, fish, or poultry. Iron absorp- liver biopsy, complete blood count,
tion is decreased by the absence erythropoietin, ferritin, hemosiderin,
(gastric resection) or diminished iron/total iron-binding capacity, lead,
presence (use of antacids) of porphyrins, and transferrin.
➤ Review the procedure with the ➤ Label the specimen, and promptly
patient. transport it to the laboratory.
➤ Inform the patient that specimen
collection takes approximately 5 to
10 minutes. Post-test:
➤ Observe venipuncture site for bleed-
Intratest: ing or hematoma formation. Apply
➤ Direct the patient to breathe pressure bandage.
normally and to avoid unnecessary ➤ Evaluate test results in relation to
movement. the patient’s symptoms and other
➤ Observe standard precautions and tests performed. Related laboratory
follow the general guidelines in tests include bone marrow biopsy,
Appendix A. Perform a venipuncture, complete blood count, erythropoi-
and collect the specimen in a 5-mL etin, ferritin, iron, hemosiderin, lead,
red- or tiger-top tube. and porphyrins.
DESCRIPTION: A kidney, ureter, and the intestines causes air to escape into
bladder (KUB) x-ray examination the abdominal cavity. When there is
provides information regarding the an intestinal obstruction, air and fluid
structure, size, and position of the collect above the area of obstruction,
abdominal organs; it also indicates distending the lumen of the intestine.
whether there is any obstruction or KUB x-rays are among the first exam-
abnormality of the abdomen caused inations done to diagnose intra-
by disease or congenital malforma- abdominal diseases such as intestinal
tion. Calcifications of the renal obstruction, masses, tumors, ruptured
calyces or renal pelvis, as well as any organs, abnormal gas accumulation,
radiopaque calculi present in the and ascites. ■
urinary tract or surrounding organs,
may be visualized. Patterns of air and INDICATIONS:
gas appear light and bright on the • Evaluate known or suspected intestinal
image. Air normally remains obstruction
contained within the intestinal tract; • Evaluate the size, shape, and position
perforation of either the stomach or of the liver, kidneys, and spleen
Copyright © 2003 F.A. Davis Company
• Evaluate the presence of renal, ureter, benefits of the procedure far outweigh
or other organ calculi the risks to the fetus and mother
• Determine the cause of acute abdomi- Factors that may impair clear
nal pain or palpable mass imaging:
• Evaluate suspected abnormal fluid, air, • Inability of the patient to cooperate or
or metallic object or obstruction in the remain still during the procedure
abdomen because of age, significant pain, or
mental status
• Evaluate the effects of lower abdominal
trauma, such as internal hemorrhage • Metallic objects within the examina-
tion field (e.g., jewelry or body rings),
RESULT which may inhibit organ visualization
and can produce unclear images
Normal Findings: • Improper adjustment of the radi-
• Normal size and shape of kidneys ographic equipment to accommodate
• Normal bladder, absence of masses and obese or thin patients, which can cause
renal calculi, and no abnormal accu- overexposure or underexposure and a
mulation of air or fluid poor-quality study
• Patients who are very obese, who may
Abnormal Findings: exceed the weight limit for the equip-
• Abnormal accumulation of bowel gas ment
• Ascites • Incorrect positioning of the patient,
which may produce poor visualization
• Bladder distention of the area to be examined, especially
• Congenital renal anomaly for oblique and decubitus views and
for films done by portable equipment
• Hydronephrosis
• Retained barium from a previous radi-
• Intestinal obstruction ologic procedure
• Organomegaly • Gas or feces in the gastrointestinal tract
• Renal hematomas resulting from inadequate cleansing or
failure to restrict food intake before the
• Renal calculi study
• Ruptured viscus • Ascites, uterine tumors, and ovarian
• Soft-tissue masses tumors, which can interfere with the
quality of the procedure
• Trauma to liver, spleen, kidneys, and
bladder Other considerations:
• Vascular calcification • Consultation with a physician should
occur before the procedure for radia-
CRITICAL VALUES: N/A tion safety concerns regarding infants
of patients who are lactating.
INTERFERING FACTORS: • Risks associated with radiographic
overexposure can result from frequent
This procedure is contraindicated x-ray procedures. Personnel in the
for: room with the patient should wear a
• Patients who are pregnant or suspected protective lead apron, stand behind a
of being pregnant, unless the potential shield, or leave the area while the
Copyright © 2003 F.A. Davis Company
KLEIHAUER-BETKE TEST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
LACTATE DEHYDROGENASE
AND ISOENZYMES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Lactate Dehydrogenase
SI Units
Age Conventional Units (Conversion Factor 1)
1–3 y 500–920 U/L 500–920 U/L
4–6 y 470–900 U/L 470–900 U/L
7–9 y 420–750 U/L 420–750 U/L
10–13 y 432–750 U/L 432–750 U/L
14–15 y 360–730 U/L 360–730 U/L
16–19 y 340–670 U/L 340–670 U/L
Adult 313–618 U/L 313–618 U/L
Copyright © 2003 F.A. Davis Company
➤ Label the specimen, and promptly the patient’s symptoms and other
transport it to the laboratory. tests performed. Related laboratory
tests include alanine aminotrans-
Post-test: ferase, aspartate aminotransferase,
C-reactive protein, complete blood
➤ Observe venipuncture site for bleed- count, creatine kinase and isoen-
ing or hematoma formation. Apply zymes, -glutamyl transpeptidase,
pressure bandage. homocysteine, body fluid LDH, mag-
➤ Evaluate test results in relation to nesium, myoglobin, 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.
Pretest:
CRITICAL VALUES:
➤ Obtain a history of the patient’s
Greater than or equal to 45 mg/dL
complaints, including a list of known
Observe the patient for signs and allergens.
symptoms of elevated levels, such as
Kussmaul’s breathing and increased pulse ➤ Obtain a history of the patient’s
cardiovascular, endocrine, hepatobil-
rate. In general, there is an inverse rela- iary, musculoskeletal, and respira-
tionship between critically elevated tory systems, as well as results of
lactate levels and survival. previously performed tests and
procedures. For related tests, refer
INTERFERING FACTORS: to the cardiovascular, endocrine,
• Drugs that may increase lactate levels hepatobiliary, musculoskeletal, and
respiratory system tables.
include albuterol, anticonvulsants
(long-term use), epinephrine, intra- ➤ Obtain a list of the medications
venous glucose, lactose, oral contracep- the patient is taking, including
tives, sodium bicarbonate, and herbs, nutritional supplements, and
nutraceuticals. The requesting health
sorbitol. care practitioner and laboratory
• Falsely low lactate levels are obtained in should be advised if the patient
samples with elevated levels of the regularly uses these products so
enzyme lactate dehydrogenase (LDH) that their effects can be taken into
consideration when reviewing
because this enzyme reacts with the results.
available lactate substrate.
➤ There are no medication restrictions
• Using a tourniquet or instructing the unless by medical direction.
patient to clench his or her fist during ➤ Instruct the patient to fast and to
a venipuncture can cause elevated restrict fluids overnight. Instruct the
levels. patient not to ingest alcohol for 12
hours before the test.
• Engaging in strenuous physical activity
(i.e., activity in which blood flow and ➤ Instruct the patient to rest for 1 hour
oxygen distribution cannot keep pace before specimen collection.
with increased energy needs) before ➤ Review the procedure with the
specimen collection can cause an patient.
elevated result. ➤ Inform the patient that specimen
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: LTT.
SPECIMEN: Plasma (1 mL) collected in gray-top (fluoride/oxalate) tube.
REFERENCE VALUE: (Method: Spectrophotometry)
Change in SI Units
Glucose Value Conventional Units (Conversion Factor 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.
LAPAROSCOPY, ABDOMINAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Assist in performing surgical proce- cially those associated with uremia and
dures such as cholecystectomy, appen- cytotoxic chemotherapy
dectomy, hernia repair, hiatal hernia
• Patients with cardiac conditions or
repair, and bowel resection
dysrhythmias
• Detect cirrhosis of the liver
• Patients with advanced respiratory or
• Stage neoplastic disorders such as cardiovascular disease
lymphomas, Hodgkin’s disease, and
• Patients with intestinal obstruction,
hepatic carcinoma
abdominal mass, abdominal hernia,
• Detect pancreatic disorders or suspected intra-abdominal hemor-
rhage
• Evaluate the extent of splenomegaly
due to portal hypertension
Factors that may impair clear
• Evaluate abdominal trauma in an visualization:
emergency • Inability of the patient to cooperate or
remain still during the procedure
RESULT because of age, significant pain, or
mental status
Normal Findings:
• Patients who are very obese, who may
• Normal appearance of the liver, spleen, exceed the weight limit for the equip-
gallbladder, pancreas, and other ment
abdominal contents
• Incorrect positioning of the patient,
Abnormal Findings: which may produce poor visualization
• Abdominal adhesions of the area to be examined
LAPAROSCOPY, GYNECOLOGIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
abdominal wall are at increased risk ➤ Obtain and record baseline vital
because organisms may be introduced signs.
into the normally sterile peritoneal
Intratest:
cavity.
➤ Administer a cleansing enema 4
hours before the procedure.
Nursing Implications and ➤ Ask the patient to void before the
Procedure ● ● ● ● ● ● ● ● ● ● ● procedure. Have the patient put on a
hospital gown.
Pretest: ➤ Ask the patient to lie still during
the procedure because movement
➤ Inform the patient that the proce- impairs clear visualization. Make
dure assesses the pelvic organs. sure jewelry, watches, chains, belts,
➤ Inform the patient that the proce- and any other metallic objects have
dure is generally performed in an been removed.
operating room by a physician while ➤ Insert an intravenous line or venous
the patient is under general anesthe- access device at a low “keep open”
sia, but that it may be done under rate.
local anesthesia. Inform the patient
➤ Administer medications, as ordered,
that the procedure takes approxi-
to reduce discomfort and to
mately 15 to 30 minutes.
promote relaxation and sedation.
➤ Assess whether the patient is aller-
➤ Place the patient on the laparoscopy
gic to latex.
table. General anesthesia is adminis-
➤ Determine the date of last menstrual tered. Then place the patient in a
period and the possibility of preg- modified lithotomy position with the
nancy in perimenopausal women. head tilted downward. Cleanse the
The procedure should not be done abdomen with an antiseptic solution
when the patient is menstruating and drape and catheterize the
and is best performed 1 week after patient, if ordered.
menses ends. ➤ The physician inserts a uterine
➤ Obtain a history of the patient’s re- manipulator through the vagina and
productive system and previously cervix and into the uterus so that the
performed laboratory tests (espe- uterus, fallopian tubes, and ovaries
cially complete blood count, pro- can be moved to permit better visu-
thrombin time, partial thromboplas- alization.
tin time, clotting and bleeding ➤ Cleanse the abdomen with antisep-
times), surgeries, therapies, and pro- tic solution and drape with sterile
cedures. For related tests, refer to drapes. CO2 is insufflated through
the genitourinary and reproductive the pneumoperitoneum needle to
system tables. separate the abdominal wall from
➤ Obtain a history of the patient’s the viscera and to aid in visualiza-
complaints, including a list of known tion of the abdominal structures.
allergens and sensitivities to anes- The pneumoperitoneum needle is
thetics and analgesics. removed, and the trocar and laparo-
➤ Obtain a list of the medications the scope are inserted through the inci-
patient is taking. sion.
➤ Restrict food or fluids for at least 8 ➤ After the examination, collection of
hours before the procedure. tissue samples, and performance of
therapeutic procedures (e.g., tubal
➤ Obtain a written, informed consent ligation), the scope is withdrawn. All
before administering any medica- possible CO2 is evacuated via the
tions prior to the procedure. trocar, which is then removed. The
➤ Wear gloves and gowns throughout skin incision is closed with sutures,
the procedure. clips, or sterile strips, and a small
Copyright © 2003 F.A. Davis Company
LATEX ALLERGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Immunoassay) Negative.
RESULT Intratest:
➤ Direct the patient to breathe
Positive findings in: Latex allergy normally and to avoid unnecessary
movement.
Negative findings in: N/A ➤ Observe standard precautions and
follow the general guidelines in
CRITICAL VALUES: N/A Appendix A. Perform a venipuncture,
and collect the specimen in a 5-mL
red-top tube.
INTERFERING FACTORS: N/A ➤ Label the specimen, and promptly
transport it to the laboratory.
Nursing Implications and Post-test:
Procedure ● ● ● ● ● ● ● ● ● ● ●
LEAD
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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 (ethylenedi-
aminetetra-acetic acid [EDTA]) tube is also acceptable.
SI Units
Conventional Units (Conversion Factor 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 Up to 40 g/dL Up to 1.93 mol/L
for occupational
exposure
OSHA Occupational Safety and Health Administration.
LECITHIN/SPHINGOMYELIN RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
RESULT Pretest:
LIPASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Lipase 667
LIPOPROTEIN ELECTROPHORESIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
tein (VLDL), (3) low-density lipopro- occur for the same reasons as in
tein (LDL), and (4) high-density Type IIa. Total cholesterol,
lipoprotein (HDL). Chylomicrons triglycerides, and LDLC are all
elevated.
and VLDL contain the highest levels
Type III: Hyperlipoproteinemia can
of triglycerides and lower amounts of
be primary, resulting from
cholesterol and protein. LDL and inherited characteristics; or
HDL contain the lowest amounts of secondary, caused by
triglycerides and relatively higher hypothyroidism, uncontrolled
amounts of cholesterol and protein. ■ diabetes, alcoholism, and
dysgammaglobulinemia. Total
INDICATIONS: cholesterol and triglycerides are
• Evaluate known or suspected disorders elevated, whereas LDLC is
associated with altered lipoprotein normal.
levels Type IV: Hyperlipoproteinemia can
be primary, resulting from
• Evaluate patients with serum choles- inherited characteristics; or
terol levels greater than 250 mg/dL, secondary, caused by poorly
which indicate a high risk for CAD controlled diabetes, alcoholism,
• Evaluate the response to treatment for nephrotic syndrome, chronic
high cholesterol, and determine the renal failure, and
need for drug therapy dysgammaglobulinemia. Total
cholesterol is normal to
RESULT: moderately elevated,
triglycerides are moderately to
Type I: Hyperlipoproteinemia or grossly elevated, and LDLC is
increased chylomicrons can be normal.
primary, resulting from an
inherited deficiency of Type V: Hyperlipoproteinemia can
lipoprotein lipase; or secondary, be primary, resulting from
caused by uncontrolled diabetes, inherited characteristics; or
systemic lupus erythematosus, secondary, caused by
and dysgammaglobulinemia. uncontrolled diabetes,
Total cholesterol is normal to alcoholism, nephrotic syndrome,
moderately elevated and and dysgammaglobulinemia.
triglycerides (mostly exogenous Total cholesterol is normal to
chylomicrons) are grossly moderately elevated,
elevated. If the condition is triglycerides are grossly
inherited, symptoms will appear elevated, and LDLC is normal.
in childhood.
Type IIa: Hyperlipoproteinemia can
CRITICAL VALUES: N/A
be primary, resulting from
inherited characteristics or INTERFERING FACTORS:
secondary, caused by • Failure to follow usual diet for 2 weeks
hypothyroidism, nephrotic before the test can yield results that do
syndrome, and not accurately reflect patient’s choles-
dysgammaglobulinemia. Total terol values.
cholesterol is elevated, • Ingestion of alcohol 24 hours before
triglycerides are normal, and LDL
the test, ingestion of food 12 hours
cholesterol (LDLC) is elevated. If
the condition is inherited,
before the test, and excessive exercise
symptoms will appear in 12 hours before the test can alter
childhood. results.
Type IIb: Hyperlipoproteinemia can • Numerous drugs can alter results (see
Copyright © 2003 F.A. Davis Company
Post-test:
Pretest:
➤ Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s ing or hematoma formation. Apply
complaints, including a list of known pressure bandage.
allergens.
➤ Instruct the patient to resume usual
➤ Obtain a history of the patient’s medication as directed by the
cardiovascular system and risk for requesting health care practitioner.
heart disease, as well as results of
previously performed tests and ➤ Abnormal lipoprotein electrophore-
procedures, particularly the results sis patterns may be associated with
of lipid tests. For related tests, refer cardiovascular disease. Nutritional
to the cardiovascular system table. therapy is recommended for the
patient identified to be at high risk
➤ Obtain a list of the medications the for developing CAD. If overweight,
patient is taking, including herbs, the patient should be encouraged to
nutritional supplements, and achieve a normal weight. The
nutraceuticals. The requesting health American Heart Association Step 1
care practitioner and laboratory and Step 2 diets may be helpful in
should be advised if the patient achieving a goal of lowering total
regularly uses these products so cholesterol and triglyceride levels.
that their effects can be taken into The Step 1 diet emphasizes a reduc-
consideration when reviewing tion in foods high in saturated fats
results. and cholesterol. Red meats, eggs,
➤ There are no medication restrictions and dairy products are the major
unless by medical direction. sources of saturated fats and choles-
➤ Instruct the patient to follow his or terol. If triglycerides also are
her usual diet for 2 weeks before elevated, the patient should be
testing. advised to eliminate or reduce alco-
hol and simple carbohydrates from
➤ Instruct the patient to fast and to the diet. The Step 2 diet recom-
avoid excessive exercise for at least mends stricter reductions.
12 hours before testing, and to
refrain from alcohol consumption for ➤ Numerous studies point to the
24 hours before testing. prevalence of excess body weight in
American children and adolescents.
➤ Review the procedure with the Experts estimate that obesity is
patient. present in 25 percent of the popula-
➤ Inform the patient that specimen tion aged 6 to 11 years. The medical,
collection takes approximately 5 to social, and emotional consequences
10 minutes. of excess body weight are signifi-
cant. Special attention should be
Intratest: given to instructing the child and
caregiver regarding health risks and
➤ Ensure that the patient has complied weight control education.
with dietary preparations and other
pretesting restrictions. ➤ Evaluate test results in relation to
the patient’s symptoms and other
➤ Direct the patient to breathe tests performed. Related laboratory
normally and to avoid unnecessary tests include apolipoprotein A and B,
movement. total cholesterol, HDL cholesterol,
➤ Observe standard precautions and LDL cholesterol, and triglycerides.
Copyright © 2003 F.A. Davis Company
DESCRIPTION: The liver and spleen around the body and reconstructed
scan is performed to help diagnose by a computer to produce images rep-
abnormalities in the function and resenting the organ at different levels
structure of the liver and spleen. It is or “slices.” For evaluation of a sus-
often performed in combination with pected hemangioma, the patient’s
lung scanning to help diagnose red blood cells are combined with
masses or inflammation in the di- Tc-99m and images are recorded over
aphragmatic area. This procedure is the liver. To confirm diagnosis, liver
useful for evaluating right-upper- and spleen scans are done in conjunc-
quadrant pain, metastatic disease, tion with CT, magnetic resonance
jaundice, cirrhosis, ascites, traumatic imaging (MRI), ultrasonography,
infarction, and radiation-induced and SPECT scans and interpreted in
organ cellular necrosis. Technetium- light of the results of liver function
99m (Tc-99m) sulfur colloid is in- tests. ■
jected intravenously and rapidly
taken up by the reticuloendothelial INDICATIONS:
cells through phagocytosis, which • Detect and differentiate between
normally function to remove particu- primary and metastatic tumor focal
late matter, including radioactive col- disease
loids in the liver and spleen. False- • Detect diffuse hepatocellular disease,
negative results may occur in patients such as hepatitis and cirrhosis
with space-occupying lesions (e.g.,
• Detect benign tumors, such as
tumors, cysts, abscesses) smaller than
adenoma and cavernous hemangioma
2 cm. This scan can detect portal hy-
pertension, demonstrated by a greater • Detect a bacterial or amebic abscess
uptake of the radionuclide in the • Detect cystic focal disease
spleen than in the liver. Single photon
emission computed tomography • Evaluate the effects of lower abdomi-
(SPECT) has significantly improved nal trauma, such as internal hemor-
the resolution and accuracy of liver rhage
scanning. SPECT enables images to • Assess the condition of the liver and
be recorded from multiple angles spleen after abdominal trauma
Copyright © 2003 F.A. Davis Company
is being done. Personnel working in which help maintain position and im-
the area where the examination is being mobilization. Ask the patient to lie
done should wear badges that reveal still during the procedure because
their level of exposure to radiation. movement produces unclear im-
ages. The radionuclide is adminis-
tered intravenously and the ab-
domen is scanned immediately for 1
Nursing Implications and minute to screen for vascular le-
Procedure ● ● ● ● ● ● ● ● ● ● ●
sions. Then images are taken in the
anterior, oblique, lateral, and poste-
Pretest: rior oblique positions.
➤ Wear gloves during the radionuclide
➤ Inform the patient that the proce- administration and while handling
dure assesses liver and spleen the patient’s urine.
function.
➤ Inform the patient that the proce- Post-test:
dure is performed in a nuclear medi-
cine department by a technologist ➤ Evaluate the patient’s vital signs.
and usually takes approximately 30 ➤ Instruct the patient to resume
to 60 minutes. normal activity, medications, and
➤ Obtain a history of the patient’s diet, unless otherwise indicated.
complaints, including a list of known ➤ Advise patient to drink increased
allergens. amounts of fluids for 24 to 48 hours
➤ Obtain a history of the patient’s liver to eliminate the radionuclide from
and spleen, as well as results of pre- the body, unless contraindicated. Tell
viously performed tests (especially the patient that radionuclide is elimi-
liver function tests) and surgical pro- nated from the body within 6 to 24
cedures. For related tests, refer to hours.
the hepatobiliary and gastrointesti- ➤ Inform the patient to flush the toilet
nal systems tables. immediately after each voiding
➤ Obtain a list of the medications the following the procedure and to wash
patient is taking. hands meticulously with soap and
water after each voiding for 24 hours
➤ Determine date of last menstrual after the procedure.
period and possibility of pregnancy
in perimenopausal women. ➤ Tell all caregivers to wear gloves
when discarding urine for 24 hours
➤ Fasting before the scan is not neces- after the procedure. Wash gloved
sary, unless otherwise indicated. hands with soap and water before
removing gloves. Then wash hands
Intratest: after the gloves are removed.
➤ Ask the patient to void before the ➤ A physician specializing in this
procedure. Have the patient put on a branch of medicine sends a written
hospital gown. report to the ordering provider, who
discusses the results with the
➤ Administer sedative to a child or to patient.
an uncooperative adult, as ordered.
➤ Evaluate test results in relation
➤ Make sure jewelry, watches, chains, to the patient’s symptoms and
belts, and any other metallic objects other tests performed. Related
have been removed from the diagnostic tests include hepatobil-
abdominal area. iary scan, liver and abdominal ultra-
➤ Place the patient in a supine position sound, and CT and MRI of the
on a flat table with foam wedges, abdomen.
Copyright © 2003 F.A. Davis Company
LUTEINIZING HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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
Pretest: Post-test:
➤ Obtain a history of the patient’s ➤ Observe venipuncture site for bleed-
complaints, including a list of known ing or hematoma formation. Apply
allergens. pressure bandage.
➤ Obtain a history of the patient’s ➤ Evaluate test results in relation to
endocrine and reproductive the patient’s symptoms and other
systems, as well as results of previ- tests performed. Related laboratory
ously performed tests and proce- tests include adrenocorticotropic
dures. For related tests, refer to the hormone, antisperm antibody, estra-
endocrine and reproductive system diol, follicle-stimulating hormone,
tables. prolactin, and testosterone.
Copyright © 2003 F.A. Davis Company
LYME ANTIBODY
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SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative.
Lymphangiography 685
LYMPHANGIOGRAPHY
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SYNONYM/ACRONYM: Lymphangiogram.
AREA OF APPLICATION: Lymphatic system.
CONTRAST: Iodine based.
Lymphangiography 687
MAGNESIUM, SERUM
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MAGNESIUM, URINE
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SYNONYMS/ACRONYM: Urine Mg .
SPECIMEN: Urine (5 mL) from a random or timed specimen collected in a
clean plastic collection container with 6N hydrochloride as a preservative.
output records with volume collected into the collection device and then to
to verify that all voids were included in pour the urine into the laboratory
the collection. collection container. Alternatively
the specimen can be left in the
collection device for a health care
Nursing Implications and staff member to add to the labora-
tory collection container.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest:
➤ Observe standard precautions and
➤ Obtain a history of the patient’s
follow the general guidelines in
complaints, including a list of known
Appendix A.
allergens.
➤ Obtain a history of the patient’s Random specimen (collect in
endocrine, gastrointestinal, and early morning):
genitourinary systems, as well as
results of previously performed
tests and procedures. For related Clean-catch specimen:
tests, refer to the endocrine, ➤ Instruct the male patient to (1) thor-
gastrointestinal, and genitourinary oughly wash his hands, (2) cleanse
system tables. the meatus, (3) void a small amount
➤ Obtain a list of medications the pa- into the toilet, and (4) void directly
tient is taking, including herbs, nutri- into the specimen container.
tional supplements, and nutraceuti- ➤ Instruct the female patient to (1)
cals. The requesting health care thoroughly wash her hands; (2)
practitioner and laboratory should be cleanse the labia from front to back;
advised if the patient regularly uses (3) while keeping the labia sepa-
these products so that their effects rated, void a small amount into the
can be taken into consideration toilet; and (4) without interrupting
when reviewing results. the urine stream, void directly into
➤ There are no food, fluid, or medica- the specimen container.
tion restrictions unless by medical
direction. Indwelling catheter:
➤ Instruct the patient to avoid exces- ➤ Put on gloves. Empty drainage tube
sive exercise and stress during the of urine. It may be necessary to
24-hour collection of urine. clamp off the catheter for 15 to 30
➤ Review the procedure with the minutes before specimen collection.
patient. Provide a nonmetallic urinal, Cleanse specimen port with antisep-
bedpan, or toilet-mounted collection tic swab, and then aspirate 5 mL of
device. urine with a 21- to 25-gauge needle
and syringe. Transfer urine to a ster-
➤ Usually a 24-hour time frame for ile container.
urine collection is ordered. Inform
the patient that all urine must be Timed specimen:
saved during that 24-hour period.
Instruct the patient not to void ➤ Obtain a clean 3-L urine specimen
directly into the laboratory collection container, toilet-mounted collection
container. Instruct the patient to device, and plastic bag (for transport
avoid defecating in the collection of the specimen container). The
device and to keep toilet tissue out specimen must be refrigerated or
of the collection device to prevent kept on ice throughout the entire
contamination of the specimen. collection period. If an indwelling
Place a sign in the bathroom to urinary catheter is in place, the
remind the patient to save all urine. drainage bag must be kept on ice.
➤ Instruct the patient to void all urine ➤ Begin the test between 6 and 8
Copyright © 2003 F.A. Davis Company
INTERFERING FACTORS:
Pretest:
This procedure is contraindicated
for: ➤ Inform the patient that the proce-
dure assesses the pituitary.
• Patients with certain ferrous metal
prostheses, valves, aneurysm clips, ➤ Inform the patient that the proce-
inner ear prostheses, or other metallic dure is performed in a special
department by a technologist and a
objects
physician and takes approximately
• Patients with metal in their body, such 30 to 60 minutes.
as shrapnel or ferrous metal in the eye ➤ Obtain a history of allergies or sensi-
tivities to contrast medium.
• Patients with cardiac pacemakers
because the pacemaker can be ➤ Obtain a list of medications the
patient is taking.
deactivated by MRI
➤ Obtain a history of the patient’s pitu-
• Patients who are claustrophobic itary, endocrine, and cranial findings,
as well as results of previously
• Patients who are pregnant or suspected
performed tests, treatments, surger-
of being pregnant, unless the potential ies, and procedures. Determine if
benefits of the procedure far outweigh the patient has ever had any device
the risks to the fetus and mother implanted into the body, including
copper intrauterine devices, pace-
Factors that may impair clear makers, ear implants, and heart
imaging: valves.
• Inability of the patient to cooperate or ➤ For related tests, refer to the
Copyright © 2003 F.A. Davis Company
the attached computer system. MRI useful for delineating the exact rela-
produces cross-sectional images of the tionship among the stomach, duode-
abdominal area in multiple planes num, and proximal jejunum and the
without the use of ionizing radiation pancreas. These agents would assist in
or the interference of bone or identifying areas of bowel wall thick-
surrounding tissue. ening, stricture, and intraluminal
MRI of the pancreas is employed abnormalities, such as tumors, sites of
to evaluate small pancreatic adenocar- perforation, and fistula. ■
cinomas, islet cell tumors, ductal
abnormalities and calculi, or INDICATIONS:
parenchymal abnormalities. A T1- • Detect a pancreatic mass
weighted, fat-saturation series of • Detect primary or metastatic tumors of
images is probably the best series of the pancreas and provide cancer stag-
images for evaluating the pancreatic ing
parenchyma. This sequence is ideal
• Detect pancreatitis
for showing fat planes between the
pancreas and peripancreatic structures • Determine vascular complications of
and for identifying abnormalities, pancreatitis, venous thrombosis, or
such as fatty infiltration of the pseudoaneurysm
pancreas, hemorrhage, adenopathy, • Differentiate tumors from other abnor-
and carcinomas. T2-weighted images malities, such as cysts, cavernous
are most useful for depicting intra- hemangiomas, and pancreatic abscesses
pancreatic or peripancreatic fluid • Detect soft tissue abnormalities
collections, pancreatic neoplasms,
• Detect pancreatic fatty infiltration,
and calculi. Imaging sequences can be
hemorrhage, and adenopathy
adjusted to display fluid in the biliary
tree and pancreatic ducts. • Monitor and evaluate the effectiveness
MRI uses the noniodinated of medical or surgical interventions
contrast medium gadopentetate and course of disease
dimeglumine (Magnevist), which is
administered intravenously to RESULT
enhance contrast differences between
Normal Findings:
normal and abnormal tissues.
Magnetic resonance angiography • Normal anatomic structures and soft
tissue density and biochemical
(MRA) is an application of MRI that
constituents of the pancreatic
provides images of blood flow and parenchyma, including blood flow
diseased and normal blood vessels
that supply the pancreas and peripan- Abnormal Findings:
creatic organs. In patients who are • Islet cell tumor
allergic to iodinated contrast
medium, MRA is used in place of • Metastasis
angiography (see monograph titled • Pancreatic mass
“Angiography, Magnetic Resonance”).
When the Food and Drug • Pancreatitis
Administration approves gastroin- • Pancreatic fatty infiltration, hemor-
testinal contrast agents, they may be rhage, and adenopathy
Copyright © 2003 F.A. Davis Company
objects from the patient before he or block out the loud, banging sounds
she enters the scanning room. that occur during the test.
➤ Inform the patient that the technolo- ➤ If an electrocardiogram or respira-
gist will place him or her in a supine tory gating is to be performed in
position on a flat table in a large, conjunction with the scan, apply
cylindrical scanner. MRI-safe electrodes to the appropri-
➤ Tell the patient to expect to hear ate sites.
loud banging from the scanner ➤ The patient can communicate with
and possibly to see magneto- the technologist doing the examina-
phosphenes (flickering lights in the tion via a microphone within the
visual field); these will stop when machine.
the procedure is over. ➤ The table is moved into the scanner.
➤ Instruct the patient to take slow, Instruct the patient to remain still.
deep breaths if nausea occurs The scanner makes noises as it
during the procedure. acquires images of the body. The
➤ Do not restrict food and fluids. patient may be asked to hold his or
her breath to facilitate visualization.
Intratest: A number of images are taken.
These images are reconstructed by
➤ By physician direction, the patient is a computer and reviewed.
given dilute barium to drink or a tap ➤ Administer the contrast medium, if
water enema to distend the bowel ordered. A second series of images
before the examination, improving is obtained.
visualization of adjacent organs.
➤ Ask the patient to remove jewelry, Post-test:
including watches, hairpins, and
other metallic objects, and credit ➤ Instruct the patient to resume
cards. medications, normal activity, and
diet, unless otherwise indicated.
➤ Ask the patient to void before the
procedure. ➤ Observe for delayed allergic reac-
tions, such as urticaria, hives,
➤ Administer a sedative to a child or to nausea, or vomiting, if contrast
an uncooperative adult, as ordered. medium was used.
➤ Administer an antianxiety agent, as ➤ A physician specializing in this
ordered, if the patient has claustro- branch of medicine sends a written
phobia. report to the ordering provider, who
➤ Place the patient in a supine position discusses the results with the
on a flat table; use foam wedges to patient.
help maintain position and immobi- ➤ Evaluate test results in relation to
lization. Ask the patient to lie still the patient’s symptoms and other
during the procedure because move- tests performed. Related diagnostic
ment produces unclear images, thus tests include ultrasound and
affecting the results and making computed tomography of the pelvis,
interpretation difficult. as well as a kidney, ureter, and blad-
➤ Supply earplugs to the patient to der (KUB) film.
Copyright © 2003 F.A. Davis Company
MAGNETIC RESONANCE
IMAGING, PITUITARY
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Mammography 717
MAMMOGRAPHY
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• Evaluate size, shape, and position of • Metallic objects within the examina-
breast masses tion field (e.g., jewelry or body rings),
• Evaluate breast pain, skin retraction, which may inhibit organ visualization
nipple erosion, or nipple discharge and can produce unclear images
• Differentiate between benign and • Improper adjustment of the radi-
neoplastic breast disease ographic equipment to accommodate
obese or thin patients, which can cause
• Evaluate nonpalpable breast masses overexposure or underexposure and a
• Monitor postoperative and post– poor-quality study
radiation treatment status of the breast • Incorrect positioning of the patient,
• Evaluate opposite breast after mastec- which may produce poor visualization
tomy of the area to be examined
• Application of substances such as
RESULT talcum powder or creams to the skin of
breasts or underarms, which may alter
Normal Findings:
test results
• Normal breast tissue, with no cysts,
tumors, or calcifications • Previous breast surgery, breast augmen-
tation, or the presence of breast
Abnormal Findings: implants, which may decrease the read-
• Breast cysts or abscesses ability of the examination
• Breast tumors Other considerations:
• Breast calcifications • Consultation with a physician should
• Hematoma resulting from trauma occur before the procedure for radia-
tion safety concerns regarding infants
• Mastitis of patients who are lactating.
• Soft-tissue masses • Risks associated with radiographic
• Vascular calcification overexposure can result from frequent
x-ray procedures. Personnel in the
CRITICAL VALUES: N/A room with the patient should wear a
protective lead apron, stand behind a
INTERFERING FACTORS: shield, or leave the area while the
examination is being done. Personnel
This procedure is contraindicated working in the area where the exami-
for: nation is being done should wear
• Patients who are pregnant or suspected badges that reveal their level of expo-
of being pregnant, unless the potential sure to radiation.
benefits of the procedure far outweigh
the risks to the fetus and mother
• Patients younger than age 25, because Nursing Implications and
the density of the breast tissue is such Procedure ● ● ● ● ● ● ● ● ● ● ●
the patient that radionuclide is elimi- wash hands after the gloves are
nated from the body within 6 to 24 removed.
hours. ➤ A physician specializing in this branch
➤ Instruct the patient to flush the toilet of medicine sends a written report to
immediately after each voiding the ordering provider, who discusses
following the procedure and to wash the results with the patient.
hands meticulously with soap and ➤ Evaluate test results in relation to
water after each voiding for 24 hours the patient’s symptoms and other
after the procedure. tests performed. Related diagnostic
➤ Tell all caregivers to wear gloves tests include abdominal, computed
when discarding urine for 24 tomography (CT), and magnetic
hours after the procedure. Wash resonance angiography; and CT and
gloved hands with soap and water magnetic resonance imaging of the
before removing gloves. Then abdomen.
MEDIASTINOSCOPY
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SYNONYM/ACRONYM: None.
AREA OF APPLICATION: Mediastinum.
CONTRAST: None.
Mediastinoscopy 723
mediastinum or extrapleurally into the before the procedure may cause the
chest procedure to be canceled or repeated.
• Evaluate a patient with signs and
symptoms of obstruction of mediasti- Nursing Implications and
nal lymph flow and a history of head or Procedure ● ● ● ● ● ● ● ● ● ● ●
neck cancer to determine recurrence or
spread Pretest:
RESULT ➤ Inform the patient that the proce-
dure is usually performed under
Normal Findings: general anesthesia in an operating
room by a physician and takes
• Normal appearance of mediastinal approximately 60 minutes.
structures
➤ Obtain a history of complaints; aller-
• No abnormal lymph node tissue gies or sensitivities to anesthetics,
analgesics, or antibiotics; thoracic or
Abnormal Findings: hematologic disorders; and treat-
ment regimen. For related tests,
• Bronchogenic carcinoma
refer to the respiratory and immuno-
• Coccidioidomycosis logic system tables.
• Granulomatous infections ➤ Obtain a list of medications the
patient is taking.
• Histoplasmosis
➤ Obtain a history of the patient’s
• Hodgkin’s disease respiratory problems as well as
results of previously performed
• Pneumocystis carinii infection tests and procedures.
• Sarcoidosis ➤ Ensure that the results of blood
typing and cross-matching are
• Tuberculosis obtained and recorded before the
procedure in the event that an emer-
Critical values: N/A gency thoracotomy should be
required.
INTERFERING FACTORS: ➤ Obtain a written, informed consent
before administering any medica-
This procedure is contraindicated tions prior to the procedure.
for: ➤ Ensure that the patient has fasted
• Patients who have had a previous for 6 to 8 hours before the scan,
mediastinoscopy, because scarring can unless otherwise indicated.
make insertion of the scope and biopsy ➤ Obtain and record baseline vital
of lymph nodes difficult signs.
• Patients who have superior vena cava
Intratest:
obstruction, because this condition
causes increased venous collateral ➤ Prepare the patient for surgery, and
circulation in the mediastinum administer sedation, as ordered.
➤ Place the patient in the supine posi-
• Patients who are pregnant or suspected
tion. General anesthesia is adminis-
of being pregnant, unless the potential tered via an endotracheal tube.
benefits of the procedure far outweigh
➤ An incision is made at the supraster-
the risks to the fetus and mother nal notch, and a path for the medi-
astinoscope is made using finger
Other considerations: dissection. The lymph nodes can be
• Failure to follow dietary restrictions palpated at this time. The lymph
Copyright © 2003 F.A. Davis Company
nodes on the right side of the discomfort may be present and that
mediastinum are most accessible the throat may be slightly sore after
and safest to biopsy by med the procedure.
astinoscopy; the lymph nodes on ➤ Warm gargles or lozenges can be
the left side are more difficult to administered for throat discomfort.
explore and biopsy because of their
proximity to the aorta. Biopsy speci- ➤ Inform the patient and caregiver
mens of nodes on the left side of the that food, fluids, and activities are
mediastinum may need to be resumed when the patient has
obtained by mediastinotomy, which recovered from general anesthesia.
involves performing a left anterior ➤ Instruct the patient to immediately
thoracotomy. report to the physician any difficulty
➤ Label the specimens for biopsy or breathing, other abnormal sensa-
culture, place them in appropriate tions or discomforts, or changes in
containers, and promptly send them vocal patterns.
to the laboratory. ➤ Instruct the patient on the symp-
toms of incisional infection, and
➤ The scope is removed, and the inci-
inform the patient of the need to
sion is closed.
promptly report any symptoms to
➤ If the patient is stable and if no the physician.
further surgery is immediately indi- ➤ A physician specializing in this
cated, the patient is extubated. branch of medicine sends a written
report to the ordering provider, who
Post-test: discusses the results with the
patient.
➤ Instruct the patient to resume usual
diet and medications, if withheld and ➤ Evaluate test results in relation to
directed by the physician. the patient’s symptoms and other
tests performed. Related tests
➤ Monitor vital signs according to insti- include computed tomography and
tution’s policy. magnetic resonance imaging of the
➤ Inform the patient that some chest chest.
METANEPHRINES
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SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (25 mL) from a timed specimen collected in a clean
amber, plastic collection container with 6N hydrochloride as a preservative.
Metanephrines 725
Metanephrines
Methemoglobin 727
METHEMOGLOBIN
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Microalbumin 729
MICROALBUMIN
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DESCRIPTION: The term microalbu- shown that the median duration from
min is used to describe concentra- onset of microalbuminuria to devel-
tions of albumin in urine that are opment of nephropathy is 5 to 7
greater than normal but undetectable years. ■
by dipstick or traditional spectropho-
tometry methods. Microalbuminuria
precedes the nephropathy associated INDICATIONS:
• Evaluate renal disease
with diabetes and is often elevated
years before creatinine clearance • Screen diabetic patients for early signs
shows abnormal values. Studies have of nephropathy
Copyright © 2003 F.A. Davis Company
Pretest: Intratest:
➤ Obtain a history of the patient’s ➤ Observe standard precautions and
complaints, including a list of known follow the general guidelines in
allergens. Appendix A.
➤ Obtain a history of the patient’s
endocrine and genitourinary Random specimen (collect in
systems as well as results of previ- early morning):
ously performed tests and proce-
dures. For related tests, refer to the
endocrine and genitourinary system Clean-catch specimen:
tables. ➤ Instruct the male patient to (1) thor-
➤ Obtain a list of medications the oughly wash his hands, (2) cleanse
patient is taking, including herbs, the meatus, (3) void a small amount
Copyright © 2003 F.A. Davis Company
Microalbumin 731
into the toilet, and (4) void directly compare the quantity of urine with
into the specimen container. the urinary output record for the
➤ Instruct the female patient to (1) collection; if the specimen contains
thoroughly wash her hands; (2) less than what was recorded as
cleanse the labia from front to back; output, some urine may have been
(3) while keeping the labia sepa- discarded, invalidating the test.
rated, void a small amount into the ➤ Label the specimen, and promptly
toilet; and (4) without interrupting transport it to the laboratory. Include
the urine stream, void directly into on the label the amount of urine and
the specimen container. test start and stop times.
2-MICROGLOBULIN
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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 preserva-
tive.
Conventional SI Units
Sample Units (Conversion Factor 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
2-Microglobulin 733
• Lung cancer
• Lymphoma Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Multiple myeloma
• Poisoning with heavy metals, such as Pretest:
mercury or cadmium ➤ Obtain a history of the patient’s
• Renal dialysis complaints, including a list of known
allergens.
• Renal disease (glomerular): serum only ➤ Obtain a history of the patient’s
• Renal disease (tubular): urine only genitourinary and immune system,
as well as results of previously
• Sarcoidosis performed tests and procedures. For
related tests, refer to the genitouri-
• Systemic lupus erythematosus nary and immune system tables.
• Vasculitis ➤ Obtain a list of the medications the
patient takes including herbs, nutri-
• Viral infections (e.g., cytomegalovirus) tional supplements, and nutraceuti-
cals. The requesting health care
Decreased in: practitioner and laboratory should be
• Renal disease (glomerular): urine only advised if the patient regularly uses
these products so their effects can
• Renal disease (tubular): serum only be taken into consideration when
reviewing results.
• Response to zidovudine (AZT)
➤ Note any recent procedures that can
CRITICAL VALUES: N/A interfere with test results.
➤ There are no food, fluid, or medica-
INTERFERING FACTORS: tion restrictions unless by medical
• Drugs and proteins that may increase direction.
serum 2-microglobulin levels include ➤ Review the procedure with the
cefuroxime, cyclosporine A, genta- patient.
micin, interferon-, pentoxifylline, Blood:
and tumor necrosis factor.
➤ Inform the patient that blood speci-
• Drugs that may decrease serum 2- men collection takes approximately
microglobulin levels include zidovu- 5 to 10 minutes.
dine.
Urine:
• Drugs that may increase urine 2-
microglobulin levels include azathio- ➤ Review the procedure with the
prine, cisplatin, cyclosporine A, patient. Provide a nonmetallic urinal,
bedpan, or toilet-mounted collection
furosemide, gentamicin, mannitol, device.
nifedipine, sisomicin, and tobramycin.
➤ Usually a 24-hour urine collection is
• Drugs that may decrease urine 2- ordered. Inform the patient that all
microglobulin levels include cilostazol. urine over a 24-hour period must be
Copyright © 2003 F.A. Davis Company
MUMPS SEROLOGY
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SYNONYMS/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative or
less than a fourfold increase in titer.
➤ Review the procedure with the ➤ Label the specimen, and promptly
patient. transport it to the laboratory.
➤ Inform the patient that several tests
may be necessary to confirm diag- Post-test:
nosis. Any individual positive result
should be repeated in 7 to 14 days to ➤ Observe venipuncture site for bleed-
monitor a change in titer. ing or hematoma formation. Apply
pressure bandage.
➤ Inform the patient that each speci-
men collection takes approximately ➤ Instruct the patient in isolation
5 to 10 minutes. precautions during the time of
communicability or contagion.
Intratest: ➤ Emphasize that the patient must
return to have a convalescent blood
➤ Direct the patient to breathe
sample taken in 7 to 14 days.
normally and to avoid unnecessary
movement. ➤ Inform the patient that the presence
➤ Observe standard precautions and of mumps antibodies ensures life-
follow the general guidelines in time immunity.
Appendix A. Perform a venipuncture, ➤ Evaluate test results in relation to
and collect the specimen in a 5-mL the patient’s symptoms and other
red-top tube. tests performed.
• Determine rest defects and reperfusion • Patients with asthma, because chemical
with delayed imaging in unstable stress with vasodilators can cause bron-
angina chospasms
remain still during the procedure • Inaccurate timing for imaging after
because of age, significant pain, or radionuclide injection can affect the
mental status results.
• Medications such as digitalis and • Consultation with a physician should
quinidine, which can alter cardiac occur before the procedure for radia-
contractility; and nitrates, which can tion safety concerns regarding infants
affect cardiac performance of patients who are lactating.
• Single-vessel disease, which can • Risks associated with radiographic
produce false-negative thallium-201 overexposure can result from frequent
scanning results x-ray procedures. Personnel in the
room with the patient should wear a
• Conditions such as chest wall or protective lead apron, stand behind a
cardiac trauma, angina that is difficult shield, or leave the area while the
to control, significant cardiac arrhyth- examination is being done. Personnel
mias, and recent cardioversion proce- working in the area where the exami-
dure nation is being done should wear
• Suboptimal cardiac stress or patient badges that reveal their level of expo-
exhaustion preventing maximum heart sure to radiation.
rate testing
• Excessive eating or exercising between
initial and redistribution imaging 4 Nursing Implications and
hours later, which produces false- Procedure ● ● ● ● ● ● ● ● ● ● ●
positive results
Pretest:
• Improper adjustment of the radiologic
equipment to accommodate obese or ➤ Inform the patient that the procedure
thin patients, which can cause overex- assesses blood flow to the heart.
posure or underexposure and a poor- ➤ Inform the patient that the proce-
quality study dure is performed in a special
department by a technologist and
• Patients who are very obese, who may takes approximately 30 to 60
exceed the weight limit for the equip- minutes for each rest and stress part
ment of the examination.
➤ Obtain a history of allergies or sensi-
• Incorrect positioning of the patient,
tivities to contrast medium.
which may produce poor visualization
of the area to be examined ➤ Obtain a list of medications the
patient is taking.
• Metallic objects within the examina- ➤ Obtain a history of cardiac tests,
tion field (e.g., jewelry or body rings), other diagnostic procedure results,
which may inhibit organ visualization laboratory test results, present
and can produce unclear images cardiac conditions or abnormalities,
and therapy received for cardiac
conditions. For related tests, refer to
Other considerations: the cardiovascular system table.
• Failure to follow dietary restrictions ➤ Determine date of last menstrual
before the procedure may cause the period and possibility of pregnancy
procedure to be canceled or repeated. in perimenopausal women.
• Improper injection of the radionuclide ➤ Reassure the patient that radioactive
that allows the tracer to seep deep into material poses no radioactive hazard
the muscle tissue produces erroneous and rarely produces side effects.
hot spots. ➤ Obtain a written, informed consent
Copyright © 2003 F.A. Davis Company
Myoglobin 743
MYOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: MB.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Nephelometry)
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.
SI Units
Conventional Units (Conversion Factor 1)
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
Copyright © 2003 F.A. Davis Company
OSMOTIC FRAGILITY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
RESULT
Nursing Implications and
Increased in: Procedure ● ● ● ● ● ● ● ● ● ● ●
Osteocalcin 749
OSTEOCALCIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age and Sex Conventional Units (Conversion Factor 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
and turnover. ■
Pretest:
INDICATIONS:
• Assist in the diagnosis of bone cancer ➤ Obtain a history of the patient’s
complaints, including a list of known
• Evaluate bone disease allergens.
• Evaluate bone metabolism ➤ Obtain a history of the patient’s
musculoskeletal system and results
• Monitor effectiveness of estrogen of previously performed tests and
replacement therapy procedures. For related tests, refer
to the musculoskeletal system
RESULT table.
➤ Obtain a list of the medications
Increased in: the patient is taking, including
herbs, nutritional supplements, and
• Adolescents undergoing a growth spurt nutraceuticals. The requesting health
• Chronic renal failure care practitioner and laboratory
should be advised if the patient
• Hyperthyroidism (primary and regularly uses these products so
secondary) that their effects can be taken
into consideration when reviewing
• Metastatic skeletal disease results.
• Paget’s disease ➤ Note any recent procedures that can
interfere with test results.
• Renal osteodystrophy
➤ There are no food, fluid, or medica-
• Some patients with osteoporosis tion restrictions unless by medical
direction.
Decreased in: ➤ Review the procedure with the
• Growth hormone deficiency patient.
➤ Inform the patient that specimen
• Pregnancy collection takes approximately 5 to
• Primary biliary cirrhosis 10 minutes.
➤ Observe standard precautions and coli, kale, tofu, legumes, and forti-
follow the general guidelines in fied orange juice are high in calcium.
Appendix A. Perform a venipuncture, Milk and milk products also contain
and collect the specimen in a 5-mL vitamin D and lactose, which assist
red-top tube. calcium absorption. Cooked vegeta-
➤ Label the specimen, and promptly bles yield more absorbable calcium
transport it to the laboratory. than raw vegetables. Patients
should be informed of the sub-
Post-test: stances that can inhibit calcium
absorption by irreversibly binding to
➤ Observe venipuncture site for bleed- some of the calcium, making it
ing or hematoma formation. Apply unavailable for absorption, such as
pressure bandage. oxalates, which naturally occur in
➤ Increased osteocalcin levels may be some vegetables; phytic acid, found
associated with skeletal disease. in some cereals; and insoluble
Nutritional therapy is indicated for dietary fiber (in excessive amounts).
individuals identified as being at high Excessive protein intake can also
risk for developing osteoporosis. negatively affect calcium absorption,
Educate the patient regarding the especially if it is combined with
National Osteoporosis Foundation’s foods high in phosphorus. Vitamin D
guidelines, which include a regular is synthesized by the skin and is also
regimen of weight-bearing exer- available in fortified dairy foods and
cises, limited alcohol intake, avoid- cod liver oil.
ance of tobacco products, and ➤ Evaluate test results in relation to
adequate dietary intake of vitamin D the patient’s symptoms and other
(400 to 800 IU/day) and calcium (120 tests performed. Related laboratory
mg/day). Dietary calcium can be tests include alkaline phosphatase,
obtained from animal or plant calcium, urine calcium, phosphorus,
sources. Milk and milk products, collagen crosslinked N-telopeptides,
sardines, clams, oysters, salmon, parathyroid hormone, phosphorus,
rhubarb, spinach, beet greens, broc- and vitamin D.
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.
tion
Pretest:
• Blastocystis—Blastocystis hominis infec-
tion ➤ Obtain a history of the patient’s
complaints, and document any travel
• Cryptosporidiosis—Cryptosporidium
to foreign countries. Obtain a list of
parvum infection known allergens.
• Enterobiasis—Enterobius vermicularis ➤ Obtain a history of the patient’s gas-
(pinworm) infection trointestinal and immune systems,
• Giardiasis—Giardia lamblia infection as well as results of previously per-
formed tests and procedures. For re-
• Hookworm disease—Ancylostoma lated tests, refer to the gastrointesti-
duodenale, Necator americanus infec- nal and immune system tables.
tion ➤ Obtain a list of the medications the
• Isospora—Isospora belli infection patient is taking, including herbs, nu-
tritional supplements, and nutraceu-
• Schistosomiasis—Schistosoma haemato- ticals. The requesting health care
bium, Schistosoma japonicum, Schisto- practitioner and laboratory should be
soma mansoni infection advised if the patient regularly uses
these products so their effects can
• Strongyloidiasis—Strongyloides sterco- be taken into consideration when re-
ralis infection viewing results.
• Tapeworm disease—Diphyllobothrium, ➤ Instruct the patient to avoid medica-
Hymenolepiasis, Taenia saginata, Taenia tions that interfere with test results.
solium infection ➤ Note any recent therapies that can
• Trematode disease—Clonorchis sinensis, interfere with test results.
Fasciola hepatica, Fasciolopsis buski ➤ Instruct the patient on handwashing
infection procedures, and inform the patient
that the infection may be conta-
• Trichuriasis—Trichuris trichiura infec- gious.
tion
➤ There are no food or fluid restrictions
unless by medical direction.
CRITICAL VALUES: N/A
➤ Review the procedure with the
INTERFERING FACTORS: patient. Warn the patient not to
• Failure to test a fresh specimen may contaminate the specimen with
urine, toilet paper, or toilet water.
yield a false-negative result.
• Antimicrobial or antiamebic therapy Intratest:
within 10 days of test may yield a false-
➤ Obtain a waterproof specimen
negative result. container with a tight-fitting lid.
• Failure to wait 1 week after a gastroin- ➤ Observe standard precautions and
testinal study using barium or after follow the general guidelines in
laxative use can affect test results. Appendix A. Collect a stool speci-
Copyright © 2003 F.A. Davis Company
OXALATE, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (25 mL) from a timed specimen collected in a clean,
plastic collection container with hydrogen chloride (HCl) as a preservative.
PAPANICOLAOU SMEAR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Conventional Units (Conversion Factor 1)
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
Adult 8–24 pg/mL 8–24 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
Adult 10–65 pg/mL 10–65 ng/L
INDICATIONS: • Sarcoidosis
• Assist in the diagnosis of hyperparathy- • Secondary hypoparathyroidism due to
roidism surgery
• Assist in the diagnosis of suspected
secondary hyperparathyroidism due to CRITICAL VALUES: N/A
chronic renal failure, malignant tumors
that produce ectopic PTH, and malab- INTERFERING FACTORS:
sorption syndromes • Drugs that may increase PTH levels
include clodronate, dopamine, estro-
• Detect incidental damage or inadver- gen/progestin therapy, foscarnet,
tent removal of the parathyroid glands furosemide, hydrocortisone, isoniazid,
during thyroid or neck surgery lithium, octreotide, pamidronate,
• Differentiate parathyroid and phosphates, prednisone, tamoxifen,
nonparathyroid causes of hypercal- and verapamil.
cemia • Drugs and vitamins that may decrease
• Evaluate autoimmune destruction of PTH levels include alfacalcidol,
the parathyroid glands aluminum hydroxide, calcitriol, cime-
tidine (C-terminal only), diltiazem,
• Evaluate parathyroid response to magnesium sulfate, pindolol, pred-
altered serum calcium levels, especially nisone (intact), and vitamin D.
those that result from malignant
processes, leading to decreased PTH • PTH levels are subject to diurnal vari-
production ation, with highest levels occurring in
the morning.
• Evaluate source of altered calcium
• PTH levels should always be measured
metabolism
in conjunction with calcium for proper
interpretation.
RESULT
Increased in:
Nursing Implications and
• Fluorosis
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ The patient should fast for 12 hours ➤ Label the specimen, and promptly
before specimen collection. transport it to the laboratory. The
➤ There are no fluid or medication tightly capped sample should be
restrictions unless by medical direc- placed in an ice slurry immediately
tion. after collection. Information on the
specimen label can be protected
➤ Early morning specimen collection is from water in the ice slurry if the
recommended because of the diur- specimen is first placed in a protec-
nal variation in PTH levels. tive plastic bag.
➤ Review the procedure with the
patient. Post-test:
➤ Inform the patient that specimen
collection takes approximately 5 to ➤ Observe venipuncture site for bleed-
10 minutes. ing or hematoma formation. Apply
pressure bandage.
➤ Prepare an ice slurry in a cup or plas-
tic bag to have on hand for immedi- ➤ Patients with abnormal parathyroid
ate transport of the specimen to the levels are also likely to experience
laboratory. the effects of calcium level imbal-
ances. Instruct the patient to report
Intratest: signs and symptoms of hypocal-
cemia and hypercalcemia to the
➤ Ensure that the patient has complied requesting health care practitioner.
with dietary preparations and other (For critical values, signs and symp-
pretesting restrictions. toms of calcium imbalance, and
➤ Direct the patient to breathe nutritional information, see mono-
normally and to avoid unnecessary graph titled “Calcium.”)
movement. ➤ Evaluate test results in relation to
➤ Observe standard precautions and the patient’s symptoms and other
follow the general guidelines in tests performed. Related laboratory
Appendix A. Perform a venipuncture, tests include calcium, ionized
and collect the specimen in a 5-mL calcium, serum and urine phospho-
red- and lavender-top tube. rus, and vitamin D.
PARATHYROID SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
➤ Tell all caregivers to wear gloves the ordering provider, who discusses
when discarding urine for 24 hours the results with the patient.
after the procedure. Wash gloved ➤ Evaluate test results in relation to
hands with soap and water before the patient’s symptoms and other
removing gloves. Then wash hands tests performed. Related diagnostic
after the gloves are removed. tests include computed tomography
➤ A physician specializing in this branch and magnetic resonance imaging of
of medicine sends a written report to the chest.
PARTIAL THROMBOPLASTIN
TIME, ACTIVATED
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: APTT.
SPECIMEN: Plasma (1 mL) collected in a completely filled blue-top
(sodium citrate) tube.
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (2 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Immunoassay)
SYNONYM/ACRONYM: N/A.
SPECIMEN: Pericardial fluid (5 mL) collected in a red- or green-top
(heparin) tube for glucose, lavender-top (ethylenediaminetetra-acetic acid
[EDTA]) tube for cell count, and sterile containers for microbiology speci-
mens. Ensure that there is an equal amount of fluid to fixative in a clear
container for cytology.
➤ Obtain a list of the medications the ➤ Assist the patient into a supine posi-
patient is taking, including herbs, nu- tion with the head elevated 45º to
tritional supplements, and nutraceu- 60º.
ticals. The requesting health care ➤ Direct the patient to breathe
practitioner and laboratory should be normally and to avoid unnecessary
advised if the patient regularly uses movement.
these products so that their effects
can be taken into consideration ➤ Take and record baseline vital signs.
when reviewing results. ➤ Observe standard precautions and
➤ Restrict food and fluids for 6 to 8 follow the general guidelines in
hours before the procedure, as Appendix A.
directed. ➤ Cleanse the skin with an antiseptic
➤ The requesting health care practi- solution, and protect the area with a
tioner may request that anticoagu- sterile drape. The skin at the injec-
lants and aspirin be withheld. tion site is anesthetized.
➤ Review the procedure with the ➤ The precordial (V) cardiac lead wire
patient. Inform the patient where is attached to the cardiac needle
the test will be performed (some with an alligator clip. The cardiac
procedures are performed in a needle is inserted just below and to
cardiac laboratory). the left of the breastbone, and fluid
is removed.
➤ Explain the importance of remaining
still during the procedure. ➤ Monitor vital signs every 15 minutes
for signs of hypovolemia or shock.
➤ Inform the patient that an intra- Monitor electrocardiogram for
venous infusion will be started needle-tip positioning to indicate
before and during the procedure. accidental puncture of the right
➤ Inform the patient that a local anes- atrium.
thetic will be administered at the
➤ The needle is withdrawn and slight
needle insertion site immediately
pressure applied to the site. If there
before the procedure to reduce
is no evidence of bleeding or
discomfort during needle aspiration.
drainage, a sterile dressing is applied
Explain that the anesthetic injection
to the site.
may cause a stinging sensation.
Explain that after the skin has been ➤ If there is no sign of arrhythmia, the
anesthetized, a large needle will be cardiac monitor can be removed.
inserted through the chest to obtain ➤ Fill the appropriate collection
the fluid. containers with fluid for analysis.
➤ Assess whether the patient has an ➤ Label the specimens, and promptly
allergy to local anesthetic, and transport them to the laboratory.
inform the health care practitioner
accordingly. Post-test:
➤ Obtain written and informed
consent before administering any ➤ Instruct the patient to resume usual
medications prior to the procedure. diet and medication, if withheld and
as directed by the requesting health
➤ Have the patient void before the care practitioner.
procedure.
➤ Observe the patient for signs of res-
➤ Inform the patient that specimen
piratory and cardiac distress, such as
collection takes approximately 30
shortness of breath, cyanosis, or
minutes.
rapid pulse.
➤ Inform the patient that 1 hour or
Intratest: more of bed rest is required after the
➤ Ensure that the patient has complied procedure.
with dietary preparations and other ➤ Take vital signs every 15 minutes for
pretesting restrictions. the first hour, every 30 minutes for
Copyright © 2003 F.A. Davis Company
the next 2 hours, every hour for the ➤ Administer antibiotics, as ordered,
next 4 hours, and every 4 hours for and instruct the patient in the impor-
the next 24 hours. Take the patient’s tance of completing the entire
temperature every 4 hours for 24 course of antibiotic therapy even if
hours. Monitor intake and output for no symptoms are present.
24 hours. ➤ Evaluate test results in relation to
➤ Continue intravenous fluids until vital the patient’s symptoms and other
signs are stable and the patient can tests performed. Related tests
resume fluid intake independently. include 1-fetoprotein, bacterial
➤ Assess the puncture site for bleed- culture, CA 15-3, CA 19-9, CA 125,
ing or drainage and signs of inflam- carcinoembryonic antigen, fungal
mation each time vital signs are culture, mycobacterial culture, and
taken and daily thereafter for several viral culture.
days.
PHOSPHORUS, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 0.323)
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
PHOSPHORUS, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
➤ Obtain a list of the medications the oughly wash his hands, (2) cleanse
patient is taking, including herbs, nu- the meatus, (3) void a small amount
tritional supplements, and nutraceu- into the toilet, and (4) void directly
ticals. The requesting health care into the specimen container.
practitioner and laboratory should be
➤ Instruct the female patient to (1)
advised if the patient regularly uses
thoroughly wash her hands; (2)
these products so that their effects
cleanse the labia from front to back;
can be taken into consideration
(3) while keeping the labia sepa-
when reviewing results.
rated, void a small amount into the
➤ There are no food, fluid, or medica- toilet; and (4) without interrupting
tion restrictions unless by medical the urine stream, void directly into
direction. the specimen container.
➤ Instruct the patient to avoid exces-
sive exercise and stress during the Timed specimen:
24-hour collection of urine. ➤ 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. specimen must be refrigerated or
➤ Usually a 24-hour time frame kept on ice throughout the
for urine collection is ordered. entire collection period. If an
Inform the patient that all urine must indwelling urinary catheter is in
be saved during that 24-hour place, the drainage bag must be
period. Instruct the patient not kept on ice.
to void directly into the laboratory ➤ Begin the test between 6 and 8
collection container. Instruct the a.m., if possible. Collect first voiding
patient to avoid defecating in and discard. Record the time the
the collection device and to keep specimen was discarded as the
toilet tissue out of the collection beginning of the timed collection
device to prevent contamination of period. The next morning, ask the
the specimen. Place a sign in the patient to void at the same time the
bathroom to remind the patient to collection was started and add this
save all urine. last voiding to the container.
➤ Instruct the patient to void all urine ➤ If an indwelling catheter is in place,
into the collection device and then to replace the tubing and container
pour the urine into the laboratory system at the start of the collection
collection container. Alternatively time. Keep the container system on
the specimen can be left in the ice during the collection period, or
collection device for a health care empty the urine into a larger
staff member to add to the labora- container periodically during the
tory collection container. collection period; monitor to ensure
continued drainage, and conclude
Intratest: the test the next morning at the
same hour the collection was
➤ Observe standard precautions and begun.
follow the general guidelines in
Appendix A. ➤ At the conclusion of the test,
compare the quantity of urine with
Random specimen (collect in the urinary output record for the
early morning): collection; if the specimen contains
less than what was recorded as
output, some urine may have been
Clean-catch specimen: discarded, invalidating the test.
➤ Instruct the male patient to (1) thor- ➤ Label the specimen, and promptly
Copyright © 2003 F.A. Davis Company
Plasminogen 781
PLASMINOGEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
PLATELET ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Serum (1 mL) collected in a red-top tube for indirect IgG anti-
body. Whole blood (7 mL) collected in lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube for direct antibody.
PLATELET COUNT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Thrombocytes.
Copyright © 2003 F.A. Davis Company
SI Units
Age Platelet Count* (Conversion Factor 106) 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
Note: Platelet counts decrease with age.
* Conventional units.
MPV mean platelet volume.
DESCRIPTION: Platelets are non- normal limits, but the patient may
nucleated, cytoplasmic, round or oval exhibit signs of internal bleeding;
disks formed by budding off of large, this circumstance usually indicates
multinucleated cells (megakaryo- an anomaly in platelet function.
cytes). Platelets have an essential Abnormal scatterplot findings by
function in coagulation, hemostasis, automated cell counters may indicate
and blood thrombus formation. the need to review a smear of periph-
Thrombocytosis is an increase in eral blood for platelet estimate.
platelet count. In reactive thrombo- Abnormally large or giant platelets
cytosis, the increase is transient may result in underestimated auto-
and short lived, and it usually mated counts by 30 to 50 percent.
does not pose a health risk. One A large discrepancy between the
exception may be reactive thrombo- automated count and the estimate
cytosis occurring after coronary requires that a manual count be
bypass surgery. This circumstance performed. The significance of
has been identified as an important platelet sizing is becoming more
risk factor for postoperative infarc- widely known, as modern cell coun-
tion and thrombosis. The term ters are capable of reporting platelet
thrombocythemia is used to describe indexes that are analogous to red
platelet increases associated with blood cell (RBC) indices. Platelet
chronic myeloproliferative disorders. size, reflected by mean platelet
Thrombocytopenia is used to des- volume (MPV) and cellular age, are
cribe platelet counts of less than inversely related; that is, younger
140 106/L. Decreased platelet platelets tend to be larger. An increase
counts occur whenever the body’s in MPV indicates an increase in
need for platelets exceeds the rate of platelet turnover. Therefore, in a
platelet production; this circum- normal patient the platelet count and
stance will arise if production rate MPV have an inverse relationship.
decreases or platelet loss increases. Abnormal platelet size may also indi-
The severity of bleeding is related to cate the presence of a disorder. MPV
platelet count as well as platelet func- and platelet distribution width
tion. Platelet counts can be within (PDW) are both increased in idio-
Copyright © 2003 F.A. Davis Company
• Failure to fill the tube sufficiently (i.e., ➤ There are no food, fluid, or medica-
tube less than three-quarters full) may tion restrictions unless by medical
yield inadequate sample volume for direction.
automated analyzers and may be ➤ Review the procedure with the
reason for specimen rejection. patient.
• Hemolysis or clotted specimens are ➤ Inform the patient that specimen
reasons for rejection. collection takes approximately 5 to
10 minutes.
• Complete blood count should be care-
fully evaluated after transfusion or Intratest:
acute blood loss because the value may
➤ Direct the patient to breathe
appear to be normal. normally and to avoid unnecessary
• A white blood cell count greater than movement.
100,000 per mm3, severe RBC frag- ➤ Observe standard precautions and
mentation, and extraneous particles in follow the general guidelines in
the fluid used to dilute the sample can Appendix A. Perform a venipuncture,
alter test results. and collect the specimen in a 5-mL
lavender-top tube. The specimen
should be mixed gently by inverting
the tube 10 times. The specimen
Nursing Implications and should be analyzed within 6 hours
Procedure ● ● ● ● ● ● ● ● ● ● ●
when stored at room temperature or
within 24 hours if stored at refriger-
Pretest: ated temperature. In addition, if it is
➤ Obtain a history of the patient’s anticipated that the specimen will
complaints, including a list of known not be analyzed within 4 to 6 hours,
allergens. two blood smears should be made
immediately after the venipuncture
➤ Obtain a history of the patient’s and should be submitted with the
hematopoietic and immune sys- blood sample.
tems, a history of any bleeding
disorders, and results of previously ➤ Label the specimen, and promptly
performed tests and procedures, transport it to the laboratory.
especially bleeding time, complete
blood count, clotting time, partial Post-test:
thromboplastin time, prothrombin
time, and platelets. For related tests, ➤ Observe venipuncture site for bleed-
refer to the hematopoietic and ing or hematoma formation. Apply
immune system tables. pressure bandage.
➤ Obtain a list of the medications the ➤ Instruct the patient to report bleed-
patient is taking to include anticoag- ing from any areas of the skin or
ulant therapy, acetylsalicylic acid, mucous membranes.
herbals, and nutraceuticals known ➤ Inform the patient with a decreased
to affect coagulation. It is recom- platelet count of the importance of
mended that use be discontinued 14 taking precautions against bruising
days before dental or surgical proce- and bleeding, including the use of a
dures. The requesting health care soft bristle toothbrush, use of an
practitioner and laboratory should be electric razor, avoidance of constipa-
advised if the patient regularly uses tion, avoidance of acetylsalicylic acid
these products so that their effects and similar products, and avoidance
can be taken into consideration of intramuscular injections.
when reviewing results. ➤ Inform the patient of the importance
➤ Note any recent procedures that can of periodic laboratory testing if he or
interfere with test results. she is taking an anticoagulant.
Copyright © 2003 F.A. Davis Company
Plethysmography 789
PLETHYSMOGRAPHY
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Plethysmography 791
PORPHYRINS, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
drugs classified as unsafe for high-risk ➤ There are no food, fluid, or medica-
individuals include antipyrine, tion restrictions unless by medical
aminopyrine, aminoglutethimide, bar- direction.
biturates, carbamazepine, carbromal, ➤ Review the procedure with the
chlorpropamide, danazol, dapsone, di- patient. Provide a nonmetallic urinal,
clofenac, diphenylhydantoin, ergot bedpan, or toilet-mounted collection
device.
preparations, ethchlorvynol, ethina-
mate, glutethimide, griseofulvin, N- ➤ Usually a 24-hour time frame for
urine collection is ordered. Inform
isopropyl meprobamate, mephenytoin, the patient that all urine must be
meprobamate, methyprylon, N- saved during that 24-hour period.
butylscopolammoniumine bromide, Instruct the patient not to void
novobiocin, phenylbutazone, primi- directly into the laboratory collection
done, pyrazolone preparations, succin- container. Instruct the patient to
imides, sulfonamide antibiotics, sul- avoid defecating in the collection
fonethylmethane, sulfonmethane, device and to keep toilet tissue out
synthetic estrogens and progestins, to- of the collection device to prevent
lazamide, tolbutamide, trimethadione, contamination of the specimen.
Place a sign in the bathroom to
and valproic acid. remind the patient to save all urine.
• Exposure of the specimen to light can ➤ Instruct the patient to void all urine
falsely decrease values. into the collection device and then to
pour the urine into the laboratory
• Screening methods are not well stan- collection container. Alternatively
dardized and can produce false- the specimen can be left in the
negative results. collection device for a health care
staff member to add to the labora-
• Failure to collect all urine and store tory collection container.
specimen properly during the 24-hour
test period will interfere with results. Intratest:
➤ Observe standard precautions and
follow the general guidelines in
Nursing Implications and Appendix A.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Random specimen (collect in
Pretest: early morning):
➤ Obtain a history of the patient’s
complaints, including a list of known Clean-catch specimen:
allergens. ➤ Instruct the male patient to (1) thor-
➤ Obtain a history of the patient’s oughly wash his hands, (2) cleanse
hematopoietic system and results of the meatus, (3) void a small amount
previously performed tests and into the toilet, and (4) void directly
procedures. For related tests, refer into the specimen container.
to the hematopoietic system table. ➤ Instruct the female patient to (1)
➤ Obtain a list of medications the thoroughly wash her hands; (2)
patient is taking, including herbs, cleanse the labia from front to back;
nutritional supplements, and (3) while keeping the labia sepa-
nutraceuticals. The requesting health rated, void a small amount into the
care practitioner and laboratory toilet; and (4) without interrupting
should be advised if the patient the urine stream, void directly into
regularly uses these products so the specimen container.
that their effects can be taken Indwelling catheter:
into consideration when reviewing
results. ➤ Put on gloves. Empty drainage tube
Copyright © 2003 F.A. Davis Company
ment
• Incorrect positioning of the patient, Pretest:
which may produce poor visualization ➤ Inform the patient that the proce-
of the area to be examined dure assesses blood flow to the
brain and brain tissue metabolism.
• Drugs that alter glucose metabolism,
such as tranquilizers or insulin, because ➤ Inform the patient that the proce-
dure is performed in a special
hypoglycemia can alter PET results
department by a technologist and
• The use of alcohol, tobacco, or takes approximately 30 to 120
caffeine-containing drinks at least 24 minutes.
hours before the study, because the ➤ Restrict alcohol, tobacco, or caffeine-
Copyright © 2003 F.A. Davis Company
hands with soap and water before of the brain scan may indicate the
removing gloves. Then wash hands need for additional studies.
after the gloves are removed. ➤ Evaluate test results in relation to
➤ A physician specializing in this the patient’s symptoms and other
branch of medicine sends a written tests performed.
report to the ordering provider, who ➤ Related diagnostic tests include
discusses the results with the electroencephalogram, CT and
patient. magnetic resonance imaging of the
➤ Inform the patient that abnormalities brain, and Doppler ultrasound.
POSITRON EMISSION
TOMOGRAPHY, HEART
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➤ Ask the patient to void before the ➤ If the patient must return for further
procedure. Have the patient put on a imaging, advise the patient to rest in
hospital gown. the interim and restrict diet to liquids
➤ Make sure jewelry, watches, chains, before further studies.
belts, and any other metallic objects ➤ Advise patient to drink increased
have been removed from the pelvic amounts of fluids for 24 hours to
area. eliminate the radionuclide from the
➤ Ask the patient to lie still during the body, unless contraindicated. Tell the
procedure because movement patient that radionuclide is elimi-
produces unclear images. nated from the body within 6 to 24
hours.
➤ An intravenous line may be started.
➤ Instruct the patient to flush the toilet
➤ The radionuclide is injected, and
immediately after each voiding
imaging is started after a 45-minute
following 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-
ies are indicated, additional injec- ➤ Tell all caregivers to wear gloves
tions of radionuclide may be when discarding urine for 24
needed. hours after the procedure. Wash
gloved hands with soap and water
➤ If required, the bladder may need to
before removing gloves. Then
be lavaged via a urinary catheter
wash hands after the gloves are
with 2 L of 0.9% saline solution to
removed.
remove concentrated radionuclide.
➤ Wear gloves during the radionuclide ➤ Inform the patient that abnormalities
injection and while handling the of the pelvic scan may indicate the
patient’s urine. need for additional studies.
➤ A physician specializing in this
Post-test: branch of medicine sends a written
report to the ordering provider, who
➤ Observe the injection site for discusses the results with the
redness, swelling, or hematoma. patient.
➤ Observe the patient for 60 minutes ➤ Evaluate test results in relation to
after the procedure for possible the patient’s symptoms and other
reaction to the radionuclide or other tests performed. Related diagnostic
procedure complications. tests include computed tomogra-
➤ Instruct the patient to resume phy; magnetic resonance imaging;
normal activity and diet, unless and kidney, ureter, and bladder
otherwise indicated. (KUB) film.
POTASSIUM, SERUM
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POTASSIUM, URINE
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SI Units
Age Conventional Units (Conversion Factor 1)
6–10 y
Male 17–54 mEq/24 h 17–54 mmol/24 h
Female 8–37 mEq/24 h 8–37 mmol/24 h
10–14 y
Male 22–57 mEq/24 h 22–57 mmol/24 h
Female 18–58 mEq/24 h 18–58 mmol/24 h
Adult 26–123 mEq/24 h 26–123 mmol/24 h
Note: Reference values depend on potassium intake and diurnal variation. Excretion is
significantly higher at night.
Intratest:
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Observe standard precautions and
follow the general guidelines in
Pretest: Appendix A.
PREALBUMIN
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SYNONYM/ACRONYM: Transthyretin.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
Copyright © 2003 F.A. Davis Company
Prealbumin 819
PROCTOSIGMOIDOSCOPY
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Proctosigmoidoscopy 821
INDICATIONS: • Tumors
• Screen and excise polyps • Ulcerative colitis
• Examine the distal colon before • Vascular abnormalities
barium enema x-ray to obtain
improved visualization of the area, and • Rectal prolapse
after a barium enema when x-ray find-
ings are inconclusive CRITICAL VALUES: N/A
• Evaluate the cause of blood, pus, or INTERFERING FACTORS:
mucus in the stool
This procedure is contraindicated
• Determine the cause of pain and rectal for:
prolapse during defecation
• Patients with bleeding disorders, espe-
• Determine the cause of rectal itching, cially disorders associated with uremia
pain, or burning and cytotoxic chemotherapy
• Confirm the diagnosis of diverticular • Patients with cardiac conditions or
disease arrhythmias
• Confirm the diagnosis of • Patients with bowel perforation, acute
Hirschsprung’s disease and colitis in peritonitis, ischemic bowel necrosis,
children toxic megacolon, diverticulitis, recent
bowel surgery, advanced pregnancy,
• Evaluate postoperative anastomosis of
severe cardiac or pulmonary disease,
the colon
recent myocardial infarction, known
• Reduce volvulus of the sigmoid colon or suspected pulmonary embolus, large
Copyright © 2003 F.A. Davis Company
Proctosigmoidoscopy 823
PROGESTERONE
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SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay)
SI Units
Hormonal State Conventional Units (Conversion Factor 0.0318)
Prepubertal males Less than 20 ng/dL Less than 0.6 nmol/L
and females
Men 10–50 ng/dL 0.3–1.6 nmol/L
Women
Follicular phase Less than 50 ng/dL Less than 1.6 nmol/L
Luteal phase 300–2500 ng/dL 9.5–79.5 nmol/L
Pregnancy, first 725–4400 ng/dL 23.0–139.9 nmol/L
trimester
Pregnancy, second 1950–8250 ng/dL 62.0–262.3 nmol/L
trimester
Pregnancy, third 6500–22,900 ng/dL 206.7–728.2 nmol/L
trimester
Postmenopausal Less than 40 ng/dL Less than 1.3 nmol/L
period
Progesterone 825
PROLACTIN
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SI Units
Age Conventional Units (Conversion Factor 1)
Prepubertal males 3.2–20.0 ng/mL 3.2–20.0 g/L
and females
Men 2.4–13.8 ng/mL 2.4–13.8 g/L
Women 3.3–26.7 ng/mL 3.3–26.7 g/L
Pregnant 5.3–215.3 ng/mL 5.3–215.3 g/L
Postmenopausal 2.4–24.0 ng/mL 2.4–24.0 g/L
Prolactin 827
PROSTATE-SPECIFIC ANTIGEN
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SYNONYM/ACRONYM: PSA.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Immunoassay)
SI Units
Sex Conventional Units (Conversion Factor 1)
Male Less than 4 ng/mL Less than 4 g/L
Female Less than 0.5 ng/mL Less than 0.5 g/L
PROTEIN C
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Protein C 831
PROTEIN S
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SI Units
Conventional Units (Conversion Factor .01)
Total protein S 70–140% activity 0.7–1.4 U/mL
Free protein S 60–120% activity 0.6–1.2 U/mL
The low end of “normal” is lower in children younger than age 16 years because of the
immaturity of the liver.
Protein S 833
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (5 mL) from an unpreserved random or timed specimen
collected in a clean, plastic collection container.
SI Units
Conventional Units (Conversion Factor 0.001)
Total protein 10–140 mg/24 h 0.01–0.14 g/24 h
Electrophoresis for fractionation is qualitative: No monoclonal gammopathy detected.
(Urine protein electrophoresis should be ordered along with serum protein
electrophoresis.)
PSEUDOCHOLINESTERASE AND
DIBUCAINE NUMBER
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SI Units
Test Conventional Units (Conversion Factor 1)
Pseudocholinesterase 2–11 U/mL 2–11 kU/L
TV 500 mL at rest
RV 1200 mL (approximate)
IRV 3000 mL (approximate)
ERV 1100 mL (approximate)
VC 4600 mL (approximate)
TLC 5800 mL (approximate)
IC 3500 mL (approximate)
FRC 2300 mL (approximate)
FVC 3000–5000 mL (approximate)
FEV1/FVC 81–83%
MMEF 25–75%
FIF 25–75%
MVV 25–35% or 170 L/min
PIFR 300 L/min
PEFR 450 L/min
F-V loop Normal curve
DCOL 25 mL/min per mm Hg (approximate)
CV 10–20% of VC
Viso Based on age formula
Bronchial provocation No change, or less than 20% reduction in
FEV1
Note: Normal values listed are estimated values for adults. Actual pediatric and adult
values are based on age, height, and gender. These normal values are included on the
patient’s pulmonary function laboratory report.
TV tidal volume; RV residual volume; IRV inspiratory reserve volume; ERV
expiratory reserve volume; VC vital capacity; TLC total lung capacity; IC inspiratory
capacity; FRC functional residual capacity; FVC forced vital capacity in 1 second;
FEV1 forced expiratory volume in 1 second; MMEF maximal midexpiratory flow (also
known as FEF25–75%); FIF forced inspiratory flow rate; MVV maximal voluntary
ventilation; PIFR peak inspiratory flow rate; PEFR peak expiratory flow rate; F-V loop
flow-volume loop; DCOL diffusing capacity of the lungs; CV closing volume; Viso
isoflow volume.
Copyright © 2003 F.A. Davis Company
Normal adult lung volumes, capaci- • Exercise caution with patients who
ties, and flow rates are as follows: have upper respiratory infections, such
as a cold or acute bronchitis.
Abnormal Findings:
• Allergy
Nursing Implications and
• Asbestosis
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Asthma
Pretest:
• Bronchiectasis
➤ Explain the purpose of the study,
• Chest trauma and inform the patient that it will not
cause any pain.
• Chronic bronchitis
➤ Explain that the procedure is
• Curvature of the spine generally performed in a specially
equipped room or in a physician’s
• Emphysema office by a technologist and usually
lasts 1 hour.
• Myasthenia gravis
➤ Measure the patient’s height and
• Obesity weight.
➤ Assess medication history for recent
• Pulmonary fibrosis administration of analgesics that
may depress respiratory function.
• Pulmonary tumors
Ensure that medications such as
• Respiratory infections bronchodilators (oral or inhalant) are
withheld at least 4 hours before the
• Sarcoidosis study.
➤ Obtain a history of suspected or
INTERFERING FACTORS: known pulmonary conditions, respi-
• The aging process can cause decreased ratory status and patterns, medica-
tions (oral, inhalant, other), smoking
values (FVC, DCOL) depending on
history, and previously performed
the study done. tests and procedures. For related
• Inability of the patient to put forth the tests, refer to the respiratory system
table.
necessary breathing effort affects the
results. ➤ Ensure that the patient has refrained
from smoking tobacco or eating a
• Medications such as brochodilators can heavy meal for 4 to 6 hours.
affect results.
Intratest:
• Improper placement of the nose clamp
➤ Obtain an inhalant bronchodilator to
or mouthpiece that allows for leakage treat any bronchospasms that can
can affect volume results. occur with testing.
• Confusion or inability to understand ➤ Ask patient to void and loosen any
instructions or cooperate during the restrictive clothing.
study can cause inaccurate results. ➤ Place the patient in a sitting position
on a chair near the spirometry equip-
• Testing is contraindicated in patients ment.
with cardiac insufficiency, recent ➤ Place a soft clip on the patient’s
myocardial infarction, and presence of nose to restrict nose breathing, and
chest pain that affects inspiration or instruct the patient to breathe
expiration ability. through the mouth.
Copyright © 2003 F.A. Davis Company
Functional
residual (FRC) Residual
capacity volume
FIGURE 1–1
Copyright © 2003 F.A. Davis Company
FIGURE 1–2
PULSE OXIMETRY
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CONTRAST: None.
➤ Ensure that the patient does not ➤ Place the photodetector probe over
have false fingernails and that nail the finger in such a way that the light
polish has been removed. beams and sensors are opposite
➤ Instruct the patient not to smoke for each other. Turn the power switch to
24 hours before the test. the oximeter monitor, which will
display information about heart rate
➤ If a finger probe is used, instruct the and SaO2.
patient not to grip treadmill rail or
bedrail tightly; doing so restricts ➤ Remove the clip for monitoring
blood flow. when the test is complete.
➤ When used in the presence of flam- Post-test:
mable gases, the equipment must
be approved for that specific use. ➤ Compare new value with previous
➤ There are no food, fluid, or medica- value to determine response to
tion restrictions. medical problem or treatment.
➤ Consider test results as they relate
Intratest: to ABGs.
➤ Closely observe SPO2, and report if
➤ Massage or apply a warm towel to it decreases to 90 percent.
the upper earlobe or finger to
increase the blood flow. ➤ Determine if the patient or family
members have any further ques-
➤ The index finger is normally used, tions or concerns.
but if the patient’s finger is too large
for the probe, a smaller finger can be ➤ Evaluate test results in relation
used. to the patient’s symptoms and
other tests performed. Related
➤ If the earlobe is used, make sure diagnostic tests include electro-
good contact is achieved. cardiogram, x-ray, computed tomog-
➤ With infants, the big toe, top or raphy, and magnetic resonance
bottom of the foot, or sides of the imaging of the chest; and pulmonary
heel may be used. function tests.
PYRUVATE KINASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: PK assay.
SPECIMEN: Whole blood collected in yellow-top (acid-citrate-dextrose
[ACD]) tube. Specimens collected in a lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) or green-top (heparin) tube also may be acceptable in
some laboratories.
tion safety concerns regarding infants metallic objects have been removed
of patients who are lactating. from the neck area.
➤ Administer the I-123 orally (pill form).
➤ At 2, 6, and 24 hours, place the
Nursing Implications and patient in a sitting or supine position
Procedure ● ● ● ● ● ● ● ● ● ● ●
in front of a radionuclide detector
that will determine the thyroid
gland’s ability to bind iodine.
Pretest:
➤ Ask the patient to hold very still
➤ Inform the patient that the proce- during the procedure because move-
dure assesses thyroid function. ment will produce unclear images.
➤ Inform the patient that the ➤ Wear gloves during the radionuclide
procedure is performed in a special administration and while handling
nuclear medicine department the patient’s urine.
by a technologist and usually
takes approximately 30 minutes,
Post-test:
and that delayed images are
needed 24 hours later. The patient ➤ Instruct the patient to resume
may leave the department and normal activity, medications, and
return later to undergo delayed diet, unless otherwise indicated.
imaging.
➤ Advise patient to drink increased
➤ Obtain a history of the patient’s amounts of fluids for 24 hours to
complaints, including a list of known eliminate the radionuclide from the
allergens. body, unless contraindicated. Tell the
➤ Obtain a history of the patient’s patient that radionuclide is elimi-
thyroid system and results of previ- nated from the body within 24 to 48
ously performed laboratory tests, hours.
surgical procedures, and thyroid ➤ Instruct the patient to flush the toilet
therapy. For related tests, refer to immediately after each voiding
the endocrine system table. following the procedure and to wash
➤ Obtain a list of the medications the hands meticulously with soap and
patient is taking, including herbs, water after each voiding for 24 hours
nutritional supplements, and after the procedure.
nutraceuticals. ➤ Tell all caregivers to wear gloves
➤ All thyroid blood tests should be when discarding urine for 24
taken before the procedure. hours after the procedure. Wash
➤ Determine date of last menstrual gloved hands with soap and water
period and possibility of pregnancy before removing gloves. Then
in perimenopausal women. wash hands after the gloves are
removed.
➤ Ensure that the patient has fasted
for 8 to 12 hours before the uptake, ➤ A physician specializing in this
but the patient may eat 4 hours after branch of medicine sends a written
the test begins, unless otherwise report to the ordering provider, who
indicated. discusses the results with the
patient.
➤ All radiographic procedures using
iodinated contrast medium should ➤ Evaluate test results in relation to
be done after this procedure is the patient’s symptoms and other
complete. tests performed. Related diagnostic
tests include ultrasound of the
Intratest: thyroid, upper gastrointestinal
series, and computed tomography
➤ Make sure jewelry and any other of the spine.
Copyright © 2003 F.A. Davis Company
RADIOGRAPHY, BONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
x-ray is taken and then to exhale family members have any further
after the film is taken. Warn the questions or concerns.
patient that the extremity’s position ➤ A physician specializing in this
during the procedure may be branch of medicine sends a written
uncomfortable, but ask the patient report to the ordering provider, who
to hold very still during the proce- discusses the results with the
dure because movement will patient.
produce unclear images.
➤ Inform the patient that further exam-
➤ Numerous x-rays may be taken inations may be necessary to evalu-
depending on the bones or joint ate progression of the disease
affected. process or to determine the need for
a change in therapy.
Post-test: ➤ Evaluate test results in relation to
the patient’s symptoms and other
➤ Tell the patient to contact the physi- tests performed. Related diagnostic
cian if the injured area does not tests include bone scan, magnetic
improve. resonance imaging, and computed
➤ Determine whether the patient or tomography of the suspected area.
SYNONYM/ACRONYM: RBC.
SPECIMEN: Whole blood (1 mL) collected in a lavender-top (ethylenedi-
aminetetra-acetic acid [EDTA]) tube.
SI Units
Age Conventional Units (Conversion Factor 1)
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
Adult female 4.20–4.87 106 cells/mm3 4.20–4.87 1012 cells/L
cheese, eggs, and fortified soy milk taken, but the danger of toxicity
products. Sources of folate are should be explained to the patient.
meats (especially liver), kidney Very large supplemental doses, in
beans, beets, vegetables in the excess of 600 mg of vitamin E over
cabbage family, oranges, canta- a period of 1 year, may result in
loupe, and green leafy vegetables excess bleeding. Vitamin E is heat
such as spinach, asparagus, and stable but is very negatively affected
broccoli. by light.
➤ A diet deficient in vitamin E puts the ➤ Evaluate test results in relation to
patient at risk for increased RBC the patient’s symptoms and other
destruction, which could lead to tests performed. Related laboratory
anemia. Nutritional therapy may be tests include the other tests
indicated for these patients. Vitamin included in a CBC, erythropoietin,
E is found in many of the previously ferritin, folate, iron/total iron-binding
mentioned foods, as well as in capacity, RBC morphology and
vegetable oils and wheat germ. inclusions, reticulocyte count, and
Supplemental vitamin E may also be vitamin B12.
MCH MCHC
Age MCV (fl) (pg/cell) (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
Adult 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 red blood cell distribution width.
Copyright © 2003 F.A. Davis Company
(occupational exposure).
Pretest:
• Drugs that may decrease MCV include
➤ Obtain a history of the patient’s
nitrofurantoin. complaints, including a list of known
• Drugs that may increase MCV include allergens.
colchicine, pentamidine, pyrimetha- ➤ Obtain a history of the patient’s
mine, and triamterene. gastrointestinal, hematopoietic,
immune, and respiratory systems,
• Drugs that may increase the MCH and as well as results of previously
MCHC include oral contraceptives performed tests and procedures. For
(long-term use). related tests, refer to the gastroin-
testinal, hematopoietic, immune,
• Diseases that cause agglutination of and respiratory system tables.
RBCs will alter test results.
➤ Obtain a list of the medications the
• Cold agglutinins may falsely increase patient is taking, including herbs,
the MCV and decrease the RBC count. nutritional supplements, and nutra-
This can be corrected by warming the ceuticals. The requesting health care
blood or diluting the sample with practitioner and laboratory should be
warmed saline and then correcting the advised if the patient regularly uses
these products so that their effects
RBC count mathematically. can be taken into consideration
• RBC counts can vary depending on when reviewing results.
the patient’s position, decreasing when ➤ Note any recent procedures that can
the patient is recumbent as a result of interfere with test results.
hemodilution and increasing when the ➤ There are no food, fluid, or medica-
patient rises as a result of hemocon- tion restrictions unless by medical
centration. direction.
• Care in evaluating the CBC after trans- ➤ Review the procedure with the
patient.
fusion should be taken into considera-
tion. ➤ Inform the patient that specimen
collection takes approximately 5 to
• Venous stasis can falsely elevate RBC 10 minutes.
counts; therefore the tourniquet
should not be left on the arm for Intratest:
longer than 60 seconds.
➤ Direct the patient to breathe
• Failure to fill the tube sufficiently (i.e., normally and to avoid unnecessary
tube less than three-quarters full) may movement.
yield inadequate sample volume for ➤ Observe standard precautions and
automated analyzers and may be follow the general guidelines in
reason for specimen rejection. Appendix A. Perform a venipuncture,
and collect the specimen in a 5-mL
• Hemolyzed or clotted specimens lavender-top (EDTA) tube. The speci-
should be rejected. men should be mixed gently by
inverting the tube 10 times. It is
• Lipemia and elevated white blood cell stable when stored for up to 6 hours
count (greater than 50,000/mm3) will at room temperature or 24 hours if
falsely increase the hemoglobin meas- stored refrigerated. In addition, if it is
urement, also affecting the MCV and anticipated that the specimen will
MCH. not be analyzed within 4 to 6 hours,
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: N/A.
SPECIMEN: Whole blood from one full lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube or Wright’s-stained, thin-film peripheral blood
smear. The laboratory should be consulted as to the necessity of thick-film
smears for the evaluation of malarial inclusions.
Red Within
Blood Cell Normal
Morphology Limits 1 2 3 4
Drepanocytes (sickle cells) Absent Reported as present or absent
Helmet cells Absent Reported as present or absent
Agglutination Absent Reported as present or absent
Rouleaux Absent Reported as present or absent
Hemoglobin (Hgb) 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
Inclusions
Cabot rings Absent Reported as present or absent
Basophilic stippling 0–1 1–5 5–10 10–20 Greater than 20
Howell-Jolly bodies Absent 1–2 3–5 5–10 Greater than 10
Heinz bodies Absent Reported as present or absent
Hgb 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, Trypanosoma)
Copyright © 2003 F.A. Davis Company
RENIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age and Position Conventional Units (Conversion Factor 1)
Renin 873
• Primary hyperaldosteronism
Pretest:
CRITICAL VALUES: N/A ➤ Obtain a history of the patient’s
complaints, including a list of known
INTERFERING FACTORS: allergens.
• Drugs that may increase renin ➤ Obtain a history of the patient’s
levels include albuterol, amiloride, endocrine and genitourinary
azosemide, benazepril, bendroflume- systems, as well as results of previ-
thiazide, captopril, chlorthalidone, ously performed tests and proce-
Copyright © 2003 F.A. Davis Company
dures. For related tests, refer to the ➤ Label the specimen, and promptly
endocrine and genitourinary system transport it to the laboratory on ice.
tables. Specify patient position (upright or
➤ Obtain a list of the medications the supine) and exact source of speci-
patient is taking, including herbs, men (peripheral vs. arterial).
nutritional supplements, and
nutraceuticals. The requesting health Post-test:
care practitioner and laboratory
➤ Observe venipuncture site for bleed-
should be advised if the patient
ing or hematoma formation. Apply
regularly uses these products so
pressure bandage.
that their effects can be taken into
consideration when reviewing ➤ Instruct the patient to resume usual
results. medication, if withheld and as
➤ Note any recent procedures that can directed by the requesting health
interfere with test results. care practitioner.
➤ The patient should be on a normal ➤ Instruct the patient to notify the
sodium diet (1 to 2 g sodium per requesting health care practitioner
day) for 2 to 4 weeks before the test. of any signs and symptoms of dehy-
dration or fluid overload related to
➤ By medical direction, the patient abnormal renin levels or compro-
should avoid diuretics, antihyperten- mised sodium regulatory mecha-
sive drugs, herbals, cyclic progesto- nisms. Fluid loss or dehydration is
gens, and estrogens for 2 to 4 signaled by the thirst response.
weeks before the test. Decreased skin turgor, dry mouth
➤ Review the procedure with the and multiple longitudinal furrows in
patient. Inform the patient that the tongue are symptoms of dehy-
multiple specimens may be dration. Fluid overload may be
required. signaled by a loss of appetite and
➤ Inform the patient or family member nausea. Excessive fluid also causes
that the position required (supine or pitting edema: When firm pressure
upright) must be maintained for 2 is placed on the skin over a bone
hours before specimen collection. (e.g., the ankle) the indentation will
remain after 5 seconds.
➤ Inform the patient that each speci-
men collection takes approximately ➤ Educate patients of the importance
5 to 10 minutes. of proper water balance. There is no
recommended daily allowance
Intratest: (RDA) for water. Adults need 1
mL/kcal per day; infants need more
➤ Ensure that the patient has complied because their basal metabolic heat
with dietary preparations and other production is much higher. In build-
pretesting restrictions. ings with hard water, untreated tap
➤ Direct the patient to breathe water contains minerals such as
normally and to avoid unnecessary calcium, magnesium, and iron.
movement. Water-softening systems replace
these minerals with sodium, and
➤ Observe standard precautions and
therefore patients on a low-sodium
follow the general guidelines in
diet should avoid drinking treated
Appendix A. Perform a venipuncture
tap water and drink bottled water
after the patient has been in the
instead.
upright (sitting or standing) position
for 2 hours. If a supine specimen is ➤ Renin levels affect the regulation
requested on an inpatient, the spec- of fluid balance and electrolytes.
imen should be collected early in the If appropriate, educate patients with
morning before the patient rises. low sodium levels that the major
Collect the specimen in a 5-mL source of dietary sodium is found
lavender-top (EDTA) tube. in table salt. Many foods, such as
Copyright © 2003 F.A. Davis Company
Renogram 875
milk and other dairy products, are intake of sodium. The requesting
also good sources of dietary health care practitioner or nutrition-
sodium. Most other dietary sodium ist should be consulted before
is available through the consumption the patient on a low-sodium diet
of processed foods. Patients on begins using salt substitutes.
low-sodium diets should be advised There are no RDAs established for
to avoid beverages such as colas, potassium, but the estimated mini-
ginger ale, sports drinks, lemon- mum intake for adults is 200
lime sodas, and root beer. Many mEq/day. Potassium is present in all
over-the-counter medications includ- plant and animal cells, making
ing antacids, laxatives, analgesics, dietary replacement fairly simple to
sedatives, and antitussives contain achieve.
significant amounts of sodium. ➤ Evaluate test results in relation to
The best advice is to emphasize the the patient’s symptoms and other
importance of reading all food, tests performed. Related laboratory
beverage, and medicine labels. tests include aldosterone, creati-
In 1989, the Subcommittee on the nine, kidney biopsy, serum and urine
10th Edition of the RDA established potassium, urine protein, serum and
500 mg as the recommended urine sodium, blood urea nitrogen,
maximum daily intake for dietary and urinalysis.
RENOGRAM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
filtration rate and effective renal • Evaluate kidney transplant for acute or
plasma flow can be calculated. With chronic rejection
the use of diuretic stimulation during
the excretory phase, it is possible RESULT
to differentiate between anatomic
Normal Findings:
obstruction and nonobstructive
• Normal shape, size, position, symme-
residual dilation from previous
try, vasculature, perfusion, and func-
hydronephrosis. All information tion of the kidneys
obtained is stored in a computer to be
used for further interpretation and • Radionuclide material circulates bilat-
erally, symmetrically, and without
computations. Renal function can be
interruption through the renal
monitored by serially repeating this parenchyma, ureters, and urinary blad-
test and comparing results. ■ der, with 50 percent of the radionu-
clide excreted within the first 10
INDICATIONS: minutes
• Aid in the diagnosis of renal artery
stenosis resulting from renal dysplasia Abnormal Findings:
or atherosclerosis and causing arterial
• Acute tubular necrosis
hypertension and reduced glomerular
filtration rate • Congenital anomalies (e.g., absence of
a kidney)
• Aid in the diagnosis of renal vein
thrombosis resulting from dehydration • Decreased renal function
in infants or obstruction of blood flow • Diminished blood supply
in the presence of renal tumors in
adults • Infection or inflammation (pyelo-
nephritis, glomerulonephritis)
• Aid in the diagnosis of renal artery
• Masses
embolism or renal infarction causing
obstruction • Obstructive uropathy
• Evaluate obstruction caused by stones • Renal failure, infarction, cyst, or
or tumor abscess
• Determine the presence and effects of • Renal vascular disease including renal
renal trauma, such as arterial injury, artery stenosis or renal vein thrombosis
renal contusion, hematoma, rupture, • Trauma
arteriovenous fistula, or urinary
extravasation CRITICAL VALUES: N/A
• Detect renal infectious or inflamma-
tory diseases, such as acute or chronic INTERFERING FACTORS:
pyelonephritis, renal abscess, or
This procedure is contraindicated
nephritis for:
• Evaluate chronic urinary tract infec- • Patients who are pregnant or suspected
tions, especially in children of being pregnant, unless the potential
benefits of the procedure far outweigh
• Determine the presence, location, and
the risks to the fetus and mother
cause of obstructive uropathy, such as
calculi, neoplasm, congenital disorders, Factors that may impair clear
scarring, or inflammation imaging:
• Evaluate acute and chronic renal failure • Inability of the patient to cooperate or
Copyright © 2003 F.A. Davis Company
Renogram 877
remain still during the procedure • Inaccurate timing of imaging after the
because of age, significant pain, or radionuclide injection can affect the
mental status results.
• Patients who are very obese, who may
exceed the weight limit for the equip-
ment
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
RETICULOCYTE COUNT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
RETROGRADE
URETEROPYELOGRAPHY
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SYNONYM/ACRONYM: Retrograde.
AREA OF APPLICATION: Renal calyces, ureter.
CONTRAST: Radiopaque iodine-based contrast medium.
Copyright © 2003 F.A. Davis Company
➤ Inform the patient that if a local patient that additional views may be
anesthetic is used, the patient may necessary to visualize the area in
feel (1) some pressure in the kidney question.
area as the catheter is introduced ➤ Additional contrast medium is
and contrast medium injected, or (2) injected through the catheter to
the urgency to void. outline the ureters as the catheter is
➤ Inform the patient that he or she withdrawn.
may receive a laxative the night ➤ Additional x-ray exposures are taken
before the test, an enema, or a 10 to 15 minutes after the catheter is
cathartic the morning of the test, as removed to evaluate retention of the
ordered. contrast medium, indicating urinary
➤ Instruct the patient to increase fluid stasis.
intake the day before the test, but to ➤ The catheter may be kept in place
withhold food and fluids for 8 hours and attached to a gravity drainage
before the test. unit until urinary flow has returned or
➤ Schedule GI or any barium studies is corrected.
after this study.
➤ Obtain and record baseline vital Post-test:
signs.
➤ Monitor vital and neurologic signs
until they return to preprocedure
Intratest: levels.
➤ Have the patient put on a hospital ➤ Instruct the patient to resume
gown. usual diet and medications, unless
➤ Make sure jewelry, watches, chains, otherwise indicated. Renal function
belts, and any other metallic objects should be assessed before
have been removed from the metformin is restarted.
abdominal area. ➤ Monitor fluid intake and urinary
➤ Remove any wires connected to output following the procedure.
electrodes, if allowed. Decreased urine output may indicate
impending renal failure or edema
➤ Place patient on the table in a supine caused by instrumentation.
position in the lithotomy position.
➤ Monitor for signs of sepsis and
➤ A kidney, ureter, and bladder (KUB) severe pain in the kidney area.
or plain film is taken to ensure
that no barium or stool will ➤ Maintain the patient on adequate
obscure visualization of the urinary hydration after the procedure.
system. Ask the patient to lie still Encourage the patient to drink lots
during the procedure because of fluids to prevent stasis and to
movement produces unclear prevent the buildup of bacteria.
images. The patient may be asked to ➤ Determine whether the patient or
hold his or her breath to facilitate family members have any further
visualization. questions or concerns.
➤ While the patient is anesthetized, a ➤ A physician specializing in this
cystoscopic examination is per- branch of medicine sends a written
formed and the bladder is inspected. report to the ordering health care
➤ A catheter is inserted, and the renal provider, who discusses the results
pelvis is emptied by gravity. Contrast with the patient.
medium is introduced into the ➤ Inform the patient that further exam-
catheter. Inform the patient that the inations may be necessary to evalu-
contrast medium may cause a ate progression of the disease
temporary flushing of the face, a process or to determine the need for
feeling of warmth, or nausea. a change in therapy.
➤ X-ray exposures are made and the ➤ Evaluate test results in relation to
results processed. Inform the the patient’s symptoms and other
Copyright © 2003 F.A. Davis Company
RHEUMATOID FACTOR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
RUBELLA ANTIBODIES
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RUBEOLA ANTIBODIES
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SEMEN ANALYSIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Semen from ejaculate specimen collected in a clean, dry, glass
container known to be free of detergent. The specimen container should be
kept at body temperature (37C) during transportation.
Volume 2–5 mL
Color White or opaque
Appearance Viscous (pours in droplets not clumps
or strings)
Clotting and liquefaction Complete in 20–30 minutes
pH 7.5–8.5
Sperm count 20–200 million/mL
Motility At least 60%
Morphology At least 70% normal oval-headed forms
• Orchitis
Pretest:
• Postvasectomy period
➤ Obtain a history of the patient’s
• Primary and secondary testicular fail- complaints, including a list of known
ure allergens.
• Testicular atrophy (e.g., recovery from ➤ Obtain a history of the patient’s
mumps) reproductive system as well as
results of previously performed
• Varicocele tests and procedures. For related
tests, refer to the reproductive
CRITICAL VALUES: N/A system table.
➤ Obtain a list of medications the
INTERFERING FACTORS: patient is taking, including herbs,
• Drugs and substances that may nutritional supplements, and nutra-
ceuticals. The requesting health care
decrease sperm count include arsenic, practitioner and laboratory should be
azathioprine, cannabis, cimetidine, advised if the patient regularly uses
cocaine, cyclophosphamide, estrogens, these products so that their effects
fluoxymesterone, ketoconazole, lead, can be taken into consideration
methotrexate, methyltestosterone, when reviewing results.
nitrofurantoin, nitrogen mustard, ➤ Note any recent procedures that can
procarbazine, sulfasalazine, and interfere with test results.
vincristine. ➤ There are no food, fluid, or medica-
• Testicular radiation may decrease tion restrictions unless by medical
sperm counts. direction.
➤ The requesting health care practi-
• Cigarette smoking is associated with tioner usually provides the patient
decreased production of semen. with instructions for specimen
collection.
• Caffeine consumption is associated
with increased sperm density and ➤ Review the procedure with the
number of abnormal forms. patient. Sensitivity to cultural and
social issues, as well as concern for
• Delays in transporting the specimen modesty, is important in providing
and failure to keep the specimen warm psychological support.
during transportation are the most ➤ Instruct the patient to refrain from
Copyright © 2003 F.A. Davis Company
SODIUM, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Serum Na .
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
SODIUM, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Salt-losing nephritis
Pretest:
Decreased in: ➤ Obtain a history of the patient’s
• Adrenal hyperfunction complaints, including a list of known
allergens.
• Congestive heart failure ➤ Obtain a history of the patient’s
• Diarrhea endocrine and genitourinary
systems, as well as results of previ-
• Excessive sweating ously performed tests and proce-
dures. For related tests, refer to the
• Extrarenal sodium loss with adequate endocrine and genitourinary system
hydration tables.
• Insufficient intake ➤ Obtain a list of medications the
patient is taking, including herbs,
• Postoperative period (first 24 to 48 nutritional supplements, and
hours) nutraceuticals. The requesting health
Copyright © 2003 F.A. Davis Company
care practitioner and laboratory rated, void a small amount into the
should be advised if the patient toilet; and (4) without interrupting
regularly uses these products so the urine stream, void directly into
that their effects can be taken into the specimen container.
consideration when reviewing
results. Timed specimen:
➤ There are no food, fluid, or medica- ➤ Obtain a clean 3-L urine specimen
tion restrictions unless by medical container, toilet-mounted collection
direction. device, and plastic bag (for transport
➤ Review the procedure with the of the specimen container). The
patient. Provide a nonmetallic urinal, specimen must be refrigerated or
bedpan, or toilet-mounted collection kept on ice throughout the entire
device. collection period. If an indwelling
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
the patient that all urine must be ➤ Begin the test between 6 and 8
saved during that 24-hour period. a.m., if possible. Collect first voiding
Instruct the patient not to void and discard. Record the time the
directly into the laboratory collection specimen was discarded as the
container. Instruct the patient to beginning of the timed collection
avoid defecating in the collection period. The next morning, ask the
device and to keep toilet tissue out patient to void at the same time the
of the collection device to prevent collection was started and add this
contamination of the specimen. last voiding to the container.
Place a sign in the bathroom to ➤ If an indwelling catheter is in place,
remind the patient to save all urine. replace the tubing and container
➤ Instruct the patient to void all urine system at the start of the collection
into the collection device and then to time. Keep the container system on
pour the urine into the laboratory ice during the collection period, or
collection container. Alternatively empty the urine into a larger
the specimen can be left in the container periodically during the
collection device for a health care collection period; monitor to ensure
staff member to add to the labora- continued drainage, and conclude
tory collection container. the test the next morning at the
same hour the collection was
Intratest: begun.
➤ At the conclusion of the test,
➤ Observe standard precautions and compare the quantity of urine with
follow the general guidelines in the urinary output record for the
Appendix A. collection; if the specimen contains
less than what was recorded as
Random specimen (collect in output, some urine may have been
early morning): discarded, invalidating the test.
➤ Label the specimen, and promptly
Clean-catch specimen: transport it to the laboratory. Include
on the label the amount of urine,
➤ Instruct the male patient to (1) thor-
test start and stop times, and inges-
oughly wash his hands, (2) cleanse
tion of any foods or medications that
the meatus, (3) void a small amount
can affect test results.
into the toilet, and (4) void directly
into the specimen container.
Post-test:
➤ Instruct the female patient to (1)
thoroughly wash her hands; (2) ➤ If appropriate, educate patients with
cleanse the labia from front to back; low sodium levels that the major
(3) while keeping the labia sepa- source of dietary sodium is found in
Copyright © 2003 F.A. Davis Company
table salt. Many foods, such as milk advice is to emphasize the impor-
and other dairy products, are also tance of reading all food, beverage,
good sources of dietary sodium. and medicine labels. In 1989, the
Most other dietary sodium is avail- Subcommittee on the 10th Edition of
able through the consumption of the RDA established 500 mg as the
processed foods. Patients on low- recommended maximum daily
sodium diets should be advised to intake for dietary intake of sodium.
avoid beverages such as colas, ➤ Evaluate test results in relation to
ginger ale, sports drinks, lemon-lime the patient’s symptoms and other
sodas, and root beer. Many over-the- tests performed. Related laboratory
counter medications including tests include aldosterone, kidney
antacids, laxatives, analgesics, seda- stone analysis, serum and urine
tives, and antitussives contain signif- osmolality, potassium, urine potas-
icant amounts of sodium. The best sium, renin, and sodium.
Intratest:
Nursing Implications and
➤ Direct the patient to breathe
Procedure ● ● ● ● ● ● ● ● ● ● ●
normally and to avoid unnecessary
movement.
Pretest:
➤ Record baseline vital signs.
➤ Obtain a history of the patient’s ➤ Observe standard precautions and
complaints, including a list of known follow the general guidelines in
allergens. Appendix A.
➤ Obtain a history of the patient’s ➤ Assemble the necessary equip-
immune and musculoskeletal ment, including an arthrocentesis
systems as well as results of previ- tray with solution for skin prepara-
ously performed tests and proce- tion, local anesthetic, a 20-mL
dures. For related tests, refer to the syringe, needles of various sizes,
immune and musculoskeletal sterile drapes, sterile gloves, and
system tables. specimen collection tubes and
➤ Obtain a list of medications the containers for the tests to be
patient is taking, including herbs, performed.
Copyright © 2003 F.A. Davis Company
SYPHILIS SEROLOGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
TESTOSTERONE, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
SI Units
Age Conventional Units (Conversion Factor 0.0347)
Cord blood
Male 13–55 ng/dL 0.45–1.91 nmol/L
Female 5–45 ng/dL 0.17–1.56 nmol/L
Newborn
Male 75–400 ng/dL 2.6–13.9 nmol/L
Female 20–64 ng/dL 0.69–2.22 nmol/L
1–5 mo
Male 1–177 ng/dL 0.03–6.14 nmol/L
Female 1–5 ng/dL 0.03–0.17 nmol/L
6–11 mo
Male 2–7 ng/dL 0.07–0.24 nmol/L
Female 2–5 ng/dL 0.07–0.17 nmol/L
1–5 y
Male 2–25 ng/dL 0.07–0.87 nmol/L
Female 2–10 ng/dL 0.07–0.35 nmol/L
6–9 y
Male 3–30 ng/dL 0.10–1.04 nmol/L
Female 2–20 ng/dL 0.07–0.35 nmol/L
10–11 y
Male 5–50 ng/dL 0.17–1.73 nmol/L
Female 5–25 ng/dL 0.17–0.87 nmol/L
12–14 y
Male 10–572 ng/dL 0.35–19.83 nmol/L
Female 10–40 ng/dL 0.35–1.39 nmol/L
15–17 y
Male 220–800 ng/dL 7.63–27.74 nmol/L
Female 5–40 ng/dL 0.17–1.39 nmol/L
Adult
Male 280–1100 ng/dL 9.71–38.14 nmol/L
Female 15–70 ng/dL 0.52–2.43 nmol/L
Copyright © 2003 F.A. Davis Company
Thyroglobulin 907
THYROGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Tg.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay)
Copyright © 2003 F.A. Davis Company
SI Units
Age Conventional Units (Conversion Factor 1)
Cord blood 20.7–28.1 ng/mL 20.7–28.1 g/L
1h 25.5–33.9 ng/mL 25.5–33.9 g/L
48 h 36.1–47.7 ng/mL 36.1–47.7 g/L
Adult 3.0–42.0 ng/mL 3.0–42.0 g/L
Athyrotic patient Less than 5 ng/mL Less than 5 g/L
solitary nodules
Pretest:
RESULT ➤ Obtain a history of the patient’s
complaints, including a list of known
Increased in:
allergens.
• Differentiated thyroid cancer
➤ Obtain a history of the patient’s
• Graves’ disease (untreated) endocrine system as well as results
of previously performed tests and
• Neonates procedures. For related tests, refer
• Pregnancy to the endocrine system table.
➤ Obtain a list of medications the
• Surgery or irradiation of the thyroid patient is taking, including herbs,
(elevated levels indicate residual or nutritional supplements, and
disseminated carcinoma) nutraceuticals. The requesting health
• T4-binding globulin deficiency care practitioner and laboratory
should be advised if the patient is
• Thyroiditis regularly using these products so
Copyright © 2003 F.A. Davis Company
that their effects can be taken into ➤ Observe standard precautions and
consideration when reviewing follow the general guidelines in
results. Appendix A. Perform a venipuncture,
➤ Note any recent procedures that can and collect the specimen in a 5-mL
interfere with test results. red- or tiger-top tube.
➤ There are no food, fluid, or medica- ➤ Label the specimen and promptly
tion restrictions unless by medical transport to the laboratory.
direction.
➤ Review the procedure with the Post-test:
patient.
➤ Observe venipuncture site for bleed-
➤ Inform the patient that specimen ing or hematoma formation. Apply
collection takes approximately 5 to pressure bandage.
10 minutes.
➤ Evaluate test results in relation
Intratest: to the patient’s symptoms and
other tests performed. Related
➤ Direct the patient to breathe laboratory tests include thyroid-
normally and to avoid unnecessary stimulating hormone, T4, free T4, T3,
movement. and free T3.
THYROID-BINDING INHIBITORY
IMMUNOGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
THYROID SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
working in the area where the exami- ➤ Ask the patient to lie still during the
nation is being done should wear procedure because movement
badges that reveal their level of expo- produces unclear images. Make
sure to radiation. sure jewelry and any other metallic
objects have been removed from
the neck area.
Nursing Implications and ➤ Administer oral I-123 24 hours
before scanning or IV technetium-
Procedure ● ● ● ● ● ● ● ● ● ● ●
99m 20 minutes before scanning.
Place the patient in a supine position
Pretest: on a flat table. Scanning is
➤ Inform the patient that the proce- performed over the anterior neck
dure assesses thyroid function and area, and the images are recorded
structure. on film or stored electronically for
recall and postprocedural interpreta-
➤ Inform the patient that the proce- tion by a physician.
dure is performed in a special
nuclear medicine department by a ➤ Wear gloves during the radionuclide
technologist and usually takes administration and while handling
approximately 30 minutes. the patient’s urine.
➤ Obtain a history of the patient’s
complaints, including a list of known Post-test:
allergens.
➤ Instruct the patient to resume
➤ Obtain a history of the patient’s normal activity, medications, and
thyroid system as well as results of diet, unless otherwise indicated.
previously performed laboratory
tests, surgical procedures, thyroid ➤ Advise patient to drink increased
therapy, and other radiologic proce- amounts of fluids for 24 to 48 hours
dures. For related tests, refer to the to eliminate the radionuclide from
endocrine system table. the body, unless contraindicated. Tell
the patient that radionuclide is elimi-
➤ Obtain a list of medications the
nated from the body within 6 to 24
patient is taking, including herbs,
hours.
nutritional supplements, and
nutraceuticals. ➤ Instruct the patient to flush the toilet
➤ All thyroid blood tests should be immediately after each voiding
done before doing this test. following the procedure and to wash
hands meticulously with soap and
➤ Determine date of last menstrual water after each voiding for 24 hours
period and possibility of pregnancy after the procedure.
in perimenopausal women.
➤ Tell all caregivers to wear gloves
➤ All radiographic procedures done when discarding urine for 24 hours
with iodinated contrast medium after the procedure. Wash gloved
should be scheduled after this proce- hands with soap and water before
dure and after radioactive iodine removing gloves. Then wash hands
uptake is completed. after the gloves are removed.
➤ Ensure that the patient fasted for 8
➤ A physician specializing in this
to 12 hours before the procedure,
branch of medicine sends a written
unless otherwise indicated.
report to the ordering provider, who
discusses the results with the
Intratest:
patient.
➤ Ask the patient to void before the ➤ Evaluate test results in relation to
procedure. Have the patient put on a the patient’s symptoms and other
hospital gown. tests performed. Related diagnostic
➤ Administer sedative to a child or to tests include thyroid uptake and
an uncooperative adult, as ordered. thyroid ultrasound.
Copyright © 2003 F.A. Davis Company
THYROID-STIMULATING HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 1)
Neonates–3 d Less than 20 IU/mL Less than 20 mIU/L
Adults 0.4–4.2 IU/mL 0.4–4.2 mIU/L
THYROID-STIMULATING
IMMUNOGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
THYROTROPIN-RELEASING HORMONE
STIMULATION TEST
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THYROXINE-BINDING GLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: TBG.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay)
Conventional SI Unit
Age Units (Conversion Factor 10)
0–1 wk 3–8 mg/dL 30–80 mg/L
1–12 mo 1.6–3.6 mg/dL 16–36 mg/L
14 y–adult 1.2–2.5 mg/dL 12–25 mg/L
Adult
Pregnancy, third trimester 4.7–5.9 mg/dL 47–59 mg/L
Oral contraceptives 1.5–5.5 mg/dL 15–55 mg/L
THYROXINE, FREE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 12.9)
Newborn 0.8–2.8 ng/dL 10–36 pmol/L
1–12 mo 0.8–2.0 ng/dL 10–26 pmol/L
1–18 y 0.8–1.7 ng/dL 10–22 pmol/L
Adult 0.8–1.5 ng/dL 10–19 pmol/L
THYROXINE, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: T4.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
SI Units
Age Conventional Units (Conversion Factor 12.9)
1–3 d 11.8–22.6 g/dL 152–292 nmol/L
1–2 wk 9.8–16.6 g/dL 126–214 nmol/L
1–4 mo 7.2–14.4 g/dL 93–186 nmol/L
5–12 mo 7.8–16.5 g/dL 101–213 nmol/L
1–5 y 7.3–15.0 g/dL 94–194 nmol/L
5–10 y 6.4–13.3 g/dL 83–172 nmol/L
10–15 y 5.6–11.7 g/dL 72–151 nmol/L
Adult
Man 4.6–10.5 g/dL 59–135 nmol/L
Woman 5.5–11.0 g/dL 71–142 nmol/L
Pregnant
woman 5.5–16.0 g/dL 71–155 nmol/L
Over 60 y 5.0–10.7 g/dL 65–138 nmol/L
At levels less than 2.0 g/dL, the cillin, phenylacetic acid derivatives,
patient is at risk for myxedema coma. phenylbutazone, potassium iodide,
Signs and symptoms of severe hypothy- propylthiouracil, reserpine, salicylate,
roidism include hypothermia, hypoten- sodium nitroprusside, stanozolol,
sion, bradycardia, hypoventilation, sulfonylureas, tetrachlorothyronine,
lethargy, and coma. Possible interven- tolbutamide, and triiodothyronine
tions include airway support, hourly (T3).
monitoring for neurologic function and
blood pressure, and administration of
intravenous thyroid hormone. Nursing Implications and
At levels greater than 20.0 g/dL, the Procedure ● ● ● ● ● ● ● ● ● ● ●
patient is at risk for thyroid storm. Signs
and symptoms of severe hyperthyroidism Pretest:
include hyperthermia, diaphoresis,
vomiting, dehydration, and shock. ➤ Obtain a history of the patient’s
Possible interventions include supportive complaints.
treatment for shock, fluid and electrolyte ➤ Obtain a history of the patient’s
replacement for dehydration, and admin- endocrine system and results of
istration of antithyroid drugs (propyl- previously performed tests and
thiouracil and Lugol’s solution). procedures. For related tests, refer
to the endocrine system table.
INTERFERING FACTORS: ➤ Obtain a list of medications the
• Drugs that may increase T4 levels patient is taking, including herbs,
include amiodarone, amphetamines, nutritional supplements, and
corticosteroids, ether, fluorouracil, nutraceuticals. The requesting health
care practitioner and laboratory
glucocorticoids, halofenate, insulin, should be advised if the patient
iobenzamic acid, iopanoic acid, regularly uses these products so
ipodate, levarterenol, levodopa, that their effects can be taken into
levothyroxine, opiates, oral contra- consideration when reviewing
ceptives, phenothiazine, and results.
prostaglandins. ➤ There are no food, fluid, or medica-
• Drugs, substances, and treatments that tion restrictions unless by medical
direction.
may decrease T4 levels include amino-
glutethimide, aminosalicylic acid, ➤ Review the procedure with the
amiodarone, anabolic steroids, anti- patient.
convulsants, asparaginase, acetylsali- ➤ Inform the patient that specimen
cylic acid, barbiturates, carbimazole, collection takes approximately 5 to
chlorpromazine, chlorpropamide, 10 minutes.
cholestyramine, clofibrate, cobalt,
colestipol, corticotropin, cortisone, Intratest:
cotrimoxazole, cytostatic therapy, ➤ Direct the patient to breathe
danazol, dehydroepiandrosterone, normally and to avoid unnecessary
dexamethasone, diazepam, diazo dyes, movement.
dinitrophenol, ethionamide, Evans ➤ Observe standard precautions and
blue, fenclofenac, halofenate, hydroxy- follow the general guidelines in
phenylpyruvic acid, interferon alfa-2b, Appendix A. Perform a venipuncture,
iothiouracil, iron, isotretinoin, liothy- and collect the specimen in a 5-mL
ronine, lithium, lovastatin, methima- red- or tiger-top tube.
zole, methylthiouracil, mitotane, ➤ Label the specimen, and promptly
norethindrone, penicillamine, peni- transport it to the laboratory.
Copyright © 2003 F.A. Davis Company
Total Protein
SI Units
Age Conventional Units (Conversion Factor 10)
Newborn–5 d 3.8–6.2 g/dL 38–62 g/L
1–3 y 5.9–7.0 g/dL 59–70 g/L
4–6 y 5.9–7.8 g/dL 59–78 g/L
7–9 y 6.2–8.1 g/dL 62–81 g/L
10–19 y 6.3–8.6 g/dL 63–86 g/L
Adult 6.0–8.0 g/dL 60–80 g/L
Protein Fractions
SI Units
Conventional Units (Conversion Factor 10)
Albumin 3.4–4.8 g/dL 34–48 g/L
1-Globulin 0.2–0.4 g/dL 2–4 g/L
2-Globulin 0.4–0.8 g/dL 4–8 g/L
-Globulin 0.5–1.0 g/dL 5–10 g/L
-Globulin 0.6–1.2 g/dL 6–12 g/L
Copyright © 2003 F.A. Davis Company
TOXOPLASMA ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Transferrin 929
tory should be advised if the patient ➤ Label the specimen, and promptly
regularly uses these products so transport it to the laboratory.
that their effects can be taken into
consideration when reviewing Post-test:
results.
➤ There are no food, fluid, or medica- ➤ Observe venipuncture site for bleed-
tion restrictions unless by medical ing or hematoma formation. Apply
direction. pressure bandage.
➤ Review the procedure with the ➤ Instruct the patient in isolation
patient. precautions during time of commu-
nicability or contagion.
➤ Inform the patient that several tests
may be necessary to confirm the ➤ Emphasize the need to return to
diagnosis. Any individual positive have a convalescent blood sample
result should be repeated in 3 taken in 3 weeks.
weeks to monitor a change in titer. ➤ Recognize anxiety related to test
➤ Inform the patient that each speci- results and provide emotional
men collection takes approximately support if results are positive and
5 to 10 minutes. the patient is pregnant and/or
immunocompromised. Provide
Intratest: teaching and information regarding
the clinical implications of the test
➤ Direct the patient to breathe results, as appropriate. Educate the
normally and to avoid unnecessary patient regarding access to counsel-
movement. ing services.
➤ Observe standard precautions and ➤ Evaluate test results in relation to
follow the general guidelines in the patient’s symptoms and other
Appendix A. Perform a venipuncture, tests performed. Related laboratory
and collect the specimen in a 5-mL tests include cytomegalovirus,
red-top tube. herpes simplex, and rubella.
TRANSFERRIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Age Conventional Units (Conversion Factor 0.01)
Newborn 130–275 mg/dL 1.3–2.75 g/L
Adult
Male 215–365 mg/dL 2.2–3.6 g/L
Female 250–380 mg/dL 2.5–3.8 g/L
Copyright © 2003 F.A. Davis Company
• Malnutrition Intratest:
• Hereditary atransferrinemia ➤ Ensure that the patient has complied
with dietary preparations and other
CRITICAL VALUES: N/A pretesting restrictions.
➤ Direct the patient to breathe
INTERFERING FACTORS: normally and to avoid unnecessary
• Drugs that may increase transferrin movement.
Copyright © 2003 F.A. Davis Company
Triglycerides 931
TRIGLYCERIDES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Conventional (Conversion Factor
Age Units 0.0113)
0–9 y
Male 30–100 mg/dL 0.34–1.13 mmol/L
Female 35–110 mg/dL 0.40–1.24 mmol/L
10–20 y
Male 32–148 mg/dL 0.36–1.67 mmol/L
Female 37–124 mg/dL 0.42–1.40 mmol/L
Risk
Adult Less than 150 Less than 1.70 Normal
mg/dL mmol/L
150–199 mg/dL 1.70–2.25 mmol/L Borderline high
200–499 mg/dL 2.26–5.64 mmol/L High
Greater than 500 Greater than 5.65 Very high
mg/dL mmol/L
tissue, and the fatty acids provide the • Glycogen storage disease
raw materials needed for conversion • Gout
to glucose (gluconeogenesis) or for
direct use as an energy source. • Hyperlipoproteinemia
Although fatty acids originate in the • Hypertension
diet, many are also derived from
• Hypothyroidism
unused glucose and amino acids that
the liver converts into stored energy. • Impaired glucose tolerance
Triglyceride levels vary by age, sex, • Nephrotic syndrome
weight, and race:
Levels increase with age. • Obesity
Levels are higher in men than in • Pancreatitis (acute and chronic)
women (among women, those
who take oral contraceptives • Pregnancy
have levels that are 20 to 40 • Renal failure
mg/dL higher compared to those
who do not). • Respiratory distress syndrome
Levels are higher in overweight • Stress
and obese populations compared
to those with normal weight. • Viral hepatitis
Levels in African-Americans are • Werner’s syndrome
approximately 10 to 20 mg/dL
lower compared to Caucasians. ■
Decreased in:
• Brain infarction
INDICATIONS:
• Evaluate known or suspected disorders • Chronic obstructive lung disease
associated with altered triglyceride (COPD)
levels
• End-stage liver disease
• Identify hyperlipoproteinemia (hyper-
lipidemia) in patients with a family • Hyperparathyroidism
history of the disorder • Hyperthyroidism
• Monitor the response to drugs known • Hypolipoproteinemia and a--lipopro-
to alter triglyceride levels teinemia
• Screen adults who are either over 40 • Intestinal lymphangiectasia
years of age or obese to estimate the
risk for atherosclerotic cardiovascular • Malabsorption disorders
disease • Malnutrition
Triglycerides 933
TRIIODOTHYRONINE, FREE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Conventional (Conversion Factor
Age Units 0.0154)
Children and adults 260–480 pg/dL 4.0–7.4 pmol/L
Pregnant women 196–338 pg/dL 3.0–5.2 pmol/L
(4–9 mo gestation)
TRIIODOTHYRONINE, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: T3.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
Conventional SI Units
Age Units (Conversion Factor 0.0154)
1–3 d 100–740 ng/dL 1.54–11.40 nmol/L
1–12 mo 105–245 ng/dL 1.62–3.77 nmol/L
1–5 y 105–269 ng/dL 1.62–4.14 nmol/L
6–10 y 94–241 ng/dL 1.45–3.71 nmol/L
16–20 y 80–210 ng/dL 1.20–3.20 nmol/L
Adult 70–204 ng/dL 1.08–3.14 nmol/L
Pregnant woman 116–247 ng/dL 1.79–3.80 nmol/L
(last 4 mo gestation)
TROPONINS I AND T
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Nursing Implications and ➤ Have epinephrine hydrochloride
Procedure ● ● ● ● ● ● ● ● ● ● ● solution (1:1000) available in the
event of anaphylaxis.
Pretest: ➤ Observe standard precautions and
follow the general guidelines in
➤ Obtain a history of the patient’s Appendix A.
complaints, including a list of known
➤ Cleanse the skin site on the lower
allergens.
anterior forearm with alcohol swabs
➤ Obtain a history of tuberculosis or and allow to air-dry.
tuberculosis exposure, signs and
symptoms indicating possible tuber- Multipuncture test:
culosis, other diagnostic procedures
and results, and other skin test or ➤ Remove the cap covering the tines
vaccinations and sensitivities. and stretch the forearm skin taut.
Firmly press the device into the
➤ Obtain a history of the patient’s prepared site, hold it in place for 1
immune and respiratory systems as second, and then remove it. Four
well as results of previously punctures should be visible. Record
performed tests and procedures. For the site, and remind the patient to
related tests, refer to the immune return in 48 to 72 hours to have the
and respiratory system tables. test read. At the time of the reading,
➤ Obtain a list of medications the use a plastic ruler to measure the
Copyright © 2003 F.A. Davis Company
RESULT
Nursing Implications and
Normal Findings: Procedure ● ● ● ● ● ● ● ● ● ● ●
ULTRASOUND, BLADDER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
ULTRASOUND, BREAST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Post-test:
Nursing Implications and ➤ When the study is completed,
Procedure ● ● ● ● ● ● ● ● ● ● ●
remove the gel from the skin.
➤ Instruct the patient in the monthly
Pretest: breast self-examination procedure,
and ask the patient to demonstrate
➤ Inform the patient that the proce- the technique of breast self-
dure assesses the breasts. examination.
➤ Inform the patient that the proce- ➤ A physician specializing in this
dure is performed in a specialized branch of medicine sends a written
area by a technologist and usually report to the ordering provider, who
takes approximately 30 to 60 discusses the results with the
minutes. patient.
➤ Obtain a history of suspected or ➤ Inform the patient that an abnormal
existing disease of the breast. examination may indicate the need
➤ Obtain the results of other tests and for additional studies.
procedures done to diagnose and/or ➤ Evaluate test results in relation to
monitor disorders of or treatments the patient’s symptoms and any
to the breast region. For related related tests performed.
Copyright © 2003 F.A. Davis Company
ULTRASOUND, KIDNEY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Normal Findings:
• Normal size, position, and shape of the Pretest:
kidneys and associated structures ➤ Inform the patient that the proce-
• Absence of calculi, cysts, hydronephro- dure assesses the kidneys.
sis, obstruction, or tumor ➤ Inform the patient that the proce-
dure is performed in a specialized
Abnormal Findings: area by a technologist and usually
takes approximately 30 minutes.
• Acute glomerulonephritis
➤ Obtain a history of suspected or
• Acute pyelonephritis existing renal disease.
• Congenital anomalies, such as absent, ➤ Obtain the results of other tests and
horseshoe, ectopic, or duplicated procedures done to diagnose disor-
kidney ders of or treatments to the renal
system. For related tests, refer to
• Hydronephrosis the genitourinary system table.
• Obstruction of ureters ➤ Inform the patient that the proce-
dure is painless and carries no risks.
• Perirenal abscess or hematoma ➤ Note recent administration of
• Polycystic kidney barium because residual barium can
obscure the organ to examined.
• Rejection of renal transplant There should be 24 hours between
administration of barium and this
• Renal calculi test.
• Renal cysts, hypertrophy, or tumors ➤ Do not restrict food or fluids before
the procedure.
• Ureteral obstruction
Intratest:
INTERFERING FACTORS
➤ Ask the patient to put on a hospital
gown and void.
Factors that may impair clear
imaging: ➤ Place the patient in a supine position
on the examining table; other posi-
• Inability of the patient to cooperate or tions may be used during the exam-
remain still during the procedure ination.
because of age, significant pain, or
➤ Expose the abdomen/kidney area
mental status and drape the patient.
• Incorrect placement of the transducer ➤ Apply a conductive gel to the skin,
over the desired test site and move the transducer over the
Copyright © 2003 F.A. Davis Company
area to obtain several images of the normal activity, medication, and diet,
area of interest; the sound wave unless otherwise indicated.
images are projected on the screen ➤ A physician specializing in this
and stored electronically for future branch of medicine sends a written
viewing or reproduced on a film. Ask report to the ordering provider, who
the patient to lie still during the discusses the results with the
procedure because movement patient.
produces unclear images.
➤ Inform the patient that an abnormal
➤ If necessary for better visualization examination may indicate the need
of the upper portions of the kidneys, for additional studies.
ask the patient to inhale deeply and
hold his or her breath. ➤ Evaluate test results in relation to
the patient’s symptoms and other
tests performed. Related diagnostic
Post-test: tests include IVP; renal angiogram;
renogram; kidney, ureter, and blad-
➤ When the study is completed, der (KUB) film; and computed
remove the gel from the skin. tomography and magnetic reso-
➤ Instruct the patient to resume nance imaging of the abdomen.
ULTRASOUND, OBSTETRIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
INDICATIONS: RESULT
• Determine and confirm pregnancy or
multiple gestation by determining the Normal Findings:
number of gestational sacs in the first • Normal age, size, viability, position,
trimester and functional capacities of the fetus
• Determine fetal heart and body move- • Normal placenta size, position, and
ments and detect high-risk pregnancy structure; adequate volume of amniotic
by monitoring fetal heart and respira- fluid
tory movements in combination with
Doppler ultrasound or real-time gray Abnormal Findings:
scale scanning
• Abruptio placentae
• Measure fetal gestational age and eval-
uate umbilical artery, uterine artery, • Cardiac abnormalities
and fetal aorta by Doppler examina- • Ectopic pregnancy
tion to determine fetal intrauterine
growth retardation (IUGR) • Fetal malpresentation (breech, trans-
verse)
• Determine fetal gestational age by
uterine size and measurements of • Fetal hydrops
crown-rump length, biparietal diame- • Fetal death
ter, fetal extremities, head, and other
parts of the anatomy at key phases of • Hydrocephalus
fetal development • Intestinal atresia
• Determine fetal structural anomalies, • Myelomeningocele
usually at 20th week or later
• Multiple pregnancy
• Detect fetal death, evidenced by
absence of movement and fetal heart • Placenta previa
tones • Renal or skeletal defects
• Blighted ovum (missed abortion),
evidenced by empty gestational sac CRITICAL VALUES: N/A
• Determine cause of bleeding such as INTERFERING FACTORS:
placenta previa or abruptio placentae
• Determine the placental size, location, This procedure is contraindicated
and site of implantation for:
• Patients with latex allergy; the vaginal
• Monitor placental growth and amni- probe requires the probe to be covered
otic fluid volume with a condom-like sac, usually made
• Detect fetal position before birth, such from latex.
as breech or transverse presentations
Factors that may impair clear
• Guide the needle during amniocentesis imaging:
and fetal transfusion • Inability of the patient to cooperate or
• Determine fetal effects of Rh incom- remain still during the procedure
patibility because of age, significant pain, or
mental status
• Detect tubal and other forms of
ectopic pregnancy • Incorrect placement of the transducer
over the desired test site
• Differentiate a tumor (hydatidiform
mole) from a normal pregnancy • Incorrect positioning of the patient,
Copyright © 2003 F.A. Davis Company
ULTRASOUND, PANCREAS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
and lubricated probe is inserted into normal activity, medication, and diet,
the vagina and moved to different unless otherwise indicated.
levels. Images are obtained and ➤ A physician specializing in this
recorded. A full bladder is not branch of medicine sends a written
required for transvaginal ultrasound. report to the ordering provider, who
discusses the results with the
Post-test: patient.
➤ Allow the patient to void, as needed. ➤ Inform the patient that an abnormal
examination may indicate the need
➤ When the study is completed, for additional studies.
remove the gel from the skin or the
➤ Evaluate test results in relation to
probe from the vagina.
the patient’s symptoms and any
➤ Instruct the patient to resume related tests performed.
exceed the weight limit for the equip- ➤ Apply conductive gel to the skin, and
ment slowly move the transducer over the
site. A swishing sound is heard in a
• Venous or arterial occlusive disease vein that is patent; absence of sound
proximal to the site being tested indicates venous occlusion or incor-
rect placement of the transducer.
ULTRASOUND, PROSTATE
(TRANSRECTAL)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
normal activity, medication, and diet, ➤ Inform the patient that an abnormal
unless otherwise indicated. examination may indicate the need
➤ A physician specializing in this for additional studies.
branch of medicine sends a written ➤ Evaluate test results in relation to
report to the ordering provider, who the patient’s symptoms and any
discusses the results with the related tests performed.
patient.
ULTRASOUND, SCROTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
ULTRASOUND, SPLEEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
aries between organs and tissue struc- obscure the organ to be examined.
tures There should be a 24-hour waiting
period between administration of
• Patients who are very obese, exceeding barium and this test.
the weight limit for the equipment and ➤ Restrict food and fluids 12 hours
preventing the sound beam from pene- before the procedure.
trating to the site
• Retained gas, feces, or barium from a Intratest:
previous radiologic procedure, inade- ➤ Ask the patient to put on a front-
quate cleansing, or failure to restrict opening hospital gown and void.
food intake before the study ➤ Place the patient in a supine position
on the examining table; other posi-
Other considerations: tions may be used during the exam-
• Ensure that the examination is ination.
performed before endoscopy, endo- ➤ Expose the abdomen/splenic area
scopic retrograde cholangiopancreatog- and drape the patient.
raphy (ERCP), barium studies, and ➤ Apply a conductive gel to the skin,
colonoscopy. and move the transducer over the
skin; the sound wave images are
projected on the screen and stored
electronically for future viewing or
Nursing Implications and reproduced on a film. Ask the patient
Procedure ● ● ● ● ● ● ● ● ● ● ● to lie still during the procedure
because movement produces
Pretest: unclear images. The patient may be
requested to inhale deeply and hold
➤ Inform the patient that the proce- his or her breath to obtain better
dure assesses the spleen. views of the spleen.
➤ Inform the patient that the proce-
dure is performed in a specialized Post-test:
area by a technologist and usually
takes approximately 45 minutes. ➤ When the study is completed,
remove the gel from the skin.
➤ Obtain a history of suspected or
➤ Instruct the patient to resume
existing disease of or trauma to the
normal activity, medication, and diet,
spleen.
unless otherwise indicated.
➤ Obtain the results of tests and
➤ A physician specializing in this
procedures done to diagnose disor-
branch of medicine sends a written
ders of or treatments to the splenic
report to the ordering provider, who
system. For related tests, refer to
discusses the results with the
the hematopoietic and gastrointesti-
patient.
nal system tables.
➤ Inform the patient that an abnormal
➤ Ensure that the patient has examination may indicate the need
abstained from smoking several for additional studies.
hours before the procedure to
prevent the swallowing of air. ➤ Evaluate test results in relation to
the patient’s symptoms and other
➤ Inform the patient that the proce- tests performed. Related diagnostic
dure is painless and carries no risks tests include abdominal angiogram,
to the patient or fetus. CT and magnetic resonance angiog-
➤ Note recent administration of raphy, and CT and magnetic reso-
barium because residual barium can nance imaging of the abdomen.
Copyright © 2003 F.A. Davis Company
pregnancy
Pretest:
RESULT ➤ Inform the patient that the proce-
dure assesses the thyroid and
Normal Findings: parathyroid glands.
• Normal size, position, contour, and ➤ Inform the patient that the proce-
structure of the thyroid and parathy- dure is performed in a specialized
roid glands with uniform echo patterns area by a technologist and usually
throughout the glands; no evidence of takes approximately 30 to 60
tumor cysts or nodules in the glands minutes. The room may be darkened
for better visualization of the glands.
Abnormal Findings: ➤ Obtain a history of suspected or
existing disease of the thyroid and
• Glandular enlargement parathyroid glands.
• Goiter ➤ Obtain the results of tests and
procedures done to diagnose disor-
• Graves’ disease ders of or treatments to the thyroid
• Parathyroid tumor or hyperplasia and parathyroid glands. For related
tests, refer to the endocrine system
• Thyroid cysts table.
• Thyroid tumors (benign or malignant) ➤ Inform the patient that the proce-
dure is painless and carries no risks.
INTERFERING FACTORS ➤ Do not restrict food or fluids before
the procedure.
Factors that may impair clear
imaging: Intratest:
• Inability of the patient to cooperate or ➤ Ask the patient to remove clothing
remain still during the procedure from the waist up, to put on a hospi-
because of age, significant pain, or tal gown with the opening in the
mental status front, and to void.
➤ Make sure jewelry, chains, and any
• Incorrect placement of the transducer other metallic objects have been
over the desired test site removed from the neck area.
• Incorrect positioning of the patient, ➤ Place the patient in a supine position
Copyright © 2003 F.A. Davis Company
sound waves into electric signals that flow during respirations; or failure of
are transformed by a computer into the veins to compress completely when
audible sounds, graphic readings, and the extremity is compressed
gray-scale images. Blood flow direc- • Determine the source of emboli when
tion and velocity can be readily pulmonary embolism is suspected or
assessed; and the presence of blood diagnosed
flow disturbances, which are propor- • Determine venous damage after
tional to blood flow velocity, can be trauma to the site
determined.
• Evaluate the patency of the venous
For diagnostic studies, the proce- system in patients with a swollen
dure is done bilaterally. The sound painful leg
waves hit the moving red blood cells
and are reflected back to the trans- • Differentiate between primary and
secondary varicose veins
ducer. The sound emitted by the
equipment corresponds to the veloc- • Determine if further diagnostic proce-
ity of the blood flow through the dures are needed to make or confirm a
vessel occurring with spontaneous diagnosis
respirations. Changes in these sounds • Monitor the effectiveness of therapeu-
during respirations indicate the tic interventions
possibility of abnormal venous
flow secondary to occlusive disease;
RESULT
the absence of sound indicates Normal Findings:
complete obstruction. Compression • Normal blood flow through the veins
with a transducer augments a vessel of the extremities with no evidence of
for evaluation of thrombosis. vessel occlusion
Noncompressibility of the vessel indi-
cates a thrombosis. Plethysmography Abnormal Findings:
may be performed to determine the • Chronic venous insufficiency
filling time of calf veins to diagnose • Primary varicose veins
thrombotic disorder of a major vein
and to identify incompetent valves in • Secondary varicose veins
the venous system. An additional • Superficial thrombosis or DVT
method used to evaluate incompetent • Venous trauma
valves is the Valsalva technique
combined with venous duplex • Venous occlusion
imaging. ■ • Recannulization in the area of an old
thrombus
INDICATIONS:
• Detect chronic venous insufficiency, CRITICAL VALUES: N/A
evidenced by reverse blood flow indi-
cating incompetent valves INTERFERING FACTORS:
• Inability of the patient to maintain a
• Aid in the diagnosis of superficial
stable position during the procedure
thrombosis or deep vein thrombosis
(DVT) leading to venous occlusion or • Inability of the patient to cooperate or
obstruction, evidenced by absence of remain still during the procedure
venous flow, especially upon augmen- because of age, significant pain, or
tation of the extremity; variations in mental status
Copyright © 2003 F.A. Davis Company
eliminate the barium, or if the stool discusses the results with the
does not return to normal color, the patient.
patient should notify the physician. ➤ Evaluate test results in relation to
➤ Determine whether the patient or the patient’s symptoms and other
family members have any further tests performed. Related diagnostic
questions or concerns. tests include endoscopic retrograde
cholangiopancreatography (ERCP);
➤ A physician specializing in this kidney, ureter, and bladder (KUB)
branch of medicine sends a written film; and CT and magnetic reso-
report to the ordering provider, who nance imaging of the abdomen.
SYNONYM/ACRONYM: BUN.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma
(1 mL) collected in green-top (heparin) tube is also acceptable.
SI Units
Age Conventional Units (Conversion Factor 0.357)
Newborn–3 y 5–17 mg/dL 1.8–6.0 mmol/L
4–13 y 7–17 mg/dL 2.5–6.0 mmol/L
14 y–adult 8–21 mg/dL 2.9–7.5 mmol/L
Adult older than 90 y 10–31 mg/dL 3.6–11.1 mmol/L
• Low-protein/high-carbohydrate diet
Pretest:
• Malabsorption syndromes
➤ Obtain a history of the patient’s
• Pregnancy complaints, including a list of known
allergens.
• Severe liver disease
➤ Obtain a history of the patient’s
genitourinary and hepatobiliary
CRITICAL VALUES: Potential systems, as well as results of previ-
critical value is greater than 100 mg/dL ously performed tests and proce-
(except in the case of renal dialysis dures. For related tests, refer to the
patients). A patient with a grossly genitourinary and hepatobiliary
elevated BUN may have signs and symp- system tables.
toms including acidemia, agitation, ➤ Obtain a list of medications the
confusion, fatigue, nausea, vomiting, and patient is taking, including herbs,
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine (5 mL) from an unpreserved random or timed specimen
collected in a clean plastic collection container.
SI Units
Conventional Units (Conversion Factor 35.7)
12–20 g/24 h 428–714 mmol/24 h
URETHROGRAPHY, RETROGRADE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: None.
AREA OF APPLICATION: Urethra.
CONTRAST: Radiopaque contrast medium.
belts, and any other metallic objects output for 24 hours after the proce-
have been removed from the dure. Decreased urine output may
abdominal area. indicate impending renal failure.
➤ Place the patient on the table in a ➤ Monitor for signs and symptoms of
supine position in the recumbent sepsis, including fever, chills, and
position. Ask the patient to lie still severe pain in the kidney area.
during the procedure because move- ➤ Maintain the patient on adequate
ment produces unclear images. hydration after the procedure.
➤ A single plain film is taken of the Encourage the patient to drink lots
bladder and urethra. of fluids to prevent stasis and to
➤ A catheter is filled with contrast prevent the buildup of bacteria.
medium to eliminate air pockets and ➤ Advise patient to drink increased
is inserted until the balloon reaches amounts of fluids for 24 to 48 hours
the meatus. Inform the patient that to eliminate the radionuclide from
the contrast medium may cause a the body, unless contraindicated. Tell
temporary flushing of the face, a the patient that radionuclide is elimi-
feeling of warmth, urticaria, nated from the body within 6 to 24
headache, vomiting, or nausea. hours.
➤ The patient is placed in the right ➤ Instruct the patient to immediately
posterior oblique position with the flush the toilet after each voiding
thigh drawn up to a 90º angle; in after the procedure and to meticu-
male patients, the penis is placed lously wash hands with soap and
parallel to the leg. water after each voiding for 24 hours
➤ After three-fourths of the contrast after the procedure.
medium is injected, another expo- ➤ Tell all caregivers to wear gloves
sure is taken while the remainder of when discarding urine for 24 hours
the contrast medium is injected. after the procedure. Wash gloved
➤ Left lateral and oblique exposures hands with soap and water before
may be taken. removing gloves. Then wash
ungloved hands after the gloves are
➤ The procedure may be done on removed.
female patients using a double
balloon to occlude the bladder neck ➤ Determine whether the patient or
from above and below the external family members have any further
meatus. questions or concerns.
➤ Wear gloves during the radionuclide ➤ A physician specializing in this
administration and while handling branch of medicine sends a written
the patient’s urine. report to the ordering provider, who
discusses the results with the
Post-test: patient.
➤ Inform the patient that further exam-
➤ Monitor vital and neurologic signs inations may be necessary to evalu-
until they return to preprocedure ate progression of the disease
levels. process or to determine the need for
➤ Instruct the patient to resume usual a change in therapy.
diet and medications, as directed by ➤ Evaluate test results in relation to
the physician. Renal function should the patient’s symptoms and other
be assessed before metformin is tests performed. Related diagnostic
restarted. tests include cystoscopy and intra-
➤ Monitor fluid intake and urinary venous pyelography.
Copyright © 2003 F.A. Davis Company
SYNONYM/ACRONYM: Urate.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
SI Units
Age Conventional Units (Conversion Factor 0.059)
Child less than 12 y 2.0–5.5 mg/dL 0.12–0.32 mmol/L
Adult younger
than 60 y
Male 4.4–7.6 mg/dL 0.26–0.45 mmol/L
Female 2.3–6.6 mg/dL 0.14–0.39 mmol/L
Adult older
than 60 y
Male 4.2–8.0 mg/dL 0.25–0.48 mmol/L
Female 3.5–7.3 mg/dL 0.21–0.43 mmol/L
Decreased in:
• Fanconi’s syndrome Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Low-purine diet
• Severe liver disease Pretest:
• Wilson’s disease ➤ Obtain a history of the patient’s
complaints, including a list of known
allergens. Especially note pain
CRITICAL VALUES: N/A and edema in joints and great
toe (caused by precipitation of
INTERFERING FACTORS: sodium urates), headache, fatigue,
• Drugs and substances that may decreased urinary output, and hyper-
increase uric acid levels include acetyl- tension.
salicylic acid (low doses), aldatense, ➤ Obtain a history of the patient’s
aminothiadiazole, anabolic steroids, genitourinary, hepatobiliary, and
antineoplastic agents, ascorbic musculoskeletal systems, as well as
Copyright © 2003 F.A. Davis Company
SI Units
Gender Conventional Units* (Conversion Factor 0.0059)*
Male 250–800 mg/24 h 1.48–4.72 mmol/24 h
Female 250–750 mg/24 h 1.48–4.43 mmol/24 h
* Values reflect average purine diet.
• All urine voided for the timed collec- into the collection device and then to
tion period must be included in the pour the urine into the laboratory
collection or else falsely decreased collection container. Alternatively
values may be obtained. Compare the specimen can be left in the
collection device for a health care
output records with volume collected staff member to add to the labora-
to verify that all voids were included in tory collection container.
the collection.
Intratest:
➤ Observe standard precautions and
Nursing Implications and follow the general guidelines in
Procedure ● ● ● ● ● ● ● ● ● ● ● Appendix A.
Urinalysis 997
time. Keep the container system on kidney stones. Educate the patient,
ice during the collection period, or if appropriate, on the importance of
empty the urine into a larger drinking a sufficient amount of water
container periodically during the when kidney stones are suspected.
collection period; monitor to ensure ➤ Increased uric acid levels may be
continued drainage, and conclude associated with gout. Nutritional
the test the next morning at the therapy may be appropriate for
same hour the collection was some patients identified as having
begun. gout. Educate the patient that foods
➤ At the conclusion of the test, high in oxalic acid include caffeinated
compare the quantity of urine with beverages, raw blackberries, goose-
the urinary output record for the berries and plums, whole-wheat
collection; if the specimen contains bread, beets, carrots, beans,
less than what was recorded as rhubarb, spinach, dry cocoa, and
output, some urine may have been Ovaltine. Foods high in purines
discarded, invalidating the test. include organ meats. In other cases,
➤ Label the specimen, and promptly the requesting health care practi-
transport it to the laboratory. Include tioner may not prescribe a low-
on the label the amount of urine, purine or purine-restricted diet for
test start and stop times, and inges- treatment of gout because medica-
tion of any medications that can tions can control the condition easily
affect test results. and effectively.
➤ Evaluate test results in relation to
Post-test: the patient’s symptoms and other
tests performed. Related laboratory
➤ Instruct the patient to resume usual tests include urine calcium,
diet as directed by the requesting complete blood count, urine creati-
health care practitioner. nine, kidney stone analysis, urine
➤ Increased uric acid levels may be oxalate, blood uric acid, and
associated with the formation of urinalysis.
URINALYSIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: UA.
SPECIMEN: Urine (15 mL) from an unpreserved, random specimen
collected in a clean, plastic collection container.
cells, white blood cells (WBCs), red blood cells (RBCs), bacteria, yeast,
sperm, and any other substances excreted in the urine that may have clinical
significance. Examination of urine sediment is performed microscopically
under high power, and results are reported as the number seen per high-
power field (hpf ). The color of normal urine ranges from light yellow to
deep amber. The color depends on the patient’s state of hydration (more
concentrated samples are darker in color), diet, medication regimen, and
exposure to other substances that may contribute to unusual color or odor.
The appearance of normal urine is clear. Cloudiness is sometimes attributa-
ble to the presence of amorphous phosphates or urates as well as blood,
WBCs, fat, or bacteria. Normal specific gravity is 1.001 to 1.035.
Dipstick
pH 5.0–9.0
Protein Less than 20 mg/dL
Glucose Negative
Ketones Negative
Hemoglobin Negative
Bilirubin Negative
Urobilinogen Up to 1 mg/dL
Nitrite Negative
Leukocyte esterase Negative
Microscopic Examination
Urinalysis 999
RESULT
Unusual Color
Color Presence of
Deep yellow Riboflavin
Orange Bilirubin, chrysophanic acid, pyridium, santonin
Pink Beet pigment, hemoglobin, myoglobin, porphyrin, rhubarb
Red Beet pigment, hemoglobin, myoglobin, porphyrin,uroerythrin
Green Oxidized bilirubin, Clorets (breath mint)
Blue Diagnex, indican, methylene blue
Brown Bilirubin, hematin, methemoglobin, metronidazole,
nitrofurantoin, metabolites of rhubarb, senna
Black Homogentisic acid, melanin
Smokey Red blood cells
Urinalysis 1001
• Large numbers of uric acid crystals are • The hemoglobin pad may detect
seen in patients with urolithiasis, gout, myoglobin, intact RBCs, and free
high dietary intake of foods rich in hemoglobin. Contamination of the
purines, or receiving chemotherapy collection container or specimen
(see monograph titled “Uric Acid, with sodium hypochlorite or iodine
Urine”). may cause false-positive hemoglobin
results. Negative or decreased hemo-
CRITICAL VALUES: Possible globin results may occur in the pres-
critical values are the presence of uric ence of formalin, elevated protein,
acid, cystine, leucine, or tyrosine crystals. nitrite, ascorbic acid, or high specific
The combination of grossly elevated gravity.
urine glucose and ketones is also consid- • False-negative nitrite results are
ered significant. common. Negative or decreased results
may be seen in the presence of ascorbic
INTERFERING FACTORS: acid and high specific gravity. Other
• Certain foods, such as onion, garlic, causes of false-negative values relate to
and asparagus, contain substances that the amount of time the urine was in
Copyright © 2003 F.A. Davis Company
Urinalysis 1003
SYNONYM/ACRONYM: VMA.
SPECIMEN: Urine (25 mL) from a timed specimen collected in a clean plas-
tic collection container with 6N hydrochloric acid as a preservative.
SI Units
Age Conventional Units (Conversion Factor 5.05)
3–6 y 1.0–2.6 mg/24 h 5–13 mol/24 h
6–10 y 2.0–3.2 mg/24 h 10–16 mol/24 h
10–16 y 2.3–5.2 mg/24 h 12–26 mol/24 h
16–83 y 1.4–6.5 mg/24 h 7–33 mol/24 h
VARICELLA ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
• Patients who are pregnant or suspected that allows the tracer to seep deep into
of being pregnant, unless the potential the muscle tissue can produce erro-
benefits of the procedure far outweigh neous hot spots.
the risks to the fetus and mother.
• Consultation with a physician should
• Elderly and other patients who are occur before the procedure for radia-
chronically dehydrated before tion safety concerns regarding infants
the test, because of their risk of of patients who are lactating.
contrast-induced renal failure.
• Risks associated with radiographic
• Patients who are in renal failure. overexposure can result from frequent
x-ray procedures. Personnel in the
• Patients with bleeding disorders. room with the patient should wear a
protective lead apron, stand behind a
Factors that may impair clear shield, or leave the area while the
imaging: examination is being done. Personnel
• Inability of the patient to cooperate or working in the area where the exami-
remain still during the procedure nation is being done should wear
because of age, significant pain, or badges that reveal their level of expo-
mental status sure to radiation.
discontinue the drug on the day of medium into the veins of the leg. A
the test and continue to withhold it tourniquet may be used on the leg to
for 48 hours after the test. Failure to prevent the dye from traveling to the
do so may result in lactic acidosis. superficial saphenous vein, thus
➤ Obtain a written, informed consent allowing all of the contrast medium
for the procedure from the patient, if to go to the deep venous system.
needed. Inform the patient that the contrast
medium may cause a temporary
➤ Determine date of last menstrual flushing of the face, a feeling of
period and possibility of pregnancy warmth, urticaria, headache, vomit-
in perimenopausal women. ing, or nausea.
➤ Restrict food and fluids for at least 4 ➤ Monitor the patient for complica-
hours before the procedure. tions related to the contrast medium
➤ Obtain and record baseline vital (e.g., allergic reaction, anaphylaxis,
signs to use for comparison after the bronchospasm, dyspnea).
procedure. ➤ Observe the injection site for signs
of contrast medium infiltration, such
Intratest:
as redness, edema, warmth, or
➤ Administer a mild sedative as tenderness.
ordered. ➤ Report signs of vein perforation,
➤ Ask the patient to put on a hospital embolism, and extravasation of
gown and void. contrast medium, including chills;
fever; rapid pulse and respiratory
➤ Make sure jewelry and any other
rates; hypotension; dyspnea; and
metallic objects have been removed
chest, abdominal, or flank pain.
from the lower extremities.
➤ Make sure emergency equipment is ➤ Report to the physician any
readily accessible. complaints of paresthesia or pain in
the catheterized limb, such as symp-
➤ If the patient has a history of severe toms of nerve irritation or vascular
allergic reactions to various compromise.
substances or drugs, administer
ordered prophylactic steroids or anti- ➤ Remove the IV line, and apply a pres-
histamines before the procedure. sure dressing over the puncture site.
Use nonionic contrast medium for
the procedure. Post-test:
➤ Using a pen, mark the site of the ➤ Observe injection site for bleeding
patient’s peripheral pulses before or hematoma formation. Apply a
angiography; this permits quicker warm compress to ease discomfort
and more consistent assessment of if a hematoma develops.
pulses after the procedure.
➤ Instruct the patient to resume usual
➤ Place electrocardiographic elec- diet, medications, and activity, as
trodes on the patient for cardiac directed by the physician. Renal
monitoring. Establish a baseline function should be assessed before
rhythm; determine whether the metformin is restarted.
patient has ventricular arrhythmias.
➤ Instruct the patient to increase fluid
➤ Place the patient in the supine posi- intake to counteract the diuretic
tion on an x-ray table. Cleanse the effects of contrast medium.
selected vein, and cover with a ster-
ile drape. ➤ Observe for a delayed allergic reac-
tion to contrast, including flushing,
➤ Establish intravenous (IV) fluid line hives, urticaria, laryngeal stridor,
for the injection of contrast medium. rash, tightening of throat, or diffi-
➤ After the contrast medium is culty breathing, and advise the
injected into a vein, x-rays are taken patient to immediately report any of
following the course of the contrast these symptoms.
Copyright © 2003 F.A. Davis Company
VITAMIN B12
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cyanocobalamin.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay)
SI Units
Age Conventional Units (Conversion Factor 0.738)
Newborn 160–1300 pg/mL 118–959 pmol/L
Adult 200–900 pg/mL 148–664 pmol/L
• Protein malnutrition
• Severe congestive heart failure Pretest:
• Some carcinomas ➤ Obtain a history of the patient’s
complaints, including a list of known
Decreased in: allergens.
• Abnormalities of cobalamin transport ➤ Obtain a history of the patient’s
gastrointestinal and hematopoietic
or metabolism
systems as well as results of previ-
• Bacterial overgrowth ously performed tests and proce-
dures. For related tests, refer to the
• Crohn’s disease gastrointestinal and hematopoietic
system tables.
• Dietary deficiency (e.g., in vegetarians)
➤ Obtain a list of medications the
• Diphyllobothrium (fish tapeworm) patient is taking, including herbs,
infestation nutritional supplements, and
nutraceuticals. The requesting health
• Gastric or small intestine surgery care practitioner and laboratory
• Hypochlorhydria should be advised if the patient is
regularly using these products so
• Inflammatory bowel disease that their effects can be taken into
consideration when reviewing
• Intestinal malabsorption results.
• Intrinsic factor deficiency ➤ Note any recent procedures that can
interfere with test results.
• Late pregnancy
➤ Instruct the patient to fast at least 12
• Pernicious anemia hours before specimen collection.
➤ There are no fluid or medication
CRITICAL VALUES: N/A restrictions unless by medical direc-
tion.
INTERFERING FACTORS: ➤ Review the procedure with the
• Drugs that may increase vitamin B12 patient.
levels include chloral hydrate.
➤ Inform the patient that specimen
• Drugs that may decrease vitamin B12 collection takes approximately 5 to
levels include alcohol, aminosalicylic 10 minutes.
acid, anticonvulsants, ascorbic acid,
cholestyramine, cimetidine, colchicine, Intratest:
metformin, neomycin, oral contracep- ➤ Ensure that the patient has complied
tives, ranitidine, and triamterene. with dietary preparations and other
• Hemolysis or exposure of the specimen pretesting restrictions.
to light invalidates results. ➤ Direct the patient to breathe
Copyright © 2003 F.A. Davis Company
VITAMIN D
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
(Conversion
Form Conventional Units Factor 2.496)
Vitamin D 25-dihydroxy 9–52 ng/mL 22.5–129.8 nmol/L
Vitamin D 1,25-dihydroxy 15–60 pg/mL 37.4–149.8 pmol/L
Vitamin D 1015
• Bowel resection
Pretest:
• Celiac disease
➤ Obtain a history of the patient’s
• Inflammatory bowel disease complaints, including a list of known
• Malabsorption allergens.
➤ Obtain a history of the patient’s
• Osteitis fibrosa cystica gastrointestinal and musculoskeletal
• Osteomalacia systems, as well as results of previ-
ously performed tests and proce-
• Pancreatic insufficiency dures. For related tests, refer to the
gastrointestinal and musculoskeletal
• Rickets system tables.
• Thyrotoxicosis ➤ Obtain a list of medications the
patient is taking, including herbs,
CRITICAL VALUES: Vitamin toxic- nutritional supplements, and
ity can be as significant as problems nutraceuticals. The requesting health
care practitioner and laboratory
brought about by vitamin deficiencies. should be advised if the patient
The potential for toxicity is especially regularly uses these products so
important to consider with respect to fat- that their effects can be taken into
soluble vitamins, which are not elimi- consideration when reviewing
nated from the body as quickly as results.
water-soluble vitamins and can accumu- ➤ There are no food, fluid, or medica-
late in the body. Most cases of toxicity are tion restrictions unless by medical
brought about by oversupplementing and direction.
Copyright © 2003 F.A. Davis Company
VITAMIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: -Tocopherol.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: High-performance liquid chromatography)
SI Units
Age Conventional Units (Conversion Factor 23.22)
1–12 y 0.3–0.9 mg/dL 7–21 mol/L
13–19 y 0.6–1.0 mg/dL 14–23 mol/L
Adult 0.5–1.8 mg/dL 12–42 mol/L
Vitamin E 1017
VITAMIN K
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
Conventional Units (Conversion Factor 2.22)
0.13–1.19 ng/mL 0.29–2.64 nmol/L
Vitamin K 1019
SI Units
(Conversion
Factor 10
Age cells/L)* Neutrophils
Total Bands Segments
(Absolute) (Absolute) (Absolute)
and % and % and %
Birth 9.0–30.0 (6.0–26.0) 61% (1.65) 9.1% (9.4) 52%
1d 9.4–34.0 (5.0–21.0) 61% (1.75) 9.2% (9.8) 52%
2 wk 5.0–20.0 (1.0–9.5) 40% (0.63) 5.5% (3.9) 34%
1 mo 5.0–19.5 (1.0–9.0) 35% (0.49) 4.5% (3.3) 30%
6 mo 6.0–17.5 (1.0–8.5) 32% (0.45) 3.8% (3.3) 28%
1y 6.0–17.5 (1.5–8.5) 31% (0.35) 3.1% (3.2) 28%
10 y 4.5–13.5 (1.8–8.0) 54% (0–1.0) 3.0% (1.8–7.0) 51%
Adult 4.5–11.0 (1.8–7.7) 59% (0–0.7) 3.0% (1.8–7.0) 56%
* WBC 103/mm3 or cells/L.
Copyright © 2003 F.A. Davis Company
RESULT
following the procedure and to wash report to the ordering provider, who
hands meticulously with soap and discusses the results with the
water after each voiding for 24 hours patient.
after the procedure.
➤ Evaluate test results in relation
➤ Tell all caregivers to wear gloves to the patient’s symptoms and
when discarding urine for 24 hours other tests performed. Related diag-
after the procedure. Wash gloved nostic tests include kidney, ureter,
hands with soap and water before and bladder (KUB) film; Ga-67
removing gloves. Then wash hands scan; ultrasound of the pelvis;
after the gloves are removed. and computed tomography and
➤ A physician specializing in this magnetic resonance imaging of the
branch of medicine sends a written abdomen.
ZINC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Zn.
SPECIMEN: Serum (1 mL) collected in a trace element–free, royal blue–top
tube.
SI Units
Age Conventional Units (Conversion Factor 0.153)
Newborn–6 mo 26–141 g/dL 4.0–21.6 mol/L
6–11 mo 29–131 g/dL 4.5–20.1 mol/L
1–4 y 31–115 g/dL 4.8–17.6 mol/L
4–5 y 48–119 g/dL 7.4–18.2 mol/L
6–9 y 48–129 g/dL 7.3–19.7 mol/L
10–13 y 25–148 g/dL 3.9–22.7 mol/L
14–17 y 46–130 g/dL 7.1–19.9 mol/L
Adult 70–120 g/dL 10.7–18.4 mol/L
Zinc 1035
RESULT Pretest:
Increased in: ➤ Obtain a history of the patient’s
• Anemia complaints, including a list of known
allergens.
• Arteriosclerosis ➤ Obtain a history of the patient’s
gastrointestinal, hepatobiliary, im-
• Coronary heart disease mune, and musculoskeletal sys-
• Primary osteosarcoma of the bone tems, as well as results of
previously performed tests and
procedures. For related tests, refer
Decreased in: to the gastrointestinal, immune,
• Acrodermatitis enteropathica hepatobiliary, and musculoskeletal
system tables.
• Acute infections
➤ Obtain a list of medications the
• Acute stress patient is taking, including herbs,
Copyright © 2003 F.A. Davis Company
SYSTEM TABLES
CARDIOVASCULAR SYSTEM
1037
Copyright © 2003 F.A. Davis Company
ENDOCRINE SYSTEM
GASTROINTESTINAL SYSTEM
GENITOURINARY SYSTEM
HEMATOPOIETIC SYSTEM
HEPATOBILIARY SYSTEM
IMMUNE SYSTEM
MUSCULOSKELETAL SYSTEM
REPRODUCTIVE SYSTEM
RESPIRATORY SYSTEM
Acetaminophen 54 Flecainide 84
Acetylsalicylic acid 54 Gentamicin 90
Albumin 14 Haloperidol 126
Alcohol, ethyl 447 Imipramine 118
Amikacin 90 Lead 660
Amitryptyline 118 Lidocaine 84
Amphetamines 447 Lithium 126
Barbiturates 447 Methotrexate 619
Benzodiazepines 447 Nortriptyline 118
Cannabinoids 447 Opiates 447
Carbamazepine 112 Phencyclidine 447
Cocaine 447 Phenobarbital 112
Cyclosporine 619 Phenytoin 112
Desipramine 118 Primidone 112
Diazepam 118 Procainamide 84
Digoxin 84 Quinidine 84
Disopyramide 84 Tobramycin 90
Doxepin 118 Tricyclic antidepressants 118
Ethanol 447 Valproic acid 112
Ethosuximide 112 Vancomycin 90
Copyright © 2003 F.A. Davis Company
APPENDIX A
1053
Copyright © 2003 F.A. Davis Company
Specific collection techniques and patient preparation vary by site, study required,
and level of invasiveness. These techniques are described in the individual mono-
graphs.
Blood Specimens
Most laboratory tests that require a blood specimen use venous blood. Venous blood
can be collected directly from the vein or by way of capillary puncture. Capillary blood
can be obtained from the fingertips or earlobes of adults and small children. Capillary
blood can also be obtained from the heel of infants. The circumstances in which the
capillary method would be selected over direct venipuncture include cases in which:
• The patient has poor veins.
• The patient has small veins.
• The patient has a limited number of available veins.
• The patient has significant anxiety about the venipuncture procedure.
Venous blood also can be obtained from vascular access devices, such as heparin
locks and central venous catheters. Examples of central venous catheters include the
triple-lumen subclavian, Hickman, and Groshong catheters.
Fetal blood samples can be obtained, when warranted, by a qualified health care
practitioner from the scalp or from the umbilical cord.
Arterial blood can be collected from the radial, brachial, or femoral artery if blood
gas analysis is requested.
There are some general guidelines one should follow in the procurement and
handling of blood specimens:
• It is essential that the patient be positively and properly identified. Specimens
should always be labeled with the patient’s name, medical record number (or
some other unique identifier), date collected, time collected, and initials of the
person collecting the sample.
• Requisitions should be completed accurately and submitted per laboratory
policy.
• The practice of an overnight fast before specimen collection is a general recom-
mendation. Reference ranges are often based on fasting populations to provide
some level of standardization for comparison. Some test results are dramatically
affected by foods, however, and fasting is a pretest requirement. The presence
of lipids in the blood also may interfere with the test method; fasting eliminates
this potential source of error, especially if the patient already has elevated lipid
levels. The laboratory should always be consulted if there is a question as to
whether fasting is a requirement or a recommendation.
• Gloves and any other additional personal protective equipment indicated by
the patient’s condition should always be worn during the specimen collection
process. Appendix F can be consulted for a more detailed description of stan-
dard precautions.
• Stress can cause variations in some test results. A sleeping patient should be
gently wakened and allowed the opportunity to become oriented before collec-
tion site selection. The comatose or unconscious patient should be greeted in
Copyright © 2003 F.A. Davis Company
the same gentle manner because although they are unable to respond, they may
be capable of hearing and understanding. Anticipate instances where patient
cooperation may be an issue. Enlist the assistance of a second person to assist
with specimen collection to ensure a safe, quality collection experience for all
involved.
• Localized activity such as the application of a tourniquet or clenching the hand
to assist in visualizing the vein can cause variations in some test results. It is
important to be aware of affected studies before specimen collection.
• Hemoconcentration may cause variations in some test results. The tourniquet
should never be left in place for longer than 1 minute.
• Previous puncture sites should be avoided when accessing a blood vessel by any
means, to reduce the potential for infection.
• Specimens should never be collected above an intravenous (IV) line because of
the potential for dilution when the specimen and the IV solution combine in
the collection container, falsely decreasing the result. It is also possible that
substances in the IV solution could contaminate the specimen and result in
falsely elevated test results.
• Changes in posture from supine to erect or long-term maintenance of a supine
posture causes variations in some test results. It is important to be aware of this
effect when results are interpreted and compared with previous values.
• Collection times for therapeutic drug (peak and trough) or other specific moni-
toring (e.g., chemotherapy, glucose, insulin, or potassium) should be docu-
mented carefully in relation to the time of medication administration. It is
essential that this information be communicated clearly and accurately to
avoid misunderstanding of the dose time in relation to the collect time.
Miscommunication between the individual administering the medication and
the individual collecting the specimen is the most frequent cause of subthera-
peutic levels, toxic levels, and misleading information used in the calculation
of future therapies.
• The laboratory should be consulted regarding minimum specimen collection
requirements when multiple tube types or samples are required. The amount
of serum or plasma collected can be estimated using assumptions of packed cell
volume or hematocrit. The packed cell volume of a healthy woman is usually
38 to 44 percent of the total blood volume. If a full 5-mL red-top tube is
collected, and the hematocrit is 38 to 44 percent, approximately 2.8 to 3.1 mL
of the total blood volume should be serum [5 (5 0.44)] to [5 (5
0.38)]. Factors that invalidate estimation include conditions such as anemia,
polcythemia, dehydration, or overhydration.
• The laboratory should be consulted regarding the preferred specimen container
before specimen collection. Specific analytes may vary in concentration
depending on whether the sample is serum or plasma. It is recommended that
when serial measurements are to be carried out, the same type of collection
container be used so that fluctuations in values caused by variations in speci-
men type are not misinterpreted as changes in clinical status. Consultation
regarding collection containers is also important because some laboratory
methods are optimized for a specific specimen type (serum versus plasma).
Copyright © 2003 F.A. Davis Company
Site Selection
Capillary Puncture: Assess the selected area. It should be free of lesions and calluses,
there should be no edema, and the site should feel warm. If the site feels cool or if the
site appears pale or cyanotic, warm compresses can be applied over 3 to 5 minutes to
dilate the capillaries. For finger sticks, the central, fleshy, distal portions of the third or
fourth fingers are the preferred collection sites (Fig. A–1). For neonatal heel sticks, the
medial and lateral surfaces of the plantar area are preferred to avoid direct puncture of
the heel bone, which could result in osteomyelitis (Fig. A–2).
Venipuncture: Assess the arm for visibly accessible veins. The selected area should
not be burned or scarred, have a tattoo, or have hematoma present. Even after the
tourniquet is applied, not all patients have a prominent median cubital, cephalic, or
basilic vein. Both arms should be observed because some patients have accessible veins
in one arm and not the other. The median cubital vein in the antecubital fossa is the
preferred venipuncture site. The patient may be able to provide the best information
regarding venous access if he or she has had previous venipuncture experience
(Fig. A–3). Alternative techniques to increase visibility of veins may include warming
the arm, allowing the arm to dangle downward for a minute or two, tapping the ante-
cubital area with the index finger, or massaging the arm upward from wrist to elbow.
The condition of the vein also should be assessed before venipuncture. Sclerotic (hard,
scarred) veins or veins in which phlebitis previously occurred should be avoided. Arms
with a functioning hemodialysis access site should not be used. The arm on the
affected side of a mastectomy should be avoided. In the case of a double mastectomy,
the requesting health care practitioner should be consulted before specimen collection.
Venipuncture of Hand and Wrist: If no veins in the arms are available, hands and
wrists should be examined as described previously. Consideration should be given to
the venipuncture equipment selected because the veins in these areas are much smaller.
Pediatric-sized collection containers and needles with a larger gauge may be more
appropriate.
Copyright © 2003 F.A. Davis Company
FIGURE A–1
CALCANEUS BONE
YES
N
O
YES
FIGURE A–2
Venipuncture of Legs and Feet: The veins in the legs and feet can be accessed as
with sites located on the arm, hand, or wrist. These extremities should be used only on
the approval of the requesting health care practitioner because veins in these locations
are more prone to infection and formation of blood clots, especially in patients with
diabetes, cardiac disease, and bleeding disorders.
Copyright © 2003 F.A. Davis Company
Cephalic
vein Basilic vein
Median
cubital vein Cephalic
Accessory vein
cephalic vein Basilic vein Basilic vein Dorsal
Metacarpal venous
Cephalic veins arch
vein Median
antebrachial
vein Digital
veins
FIGURE A–3
Radial Arterial Puncture: The radial artery is the artery of choice for obtaining
arterial blood gas specimens because it is close to the surface of the wrist and does not
require a deep puncture. Its easy access also allows for more effective compression after
the needle has been removed. The nearby ulnar artery can provide sufficient collateral
circulation to the hand during specimen collection and postcollection compression
(Fig. A–4).
Percutaneous Umbilical Cord Sampling: The blood is aspirated from the umbili-
cal cord under the guidance of ultrasonography and using a 20- or 22-gauge spinal
needle inserted through the mother’s abdomen.
Postnatal Umbilical Cord Sampling: The blood is aspirated from the umbilical
cord using a 20- or 22-gauge needle and transferred to the appropriate collection
container.
Fetal Scalp Sampling: The requesting health care practitioner makes a puncture
in the fetal scalp using a microblade, and the specimen is collected in a long
capillary tube. The tube is usually capped on both ends immediately after specimen
collection.
Locks and Catheters: These devices are inserted sometimes to provide a means for
the administration of fluids or medications and to obtain blood specimens without the
need for frequent venipuncture. The device first should be assessed for patency. The
need for heparinization, irrigation, or clot removal depends on the type of device in
use and the institution-specific or health care practitioner–specific protocols in use.
Care should be taken to use sterile technique because these devices provide direct
access to the patient’s bloodstream. When IV fluids are being administered via a device
at the time of specimen collection, blood should be obtained from the opposite side of
the body. If this is not possible, the flow should be stopped for 5 minutes before spec-
imen collection. The first 5 mL of blood collected should be discarded.
Copyright © 2003 F.A. Davis Company
Axillary
Brachial
Radial
Ulnar
FIGURE A–4
Collection Procedure
The procedures outlined here are basic in description. A phlebotomy or other text
should be consulted for specific details regarding specimen collection and complica-
tions encountered during various types of blood collection.
Capillary: Place the patient in a comfortable position either sitting or lying down.
Assess whether the patient has allergies to the disinfectant or to latex if latex gloves or
tourniquet will be used in the collection procedure. Use gloved hands to select the
collection site as described in the site selection section. Cleanse the skin with the
appropriate disinfectant and dry the area. Pull the skin tightly by moving the thumb
and index finger in opposite directions. Puncture the skin with a sterile lancet to a
depth of approximately 2 mm, using a quick, firm motion. Wipe the first drop of
blood away using the gauze. If flow is poor, the site should not be squeezed or the spec-
imen may become contaminated with tissue fluid. Do not allow the collection
container to touch the puncture site. Collect the sample in the capillary tube or
Microtainer. The capillary tube should be held in a horizontal position to avoid the
introduction of air bubbles into the sample. Microtainer tubes should be held in a
downward slanted direction to facilitate the flow of blood into the capillary scoop of
the collection device. If a smear is required, allow a drop of blood to fall onto a clean
microscope slide. Gently spread the drop across the slide using the edge of another
slide. Apply slight pressure to the puncture site with a clean piece of gauze until bleed-
ing stops, and then apply a bandage. Safely dispose of the sharps. Properly label the
specimens and transport immediately to the laboratory.
Venipuncture Using a Syringe or Vacuumized Needle and Holder System: Place
the patient in a comfortable position either sitting or lying down. Assess whether the
patient has allergies to the disinfectant or to latex if latex gloves or tourniquet will be
used in the collection procedure. Use gloved hands to select the collection site as
described in the site selection section. Locate the vein visually, then by palpation using
the index finger. The thumb should not be used because it has a pulse beat and may
cause confusion in site selection or differentiating a vein from an artery. Select the
appropriate collection materials (needle size, butterfly, syringe, collection container
size) based on the vein size, vein depth, appearance of the collection site, patient’s age,
and anticipated level of cooperation. Cleanse the skin with the appropriate disinfec-
tant and dry the area. Select the appropriate collection tubes. If blood cultures are to
be collected, disinfect the top of the collection containers as directed by the testing
laboratory. Be sure to have extra tubes within easy reach in case the vacuum in a collec-
tion tube is lost and a substitute is required. Apply the tourniquet 3 to 4 inches above
the selected collection site. Remove the sterile needle cap, and inspect the tip of the
needle for defects. Pull the skin tightly by placing the thumb of the nondominant hand
1 or 2 inches below the puncture site and moving the thumb in the opposite direction.
The thumb is placed below the puncture site to help avoid an accidental needle stick
if the patient should suddenly move. Ensure that the needle is bevel up and held at an
angle of approximately 15º to 30º (depending on the depth of the vein) (Fig. A–5).
Copyright © 2003 F.A. Davis Company
FIGURE A–5
Puncture the skin with smooth, firm motion using a sterile needle held by the domi-
nant hand. A reduction in pressure is achieved when the needle has penetrated the vein
successfully. Be sure to release the tourniquet within 1 minute of application. Fill the
vacuumized collection containers in the prescribed order of draw for the studies
ordered. Tubes with anticoagulants can be gently mixed with the free nondominant
hand as they are filled. When the required containers have been filled, withdraw the
needle and apply pressure to the collection site until the bleeding stops. In most cases,
a piece of gauze can be placed on the collection site and the arm bent upward to hold
it in place while attention is given to disposing of the sharps safely and labeling the
collection tubes properly. In cases in which a syringe is used, the barrel of the syringe
should be gently pulled back during specimen collection and gently pushed in during
the transfer to collection tubes. The vacuum in the collection container should not be
allowed to suck the sample into the container, but rather the speed of entry should be
controlled by the pressure applied to the barrel. The blood should gently roll down the
side of the tube to prevent hemolysis.
Radial Artery Puncture: Place the patient in a comfortable position either sitting or
lying down. Assess whether the patient has allergies to the disinfectant or to latex if
latex gloves or tourniquet will be used in the collection procedure. Assess if the patient
has an allergy to local anesthetics, and inform the health care practitioner accordingly.
Glove the hands, and select the collection site as described in the site selection section.
Ensure that the patient has adequate collateral circulation to the hand if thrombosis of
the radial artery occurs after arterial puncture by performing an Allen test before punc-
ture. The Allen test is performed by occlusion of the ulnar and radial arteries on the
palmar surface of the wrist with two fingers. The thumb should not be used to locate
these arteries because it has a pulse. Compress both arteries, and ask the patient to
open and close the fist several times until the palm turns pale. Release pressure only on
the ulnar artery. Color should return to the palm within 5 seconds if the ulnar artery
is functioning. If coloring returns above the wrist, the Allen test is positive. The Allen
test also should be performed on the opposite hand. The wrist to which color is
restored fastest has better circulation and should be selected as the site for blood gas
collection. Be sure to explain to the patient that an arterial puncture is painful. The
site may be anesthetized with 1% to 2% lidocaine (Xylocaine) before puncture. The
index finger of the nondominant hand is placed over the site where the needle will
enter the artery, not the site where the needle will penetrate the skin. The specimen is
collected in an air-free heparinized syringe, which is held like a dart in the dominant
hand and inserted slowly, bevel up, about 5 to 10 mm below the palpating finger at a
45º to 60º angle. When blood enters the needle hub, arterial pressure should cause
blood to pump into the syringe. When enough specimen has been collected, the needle
is withdrawn from the arm, and pressure is applied to the collection site for a mini-
Copyright © 2003 F.A. Davis Company
mum of 5 to 10 minutes. Immediately after the needle has been withdrawn safely from
the arm, the exposed end of the syringe should be stoppered.
Samples should be gently and well mixed to ensure proper mixing of the heparin
with the sample. The heparin prevents formation of small clots that result in rejection
of the sample. The tightly capped sample should 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 protective plastic bag.
Indwelling Devices: Indwelling devices are either heparinized or irrigated after spec-
imen collection. Before specimen collection, prepare the heparin in a syringe, if
required. Allow the heparin (unit dose or prepared solution in the syringe) to equili-
brate at room temperature during specimen collection. Cleanse the catheter cap or hub
with povidone-iodine and 70% alcohol over 2 minutes. Using sterile gloves, remove
the cap and attach a 5- or 10-mL syringe to the connector. Withdraw 5 mL of blood
to be discarded. Clamp the catheter. The Groshong catheter does not require clamp-
ing because it has a special valve that eliminates the need for clamping. Attach another
5- or 10-mL syringe and begin collecting blood for transfer to the collection tubes.
After the required specimen has been withdrawn, the device is heparinized. The device
is heparinized by slowly injecting the heparin into the cap or hub of the device. Clamp
the device 2 inches from the cap, remove the needle, and unclamp the device. Attach
a new sterile cap or hub if the old one has been discarded. Groshong catheters are irri-
gated rather than heparinized. Irrigation of a Groshong catheter is accomplished by
gently injecting 20 to 30 mL of sterile normal saline through the cap with moderate
force. Remove the needle using some positive pressure (pressing down on the plunger)
to prevent the solution from backing up into the syringe.
Order of Draw
• Blood culture and other tests requiring sterile specimen
• Red or red/gray (gel)
• Light blue (citrated) (If this is the only tube to be collected, draw a 5-mL red-
top tube specimen first and discard the red-top tube. This is done to eliminate
contamination of the specimen with tissue thromboplastin.)
• Green (heparin)
• Lavender (EDTA)
• Gray (oxalate/fluoride)
Urine Specimens
The patient should be informed that improper collection, storage, and transport are
the primary reasons for specimen rejection and subsequent requests for recollection. If
the specimen is to be collected at home, it should be collected in a clean plastic
container (preferably a container from the testing laboratory). Many studies require
refrigeration after collection. If the collection container includes a preservative, the
patient should be made aware of the contents and advised as to what the precaution
labels mean (caution labels such as caustic, corrosive, acid, and base should be affixed
to the container as appropriate). When a preservative or fixative is included in the
container, the patient should be advised not to remove it. The patient also should be
told not to void directly into the container. The patient should be given a collection
device, if indicated, and instructed to void into the collection device. The specimen
should be carefully transferred into the collection container. Some laboratories provide
Copyright © 2003 F.A. Davis Company
collection container. The patient should be instructed to void at the same time the
following morning and to add this last voiding to the container. This is the end time
of the collection and should be recorded along with the date on the container. For
patients who are in the hospital, the urinary output should be compared with the
volume measured in the completed collection container. Discrepancies between the
two volumes indicate that a collection might have been discarded. Many times a crea-
tinine level is requested along with the study of interest to evaluate the completeness
of the collection.
Catheterized Timed: Instructions for this type of collection are basically the same as
those for timed specimen collection. The test should begin by changing the tubing and
drainage bag. If a preservative is required, it can be placed directly in the drainage bag,
or the specimen can be removed at frequent intervals (every 2 hours) and transferred
to the collection container to which the preservative has been added. The drainage bag
must be kept on ice or emptied periodically into the collection container during the
entire collection period if indicated by the testing laboratory. The tubing should be
monitored throughout the collection period to ensure continued drainage.
Suprapubic Aspiration: This procedure is performed by inserting a needle directly
into the bladder. Because the bladder is normally sterile, the urine collected should also
be free from any contamination caused by the presence of microorganisms. First the
skin in the suprapubic region is cleansed with an antiseptic solution and draped with
sterile drapes. A local anesthetic may be administered before insertion of the needle.
After the sample has been collected, a sterile dressing is applied to the site. The site
must be observed for signs of inflammation or infection.
Pediatric: Specimen collection can be achieved by any of the above-described meth-
ods using collection devices specifically designed for pediatric patients. Appropriately
cleanse the genital area and allow the area to dry. For a random collection, remove the
covering of the adhesive strips on the collector bag and apply over the genital area.
Diaper the child. When the specimen is obtained, place the entire collection bag in the
specimen container (use a sterile container as appropriate for the requested study).
Some laboratories may have specific preferences for the submission of urine specimens
for culture. Consult the laboratory before collection to avoid specimen rejection.
Diagnostic Testing
Wear gloves and any other additional personal protective equipment indicated by the
patient’s condition. See Appendix F for a more detailed description of standard precau-
tions. Assess whether the patient has allergies to the disinfectant, anesthetic, contrast
material, medications, or to latex if latex gloves, catheter, or tourniquet will be used in
the procedure.
Copyright © 2003 F.A. Davis Company
APPENDIX B
Potential Nursing Diagnoses Associated with Laboratory and Diagnostic Testing 1067
APPENDIX C
APPENDIX D
Effective communication between the health care giver and patient is influenced by the
patient’s cognitive abilities, sensory development or deprivation, level of stress, and
environment. Effective communication with individuals at any stage of life is possible
if one recognizes that it is essential to employ age-specific communication techniques
based on an understanding of the continuum of human development as highlighted
here.
Tell jokes and play games with rules Develops concern with physical
Check for special words used to identify appearance
parents, body parts, or body functions Establishes critical need for privacy
Explain procedures in advance using Values belonging to peer group
correct terminology Perceives self as invincible
Use dolls or puppets for explanations Identity is threatened by hospitalization
when performing procedures
Provide privacy Interventions
Involve whenever possible
Likes to be treated like an adult
Allow to have some control
Do not talk to others about the patient
Promote independence
in front of him or her
Praise for good behavior
Do not ask questions about drugs, sex,
Acknowledge fear, pain, or family
or use of tobacco in front of parents
separation
Provide information about routines and
therapy
Adolescent (13 to 18 years) Provide privacy
Supplement information with rationale
Physical
Encourage questions
Growth in skeletal size is rapid Allow to maintain control
Reproductive system matures Involve in decision making and care
Vital signs approximate those of an adult Allow for expression of fear, such as
bodily injury and loss of control
Motor and Sensory
Easily fatigued Adult (19 to 65 years)
May need more rest and sleep in early
Physical
adolescence
Awkwardness in gross motor activity Reaches physical and sexual maturity
Demonstrates improving fine motor Prone to health problems related to an
skills inability to cope with new
responsibilities
Cognitive Health care needs related to preventive
medicine
Increased ability to use abstract thought
Adjustment to menopause (women) and
and logic
sexual dysfunction (men) in middle
Able to handle hypothetical situations
adulthood
and thoughts
Shows growth in self-esteem but is Motor and Sensory
challenged by bouts of insecurity
Avoids asking questions for fear of Skills are fully developed
appearing unintelligent
Cognitive
Psychosocial
Focus on time constraints and want to
Develops sexual identity learn only what is practical for them
Shows interest and confusion with own May be dual caregivers (i.e., parents and
development children)
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Psychosocial Cognitive
Experience emotional stress secondary to Experiences decrease in memory,
mate selection, vocational selection, slowing of mental functions,
assuming occupational roles, slowness in learning, and drop in
marriage, childbearing, financial performance
pressure, and independence
Psychosocial
Interventions
Encounters lifestyle changes secondary
Involve family in patient’s care and to children leaving home, children
education providing grandchildren, re-
Explain benefits of adhering to establishing a relationship as a couple,
treatment plan and retirement/hobbies
Be honest and supportive Develops increased concern for health
Respect personal values and financial security
Provide privacy Accepts concept of own mortality
Keep a hopeful attitude Faces decreased authority and autonomy
Focus on strength/not limitations Experiences depression related to
Recognize that unknown factors may decreased physical, motor, and
affect behavior cognitive abilities
Encourage patient to ask questions and
talk about concerns Interventions
Provide information and support to
Explain instructions well to patient and
make health care decisions
family
Ask questions to verify understanding
Geriatric (65 and older)
Review important points repeatedly
Physical Keep room clutter-free and call bell
within reach
Ages gradually and individually
Control room temperature for comfort
Experiences decreased tolerance to
Consider additional lighting at night
heat/cold
Watch for signs of drug toxicity
Encounters declining cardiac and renal
Give respect and provide privacy
function
Focus on strengths and not limitations
Experiences skeletal changes (bones
Avoid assuming loss of abilities
become more prominent, shrinkage in
Seek information as necessary to deal
vertebral discs, stiff joints)
with impairments
Becomes subject to increased
Include patient in conversation/activity
susceptibility to infection, increased
to prevent social isolation
susceptibility to high blood pressure
Encourage to talk about feelings
Undergoes skin changes
Use humor and stay positive
Provide information and support
Motor and Sensory
regarding end-of-life decisions
Experiences decrease in mobility, visual Provide teaching for safety
acuity, ability to respond to stimuli, Provide teaching for medications and
hearing, and motor skills test preparations
Copyright © 2003 F.A. Davis Company
APPENDIX E
The use of natural products has increased significantly, but to date, their preparation
is unregulated. Their actions can affect normal and abnormal physiologic processes as
well as interact with prescription medications. Their presence in the body, alone or in
combination with over-the-counter products or prescription medications, may physi-
ologically affect the intended target or cause analytical interference in such a way that
the test result is affected. For this reason, it is important to note their use. The herbs
listed here are contraindicated or are recommended for use with caution in patients
with body system disorders or patients taking medications for these disorders. The
requesting health care practitioner and laboratory should be advised if the patient is
regularly using these products so that their potential effects can be taken into consid-
eration when reviewing results.
This list is not all-inclusive. Questions regarding the potential benefits and
contraindications of natural products should be referred to the appropriate health care
practitioner. As a general recommendation, herbs and nutraceuticals are contraindi-
cated during pregnancy and lactation.
APPENDIX F
that may remain suspended in the air for long periods) or dust particles containing the
infectious agent. Microorganisms carried in this manner can be dispersed widely by air
currents and may become inhaled by or deposited on a susceptible host within the
same room or over a longer distance from the source patient, depending on environ-
mental factors; special air handling and ventilation are required to prevent airborne
transmission. Examples of diseases spread by airborne droplet nuclei include measles,
varicella (including disseminated zoster), and tuberculosis.
Droplet Precautions are designed to reduce the risk of droplet transmission of
infectious agents. Droplet transmission involves contact of the conjunctivae or the
mucous membranes of the nose or mouth of a susceptible person with large-particle
droplets (larger than 5 m in size) containing microorganisms generated from a
person who has a clinical disease or who is a carrier of the microorganism. Droplets are
generated from the source person primarily during coughing, sneezing, or talking and
during the performance of certain procedures such as suctioning and bronchoscopy.
Transmission via large-particle droplets requires close contact between source and
recipient persons because droplets do not remain suspended in the air and generally
travel only short distances, usually 3 ft or less, through the air. Because droplets do not
remain suspended in the air, special air handling and ventilation are not required to
prevent droplet transmission. Examples of illnesses spread by large-particle droplets
include invasive Haemophilus influenzae type B disease (including meningitis, pneu-
monia, epiglottitis, and sepsis); invasive Neisseria meningitidis disease (including
meningitis, pneumonia, and sepsis); diphtheria (pharyngeal); mycoplasmal pneumo-
nia; pertussis; pneumonic plague; streptococcal pharyngitis, pneumonia, or scarlet
fever in infants and young children; adenovirus influenza; mumps; parvovirus B19;
and rubella.
Contact Precautions are designed to reduce the risk of transmission of epidemio-
logically important microorganisms by direct or indirect contact. Direct-contact trans-
mission involves skin-to-skin contact and physical transfer of microorganisms to a
susceptible host from an infected or colonized person, such as occurs when personnel
turn patients, bathe patients, or perform other patient care activities that require phys-
ical contact. Direct-contact transmission also can occur between two patients (e.g., by
hand contact), with one serving as the source of infectious microorganisms and the
other as a susceptible host. Indirect-contact transmission involves contact of a suscep-
tible host with a contaminated intermediate object, usually inanimate, in the patient’s
environment. Examples of illnesses spread by direct contact include gastrointestinal,
respiratory, skin, or wound infections or colonization with multidrug-resistant bacte-
ria judged by the infection control program (based on current state, regional, or
national recommendations) to be of special clinical and epidemiologic significance;
enteric infections with a low infectious dose or prolonged environmental survival,
including Clostridium difficile; for diapered or incontinent patients, enterohemor-
rhagic Escherichia coli O157:H7, Shigella, hepatitis A, or rotavirus; respiratory syncy-
tial virus, parainfluenza virus, or enteroviral infections in infants and young children;
viral/hemorrhagic conjunctivitis; viral hemorrhagic infections (Ebola, Lassa, or
Marburg); and skin infections that are highly contagious or that may occur on dry
skin, including:
• Diphtheria (cutaneous)
• Herpes simplex virus (neonatal or mucocutaneous)
• Impetigo
• Major (noncontained) abscesses, cellulitis, or decubiti
• Pediculosis
Copyright © 2003 F.A. Davis Company
• Scabies
• Staphylococcal furunculosis in infants and young children
• Zoster (disseminated or in the immunocompromised host)
Standard Precautions
Use the following Standard Precautions, or the equivalent, for the care of all patients.
Hand Washing
Wash hands after touching blood, body fluids, secretions, excretions, and
contaminated items, whether or not gloves are worn. Wash hands immediately
after gloves are removed, between patient contacts, and when otherwise indicated
to avoid transfer of microorganisms to other patients or environments. It may be
necessary to wash hands between tasks and procedures on the same patient to
prevent cross-contamination of different body sites.
Use a plain (nonantimicrobial) soap for routine hand washing.
Use an antimicrobial agent or a waterless antiseptic agent for specific circumstances
(e.g., control of outbreaks or hyperendemic infections), as defined by the infection
control program. (See Contact Precautions for additional recommendations on
using antimicrobial and antiseptic agents.)
Gloves
Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body
fluids, secretions, excretions, and contaminated items.
Put on clean gloves just before touching mucous membranes and nonintact skin.
Change gloves between tasks and procedures on the same patient after contact with
material that may contain a high concentration of microorganisms.
Remove gloves promptly after use, before touching noncontaminated items and
environmental surfaces, and before going to another patient. Wash hands imme-
diately to avoid transfer of microorganisms to other patients or environments.
Gown
Wear a gown (a clean, nonsterile gown is adequate) to protect skin and to prevent
soiling of clothing during procedures and patient care activities that are likely to
generate splashes or sprays of blood, body fluids, secretions, or excretions.
Select a gown that is appropriate for the activity and amount of fluid likely to be
encountered.
Remove a soiled gown as promptly as possible. Wash hands to avoid transfer of
microorganisms to other patients or environments.
Copyright © 2003 F.A. Davis Company
Environmental Control
Ensure that the hospital has adequate procedures for the routine care, cleaning, and
disinfection of environmental surfaces, beds, bedrails, bedside equipment, and
other frequently touched surfaces, and ensure that these procedures are being
followed.
Linen
Handle, transport, and process used linen soiled with blood, body fluids, secretions,
and excretions in a manner that prevents skin and mucous membrane exposures
and contamination of clothing and that avoids transfer of microorganisms to
other patients and environments.
Patient Placement
Place a patient who contaminates the environment or who does not (or cannot be
expected to) assist in maintaining appropriate hygiene or environmental control in
a private room. If a private room is not available, consult with infection control
professionals regarding patient placement or other alternatives.
Copyright © 2003 F.A. Davis Company
Transmission-Based Precautions
Airborne Precautions
In addition to Standard Precautions, use Airborne Precautions, or the equivalent,
for patients known or suspected to be infected with microorganisms transmitted
by airborne droplet nuclei (small-particle residue [5 m or smaller in size] of
evaporated droplets containing microorganisms that remain suspended in the air
and that can be dispersed widely by air currents within a room or over a long
distance).
Patient Placement
Place the patient in a private room that has (1) monitored negative air pressure in
relation to the surrounding areas, (2) 6 to 12 air changes per hour, and (3)
appropriate discharge of air outdoors or monitored high-efficiency filtration of
room air before the air is circulated to other areas in the hospital.
Keep the room door closed and the patient in the room.
When a private room is not available, place the patient in a room with a patient who
has active infection with the same microorganism unless otherwise recommended,
but with no other infection. When a private room is not available and cohorting is
not desirable, consultation with infection control professionals is advised before
patient placement.
Respiratory Protection
Wear respiratory protection when entering the room of a patient with known or
suspected infectious pulmonary tuberculosis.
Susceptible persons should not enter the room of patients known or suspected to
have measles (rubeola) or varicella (chickenpox) if other immune caregivers are
available. If susceptible persons must enter the room of a patient known or
suspected to have measles or varicella, they should wear respiratory protection.
Persons immune to measles or varicella need not wear respiratory protection.
Patient Transport
Limit the movement and transport of the patient from the room to essential
purposes only. If transport or movement is necessary, minimize patient dispersal of
droplet nuclei by placing a surgical mask on the patient, if possible.
1
Employees who received training in the year preceding the effective date of the standard need
only receive training pertaining to any provisions not already included.
Copyright © 2003 F.A. Davis Company
Droplet Precautions
In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for a
patient known or suspected to be infected with microorganisms transmitted by
droplets (large-particle droplets [larger than 5 m in size] that can be generated during
coughing, sneezing, talking, or the performance of procedures).
Patient Placement
Place the patient in a private room. When a private room is not available, place the
patient in a room with a patient who has active infection with the same
microorganism but with no other infection (cohorting). When a private room is
not available and cohorting is not achievable, maintain spatial separation of at
least 3 ft between the infected patient and other patients and visitors.
Special air handling and ventilation are not necessary, and the door may remain open.
Mask
In addition to Standard Precautions, wear a mask when working within 3 ft of the
patient. (Logistically, some hospitals may want to implement the wearing of a
mask to enter the room.)
Patient Transport
Limit the movement and transport of the patient from the room to essential
purposes only.
If transport or movement is necessary, minimize patient dispersal of droplets by
masking the patient, if possible.
Contact Precautions
In addition to Standard Precautions, use Contact Precautions, or the equivalent, for
specified patients known or suspected to be infected or colonized with epidemiologi-
cally important microorganisms that can be transmitted by direct contact with the
patient (hand or skin-to-skin contact that occurs when performing patient care activ-
ities that require touching the patient’s dry skin) or indirect contact (touching) with
environmental surfaces or patient care items in the patient’s environment.
Patient Placement
Place the patient in a private room. When a private room is not available, place the
patient in a room with a patient who has active infection with the same
microorganism but with no other infection (cohorting).
When a private room is not available and cohorting is not achievable, consider the
epidemiology of the microorganism and the patient population when determining
patient placement. Consultation with infection control professionals is advised
before patient placement.
During the course of providing care for a patient, change gloves after having contact
with infective material that may contain high concentrations of microorganisms
(fecal material and wound drainage).
Remove gloves before leaving the patient’s environment and wash hands immediately
with an antimicrobial agent or a waterless antiseptic agent. After glove removal
and hand washing, ensure that hands do not touch potentially contaminated
environmental surfaces or items in the patient’s room to avoid transfer of
microorganisms to other patients or environments.
Gown
In addition to wearing a gown as outlined under Standard Precautions, wear a gown
(a clean, nonsterile gown is adequate) when entering the room if you anticipate
that your clothing will have substantial contact with the patient, environmental
surfaces, or items in the patient’s room or if the patient is incontinent or has
diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a
dressing.
Remove the gown before leaving the patient’s environment. After gown removal,
ensure that clothing does not contact potentially contaminated environmental
surfaces to avoid transfer of microorganisms to other patients or environments.
Patient Transport
Limit the movement and transport of the patient from the room to essential
purposes only.
If the patient is transported out of the room, ensure that precautions are maintained
to minimize the risk of transmission of microorganisms to other patients and
contamination of environmental surfaces or equipment.
employees of clinical and diagnostic laboratories; housekeepers in health care and other
facilities; personnel in hospital laundries or commercial laundries that service health
care or public safety institutions; tissue bank personnel; employees in blood banks and
plasma centers who collect, transport, and test blood; freestanding clinic employees
(e.g., hemodialysis clinics, urgent care clinics, health maintenance organization
[HMO] clinics, and family planning clinics); employees in clinics in industrial, educa-
tional, and correctional facilities (e.g., employees who collect blood and clean and
dress wounds); employees designated to provide emergency first aid; dentists, dental
hygienists, dental assistants, and dental laboratory technicians; staff of institutions for
the developmentally disabled; hospice employees; home health care workers; staff of
nursing homes and long-term care facilities; employees of funeral homes and mortu-
aries; human immunodeficiency virus (HIV) and hepatitis B virus (HBV) research
laboratory and production facility workers; employees handling regulated waste; custo-
dial workers required to clean up contaminated sharps or spills of blood or other
potentially infectious material (OPIM); medical equipment service and repair person-
nel; emergency medical technicians, paramedics, and other emergency medical service
providers; firefighters, law enforcement personnel, and correctional officers (employ-
ees in the private sector, the federal government, or a state or local government in a
state that has an OSHA-approved state plan); maintenance workers, such as plumbers,
in health care facilities; and employees of substance abuse clinics.
Blood means human blood, blood products, or blood components (plasma,
platelets, and serosanguineous fluids [e.g., exudates from wounds]). Also included are
medications derived from blood, such as immune globulins, albumin, and factors 8
and 9. Other potentially infectious materials include human body fluids, such as saliva
in dental procedures; semen; vaginal secretions; cerebrospinal, synovial, pleural, peri-
cardial, peritoneal, and amniotic fluids; body fluids visibly contaminated with blood;
unfixed human tissues or organs; HIV-containing cell or tissue cultures; and HIV-
containing or HBV-containing culture media or other solutions.
Occupational exposure means a “reasonably anticipated skin, eye, mucous
membrane, or parenteral contact [human bites that break the skin, which are most
likely to occur in violent situations such as may be encountered by prison personnel
and police and in emergency departments or psychiatric wards] with blood or other
potentially infectious materials that may result from the performance of the employee’s
duties.” The term reasonably anticipated contact includes the potential for contact and
actual contact with blood or OPIM. Lack of history of blood exposures among
designated first aid personnel of a particular manufacturing site, for instance, does
not preclude coverage. Reasonably anticipated contact includes, among others, contact
with blood or OPIM, including regulated waste, as well as incidents of needle
sticks. A compliance officer may document incidents in which an employee observes
uncapped needles or contacts other regulated waste to substantiate occupational
exposure.
Federal OSHA authority extends to all private sector employers with one or more
employees, as well as federal civilian employees. In addition, many states administer
their own occupational safety and health programs through plans approved under
section 18(b) of the Occupational Safety and Health Act. These plans must adopt stan-
dards and enforce requirements that are at least as effective as federal requirements. Of
the current 25 states and territories with plans, 23 cover the private and public (state
and local governments) sectors and 2 cover the public sector only.
Determining occupational exposure and instituting control methods and work
practices appropriate for specific job assignments are key requirements of the standard.
The required written exposure control plan and methods of compliance show how
employee exposure can be minimized or eliminated.
Copyright © 2003 F.A. Davis Company
Preventive Measures
Preventive measures such as hepatitis B vaccination, universal precautions, engineering
controls, safe work practices, PPE, and housekeeping measures help reduce the risks of
occupational exposure.
Hepatitis B Vaccination
The hepatitis B vaccination series must be made available within 10 working days of
initial assignment to every employee who has occupational exposure. The hepatitis B
vaccination must be made available without cost to the employee, at a reasonable time
and place for the employee, by a licensed health care professional,2 and according to
recommendations of the U.S. Public Health Service, including routine booster doses.3
The health care professional designated by the employer to implement this part of the
2
Licensed health care professional is a person whose legally permitted scope of practice allows
him or her to perform independently the activities required under paragraph (f ) of the standard
regarding hepatitis B vaccination and postexposure and follow-up.
3
Health care professionals can call the CDC disease information hotline (404) 332-4555,
extension 234, for updated information on hepatitis B vaccination.
Copyright © 2003 F.A. Davis Company
standard must be provided with a copy of the blood-borne pathogens standard. The
health care professional must provide the employer with a written opinion stating
whether the hepatitis B vaccination is indicated for the employee and whether the
employee has received the vaccination.
Employers are not required to offer hepatitis B vaccination (1) to employees who
have previously completed the hepatitis B vaccination series, (2) when immunity is
confirmed through antibody testing, or (3) if vaccine is contraindicated for medical
reasons. Participation in a prescreening program is not a prerequisite for receiving
hepatitis B vaccination. Employees who decline the vaccination may request and
obtain it at a later date, if they continue to be exposed. Employees who decline to
accept the hepatitis B vaccination must sign a declination form, indicating that they
were offered the vaccination but refused it. For more information, refer to
“Immunization of Health-Care Workers: Recommendations of ACIP and HICPAC,”
Morbidity and Mortality Weekly Report, vol 46, no. RR-18, 1997.
Universal Precautions
The most important measure to control transmission of HBV and HIV is to treat all
human blood and other potentially infectious materials as if they were infectious for
HBV and HIV. (Coverage under this definition also extends to blood and tissues of
experimental animals who are infected with HIV or HBV.) Application of this
approach is referred to as universal precautions. Blood and certain body fluids from all
acute-care patients should be considered as potentially infectious materials.4 These fluids
cause contamination, defined in the standard as “the presence or the reasonably antic-
ipated presence of blood or other potentially infectious materials on an item or
surface.”
Alternative concepts in infection control are called Body Substance Isolation and
Standard Precautions. These methods define all body fluids and substances as infec-
tious. These methods incorporate not only the fluids and materials covered by this
standard, but also expand coverage to include all body fluids and substances. These
concepts are acceptable alternatives to universal precautions, provided that facilities
using them adhere to all other provisions of this standard.
Methods of Control
Engineering and Work Practice Controls
Engineering and work practice controls are the primary methods used to control the
transmission of HBV and HIV in acute-care facilities. Engineering controls isolate or
remove the hazard from employees and are used in conjunction with work practices.
Personal protective equipment also is used when occupational exposure to blood-borne
pathogens remains even after instituting these controls. Engineering controls must be
examined and maintained, or replaced, on a scheduled basis. Some engineering controls
that apply to acute-care facilities and are required by the standard include the following:
• Use puncture-resistant, leak-proof containers, color-coded red or labeled,
according to the standard (see table) to discard contaminated items such as
needles, broken glass, scalpels, or other items that could cause a cut or punc-
ture wound.
4
See also “Recommendations for Prevention of HIV Transmission in Health-Care Settings,”
Morbidity and Mortality Weekly Report, vol 36(2S), August 21, 1987.
Copyright © 2003 F.A. Davis Company
Regulated waste X or X
container (e.g.,
contaminated
sharps container)
Reusable contami- X or X
nated sharps
container (e.g.,
surgical instru-
ments soaking in
a tray)
Refrigerator/freezer X
holding blood or
other potentially
infectious material
Containers used for X or X
storage, transport,
or shipping of
blood
Blood/blood-borne X
products for clini-
cal use
Individual speci- X or X or X
men containers of
blood or other
potentially infec-
tious materials
remaining in facil-
ity
(Continued on the following page)
Copyright © 2003 F.A. Davis Company
Contaminated X
equipment need- Plus a label
ing service (e.g., specifying
dialysis equip- where the
ment, suction contamina-
apparatus) tion exists
Specimens and X or X
regulated waste
shipped from the
primary facility to
another facility
for service or
disposal
Contaminated * or X or X
laundry
Contaminated X or X
laundry sent to
another facility
that does not use
universal precau-
tions
* Alternative labeling or color coding is sufficient if it permits all employees to recognize
containers as requiring compliance with universal precautions.
Similarly, work practice controls reduce the likelihood of exposure by altering the
manner in which the task is performed. All procedures minimize splashing, spraying,
splattering, and generation of droplets. Work practice requirements include the
following:
• Wash hands when gloves are removed and as soon as possible after contact with
blood or other potentially infectious materials.
• Provide and make available a mechanism for immediate eye irrigation, in the
event of an exposure incident.
• Do not bend, recap, or remove contaminated needles unless required to do so
by specific medical procedures or the employer can show that no alternative is
feasible. In these instances, use mechanical means, such as forceps or a one-
handed technique, to recap or remove contaminated needles.
• Do not shear or break contaminated needles.
• Discard contaminated needles and sharp instruments in puncture-resistant,
Copyright © 2003 F.A. Davis Company
FIGURE A–6
5
Biohazard labeling requires a fluorescent orange or orange-red label with the biologic hazard
symbol as well as the word Biohazard in contrasting color affixed to the bag or container.
Copyright © 2003 F.A. Davis Company
National Institute for Occupational Safety and Health (NIOSH): Sharps disposal
containers. Contact: www.cdc.gov/niosh/sharps1.html. Features information on
selecting, evaluating, and using sharps disposal containers.
Occupational Safety and Health Administration (OSHA): Glass capillary tubes: Joint
Safety Advisory about potential risks. Contact:
www.oshaslc.gov/OshDoc/Interpdata/I19990222.html. Describes safer alternatives
to conventional glass capillary tubes.
Occupational Safety and Health Administration (OSHA): Needlestick injuries.
Contact: www.osha-slc.gov/SLTC/needlestick/index.html. Features recent news,
recognition, evaluation, controls, compliance, and links to information on
effective engineering controls.
Safety Sharp Device Contract: Contact: www.va.gov/vasafety/osh-
issues/needlesafety/safetysharpcontracts.htm. Features safety sharp devices on
contract with the U.S. Department of Veterans Affairs (VA).
SHARPS Injury Control Program: Contact: www.ohb.org/sharps.htm. Established
by Senate Bill 2005 to study sharps injuries in hospitals, skilled nursing facilities,
and home health agencies in California. Features a beta version of Safety
Enhanced Device Database Listing by Manufacturer.
Training for Development of Innovative Control Technologies (TDICT) Project:
Contact: www.tdict.org/criteria.html. Features safety feature evaluation forms for
specific devices.
• Wear appropriate gloves when contact with blood, mucous membranes, non-
intact skin (e.g., skin with dermatitis, hangnails, cuts, abrasions, chafing, acne),
or potentially infectious materials is anticipated; when performing vascular
access procedures6; and when handling or touching contaminated items or
surfaces.
• Provide hypoallergenic gloves, liners, or powderless gloves or other alternatives
to employees who need them.
• Replace disposable, single-use gloves as soon as possible when contaminated or
if torn, punctured, or barrier function is compromised.
• Do not reuse disposable (single-use) gloves.
• Decontaminate reusable (utility) gloves after each use and discard if they show
signs of cracking, peeling, tearing, puncturing, deteriorating, or failing to
provide a protective barrier.
• Use full face shields or face masks with eye protection, goggles, or eyeglasses
with side shields when splashes of blood and other bodily fluids may occur and
when contamination of the eyes, nose, or mouth can be anticipated (e.g.,
during invasive and surgical procedures).
• Also wear surgical caps or hoods and shoe covers or boots when gross contam-
ination may occur, such as during surgery and autopsy procedures.
Remember: The selection of appropriate PPE depends on the quantity and type of
exposure expected.
Housekeeping Procedures
Equipment
The employer must ensure a clean and sanitary workplace. Contaminated work
surfaces must be decontaminated with a disinfectant on completion of procedures;
when contaminated by splashes, spills, or contact with blood or other potentially infec-
tious materials; and at the end of the work shift. Surfaces and equipment protected
with plastic wrap, foil, or other nonabsorbent materials must be inspected frequently
for contamination; these protective coverings must be changed when found to be
contaminated.
Waste cans and pails must be inspected and decontaminated on a regularly sched-
uled basis. Broken glass should be cleaned up with a brush or tongs; never pick up
broken glass with hands, even when wearing gloves.
Waste
Waste removed from the facility is regulated by local and state laws. Special precautions
are necessary when disposing of contaminated sharps and other contaminated waste
and include the following:
• Dispose of contaminated sharps in closable, puncture-resistant, leak-proof, red
or biohazard-labeled containers (see table earlier).
6
Phlebotomists in volunteer blood donation centers are exempt in certain circumstances. See
section (d)(3)(ix)(D) of the standard for specific details.
Copyright © 2003 F.A. Davis Company
Laundry
Laundering contaminated articles, including employee laboratory coats and uniforms
meant to function as PPE, is the responsibility of the employer. Contaminated laun-
dry is handled as little as possible with minimum agitation. This can be accomplished
through the use of a washer and dryer in a designated area on-site, or the contaminated
items can be sent to a commercial laundry. The following requirements should be met
with respect to contaminated laundry:
• Bag contaminated laundry as soon as it is removed and store in a designated
area or container.
• Use red laundry bags or those marked with the biohazard symbol unless univer-
sal precautions are in effect in the facility, and all employees recognize the bags
as contaminated and have been trained in handling the bags.
• Clearly mark laundry sent off-site for cleaning, by placing it in red bags or bags
clearly marked with the orange biohazard symbol; use leak-proof bags to
prevent soak-through.
• Wear gloves or other protective equipment when handling contaminated
laundry.
7
Liquid or semiliquid blood or other potentially infectious materials; items contaminated with
these fluids and materials, which could release these substances in a liquid or semiliquid state, if
compressed; items caked with dried blood or other potentially infectious materials that are
capable of releasing these materials during handling; contaminated sharps; and pathologic and
microbiologic wastes containing blood or other potentially infectious materials.
Copyright © 2003 F.A. Davis Company
status; and results of the source individual’s blood tests, if available. At that time, a
baseline blood sample should be drawn from the employee, if he or she consents. If the
employee elects to delay HIV testing of the sample, the health care professional must
preserve the employee’s blood sample for at least 90 days.8
Testing the source individual’s blood does not need to be repeated if the source
individual is known to be infectious for HIV or HBV; testing cannot be done in most
states without written consent.9 The results of the source individual’s blood tests are
confidential. As soon as possible, however, the test results of the source individual’s
blood must be made available to the exposed employee through consultation with the
health care professional.
After postexposure evaluation, the health care professional provides a written opin-
ion to the employer. This opinion is limited to a statement that the employee has been
informed of the results of the evaluation and told of the need, if any, for any further
evaluation or treatment. The employer must provide a copy of the written opinion to
the employee within 15 days. This is the only information shared with the employer
after an exposure incident; all other employee medical records are confidential.
All evaluations and follow-up must be available at no cost to the employee and at
a reasonable time and place, performed by or under the supervision of a licensed physi-
cian or another licensed health care professional, such as a nurse practitioner, and
according to recommendations of the U.S. Public Health Service guidelines current at
the time of the evaluation and procedure. In addition, all laboratory tests must be
conducted by an accredited laboratory and at no cost to the employee.
Record Keeping
There are two types of records required by the blood-borne pathogens standard:
medical and training. A medical record must be established for each employee with
occupational exposure. This record is confidential and separate from other personnel
records. This record may be kept on-site or may be retained by the health care profes-
sional who provides services to employees. The medical record contains the employee’s
name, social security number, hepatitis B vaccination status including the dates of
vaccination, and the written opinion of the health care professional regarding the
hepatitis B vaccination. If an occupational exposure occurs, reports are added to the
medical record to document the incident and the results of testing after the incident.
The postevaluation written opinion of the health care professional is also part of the
medical record. The medical record also must document what information has been
provided to the health care provider. Medical records must be maintained 30 years past
the last date of employment of the employee.
Emphasis is on confidentiality of medical records. No medical record or part of a
medical record should be disclosed without direct, written consent of the employee or
as required by law.
Training records document each training session and are to be kept for 3 years.
Training records must include the date, content outline, trainer’s name and qualifica-
tions, and names and job titles of all persons attending the training sessions.
8
If, during this time, the employee elects to have the baseline sample tested, testing is
performed as soon as feasible.
9
If consent is not obtained, the employer must show that legally required consent could not be
obtained. Where consent is not required by law, the source individual’s blood, if available,
should be tested and the results documented.
Copyright © 2003 F.A. Davis Company
If the employer ceases to do business, medical and training records are transferred
to the successor employer. If there is no successor employer, the employer must notify
the Director of the National Institute for Occupational Safety and Health, U.S.
Department of Health and Human Services, for specific directions regarding disposi-
tion of the records at least 3 months before disposal.
On request, medical and training records must be made available to the Assistant
Secretary of Labor of Occupational Safety and Health. Training records must be avail-
able to employees on request. Medical records can be obtained by the employee or
anyone having the employee’s written consent. Additional record keeping is required
for employers with 11 or more employees (see OSHA’s “Recordkeeping Guidelines for
Occupational Injuries and Illnesses” for more information.)
Consultation Programs
Consultation assistance is available to employers who want help in establishing and
maintaining a safe and healthful workplace. Largely funded by OSHA, the service is
provided at no cost to the employer. Primarily developed for smaller employers with
more hazardous operations, the consultation service is delivered by state government
agencies or universities employing professional safety consultants and health consult-
ants. Comprehensive assistance includes an appraisal of all mechanical, physical work
practice, and environmental hazards of the workplace and all aspects of the employer’s
present job safety and health program. No penalties are proposed or citations issued
for hazards identified by the consultant.
Employee Training
All employees who have occupational exposure to blood-borne pathogens should
receive training on the epidemiology, symptoms, and transmission of blood-borne
pathogen diseases. In addition, the training program covers, at a minimum, the follow-
ing elements:
• A copy and explanation of the standard
• An explanation of the Engineering Control Plan and how to obtain a copy
• An explanation of methods to recognize tasks and other activities that may
involve exposure to blood and other potentially infectious materials, including
what constitutes an exposure incident
• An explanation of the use and limitations of engineering controls, work prac-
tices, and PPE
Copyright © 2003 F.A. Davis Company
SOURCE: Bloodborne Pathogens and Acute Care Facilities (OSHA 3128), Occupational
Safety and Health Administration, Washington, DC, 1992.
Copyright 2001 by F. A. Davis Company.
Copyright © 2003 F.A. Davis Company
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INDEX
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1104 Index