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
Copyright © 2003 F.A. Davis Company
This page intentionally left blank

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 • PHILADELPHIA

F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 2003 by F. A. Davis Company
All rights reserved. This book is protected by copyright. No part of it may be reproduced,
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Printed in Canada
Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1
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Developmental Editor: Gett Services
Production Editor: Lisa J. Collins
Cover Designer: Louis J. Forgione
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
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urged when using new or infrequently ordered drugs.
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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
To my parents, James and Marceline, who always told me I could do or be anything I

wished as long as I believed in myself. To my husband, Don, and daughters, Sarah and
Margaret, for their humor, patience, support, and love throughout the entire project.
I could not have done this without them. To my writing partners, Todd and Zoanne,
for their friendship, creativity, commitment, and professional skills. To Lisa Deitch,
Acquisitions Editor, for her excellent direction and unwavering encouragement. To
Lisa Collins, Production Editor, for her outstanding editorial guidance and support.
To my medical technology and nursing friends and colleagues, Bev, Cathy, Evelyn,
Ruth, and Lynda, for their interest, support, and advice. And to Rudy and Winston,
my favorite and loyal canines, who always snoozed by my feet during countless
predawn writing sessions.
Anne M. Van Leeuwen, MA, BS, MT (ASCP)
Administrator
Eye Care for the Adirondacks, P.C.
Plattsburgh, New York
v
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
ABOUT THIS BOOK
L
aboratory and diagnostic studies are essential components of a complete patient
assessment. Examined in conjunction with an individual’s history and physical
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
viii About This Book
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.
About This Book ix
• Pretest section addresses the need to:

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

procedures and materials, describing specific tube tops used for various blood tests; a
list of common laboratory panels, the tests in them, and the minimum specimen
requirements; a summary chart that details suggested approaches to persons at various
developmental stages to assist the provider in facilitating cooperation and understand-
ing; a list of some of the herbs and nutraceuticals that have been associated with
adverse clinical reactions or have been associated with drug interactions related to the
affected body system; and guidelines for standard and universal precautions.
Finally, additional supportive materials are provided for the instructor and student
in an Instructor’s Guide. Presentations and case studies with emphasis on laboratory and
diagnostic test–related information and nursing implications have been developed for
selected conditions and body systems. Open-ended and NCLEX-type, multiple-choice
questions are provided as well as suggested critical thinking activities. This supple-
mental material will aid the instructor in integrating laboratory and diagnostic mate-
rials in assessment and clinical courses and provide examples of activities to enhance
student learning.
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

CONTENTS
DEDICATION .............................................. v
ABOUT THIS BOOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
MONOGRAPHS ............................................ 1
SYSTEM TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1037
APPENDIX A
Patient Preparation Before Diagnostic and Laboratory Procedures 1053

APPENDIX B
Organ/Disease Panels (with CPT Codes) 1065

APPENDIX C
Potential Nursing Diagnoses Associated with Laboratory

and Diagnostic Testing 1067
APPENDIX D
Guidelines for Age-Specific Communication 1069

APPENDIX E
Effects of Natural Products on Laboratory Values 1073

APPENDIX F
Standard Precautions (CDC Isolation Precautions) 1076
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1097
INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1103
xiii

ACETYLCHOLINE RECEPTOR
ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: AChR.
SPECIMEN: Serum (1 mL) collected in a red-top tube.
REFERENCE VALUE: (Method: Radioimmunoassay) Less than 0.03 nmol/L.
DESCRIPTION: When present, acetyl- • Thymoma associated with MG

choline receptor antibody (AChR)
blocks acetylcholine from binding Decreased in: N/A
to receptor sites on the muscle
membrane. AChR destroys acetyl- CRITICAL VALUES: N/A
choline receptor sites, interfering with
neuromuscular transmission and INTERFERING FACTORS:
causing muscle weakness. Antibodies • Drugs that may produce false-positive
to acetylcholine receptor sites are results include muscle relaxants, such
present in 90 percent of patients with as metocurine and succinylcholine.
myasthenia gravis (MG) and in 75 to • Drugs that may increase AChR levels
80 percent of patients who either have include penicillamine.
ocular forms of MG or are in remis-
• Immunosuppressive therapy is the
sion. ■
recommended treatment for MG;
prior immunosuppressive drug admin-
INDICATIONS: istration may result in negative test
• Confirm the presence, but not the results.
severity, of MG
• Recent radioactive scans or radiation
• Differentiate between generalized and within 1 week of the test can interfere
ocular forms of MG, because patients with test results when radioimmunoas-
with the ocular form have lower titers say is the test method.
• Monitor the effectiveness of immuno-
suppressive therapy for MG
• Monitor the remission stage of MG
Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
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
2 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications
procedures. For related tests, refer Intratest:

to the musculoskeletal system
table. ➤ Direct the patient to breathe
normally and to avoid unnecessary
➤ Obtain a list of the medications movement.
the patient is taking, especially
immunosuppressive drugs. Include ➤ Observe standard precautions and
herbs, nutritional supplements, follow the general guidelines in
and nutraceuticals. The requesting Appendix A. Perform a venipuncture;
health care practitioner and labora- collect the specimen in a 5-mL red-
tory should be advised if the patient top tube.
regularly uses these products so ➤ Label the specimen, and promptly
that their effects can be taken into transport it to the laboratory.
consideration when reviewing
results. Post-test:
➤ Note any recent procedures that can ➤ Observe venipuncture site for bleed-
interfere with test results. ing or hematoma formation. Apply
➤ There are no food, fluid, or medica- pressure bandage.
tion restrictions unless by medical ➤ Evaluate test results in relation to
direction. the patient’s symptoms and other
tests performed. Related laboratory
➤ Review the procedure with the
tests include antinuclear antibodies,
patient.
antithyroglobulin and antithyroid
➤ Inform the patient that specimen peroxidase antibodies, myoglobin,
collection takes approximately 5 to rheumatoid factor, thyroid-stimulat-
10 minutes. ing hormone, and thyroxine.
ACID PHOSPHATASE, PROSTATIC

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

monoester phosphohydrolase, PAP.
SPECIMEN: Plasma (1 mL) collected in lavender-top (ethylenediaminetetra-

acetic acid [EDTA]) tube. Serum (1 mL) collected in a red-top tube is also
acceptable, but care must be taken to use the same type of collection
container for serial measurements.
Swab with vaginal secretions may be submitted in the appropriate transfer

container. Other material such as clothing may be submitted for analysis.
Consult the laboratory or emergency services department for the proper
specimen collection instructions and containers.
REFERENCE VALUE: (Method: Enzyme immunoassay)

Acid Phosphatase, Prostatic 3
Conventional Units SI Units (Conversion Factor: 1.0)

Less than 2.5 ng/mL Less than 2.5 g/L
DESCRIPTION: Acid phosphatases are • Acute myelogenous leukemia

enzymes found in many tissues,
• Benign prostatic hypertrophy
including the prostate gland, bone,
spleen, liver, and kidney, as well as in • Gaucher’s disease
red blood cells and platelets. Seminal
• Liver disease
fluid also contains high concentra-
tions of acid phosphatase, and detec- • Metastatic bone cancer
tion of this enzyme in vaginal swabs
or from other physical evidence is • Niemann-Pick disease
used to investigate rape. Acid phos- • Paget’s disease
phatase activity is highest in the
prostate gland; however, prostatic acid • After prostate surgery, biopsy, or
phosphatase (PAP) levels are not manipulation
significantly increased in the early • Prostatic cancer
stages of prostatic cancer, so this test is
not recommended as a screening tool. • Prostatic infarct
Prostate-specific antigen has replaced • Prostatitis
PAP for the staging of carcinoma of
the prostate and diagnosis of metasta- • Sickle cell crisis
tic adenocarcinoma of the prostate. ■ • Thrombocytosis
INDICATIONS: Decreased in: N/A
• Assist in the investigation of sexual
assault and rape.
• Assist with differential diagnosis of CRITICAL VALUES: N/A
other disorders associated with elevated
PAP, red blood cell phosphatase, or INTERFERING FACTORS:
platelet acid phosphatase, such as • Drugs that may increase PAP
leukemia. levels include alglucerase, androgens
• Evaluate the effectiveness of treatment (females), buserelin, and clofibrate.
for prostatic cancer (recurrence after • Drugs that may decrease PAP levels
prostatectomy). Levels decrease with include alcohol, fluorides, ketocona-
effective treatment. Rising levels are zole, oxalates, and phosphates.
associated with a poor prognosis.
• Prostatic massage, rectal examination,
• Investigate or evaluate an enlarged or urinary catheterization within 48
prostate gland, especially if prostatic hours of the test can cause elevated
carcinoma is suspected. PAP levels.
RESULT • Specimens should be drawn in the
morning because PAP exhibits diurnal
Increased in: variation.
➤ 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: lavender-top tube.
➤ Obtain a history of the patient’s ➤ Label the specimen, and promptly
complaints, especially alterations in transport it to the laboratory,
urinary elimination. Obtain a list of because results can be altered
known allergens. within 1 hour.
➤ Obtain a history of the patient’s
genitourinary, immune, and repro- Post-test:
ductive system and results of previ- ➤ Observe venipuncture site for bleed-
ously performed tests and ing or hematoma formation. Apply
procedures. For related tests, refer pressure bandage.
to the genitourinary, immune, and
reproductive system tables. ➤ Recognize anxiety related to test
results and offer support. Provide
➤ Obtain a list of the medications teaching and disease information,
the patient is taking, including as appropriate. Counsel the male
herbs, nutritional supplements, and patient, as appropriate, that sexual
nutraceuticals. The requesting health dysfunction related to altered
care practitioner and laboratory body function, drugs, or radiation
should be advised if the patient regu- may occur. Educate the patient
larly uses these products so that regarding counseling services, as
their effects can be taken into consid- appropriate.
eration when reviewing results.
➤ Offer support, as appropriate, to
➤ Note any recent procedures that can patients who may be the victim of
interfere with test results. rape or sexual assault. Educate the
➤ There are no food, fluid, or medica- patient regarding access to counsel-
tion restrictions unless by medical ing services. Provide a nonjudgmen-
direction. tal, nonthreatening atmosphere for
➤ Review the procedure with the discussing the risks of sexually
patient. transmitted diseases. Discuss prob-
lems the patient may experience
➤ Inform the patient that blood speci- (e.g., guilt, depression, anger) if test
men collection takes approximately results indicate the presence of
5 to 10 minutes. semen.
Intratest: ➤ Evaluate test results in relation to the
patient’s symptoms and other tests
➤ Direct the patient to breathe performed. Related laboratory tests
normally and to avoid unnecessary include prostate biopsy, prostate-
movement. specific antigen, and semen analysis.
ADRENAL GLAND SCAN

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

Adrenal Gland Scan 5
AREA OF APPLICATION: Adrenal gland.

CONTRAST: Radioactive NP-59 (iodomethyl-19-norcholesterol) or
metaiodobenzylguanidine (MIBG).
DESCRIPTION: This nuclear medicine • Differentiate between asymmetric

study evaluates function of the adre- hyperplasia and asymmetry from
nal glands. The secretory function of aldosteronism with dexamethasone
the adrenal glands is controlled suppression test
primarily by the anterior pituitary, • Determine adrenal suppressibility with
which produces adrenocorticotropic prescan administration of cortico-
hormone (ACTH). ACTH stimulates steroid to diagnose and localize adrenal
the adrenal cortex to produce corti- adenoma, aldosteronomas, androgen
sone and secrete aldosterone. Adrenal excess, and low-renin hypertension
imaging is most useful in differentia- • Aid in the diagnosis of gland tissue
tion of hyperplasia versus adenoma destruction caused by infection, infarc-
in primary aldosteronism when tion, neoplasm, or suppression
computed tomography (CT) and • Aid in locating adrenergic tumors
magnetic resonance imaging (MRI)
findings are equivocal. High concen- RESULT
trations of cholesterol (the precursor
in the synthesis of adrenocortico- Normal Findings:
steroids, including aldosterone) are • Normal bilateral uptake of radionu-
stored in the adrenal cortex. This clide and secretory function of adrenal
allows the radionuclide, which at- cortex
taches to the cholesterol, to be used in • No evidence of tumors, infection,
identifying pathology in the secretory infarction, or suppression
function of the adrenal cortex. The • Normal salivary glands and urinary
uptake of the radionuclide occurs bladder, and vague shape of the liver
gradually over time; imaging is and spleen sometimes seen
performed within 24 to 48 hours of
injection of the radionuclide dose and Abnormal Findings:
continued daily for 3 to 5 days. • Adrenal gland suppression
Imaging reveals increased uptake, • Adrenal infarction
unilateral or bilateral uptake, or
absence of uptake in the detection of • Adrenal tumor
pathologic processes. Suppression • Hyperplasia
studies can be done to differentiate • Infection
the presence of tumor from hyperpla-
sia of the glands followed by prescan- • Pheochromocytoma
ning treatment with corticosteroids. ■
INTERFERING FACTORS
INDICATIONS: This procedure is contraindicated
• Aid in the diagnosis of Cushing’s for:
syndrome and aldosteronism • Patients who are pregnant or suspected
of being pregnant, unless the potential ➤ Obtain a history of the patient’s

benefits of the procedure far outweigh adrenal system and results of previ-
the risks to the fetus and mother. ously performed laboratory tests,
surgical procedures, medical therapy
Factors that may impair clear for adrenal pathology, and other
imaging: diagnostic procedures. For related
tests, refer to the endocrine system
• Inability of the patient to cooperate or table.
remain still during the procedure ➤ Obtain a list of the medications the
because of age, significant pain, or patient is taking.
mental status ➤ All adrenal blood tests should be
• Retained barium from a previous radi- done before doing this test.
ologic procedure ➤ Determine date of last menstrual
period and possibility of pregnancy
• Obesity, because patients may exceed in perimenopausal women.
the weight limit for the equipment ➤ Ask the patient to lie still during the
• Incorrect positioning of the patient, procedure because movement
which may produce poor visualization produces unreliable results.
of the area to be examined ➤ Administer saturated solution of
potassium iodide (SSKI) 24 hours
Other considerations: before the study to prevent thyroid
uptake of the free radioactive iodine.
• Consultation with a physician before
➤ An informed consent needs to be
the procedure regarding radiation obtained and witnessed.
safety concerns for infants of patients
who are lactating.
Intratest:
• Risks associated with radiographic
overexposure that can result from fre- ➤ Ask patient to remove jewelry and
any other metallic objects from the
quent radiologic procedures. Personnel area to be scanned.
in the room with the patient should
stand away from the patient or leave ➤ Have the patient put on a hospital
gown and void before scanning.
the area while the examination is being
done. Badges that reveal the level of ex- ➤ Insert an intravenous line and inject
posure to radiation should be worn by the radionuclide intravenously on
day 1; images are done on days 1, 2,
personnel working in the areas where and 3. Imaging is done from the uri-
the examination is being done. nary bladder to the base of the skull
to scan for a primary tumor. Each
image takes 20 minutes, and total
Nursing Implications and imaging time is 1 to 2 hours per day.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Ask the patient to hold still during
the procedure because movement
Pretest: produces unreliable results.
➤ The images are recorded on film or
➤ Inform the patient that the proce- stored electronically for recall and
dure detects adrenal gland function. postprocedure interpretation by a
➤ Inform the patient that a special physician.
nuclear medicine department tech-
nologist performs the test. The test
usually involves a prolonged scan- Post-test:
ning schedule over a period of days. ➤ Unless contraindicated, advise the
➤ Obtain a history of the patient’s patient to drink increased amounts
complaints, including a list of known of fluids for 48 to 72 hours to elimi-
allergens. nate the radionuclide from the body.
Adrenocorticotropic Hormone (and Challenge Tests) 7
➤ 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)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Corticotropin, ACTH.

SPECIMEN: Plasma (2 mL) from lavender-top (ethylenediaminetetra-acetic
acid [EDTA]) tube for adrenocorticotropic hormone (ACTH), and serum
(1 mL) from a red-top tube for cortisol. Collect specimens in a prechilled
heparinized plastic syringe, and carefully transfer into collection containers
by gentle injection to avoid hemolysis. Alternatively, specimens can be
collected in prechilled lavender- and red-top tubes. Tiger- and green-top
(heparin) tubes are also acceptable for cortisol, but take care to use the same
type of collection container for serial measurements. Immediately transport
specimen tightly capped and in an ice slurry to the laboratory. The speci-
mens should be immediately processed. Plasma for ACTH analysis should
be transferred to a plastic container.
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)
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
REFERENCE VALUE: (Method: Immunoradiometric assay)

ACTH
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
ACTH Challenge Tests
ACTH (Cosyntropin) SI Units

Stimulated, (Conversion
Rapid Test Conventional Units Factor 27.6)
Baseline Cortisol greater than Greater than 138
5 µg/dL nmol/L
Peak response Cortisol greater than Greater than 552
20 µg/dL nmol/L
Corticotropin- 2–4-fold increase 2–4-fold increase

Releasing Hormone over baseline over baseline
Stimulated ACTH or cortisol values
level
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
Metyrapone ACTH greater than Greater than 33
Stimulated, 150 pg/mL pmol/L
Overnight Test
SI Units
(Conversion
Cortisol less than Less than 83 nmol/L
3 µg/dL next
day
DESCRIPTION: The anterior pituitary occurring during the morning hours

gland secretes ACTH. This hormone and peak levels occurring in the
stimulates adrenal cortex secretion of evening. ■
glucocorticoids, androgens, and to a
lesser degree, mineralocorticoids. INDICATIONS:
Hypothalamic-releasing factor stimu- • Determine adequacy of replacement
lates ACTH release. Cortisol and therapy in congenital adrenal hyperpla-
ACTH test results are evaluated sia
together because any change in one • Determine adrenocortical dysfunction
causes a change in the other. ACTH
levels exhibit a diurnal variation, • Differentiate between increased ACTH
release with decreased cortisol levels
peaking between 6 and 8 a.m. and
and decreased ACTH release with
reaching the lowest point between 6 increased cortisol levels
and 11 p.m. Evening levels are gener-
ally one half to two thirds lower than RESULT: ACTH secretion exhibits diur-
morning levels. Cortisol levels also nal variation with values being highest in
vary diurnally, with the lowest values the morning. A lack of change in values
from morning to evening is clinically stimulation by ACTH occurs after an

significant. In hypopituitarism, concen- oral dose of metyrapone. Specimen col-
trations of hormones secreted by the lection and administration of the medica-
pituitary gland and hormones secreted by tion are performed as with the overnight
its target organs decrease. dexamethasone test.
The cosyntropin test is used when ad-
renal insufficiency is suspected. Cosyn- Increased in:
tropin is a synthetic form of ACTH. A • Addison’s disease (primary adrenocor-
baseline cortisol level is collected before tical hypofunction)
the injection of cosyntropin. Specimens
• Congenital adrenal hyperplasia
are subsequently collected at 30- and 60-
minute intervals. If the adrenal glands • Cushing’s disease (pituitary dependent)
function normally, cortisol levels rise sig-
• Ectopic ACTH-producing tumors
nificantly after administration of cosyn-
tropin. • Menstruation
The CRH stimulation test works as
• Nelson’s syndrome
well as the dexamethasone suppression
test (DST) in distinguishing Cushing’s • Pregnancy
disease from conditions in which ACTH
• Stress
is secreted ectopically (e.g., tumors not
located in the pituitary gland that secrete
Decreased in:
ACTH). In the cosyntropin test, cortisol
levels are measured after intravenous • Adenoma
administration of CRH. A fourfold • Adrenal carcinoma
increase in cortisol levels above baseline is
seen in Cushing’s disease. No increase in • Hypopituitarism
cortisol is seen if ectopic ACTH secretion • Secondary adrenocortical insufficiency
is the cause.
The DST is useful in differentiating the CRITICAL VALUES: N/A
causes of increased cortisol levels. Dexa-
methasone is a synthetic steroid that INTERFERING FACTORS:
suppresses secretion of ACTH. With the
• Drugs that may increase ACTH
DST, a baseline morning cortisol level is
levels include aminoglutethimide,
collected, and the patient is given a 1-mg
amphetamines, insulin, levodopa,
dose of dexamethasone at bedtime. A
metoclopramide, metyrapone, pyro-
second specimen is collected the following
gens, mifepristone (RU 486), and
morning. If cortisol levels have not been
vasopressin.
suppressed, adrenal adenoma is suspected.
The DST also produces abnormal results • Drugs that may decrease ACTH levels
in the presence of certain psychiatric include adrenal corticosteroids and
illnesses (e.g., endogenous depression). dexamethasone.
The metyrapone stimulation test
• Test results are affected by the time
is used to distinguish corticotropin-
the test is done because ACTH levels
dependent causes (pituitary Cushing’s
vary diurnally, with the highest values
disease and ectopic Cushing’s disease)
occurring between 6 and 8 a.m. and
from corticotropin-independent causes
the lowest values occurring at night.
(e.g., carcinoma of the lung or thyroid) of
Samples should be collected at the
increased cortisol levels. Metyrapone in-
same time of day, between 6 and 8 a.m.
hibits the conversion of 11-deoxycortisol
to cortisol. Cortisol levels should decrease • Excessive physical activity can produce
to less than 3 µg/dL if normal pituitary elevated levels.
• Recent radioactive scans or radiation men collection takes approximately

within 1 week before the test can inter- 5 to 10 minutes.
fere with test results when immunora- ➤ Prepare an ice slurry in a cup or plas-
diometric assay is the test method. tic bag to have on hand for immedi-
ate transport of the specimen to the
• The metyrapone stimulation test is laboratory.
contraindicated in patients with
suspected adrenal insufficiency. Intratest:
• Metyrapone may cause gastroin- ➤ Ensure that strenuous exercise was
testinal distress and/or confusion. avoided for 12 hours before the test
and that 1 hour of bed rest was
taken immediately before the test.
Specimens should be collected
Nursing Implications and between 6 and 8 a.m.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Direct the patient to breathe
Pretest: movement.
➤ 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. Perform a venipuncture,
and collect the specimen in a
➤ Obtain a history of the patient’s prechilled plastic heparinized syringe
endocrine system and results of or in prechilled collection containers
previously performed tests and listed under “Specimen.”
procedures. For related tests, refer
to the endocrine system table. ➤ Label, note the time of collection,
and promptly transport the speci-
➤ Obtain a list of the medications the men to the laboratory. The tightly
patient is taking, including herbs, nu- capped sample should be placed
tritional supplements, and nutraceu- in an ice slurry immediately after
ticals. The requesting health care collection. Information on the speci-
practitioner and laboratory should be men label can be protected from
advised if the patient regularly uses water in the ice slurry if the speci-
these products so that their effects men is first placed in a protective
can be taken into consideration plastic bag.
when reviewing results.
➤ When ACTH hypersecretion is
➤ Note any recent procedures that can suspected, a second sample may
interfere with test results. be requested between 6 and 8 p.m.
➤ No food, fluid, or medication restric- to determine if changes are the
tions exist unless by medical direc- result of diurnal variation in ACTH
tion. levels.
patient. Inform the patient that more Post-test:
than one sample may be necessary ➤ Observe venipuncture site for bleed-
to ensure accurate results and that ing or hematoma formation. Apply
the samples are obtained at specific pressure bandage.
times to determine high and low
levels of the hormone. ➤ Evaluate test results in relation
to the patient’s symptoms and other
➤ Tell the patient to refrain from stren- tests performed. Related labora-
uous exercise for 12 hours before tory tests include cortisol, follicle-
the test and to remain in bed or at stimulating hormone, growth hor-
rest for 1 hour immediately before mone, luteinizing hormone, testos-
the test. terone, thyroid-stimulating hormone,
➤ Inform the patient that each speci- and thyroxine.
ALANINE AMINOTRANSFERASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Serum glutamic pyruvate transaminase

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

(1 mL) collected in a green-top (heparin) tube is also acceptable.
REFERENCE VALUE: (Method: Spectrophotometry)
SI Units
(Conversion
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
DESCRIPTION: Alanine aminotrans- INDICATIONS:

ferase (ALT), formerly known as • Compare serially with aspartate amino-
serum glutamic pyruvic transaminase transferase (AST) levels to track the
(SGPT), is an enzyme produced by course of liver disease.
the liver. It acts as a catalyst in the • Monitor liver damage resulting from
reversible transfer of an amino group hepatotoxic drugs.
between alanine and -ketoglutarate. • Monitor response to treatment of liver
The highest concentration of ALT disease, with tissue repair indicated by
is found in liver cells, moderate gradually declining levels.
amounts are found in kidney cells,
• In blood banks, use as a routine screen
and smaller amounts are found in
for hepatitis in donor blood samples.
heart and skeletal muscle. When liver Samples are rejected if levels are greater
damage occurs, serum levels of ALT than 1.5 times the upper limits of
rise to 50 times normal, making this a normal.
useful test in evaluating liver injury.
ALT is also used to screen donated RESULT
blood before transfusion because the
enzyme may be elevated in the Increased in:
absence of detectable serologic mark- • Acute pancreatitis
ers of hepatitis. ■ • Biliary tract obstruction
Alanine Aminotransferase 13
• Burns (severe) levodopa, lincomycin, low-molecular-

weight heparin, methyldopa, mono-
• Chronic alcohol abuse
amine oxidase inhibitors, naproxen,
• Cirrhosis nifedipine, nitrofurans, oral contracep-
tives, probenecid, procainamide, qui-
• Fatty liver
nine, ranitidine, retinol, ritodrine, sul-
• Hepatic carcinoma fonylureas, tetracyclines, tobramycin,
and verapamil.
• Hepatitis
• Drugs that may decrease ALT levels
• Infectious mononucleosis
include cyclosporine and interferon.
• Muscle injury from intramuscular
injections, trauma, infection, and
seizures (recent) Nursing Implications and
• Muscular dystrophy Procedure ● ● ● ● ● ● ● ● ● ● ●
• Myocardial infarction
Pretest:
• Myositis
• Preeclampsia complaints, including a list of known
allergens.
• Shock (severe)
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,
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.
➤ Label the specimen, and promptly aged to eat simple carbohydrates

transport it to the laboratory. and emulsified fats (as in homoge-
nized milk or eggs), as opposed
Post-test: to complex carbohyderates (e.g.,
starch, fiber, and glycogen [animal
➤ Observe venipuncture site for bleed- carbohydrates]) and complex fats,
ing or hematoma formation. Apply which would require additional bile
pressure bandage. to emulsify it so that it can be used.
➤ Increased ALT levels may be associ- The cirrhotic patient should be care-
ated with liver disease. Dietary fully observed for the development
recommendations may be indicated of ascites, in which case fluid and
and vary depending on the severity electrolyte balance requires strict
of the condition. A low-protein diet attention.
may be in order if the patient’s liver
has lost the ability to process the ➤ Evaluate test results in relation
end products of protein metabolism. to the patient’s symptoms and
A diet of soft foods may be re- other tests performed. Related labo-
quired if esophageal varices have ratory tests include acetaminophen,
developed. Ammonia levels may be ammonia, AST, bilirubin, electrolytes,
used to determine whether protein γ-glutamyl transpeptidase, hepatitis
should be added to or reduced from antigens and antibodies, lactate
the diet. Patients should be encour- dehydrogenase, and liver biopsy.
ALBUMIN AND ALBUMIN/

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

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Plasma (1
mL) collected in green-top (heparin) tube is also acceptable.
REFERENCE VALUE: (Method: Spectrophotometry) Normally the

albumin/globulin (A/G) ratio is greater than 1.
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
Albumin and Albumin/Globulin Ratio 15
• Any condition that results in a decrease

DESCRIPTION: Most of the body’s of plasma water (e.g., dehydration)
total protein is a combination of
albumin and globulins. Albumin, the • Hyperinfusion of albumin
protein present in the highest
concentrations, is the main transport Decreased in:
protein in the body. Albumin also • Insufficient intake:
maintains plasma oncotic pressure. Malabsorption
Serum albumin values are affected by Malnutrition
the process of synthesis, distribution, • Decreased synthesis by the liver:
and degradation. Low levels may be Acute and chronic liver disease
the result of either inadequate pro- (e.g., alcoholism, cirrhosis,
duction or excessive loss. Albumin hepatitis)
levels are more useful as an indicator • Inflammation and chronic diseases:
of chronic deficiency than of short- Amyloidosis
term deficiency. Bacterial infections
Albumin levels are affected by Monoclonal gammopathies (e.g.,
posture. Results from specimens multiple myeloma,
collected in an upright posture are Waldenström’s
higher than results from specimens macroglobulinemia)
collected in a supine position. Neoplasm
The A/G ratio is useful in the eval- Parasitic infestations
uation of liver and kidney disease. Peptic ulcer
The ratio is calculated using the Prolonged immobilization
following formula: Rheumatic diseases
albumin/(total protein – albumin), Severe skin disease
where globulin is the difference
• Increased loss over body surface:
between the total protein value and
Rapid hydration or overhydration
the albumin value. For example, with
Burns
a total protein of 7 g/dL and albumin
of 4 g/dL, the A/G ratio is calculated Enteropathies related to sensitivity
to ingested substances (e.g.,
as 4/(7 – 4) or 4/3 = 1.33. A reversal gluten sensitivity, Crohn’s
in the ratio where globulin exceeds disease, ulcerative colitis)
albumin (i.e., ratio less than 1.0) is Fistula (gastrointestinal or
clinically significant.■ lymphatic)
Hemorrhage
INDICATIONS: Kidney disease
• Assess nutritional status of hospitalized Renal protein loss
patients, especially geriatric patients Repeated thoracentesis or
paracentesis
• Evaluate chronic illness
Trauma and crush injuries
• Evaluate liver disease
• Increased catabolism:
Fever
RESULT Cushing’s disease
Preeclampsia
Increased in: Thyroid dysfunction
• Increased blood volume (hyper- can be taken into consideration

volemia): when reviewing results.
Congestive heart failure ➤ There are no food, fluid, or medica-
Pregnancy tion restrictions unless by medical
direction.
Monoclonal gammopathies
(Waldenström’s disease, ➤ Review the procedure with the
patient.
myeloma)
CRITICAL VALUES: N/A collection takes approximately 5 to
10 minutes.
INTERFERING FACTORS: Intratest:
• Drugs that may increase albumin levels
include enalapril. ➤ Direct the patient to breathe
• Drugs that may decrease albumin movement.
levels include acetaminophen (poison- ➤ Observe standard precautions and
ing), dapsone, dextran, estrogens, follow the general guidelines in
ibuprofen, nitrofurantoin, oral contra- Appendix A.
ceptives, phenytoin, prednisone (high ➤ Perform a venipuncture, and collect
doses), trazodone, and valproic acid. the specimen in a 5-mL red- or tiger-
• Availability of administered drugs is top tube.
affected by variations in albumin levels. ➤ Label the specimen, and promptly
transport it to the laboratory.
Post-test:
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.
Aldolase 17
ALDOLASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: ALD.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube.
SI Units
(Conversion
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
DESCRIPTION: Aldolase (ALD), an RESULT

enzyme found throughout the body,
catalyzes the breakdown of glucose to Increased in:
lactate. Highest concentrations of this • Carcinoma (lung, breast, and geni-
enzyme are found in skeletal and tourinary tract, and metastasis to liver)
cardiac muscle, liver, and pancreas. • Central nervous system tumors
When trauma or disease causes
• Delirium tremens
cellular breakdown of these muscles
or organs, large amounts of ALD • Dermatomyositis
are released into the blood. Measur- • Duchenne’s muscular dystrophy
ing serum levels helps to determine
the presence, and in some cases • Gangrene
the progress, of disease. This test is • Hemolytic anemias
not commonly requested because • Hepatitis (acute viral or toxic)
the assay of other liver enzymes
and creatine kinase is generally suffi- • Infectious mononucleosis
cient to provide the necessary infor- • Leukemia (granulocytic and mega-
mation. ■ loblastic)
• Limb girdle muscular dystrophy
INDICATIONS:
• Assist in the diagnosis of Duchenne’s • Myocardial infarction
muscular dystrophy
• Pancreatitis (acute)
• Differentiate neuromuscular disorders
• Polymyositis
from neurologic disorders, such as
multiple sclerosis or myasthenia gravis • Psychoses and schizophrenia (acute)
• Severe crush injuries iary and musculoskeletal system

tables.
• Tetanus
➤ Obtain a list of the medications the
• Trichinosis patient is taking, including herbs, nu-
tritional supplements, and nutraceu-
Decreased in: ticals. The requesting health care
practitioner and laboratory should be
• Hereditary fructose intolerance advised if the patient regularly uses
these products so that their effects
CRITICAL VALUES: N/A can be taken into consideration
INTERFERING FACTORS: ➤ There are no food, fluid, or medica-
• Drugs that may increase aldolase levels tion restrictions unless by medical
include aminocaproic acid, carbenox- direction.
olone, clofibrate, chlorinated and ➤ Review the procedure with the
organophosphorus insecticides, la- patient.
betalol, and thiabendazole. ➤ Inform the patient that specimen
• Drugs that may decrease aldolase levels collection takes approximately 5 to
include phenothiazines (in schizo- 10 minutes.
phrenic patients with high initial
values) and probucol. Intratest:
• Intramuscular injections may increase ➤ Direct the patient to breathe
aldolase levels as a result of muscle normally and to avoid unnecessary
trauma. movement.
• Red blood cells contain aldolase;
follow the general guidelines in
hemolysis may cause a false elevation in Appendix A. Perform a venipuncture,
values. and collect the specimen in a 5-mL
red- or tiger-top tube.
➤ Label the specimen, and promptly
Nursing Implications and transport it to the laboratory.
Procedure ● ● ● ● ● ● ● ● ● ● ●
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.
➤ 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.
Aldosterone 19
ALDOSTERONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A.
mL) collected in green-top (heparin) or lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube is also acceptable.
REFERENCE VALUE: (Method: Radioimmunoassay)
SI Units
(Conversion
Cord blood 40–200 ng/dL 1.11–5.54 nmol/L
3 d–1 wk 7–184 ng/dL 0.19–5.10 nmol/L
1 mo–1 y 5–90 ng/dL 0.14–2.49 nmol/L
13–23 mo 7–54 ng/dL 0.19–1.50 nmol/L
2–10 y
Supine 3–35 ng/dL 0.08–0.97 nmol/L
Upright 5–80 ng/dL 0.14–2.22 nmol/L
11–15 y
Adult
These values reflect a normal-sodium diet. Values for a low-sodium diet are three to
five times higher.
DESCRIPTION: Aldosterone is a medications, and activity. This test is

mineralocorticoid secreted by the of little diagnostic value unless plasma
zona glomerulosa of the adrenal renin activity is measured simultane-
cortex in response to decreased serum ously (see chapter titled “Renin”).
sodium, decreased blood volume, Patients with serum potassium less
and increased serum potassium. than 3.6 mEq/L and 24-hour urine
Aldosterone increases sodium reab- potassium greater than 40mEq/L fit
sorption in the renal tubules, resulting the general criteria to test for aldos-
in potassium excretion and increased teronism. Renin is low in primary
water retention, blood volume, and aldosteronism and high in secondary
blood pressure. A variety of factors aldosteronism. A ratio of plasma
influence serum aldosterone levels, aldosterone to plasma renin activity
including sodium intake, certain greater than 50 is significant. ■
INDICATIONS: • Isolated aldosterone deficiency

• Evaluate hypertension of unknown
cause, especially with hypokalemia not With hypertension:
induced by diuretics • Acute alcohol intoxication
• Investigate suspected hyperaldoste- • Diabetes
ronism, as indicated by elevated levels
• Excess secretion of deoxycorticosterone
• Investigate suspected hypoaldoste-
• Turner’s syndrome (25 percent of
ronism, as indicated by decreased levels
cases)
RESULT CRITICAL VALUES: N/A
Increased with Decreased
Renin Levels INTERFERING FACTORS:
• Drugs that may increase aldosterone
Primary hyperaldosteronism: levels include amiloride, ammonium
• Adenomas (Conn’s syndrome) chloride, angiotensin, angiotensin II,
dobutamine, dopamine, endralazine,
• Bilateral hyperplasia of the fenoldopam, hydralazine, hydrochlo-
aldosterone-secreting zona glomer- rothiazide, laxatives (abuse), metoclo-
ulosa cells pramide, nifedipine, opiates, potas-
sium, spironolactone, and zacopride.
Increased with Increased
Renin Levels • Drugs that may decrease aldosterone
levels include atenolol, captopril,
Secondary hyperaldosteronism: carvedilol, cilazapril, enalapril, fadro-
• Bartter’s syndrome zole, glycyrrhiza, ibopamine, indo-
methacin, lisinopril, nicardipine,
• Cardiac failure nonsteroidal anti-inflammatory drugs,
• Chronic obstructive pulmonary disease perindopril, ranitidine, saline, sinor-
phan, and verapamil. Prolonged
• Cirrhosis with ascites formation heparin therapy also decreases aldo-
• Diuretic abuse sterone levels.
• Hypovolemia secondary to hemor- • Upright body posture, stress, strenuous
rhage and transudation exercise, and late pregnancy can lead to
increased levels.
• Laxative abuse
• Nephrotic syndrome within 1 week before the test can inter-
• Starvation (after 10 days) fere with test results when radioim-
munoassay is the test method.
• Thermal stress
• Diet can significantly affect results. A
• Toxemia of pregnancy low-sodium diet can increase serum
Decreased aldosterone, whereas a high-sodium
diet can decrease levels. Decreased
Without hypertension:
serum sodium and elevated serum
potassium increase aldosterone secre-
• Addison’s disease tion. Elevated serum sodium and
• Hypoaldosteronism secondary to renin decreased serum potassium suppress
deficiency aldosterone secretion.
Aldosterone 21
Intratest:
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
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
supine) and exact source of speci-
patient is taking, including herbs, nu-
men (peripheral versus arterial).
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
caution should be used if a low- medicine labels. In 1989, the

sodium diet is prescribed. Subcommittee on the 10th Edition of
➤ Because aldosterone levels have an the RDAs established 500 mg as the
effect on sodium levels, some recommended minimum limit for
consideration may be given to dietary intake of sodium. There are
dietary adjustment if sodium no RDAs established for potassium,
allowances need to be regulated. but the estimated minimum intake
Educate patients with low sodium for adults is 200 mEq/d. Potassium
levels that the major source of is present in all plant and animal
dietary sodium is table salt. Many cells, making dietary replacement
foods, such as milk and other dairy simple. A health care practitioner or
products, are also good sources of nutritionist should be consulted
dietary sodium. Most other dietary before considering the use of salt
sodium is available through substitutes.
consumption of processed foods. ➤ Evaluate test results in relation to
Patients who need to follow low- the patient’s symptoms and other
sodium diets should avoid bever- tests performed. Related laboratory
ages such as colas, ginger ale, tests include catecholamines, urine
Gatorade, lemon-lime sodas, and catecholamines, cortisol, creatinine,
root beer. Many over-the-counter urine creatinine, glucose, kidney
medications, including antacids, biopsy, magnesium, urine magne-
laxatives, analgesics, sedatives, and sium, osmolality, urine osmolality,
antitussives, contain significant potassium, urine potassium, urine
amounts of sodium. The best advice protein, renin, sodium, urine
is to emphasize the importance sodium, urea nitrogen, and urinal-
of reading all food, beverage, and ysis.
ALKALINE PHOSPHATASE AND

ISOENZYMES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Alk Phos, ALP and fractionation, heat-stabile ALP.

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

phatase, inhibition/electrophoresis for fractionation)
Alkaline Phosphatase and Isoenzymes 23
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
8–76 U/L
8–53 U/L
8y
8–62 U/L
8–62 U/L
9–12 y
8–81 U/L
8–62 U/L
13 y
8–48 U/L
8–50 U/L
14 y
8–48 U/L
8–48 U/L
15 y
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
8–39 U/L
8–50 U/L
17 y
8–39 U/L
8–53 U/L

SI Units
Total Conventional (Conversion Bone Liver
ALP Units Factor 0.017) Fraction Fraction
18 y
8–39 U/L
8–53 U/L
19 y
8–39 U/L
8–53 U/L
20 y
8–48 U/L
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
DESCRIPTION: ALP is an enzyme individuals with blood type O and B),

found in the liver, in Kupffer cells and ALP4 of placental origin (third
lining the biliary tract, and in bones, trimester). ALP levels vary by age and
intestines, and placenta. Additional gender. Values in children are higher
sources of ALP include the proximal than in adults because of the level of
tubules of the kidneys, pulmonary bone growth and development. An
alveolar cells, germ cells, vascular bed, immunoassay method is available for
lactating mammary glands, and gran- measuring bone-specific ALP as an
ulocytes of circulating blood. ALP is indicator of increased bone turnover
referred to as alkaline because it func- and estrogen deficiency in post-
tions optimally at a pH of 9.0. This menopausal women. ■
test is most useful for determining the
presence of liver or bone disease. INDICATIONS:
Isoelectric focusing methods can • Evaluate signs and symptoms of vari-
identify 12 isoenzymes of ALP. ous disorders associated with elevated
Certain cancers produce small ALP levels, such as biliary obstruction,
amounts of distinctive Regan and hepatobiliary disease, and bone disease,
Nagao ALP isoenzymes. Four main including malignant processes
ALP isoenzymes, however, are of clin- • Differentiate obstructive hepatobiliary
ical significance: ALP1 of liver origin, tract disorders from hepatocellular
ALP2 of bone origin, ALP3 of intes- disease; greater elevations of ALP are
tinal origin (occasionally present in seen in the former
Alkaline Phosphatase and Isoenzymes 25
• Determine effects of renal disease on Ulcerative colitis

bone metabolism
• Determine bone growth or destruction Decreased in:
in children with abnormal growth • Anemia (severe)
patterns • Cretinism
RESULT • Hypophosphatasia (congenital, rare)
• Hypothyroidism
Increased in:
• Liver disease: • Kwashiorkor
Biliary atresia • Nutritional deficiency of zinc or
Biliary obstruction magnesium
Chronic active hepatitis • Scurvy
Cirrhosis
Diabetes mellitus (diabetic hepatic CRITICAL VALUES: N/A
lipidosis)
Extrahepatic duct obstruction INTERFERING FACTORS:
Granulomatous or infiltrative liver • Drugs that may increase ALP levels by
diseases causing cholestasis include amitrypty-
Infectious mononucleosis line, anabolic steroids, androgens,
Viral hepatitis benzodiazepines, chlorothiazide, chlor-
propamide, dapsone, erythromycin,
• Bone disease: estrogens, ethionamide, gold salts,
Healing fractures imipramine, mercaptopurine, nitrofu-
Metabolic bone diseases (rickets, rans, oral contraceptives, penicillins,
osteomalacia) phenothiazines, progesterone, pro-
Metastatic tumors in bone poxyphene, sulfonamides, tamoxifen,
Osteogenic sarcoma and tolbutamide.
Osteoporosis • Drugs that may increase ALP levels by
Paget’s disease (osteitis causing hepatocellular damage include
deformans) acetaminophen (toxic), acetylsalicylic
acid, allopurinol, amiodarone, anabolic
• Other conditions:
steroids, anticonvulsants, asparaginase,
Advanced pregnancy azithromycin, bromocriptine, capto-
Amyloidosis pril, cephalosporins, chloramphenicol,
Cancer of the lung or pancreas clindamycin, clofibrate, danazol, enflu-
Chronic renal failure rane, ethambutol, ethionamide, fenofi-
Congestive heart failure brate, fluconazole, fluoroquinolones,
Growing children foscarnet, gentamicin, indomethacin,
interferon, interleukin-2, levamisole,
Hodgkin’s disease
levodopa, lincomycin, low-molecular-
Hyperparathyroidism (primary or weight heparin, methyldopa, mono-
secondary to chronic renal amine oxidase inhibitors, naproxen,
disease)
nifedipine, nitrofurans, oral contracep-
Perforated bowel tives, probenecid, procainamide, qui-
Pulmonary and myocardial nine, ranitidine, retinol, ritodrine, sul-
infarctions fonylureas, tetracyclines, tobramycin,
Sarcoidosis and verapamil.
• 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.
Allergen-Specific Immunoglobulin E 27
ALLERGEN-SPECIFIC
IMMUNOGLOBULIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Allergen profile, radioallergosorbent test (RAST).

SPECIMEN: Serum (2 mL per group of six allergens, 0.5 mL for each addi-
tional individual allergen) collected in a red- or tiger-top tube.
Alternate Scoring
RAST Scoring Method (ASM): Increasing
Method Levels of Allergy Sensitivity
Specific IgE
Antibody Level kIU/L ASM Class ASM % Reference
Absent or
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
D ESCRIPTION : Allergen-specific ing the cause of hay fever, extrinsic

immunoglobulin E (IgE) or RAST is asthma, atopic eczema, respiratory
generally requested for groups of allergies, and potentially fatal reac-
allergens commonly known to incite tions to insect venom, penicillin,
an allergic response in the affected and other drugs or chemicals. RAST
individual. The test is based on the has replaced skin tests and provoca-
use of a radiolabeled anti-IgE reagent tion procedures, which were incon-
to detect IgE in the patient’s serum, venient, painful, and hazardous to
produced in response to specific aller- patients. ■
gens. The panels include allergens
such as animal dander, antibiotics, INDICATIONS:
dust, foods, grasses, insects, trees, • Test for specific allergic sensitivity
mites, molds, venom, and weeds. before initiating immunotherapy or
Allergen testing is useful for evaluat- desensitization shots
• Test for specific allergic sensitivity,

when skin testing is unreliable Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Test for allergens when there is a

known history of severe allergic reac-
tion to skin testing Pretest:
• Evaluate patients who refuse to submit ➤ Obtain a history of the patient’s

to skin testing or who have generalized
allergens.
dermatitis or other dermatopathic
conditions ➤ Obtain a history of the patient’s
immune and respiratory system and
• Test for allergens when skin testing is results of previously performed
inappropriate, such as in infants tests and procedures. For related
tests, refer to the immune and respi-
• Monitor response to desensitization ratory system table.
procedures
➤ Obtain a list of the medications
RESULT: Different scoring systems are herbs, nutritional supplements, and
used in the interpretation of RAST nutraceuticals. The requesting health
results. care practitioner and laboratory
should be advised if the patient
Increased in: regularly uses these products so
• Allergic rhinitis that their effects can be taken into
• Anaphylaxis results.
• Asthma (exogenous) ➤ Note any recent procedures that can
interfere with test results.
• Atopic dermatitis
• Echinococcus infection tion restrictions unless by medical
direction.
• Eczema
• Hay fever patient.
• Hookworm infection ➤ Inform the patient that specimen
collection takes approximately 5 to
• Schistosomiasis 10 minutes.
• Visceral larva migrans
Intratest:
Decreased in:
• Asthma (endogenous) normally and to avoid unnecessary
• Pregnancy movement.
• Radiation therapy follow the general guidelines in
Appendix A. Perform a venipuncture,
CRITICAL VALUES: N/A and collect the specimen in a 5-mL
INTERFERING FACTORS: Recent radioac- ➤ The allergy panel desired should be
tive scans or radiation within 1 week of indicated as part of the laboratory
the test can interfere with test results requisition process. Label the speci-
when radioimmunoassay is the test men, and promptly transport it to the
method. laboratory.
Alveolar/Arterial Gradient and Arterial/Alveolar Oxygen Ratio 29
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 arterial/alveolar oxygen
pressure bandage. ratio, blood gases, complete blood
➤ Consideration should be given to count, eosinophil count, hypersensi-
diet if food allergies are present. tivity pneumonitis, IgE, ova and para-
Lifestyle adjustments may be neces- sites, and theophylline.
sary depending on the specific aller-
gens identified.
ALVEOLAR/ARTERIAL GRADIENT
AND ARTERIAL/ALVEOLAR OXYGEN
RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYMS: Alveolar-arterial difference, A/a gradient, a/A ratio.

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

and pCO2)
Alveolar/arterial gradient Less than 10 mm Hg at rest

(room air)
20–30 mm Hg at maximum
exercise activity (room air)
Arterial/alveolar oxygen ratio Greater than 0.75 (75%)
DESCRIPTION: The ability of oxygen alveoli without perfusion, unventi-

to diffuse from the alveoli into the lated alveoli with perfusion, or
lungs is of use when assessing a collapse of alveoli and associated
patient’s level of oxygenation. This blood vessels. Information regarding
test can help identify the cause of the alveolar/arterial (A/a) gradient can
hypoxemia (low oxygen levels in the be estimated indirectly using the
blood) and intrapulmonary shunting partial pressure of oxygen (pO2)
that might result from one of the (obtained from blood gas analysis) in
following three situations: ventilated a simple mathematical formula:
A/a gradient pO2 in alveolar • Assess intrapulmonary or coronary

air (estimated) pO2 in artery shunting
arterial blood (measured)
An estimate of alveolar pO2 is accom- RESULT
plished by subtracting the water vapor
pressure from the barometric pres- Increased in:
sure, multiplying the resulting pres- • Acute respiratory distress syndrome
sure by the fraction of inspired • Atelectasis
oxygen (FIO2; percentage of oxygen
• Atrial venous shunts
the patient is breathing), and
subtracting this from 11/4 times the • Bronchospasm
arterial partial pressure of carbon • Chronic obstructive pulmonary disease
dioxide (pCO2). The gradient is
• Congenital cardiac septal defects
obtained by subtracting the patient’s
arterial pO2 from the calculated alve- • Underventilated alveoli (mucus plugs)
olar pO2. • Pneumothorax
Alveolar pO2 [(barometric
pressure water vapor pressure) • Pulmonary edema
FIO2] [11/4 pCO2] • Pulmonary embolus
A/a gradient arterial pO2 • Pulmonary fibrosis
(measured) alveolar pO2
(estimated)
CRITICAL VALUES: N/A
The arterial/alveolar (a/A) ratio
reflects the percentage of alveolar pO2 INTERFERING FACTORS:
that is contained in arterial pO2. It is • Specimens should be collected before
calculated by dividing the arterial administration of oxygen therapy.
pO2 by the alveolar pO2:
• The temperature of the patient should
a/A paO2/pAO2.
be noted and reported to the labora-
The A/a gradient increases as the tory if significantly elevated or
concentration of oxygen the patient depressed so that measured values can
inspires increases. If the gradient is be corrected to actual body tempera-
abnormally high, either there is a ture.
problem with the ability of oxygen to
• Exposure of sample to room air affects
pass across the alveolar membrane or test results.
oxygenated blood is being mixed with
nonoxygenated blood. The a/A ratio • Values normally increase with increas-
is not dependent on FIO2; it does not ing age (see monograph titled “Blood
Gases”).
increase with a corresponding increase
in inhaled oxygen. For patients on a • Samples for A/a gradient evaluation are
mechanical ventilator with a changing obtained by arterial puncture,
FIO2, the a/A ratio can be used to which carries a risk of bleeding,
determine if oxygen diffusion is especially in patients with bleeding
disorders or who are taking medica-
improving. ■
tions for a bleeding disorder.
INDICATIONS: • Prompt and proper specimen process-
• Assist in identifying the cause of ing, storage, and analysis are important
hypoxemia to achieve accurate results. Specimens
Alveolar/Arterial Gradient and Arterial/Alveolar Oxygen Ratio 31
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 ● ● ● ● ● ● ● ● ● ● ●
movement.
Pretest:
➤ 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.
ALZHEIMER’S DISEASE MARKERS

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

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

protein and -amyloid 42 measurements in CSF are used in conjunction as
biochemical markers of Alzheimer’s disease (AD). Scientific studies indicate
that a combination of elevated tau protein and decreased -amyloid 42
protein levels are consistent with the presence of AD. Values are highly
dependent on the reagents and standards used in the assay. Ranges vary
among laboratories; the testing laboratory should be consulted for interpre-
tation of results.
DESCRIPTION: AD is the most present in CSF. It is believed to accu-

common cause of dementia in the mulate in the central nervous system
elderly population. AD is a disorder of patients with AD, causing the
of the central nervous system that formation of amyloid plaques on
results in progressive and profound brain tissue. The result is that these
memory loss followed by loss of patients have lower CSF values
cognitive abilities and death. It may compared to age-matched non-AD
follow years of progressive formation control subjects. ■
of amyloid plaques and brain tangles,
or it may appear as an early-onset INDICATIONS:
form of the disease. Two recognized • Assist in establishing a diagnosis of AD
pathological features of AD are
neurofibrillary tangles and amyloid RESULT
plaques found in the brain. Abnormal
Increased in:
forms of the microtubule-associated
tau protein are the main component • Acquired immunodeficiency syndrome
of the classic neurofibrillary tangles
• AD
found in patients with AD. Tau
protein concentration is believed to • Cerebrovascular disease
reflect the number of neurofibrillary • Creutzfeldt-Jakob disease
tangles and may be an indication of
• Meningoencephalitis
the severity of the disease. -Amyloid
42 is a free-floating protein normally • Pick’s disease
Alzheimer’s Disease Markers 33
CRITICAL VALUES: N/A inform the health care practitioner

accordingly.
INTERFERING FACTORS: ➤ Obtain written and informed
• Some patients with AD may have consent before administering any
normal levels of tau protein because of medication before the procedure.
an insufficient number of neurofibril-
lary tangles. Intratest:
movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Appendix A.
Pretest:
➤ To perform a lumbar puncture, posi-
➤ Obtain a history of the patient’s tion the patient in the knee-chest
complaints, including a list of known position at the side of the bed.
allergens. Provide pillows to support the spine
➤ Review results of tests and proce- or for the patient to grasp. The sitting
dures previously performed. position is an alternative. In this posi-
tion, the patient must bend the neck
➤ Obtain a list of the medications the and chest to the knees.
tritional supplements, and nutraceu- ➤ Prepare the site (usually between L3
ticals. The requesting health care and L4 or L4 and L5) with povidone-
practitioner and laboratory should be iodine, and drape the area.
advised if the patient regularly uses ➤ A local anesthetic is injected. Using
these products so that their effects sterile technique, the health care
can be taken into consideration practitioner inserts the spinal needle
when reviewing results. through the spinous processes of
➤ There are no food, fluid, or medica- the vertebrae and into the subarach-
tion restrictions unless by medical noid space. The stylet is removed.
direction. CSF drips from the needle if it is
properly placed.
➤ Inform the patient that the posi-
tion required for the lumbar punc- ➤ Attach the stopcock and manometer,
ture may be awkward but that and measure initial CSF pressure.
someone will assist. Stress the im- Normal pressure for an adult in the
portance of remaining still and lateral recumbent position is 90 to
breathing normally throughout the 180 mm H2O. These values depend
procedure. on the body position and are differ-
ent in a horizontal or sitting position.
➤ Inform the patient that a stinging
sensation may be felt as the local ➤ If the initial pressure is elevated, the
anesthetic is injected. Tell the patient health care practitioner may perform
to report any pain or other sensa- Queckenstedt’s test. To perform this
tions that may require repositioning test, apply pressure to the jugular
of the spinal needle. vein for about 10 seconds. CSF
pressure usually rises in response to
➤ Review the procedure with the the occlusion, then rapidly returns to
patient. normal within 10 seconds after the
➤ Inform the patient that the proce- pressure is released. Sluggish
dure will be performed by a health response may indicate CSF obstruc-
care practitioner and will take tion.
approximately 20 minutes. ➤ Obtain CSF. Take a final pressure
➤ Determine whether the patient has reading and remove the needle.
an allergy to local anesthetics and Clean the puncture site with an anti-
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.
AMINO ACID SCREEN, BLOOD

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

amino acids. The following tables include the most frequently screened. All
units are nanomoles per milliliter (nmol/mL).
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
Amino Acid Screen, Blood 35
γ-Amino- β-Aminoiso- Aspartic

Age butyric Acid butyric Acid Arginine Asparagine Acid
Premature 0 0 34–96 90–295 24–50
Newborn– 0–2 0 6–140 29–132 20–129
1 mo
2 mo–2 y 0 0 12–133 21–95 0–23
2–18 y 0 0 10–140 23–112 1–24
Adult 0 0 15–128 35–74 1–25
Cysta- Ethanol-
Age Carnosine Citrulline thionine Cystine amine
Premature — 20–87 5–10 15–70 —
Newborn– 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
Premature 0 0–80 23–85 151–220 128–255

Newborn– 0–7 0–91 26–91 48–160 92–325
1 mo
2 mo–2 y 0–7 0–63 31–86 47–155 52–196
2–18 y 0–2 3–45 22–107 49–216 48–284
Adult 0 0–53 30–108 72–201 116–296
1-Methyl- 3-Methyl- Phenyl-

Age Methionine histidine histidine Ornithine alanine
Premature 37–91 4–28 5–33 77–212 98–213
Newborn–
1 mo 10–60 0–43 0–5 48–211 38–137
2 mo–2 y 9–42 0–44 0–5 22–103 31–75
2–18 y 7–47 0–42 0–5 10–163 26–91
Adult 10–42 0–39 0–8 48–195 35–85

Phospho- Phospho-
Age ethanolamine serine Proline Sarcosine Serine
Premature 5–35 10–45 92–310 0 127–248
Newborn– 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
DESCRIPTION: Screening for inborn • Diabetes

errors of amino acid metabolism is • Eclampsia
generally performed on infants after
an initial urine test comes back posi- • Fructose intolerance (hereditary)
tive. Certain congenital enzyme defi- • Malabsorption
ciencies interfere with normal amino
• Renal failure (acute or chronic)
acid metabolism and cause excessive
accumulation of or deficiencies in • Reye’s syndrome
amino acid levels. Reduced growth • Severe liver damage
rates, mental retardation, or various
unexplained symptoms can result • Shock
unless the abnormality is identified
and corrected early in life. ■ Decreased (total amino acids) in:
• Adrenocortical hyperfunction
INDICATIONS:
• Assist in the detection of noninherited • Carcinoid syndrome
disorders evidenced by elevated amino • Fever
acid levels
• Glomerulonephritis
• Detect inborn errors of amino acid
metabolism • Hartnup disease
• Huntington’s chorea
RESULT
• Malnutrition
Increased (total amino acids) in:
• Nephrotic syndrome
• Aminoacidopathies (usually inherited;
specific amino acids are implicated) • Pancreatitis (acute)
• Brain damage (severe) • Polycystic kidney disease
• Burns • Rheumatoid arthritis
Amino Acid Screen, Blood 37
CRITICAL VALUES: N/A least 12 hours before specimen

collection.
INTERFERING FACTORS: ➤ Review the procedure with the
• Drugs that may increase plasma amino patient.
acid levels include bismuth salts, ➤ Inform the patient that specimen
glucocorticoids, levarterenol, 11- collection takes approximately 5 to
oxysteroids, and testosterone (elderly). 10 minutes.
• Drugs that may decrease plasma amino Intratest:

acid levels include cerulein, estrogens
(males), epinephrine, glucose, oral ➤ Ensure that the patient has complied
with dietary and other pretesting
contraceptives, progesterone (males), restrictions.
and secretin.
• Amino acids exhibit a strong circadian normally and to avoid unnecessary
rhythm; values are highest in the after- movement.
noon and lowest in the morning. ➤ Observe standard precautions and
Protein intake does not influence diur- follow the general guidelines in
nal variation but significantly affects Appendix A. Perform a venipuncture,
absolute concentrations. A 12-hour and collect the specimen in a 5-mL
fast before specimen collection is red- or tiger-top tube.
required. ➤ Label the specimen, and promptly
Post-test:
Procedure ● ● ● ● ● ● ● ● ● ● ●
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,
and asparagine. A high intake of the patient regarding access to

specific amino acids can cause genetic or other counseling serv-
other amino acids to become essen- ices.
tial. ➤ Evaluate test results in relation to
➤ Recognize anxiety related to test the patient’s symptoms and other
results and offer support, as appro- tests performed. Related laboratory
priate. Provide teaching and disease tests include ammonia and urine
information, as appropriate. Educate amino acid screen.
AMINO ACID SCREEN, URINE

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

amino acids. The following tables include the most frequently screened. All
units are nanomoles per milligram (nmol/mg) creatinine.
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
γ-Amino- β-Aminoiso- Aspartic

Age butyric Acid butyric Acid Arginine Asparagine Acid
Premature 20–260 50–470 190–820 1350–5250 580–1520
Newborn–1 0–15 421–3133 35–214 185–1550 336–810
mo
2 mo–2 y 0–105 802–4160 38–165 252–1280 230–685
2–18 y 15–30 291–1482 31–109 72–332 0–120
Adult 15–30 10–510 10–90 99–470 60–240
Amino Acid Screen, Urine 39
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
1-Methyl- 3-Methyl- Phenyl-

Age Methionine histidine histidine Ornithine alanine
Premature 500–1230 170–880 420–1340 260–3350 920–2280
Newborn–1 342–880 96–499 189–680 118–554 91–457
mo
2 mo–2 y 174–1090 106–1275 147–391 55–364 175–1340
2–18 y 16–114 170–1688 182–365 31–91 61–314
Adult 38–210 170–1680 160–520 20–80 51–250
Phospho- Phospho-
Age ethanolamine serine Proline Sarcosine Serine
Premature 80–340 500–1690 1350–10,460 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

Age Taurine Threonine Tryptophan Tyrosine Valine

Premature 5190–23,620 840–5700 0 1090–6780 180–890
Newborn–1 1650–6220 445–1122 0 220–1650 113–369
mo
2 mo–2 y 545–3790 252–1528 0–93 333–1550 99–316
2–18 y 639–1866 121–389 0–108 122–517 58–143
Adult 380–1850 130–370 0–70 90–290 27–260
DESCRIPTION: Urine amino acid Galactosemia

testing is used in the initial screening Hartnup disease
for congenital defects and disorders of Lactose intolerance
amino acid metabolism. The major Lowe’s syndrome
genetic disorders include phenylke- Maple syrup disease
tonuria, tyrosinuria, and alcap- Tyrosinosis
tonuria, a defect in the phenyl- Wilson’s disease
alanine-tyrosine conversion pathway.
• Secondary causes (noninherited):
Renal aminoaciduria is also associated
Chronic renal failure
with conditions marked by defective
Diabetic ketosis
tubular reabsorption from congenital
Hyperparathyroidism
disorders, such as hereditary fructose
intolerance, cystinuria, and Hartnup Hyperthyroidism
disease. Early diagnosis and treatment Multiple myeloma
of certain aminoacidurias can prevent Osteomalacia
mental retardation, reduced growth Liver necrosis and cirrhosis
rates, or various unexplained symp- Muscular dystrophy (progressive)
toms. Values are age dependent. A Thalassemia major
positive screen on a random sample Vitamin deficiency (B, C, and D)
should be followed up with a timed Viral hepatitis
collection. ■
Decreased in: N/A
INDICATIONS:
• Assist in the detection of noninherited CRITICAL VALUES: N/A
disorders evidenced by elevated amino
acid levels INTERFERING FACTORS:
• Screen for inborn errors of amino acid • Drugs that may increase urine amino
metabolism acid levels include acetaminophen,
amikacin, aminocaproic acid, amphet-
RESULT amine, ampicillin, cephalexin, colistin,
corticotropin, dopamine, ephedrine,
Increased (total amino acids) in: epinephrine, erythromycin, ethylene-
• Primary causes (inherited): diamine, gentamicin, hydrocortisone,
hydroxyaminobutyric acid, kana-
Aminoaciduria (specific) mycin, levarterenol, levodopa,
Cystinosis mafenide, metanephrine, metham-
Fanconi’s syndrome phetamine, methyldopa, neomycin,
Fructose intolerance normetanephrine, penicillamine,
Amino Acid Screen, Urine 41
phenacetin, phenobarbital, phenyl- sive exercise and stress during the

ephrine, phenylpropanolamine, poly- 24-hour collection of urine.
myxin, primidone, proSobee, pseudo- ➤ Review the procedure with the
ephedrine, streptozocin, tetracycline, patient. Provide a nonmetallic urinal,
triamcinolone, and vigabatrin. bedpan, or toilet-mounted collection
device.
• Drugs that may decrease urine amino ➤ If a timed collection is requested,
acid levels include insulin. inform the patient that all urine
• Amino acids exhibit a strong circadian collected over a 24-hour period must
rhythm; values are highest in the after- be saved; if a preservative has been
added to the container, instruct the
noon and lowest in the morning. patient not to discard the preserva-
Protein intake does not influence tive. Instruct the patient not to void
diurnal variation but significantly directly into the laboratory collection
affects absolute concentrations; a 12- container. Instruct the patient to
hour fast before specimen collection is avoid defecating in the collection
required. device and to keep toilet tissue out
of the collection device to prevent
• Dilute urine (specific gravity less contamination of the specimen.
than 1.010) should be rejected for Place a sign in the bathroom as a
analysis. reminder to save all urine.
➤ Instruct the patient to void all urine
into the collection device and pour
Nursing Implications and the urine into the laboratory collec-
Procedure ● ● ● ● ● ● ● ● ● ● ● tion container. Alternatively, the
specimen can be left in the collec-
Pretest: tion device for a health care staff
member to add to the laboratory
➤ Obtain a history of the patient’s collection container.
allergens. Intratest:
reproductive system as it relates to ➤ Ensure that the patient has complied
genetic disease, as well as results of with dietary preparations and other
previously performed tests and pretesting restrictions.
procedures. For related tests, refer ➤ Observe standard precautions and
to the reproductive system table. follow the general guidelines in
➤ Obtain a list of the medications Appendix A.
herbs, nutritional supplements, and Random specimen (collect in
nutraceuticals. The requesting health early morning):
care practitioner and laboratory
should be advised if the patient ➤ Infant: Clean and dry the genital
regularly uses these products so area, attach the collection device
that their effects can be taken into securely to prevent leakage, and
consideration when reviewing observe for voiding. Remove collec-
results. tion device carefully from the skin
to prevent irritation. Transfer the
➤ There are no fluid or medication urine into a specimen container. For
restrictions unless by medical direc- dipstick method, place dipstick or
tion. reagent pad into the urine specimen
➤ Instruct the patient to fast for at or on the diaper saturated with
least 12 hours before specimen urine. Remove, compare with color
collection. chart, and record results.
➤ Instruct the patient to avoid exces- ➤ Adult: Instruct the patient to obtain
a clean-catch specimen as described ➤ Label the specimen, and promptly

in Appendix A. If an indwelling transport it to the laboratory. Include
catheter is in place, it may be neces- on the label the amount of urine,
sary to clamp off the catheter for 15 test start and stop times, and age of
to 30 minutes before specimen the patient.
collection. Cleanse specimen port
with antiseptic swab, and then aspi-
rate 5 mL of urine with a 21- to 25- Post-test:
gauge needle and syringe. Transfer
urine to a plastic container. ➤ Instruct the patient to resume usual
diet as directed by the health care
practitioner.
Timed specimen:
➤ Instruct caregiver in special dietary
➤ Obtain a clean 3-L urine specimen modifications, as appropriate, to
container, toilet-mounted collection treat deficiency, or refer caregiver to
device, and plastic bag (for transport a qualified nutritionist. Amino acids
of the specimen container). The are classified as essential (i.e., must
specimen must be refrigerated or be present simultaneously in suffi-
kept on ice throughout the entire cient quantities); conditionally or
collection period. If an indwelling acquired essential (i.e., under certain
urinary catheter is in place, the stressful conditions, they become
drainage bag must be kept on ice. essential); and nonessential (i.e.,
➤ Begin the test between 6 and 8 can be produced by the body,
a.m., if possible. Collect first voiding when needed, if diet does not
and discard. Record the time the provide them). Essential amino
specimen was discarded as the acids include lysine, threonine, histi-
beginning of the timed collection dine, isoleucine, methionine, phe-
period. The next morning, ask the nylalanine, tryptophan, and valine.
patient to void at the same time the Conditionally essential amino acids
collection was started and add this include cysteine, tyrosine, arginine,
last voiding to the container. citrulline, taurine, and carnitine.
➤ If an indwelling catheter is in place, Nonessential amino acids include
replace the tubing and container alanine, glutamic acid, aspartic
system at the start of the collection acid, glycine, serine, proline, gluta-
time. Keep the container system on mine, and asparagine. A high intake
ice during the collection period or of specific amino acids can cause
empty the urine into a larger other amino acids to become essen-
container periodically during the tial.
collection period; monitor to ensure ➤ Recognize anxiety related to test
continued drainage, and conclude results and offer support, as appro-
the test the next morning at the priate. Provide teaching and disease
same hour the collection started. information, as appropriate. Educate
➤ At the conclusion of the test, the patient regarding access to
compare the quantity of urine with genetic or other counseling services.
the urinary output record for the ➤ Evaluate test results in relation to
collection; if the specimen contains the patient’s symptoms and other
less than what was recorded as tests performed. Related laboratory
output, some urine may have been tests include ammonia and blood
discarded, invalidating the test. amino acid screen.
-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.
Conventional Units SI Units (Conversion Factor 7.626)

1.5–7.5 mg/24 h 11.4–57.2 mol/24 h
D ESCRIPTION : -Aminolevulinic • Lead poisoning

acid (-ALA) is involved in the
formation of porphyrins. Distur- Decreased in:
bances in porphyrin metabolism can • Liver disease (alcoholic)
cause an increase in -ALA excretion
in urine. Although lead poisoning can CRITICAL VALUES: N/A
cause increased urinary excretion, the
measurement of -ALA is not useful INTERFERING FACTORS:
to indicate lead toxicity because it is • Drugs that may increase -ALA levels
not detectable in the urine until the include ammonia, glucosamine, and
blood lead level approaches and penicillins.
exceeds 40 g/dL. ■ • Cisplatin may decrease -ALA levels.
• Numerous drugs are suspected as
INDICATIONS: potential initiators of attacks of
• Assist in the diagnosis of porphyrias acute porphyria, but those classified
as unsafe for high-risk individuals
include antipyrine, aminopyrine,
RESULT aminoglutethimide, barbiturates, car-
bamazepine, carbromal, chlorpropa-
Increased in: mide, danazol, dapsone, diclofenac,
• Acute porphyrias diphenylhydantoin, ergot prepara-
tions, ethchlorvynol, ethinamate,
• Aminolevulinic acid dehydrase defi-
glutethimide, griseofulvin, mepheny-
ciency
toin, meprobamate, methyprylone,
• Hereditary tyrosinemia N-isopropyl meprobamate, novobio-
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.
Nursing Implications and Intratest:

Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: follow the general guidelines in
Appendix A.
➤ Obtain a history of the patient’s ➤ Obtain a clean 3-L urine specimen
complaints, including a list of known container, toilet-mounted collection
allergens. device, and plastic bag (for trans-
➤ Obtain a history of the patient’s port of the specimen container).
hematopoietic system and results of The specimen must be refriger-
previously performed tests and ated or kept on ice throughout
procedures. For related tests, refer the entire collection period. If an
to the hematopoietic system table. indwelling urinary catheter is in
➤ Obtain a list of the medications place, the drainage bag must be
the patient is taking, including kept on ice.
herbs, nutritional supplements, and ➤ Begin the test between 6 and 8
nutraceuticals. The requesting health a.m., if possible. Collect first voiding
care practitioner and laboratory and discard. Record the time the
should be advised if the patient specimen was discarded as the
regularly uses these products so beginning of the timed collection
that their effects can be taken into period. The next morning, ask
consideration when reviewing the patient to void at the same
results. time the collection was started,
➤ There are no food, fluid, or medica- and add this last voiding to the
tion restrictions unless by medical container.
direction. ➤ If an indwelling catheter is in place,
➤ Review the procedure with the replace the tubing and container
patient. Provide a nonmetallic urinal, system at the start of the collection
bedpan, or toilet-mounted collection time. Keep the container system on
device. ice during the collection period, or
➤ Usually a 24-hour time frame for empty the urine into a larger
urine collection is ordered. Inform container periodically during the
the patient that all urine must be collection period. Monitor to ensure
saved during that 24-hour period. continued drainage, and conclude
Instruct the patient not to void the test the next morning at the
directly into the laboratory collection same hour the collection was
container. Instruct the patient to begun.
avoid defacating in the collection ➤ At the conclusion of the test,
device and to keep toilet tissue compare the quantity of urine with
out of the collection device to the urinary output record for the
prevent contamination of the speci- collection; if the specimen contains
men. Place a sign in the bathroom less than what was recorded as
to remind the patient to save all output, some urine may have been
urine. discarded, invalidating the test.
Ammonia 45
➤ Label the specimen, and promptly Post-test:

transport it to the laboratory. Include
on the label the amount of urine as ➤ Evaluate test results in relation to
well as test start and stop times. On the patient’s symptoms and other
the label, note the ingestion of any tests performed. Related laboratory
medications that may affect test tests include lead and urine
results. porphyrins.
AMMONIA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: NH3.
SPECIMEN: Plasma (1 mL) collected in completely filled green-top
(heparin) tube. Specimen should be transported tightly capped and in an ice
slurry.
Conventional SI Units (Conversion Factor

Age Units 0.587)
Newborn 170–341g/dL 100–200 mol/L
Adult 19–60 g/dL 11–35 mol/L
DESCRIPTION: Blood ammonia INDICATIONS:

(NH3) comes from two sources: • Evaluate advanced liver disease or other
deamination of amino acids during disorders associated with altered serum
protein metabolism and degradation ammonia levels
of proteins by colon bacteria. The
liver converts ammonia in the portal • Identify impending hepatic
encephalopathy with known liver
blood to urea, which is excreted by
disease
the kidneys. When liver function is
severely compromised, especially in • Monitor the effectiveness of treatment
situations in which decreased hepato- for hepatic encephalopathy, indicated
cellular function is combined with by declining levels
impaired portal blood flow, ammonia
levels rise. Ammonia is potentially • Monitor patients receiving hyperali-
toxic to the central nervous system. ■ mentation therapy
RESULT Nursing Implications and

Procedure ● ● ● ● ● ● ● ● ● ● ●
Increased in:
Pretest:
• Gastrointestinal hemorrhage
• Genitourinary tract infection with complaints, including a list of known
distention and stasis allergens.
• Inborn enzyme deficiency gastrointestinal, genitourinary, and
hepatobiliary systems, as well as
• Hepatic coma results of previously performed
• Liver failure, late cirrhosis tests, refer to the gastrointestinal,
genitourinary, and hepatobiliary
• Reye’s syndrome system tables.
• Total parenteral nutrition patient is taking, including herbs,
nutritional supplements, and
Decreased in: N/A nutraceuticals. The requesting health
CRITICAL VALUES: N/A regularly uses these products so
that their effects can be taken into
INTERFERING FACTORS: results.
• Drugs that may increase ammonia ➤ There are no food, fluid, or medica-
levels include ammonium salts, tion restrictions unless by medical
asparaginase, barbiturates, diuretics, direction.
ethanol, fibrin hydrolysate, fluorides, ➤ Review the procedure with the
furosemide, thiazides, and valproic patient.
acid. ➤ Inform the patient that specimen
• Drugs/organisms that may decrease
10 minutes.
ammonia levels include diphen-
hydramine, kanamycin, neomycin, Intratest:
tetracycline, and Lactobacillus aci-
dophilus. ➤ Direct the patient to breathe
• Hemolysis falsely increases ammonia movement.
levels. ➤ Observe standard precautions and
• Prompt and proper specimen process- Appendix A.
ing, storage, and analysis are important
➤ Perform a venipuncture, and collect
to achieve accurate results. The speci- the specimen in a 5-mL green-top
men should be collected on ice; the tube.
collection tube should be filled
completely, and then kept tightly transport it to the laboratory. The
stoppered. Ammonia increases rapidly tightly capped sample should be
in the collected specimen, so analysis placed in an ice slurry immediately
should be performed within 20 after collection. Information on the
minutes of collection. specimen label can be protected
Amniotic Fluid Analysis 47
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.
AMNIOTIC FLUID ANALYSIS

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

and appearance, radioimmunoassay for -fetoprotein, electrophoresis for
acetylcholinesterase, spectrophotometry for creatinine and bilirubin, chro-
matography for lecithin/sphingomyelin [L/S] ratio and phosphatidylglyc-
erol, tissue culture for chromosome analysis, dipstick for leukocyte esterase,
and automated cell counter for white blood cell count and lamellar bodies)
Test Reference Value

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

formed in the membranous sac that maternal age (some of the aforemen-
surrounds the fetus. The total volume tioned tests are routinely requested in
of fluid at term is 500 to 2500 mL. In mothers aged 35 years and older)
amniocentesis, fluid is obtained by • Evaluate fetus in mothers with a
ultrasound-guided needle aspiration history of miscarriage or stillbirth
from the amniotic sac. This procedure • Evaluate known or suspected hemo-
is generally performed between 14 lytic disease involving the fetus in an
and 16 weeks’ gestation, but it also Rh-sensitized pregnancy, indicated by
can be done between 26 and 35 rising bilirubin levels, especially after
weeks’ gestation if fetal distress is the 30th week of gestation
suspected. Amniotic fluid is tested to • Evaluate suspected neural tube defects,
identify genetic and neural tube such as spina bifida or myelomeningo-
defects, hemolytic diseases of the cele, as indicated by elevated -
newborn, fetal infection, fetal renal fetoprotein (see monograph titled “1-
malfunction, or maturity of the fetal Fetoprotein” for information related to
lungs (see monograph titled triple-marker testing)
“Lecithin/Sphingomyelin Ratio”) ■ • Detect infection secondary to ruptured
membranes
INDICATIONS: • Determine fetal maturity when
• Assist in the diagnosis of (in utero) preterm delivery is being considered.
metabolic disorders, such as cystic Fetal maturity is indicated by an L/S
fibrosis; or errors of lipid, carbohy- ratio of 2:1 or greater (see monograph
drate, or amino acid metabolism titled “Lecithin/Sphingomyelin Ratio”)
• Evaluate fetus in families with a history • Determine fetal sex when the mother is
of genetic disorders, such as Down a known carrier of a sex-linked abnor-
syndrome, Tay-Sachs disease, chromo- mal gene that could be transmitted to
some or enzyme anomalies, or inher- male offspring, such as hemophilia or
ited hemoglobinopathies Duchenne’s muscular dystrophy
Amniotic Fluid Analysis 49
• 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.
• 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
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.

Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: movement.
➤ Obtain a history of the patient’s ➤ Record maternal and fetal baseline
complaints, including a list of known vital signs. Monitor for uterine
allergens. contractions.
reproductive system and previous follow the general guidelines in
pregnancies, as well as other Appendix A.
tests and procedures previously ➤ Assemble the necessary equip-
performed. For related tests, refer to ment, including an amniocentesis
the reproductive system table. tray with solution for skin prepara-
➤ Obtain a list of medications the tion, local anesthetic, 10- or 20-mL
patient is taking, including herbs, syringe, needles of various sizes
nutritional supplements, and nutra- (including a 22-gauge, 5-inch spinal
ceuticals. The requesting health care needle), sterile drapes, sterile
practitioner and laboratory should be gloves, and foil-covered or amber
advised if the patient is regularly specimen collection containers.
using these products so that their ➤ Ensure that the patient has a full
effects can be taken into considera- bladder before the procedure if
tion when reviewing results. gestation is 20 weeks or less; have
Amylase 51
patient void before procedure if for 30 to 60 minutes after the amnio-

gestation is 21 weeks or more. centesis procedure.
➤ Assist the patient to a supine posi- ➤ Explain that slight cramping can
tion. Raise the head or legs slightly occur after the procedure.
to promote comfort and to relax ➤ Tell the patient to report fever, leak-
abdominal muscles. If the uterus is ing amniotic fluid, vaginal bleeding,
large, place a pillow or rolled blanket uterine contractions, or changes in
under the patient’s right side to fetal activity (either an increase or a
prevent hypertension resulting from decrease) to a health care practi-
great-vessel compression. tioner.
➤ Note fetal position and pocket of ➤ Inform the patient that it may be 2 to
amniotic fluid as determined by 4 weeks before all results are avail-
ultrasound and palpation. able.
➤ Cleanse suprapubic area with an ➤ Recognize anxiety related to test
antiseptic solution and protect with results and offer support. Provide
sterile drapes. A local anesthetic is teaching and information regarding
injected. Explain that this may cause the clinical implications of the test
a stinging sensation. results, as appropriate. Encourage
➤ A 22-gauge, 5-inch spinal needle is the family to seek appropriate coun-
inserted through the abdominal and seling if concerned with pregnancy
uterine walls. Explain that a sensa- termination, and to seek genetic
tion of pressure may be experienced counseling if a chromosomal abnor-
when the needle is inserted. Explain mality is determined. Decisions
to the patient how to use focusing regarding elective abortion should
and controlled breathing for relax- take place in the presence of both
ation during the procedure. parents. Provide a nonjudgmental,
➤ After the fluid is collected and the nonthreatening atmosphere for
needle is withdrawn, apply slight discussing the risks and difficulties
pressure to the site. If there is no of delivering and raising an abnormal
evidence of bleeding or other infant, as well as exploring other
drainage, apply a sterile adhesive options (termination of pregnancy or
bandage to the site. adoption). It is also important to
discuss problems the mother and
➤ Label the specimen, and promptly father may experience (guilt, depres-
transport it to the laboratory. sion, anger) if fetal abnormalities are
detected.
Post-test:
➤ Evaluate test results in relation
➤ Fetal heart rate and maternal life to the patient’s symptoms and
signs (heart rate, blood pressure, other tests performed. Re-
pulse, and respiration) should be lated laboratory tests include -
compared with baseline values and fetoprotein, chromosome analysis,
closely monitored every 15 minutes and L/S ratio.
AMYLASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

(1 mL) collected in green-top (heparin) tube is also acceptable.

30–110 U/L 0.51–1.87 Kat/L
DESCRIPTION: Amylase, a digestive RESULT

enzyme, splits starch into disaccha-
rides. Although many cells have Increased in:
amylase activity (e.g., liver, small • Abdominal trauma
intestine, ovaries, skeletal muscles), • Alcoholism
circulating amylase is derived from
the parotid glands and the pancreas. • Carcinoma of the head of the pancreas
Amylase is a sensitive indicator of (advanced)
pancreatic acinar cell damage and • Common bile duct obstruction
pancreatic obstruction. Newborns • Diabetic ketoacidosis
and children up to 2 years old have
little measurable serum amylase. • Duodenal obstruction
Most of this enzyme in the early years • Ectopic pregnancy
of life is produced by the salivary
• Gastric resection
glands. ■
• Macroamylasemia
INDICATIONS: • Mumps
• Assist in the diagnosis of early acute
pancreatitis; serum amylase begins to • Pancreatitis
rise within 6 to 24 hours after onset • Pancreatic cyst and pseudocyst
and returns to normal in 2 to 7 days
• Parotitis
• Assist in the diagnosis of macroamy-
lasemia, a disorder seen in alcoholism, • Perforated peptic ulcer involving the
malabsorption syndrome, and other pancreas
digestive problems • Peritonitis
• Assist in the diagnosis of pancreatic • Postoperative period
duct obstruction, which causes serum
levels to remain elevated • Some tumors of the lung and ovaries
• Detect blunt trauma or inadvertent • Viral infections

surgical trauma to the pancreas
Decreased in:
• Differentiate between acute pancreati- • Cystic fibrosis (advanced)
tis and other causes of abdominal pain
that require surgery • Hepatic disease (severe)
Amylase 53
• Pancreatic insufficiency ➤ Inform the patient that specimen

• Pancreatectomy 10 minutes.

Intratest:
INTERFERING FACTORS: ➤ Direct the patient to breathe
• Drugs and substances that may normally and to avoid unnecessary
increase amylase levels include asparag- movement.
inase, captopril, cimetidine, clofibrate, ➤ Observe standard precautions and
corticosteroids, estrogens, ethacrynic follow the general guidelines in
acid, furosemide, ibuprofen, methyl- Appendix A. Perform a venipuncture,
dopa, nitrofurantoin, oral contracep- and collect the specimen in a 5-mL
tives, pentamidine, sulfonamides, red- or tiger-top tube.
tetracycline, thiazide diuretics, valproic ➤ Label the specimen, and promptly
acid, zalcitabine, and alcohol. transport it to the laboratory.
• Drugs that may decrease amylase levels

include anabolic steroids, citrates, and Post-test:
fluorides. ➤ Observe venipuncture site for bleed-
pressure bandage.
Nursing Implications and ➤ Increased amylase levels may be
Procedure ● ● ● ● ● ● ● ● ● ● ●
associated with gastrointestinal
disease or alcoholism. Small,
Pretest: frequent meals work best for
patients with gastrointestinal disor-
➤ Obtain a history of the patient’s ders. Consideration should be given
complaints, including a list of known to dietary alterations in the case of
allergens. gastrointestinal disorders. Usually
➤ Obtain a history of the patient’s after acute symptoms subside and
endocrine, gastrointestinal, and bowel sounds return, patients are
hepatobiliary systems, as well as given a clear liquid diet, progressing
results of previously performed to a low-fat, high-carbohydrate diet.
tests and procedures. For related Vitamin B12 may be ordered for
tests, refer to the endocrine, parenteral administration to patients
gastrointestinal, and hepatobiliary with decreased levels, especially if
system tables. their disease prevents adequate
absorption of the vitamin. The alco-
➤ Obtain a list of the medications the holic patient should be encouraged
patient is taking, including herbs, to avoid alcohol and to seek appro-
nutritional supplements, and priate counseling for substance
nutraceuticals. The requesting health abuse.
should be advised if the patient ➤ Evaluate test results in relation to
regularly uses these products so the patient’s symptoms and other
that their effects can be taken into tests performed. Related laboratory
consideration when reviewing tests include alanine aminotrans-
results. ferase, alkaline phosphatase, aspar-
tate aminotransferase, fluid
➤ There are no food, fluid, or medica- amylase, bilirubin, CA 19-9, calcium,
tion restrictions unless by medical fecal fat, -glutamyl transpeptidase,
direction. lipase, magnesium, mumps serol-
➤ Review the procedure with the ogy, triglycerides, and white blood
patient. cell count.
ANALGESIC AND ANTIPYRETIC

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

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

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

Drug Dose* Units -Life Distribution Binding Excretion
(Conversion
Factor 6.62)
Acetaminophen 10–30 66–199 1–3 h 0.95 20–50% 85–95%
g/mL mol/L L/kg hepatic,
metabo-
lites, renal
(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.
DESCRIPTION: Acetaminophen is Reye’s syndrome. Acetaminophen is

used for headache, fever, and pain rapidly absorbed from the gastroin-
relief, especially for individuals unable testinal tract and reaches peak
to take salicylate products or who concentration within 30 to 60
have bleeding conditions. It is the minutes after administration of a
analgesic of choice for children less therapeutic dose. It can be a silent
than 13 years of age; salicylates are killer because by the time symptoms
avoided in this age group because of of intoxication appear 24 to 48 hours
the association between aspirin and after ingestion, the antidote is ineffec-
Analgesic and Antipyretic Drugs: Acetaminophen, Acetylsalicylic Acid 55
tive. Acetylsalicylic acid (ASA) is also Acetaminophen: Greater than

used for headache, fever, and pain 150 mg/mL
relief. Some patients with cardiovas- Signs and symptoms of acetaminophen
cular disease take small prophylactic intoxication occur in stages over a period
doses. The main site of toxicity for of time. In stage I (0 to 24 hours after
both drugs is the liver, particularly in ingestion), symptoms may include
the presence of liver disease or gastrointestinal irritation, pallor, lethargy,
decreased drug metabolism and excre- diaphoresis, metabolic acidosis, and
tion. possibly coma. In stage II (24 to 48 hours
Many factors must be considered after ingestion), signs and symptoms may
in interpreting drug levels, including include right upper quadrant abdominal
pain; elevated liver enzymes, aspartate
patient age, patient weight, interact-
aminotransferase (AST) and alanine
ing medications, electrolyte balance, aminotransferase (ALT); and possible
protein levels, water balance, condi- decreased renal function. In stage III (72
tions that affect absorption and excre- to 96 hours after ingestion), signs and
tion, and foods, herbals, vitamins, symptoms may include nausea, vomiting,
and minerals that can potentiate or jaundice, confusion, coagulation disor-
inhibit the intended target concentra- ders, continued elevation of AST and
tion. ■ ALT, decreased renal function, and coma.
Intervention may include gastrointestinal
decontamination (stomach pumping) if
INDICATIONS: the patient presents within 6 hours of
• Suspected overdose ingestion or administration of acetylcys-
teine in the case of an acute intoxication
• Suspected toxicity in which the patient presents more than
• Therapeutic monitoring 6 hours after ingestion.
ASA: Greater than 50 mg/dL

RESULT
Signs and symptoms of salicylate intoxi-
Increased in:
cation include ketosis, convulsions, dizzi-
ness, nausea, vomiting, hyperactivity,
• Acetaminophen hyperglycemia, hyperpnea, hyperther-
Alcoholic cirrhosis mia, respiratory arrest, and tinnitus.
Liver disease Possible interventions include adminis-
Toxicity tration of a cathartic-like syrup of ipecac
to induce emesis if the patient is
• ASA conscious, administration of activated
Toxicity charcoal as vomiting ceases, alkaliniza-
tion of the urine with bicarbonate, and a
Decreased in: single dose of vitamin K (for rare
• Noncompliance with therapeutic regi- instances of hypoprothrombinemia).
men
INTERFERING FACTORS:
• Drugs that may increase acetamino-
CRITICAL VALUES: Note: The
phen levels include diflunisal, metoclo-
adverse effects of subtherapeutic levels
pramide, and probenecid.
are also important. Care should be
taken to investigate signs and symptoms • Drugs that may decrease acetamino-
of too little and too much medication. phen levels include cholestyramine,
iron, oral contraceptives, and propan- collection takes approximately 5 to

theline. 10 minutes.
• Drugs that increase ASA levels include Intratest:

sulfinpyrazone.
• Drugs that decrease ASA levels include normally and to avoid unnecessary
activated charcoal, antacids (aluminum movement.
hydroxide), and iron. ➤ Observe standard precautions and
Nursing Implications and and collect the specimen in a 5-mL
red-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: transport it to the laboratory.
➤ Obtain a history of the patient’s Post-test:

allergens. ➤ Observe venipuncture site for bleed-
➤ Review results of previously pressure bandage.
performed tests and procedures. For
related tests, refer to the genitouri- ➤ Explain to the patient the impor-
nary, hepatobiliary, and therapeutic/ tance of following the medication
toxicology system tables. regimen and instructions regarding
food and drug interactions.
patient is taking, including herbs, ➤ Instruct the patient to be prepared to
nutritional supplements, and list to the pharmacist any other
nutraceuticals. The requesting health medications he or she is already
care practitioner and laboratory taking in the event that the request-
should be advised if the patient is ing health care practitioner gives the
regularly using these products so patient a prescription to be filled.
that their effects can be taken into ➤ Evaluate test results in relation
consideration when reviewing to the patient’s symptoms and
results. other tests performed. Related
➤ There are no food, fluid, or medica- laboratory tests include ALT, AST,
tion restrictions unless by medical bilirubin, complete blood count,
direction. creatinine, electrolytes, glucose,
lactic acid, liver biopsy, activated
➤ Review the procedure with the partial thromboplastin time, pro-
patient. thrombin time, and blood urea nitro-
➤ Inform the patient that specimen gen.
ANGIOGRAPHY, ABDOMEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Abdominal angiogram, abdominal arteriography.

Angiography, Abdomen 57
AREA OF APPLICATION: Abdomen.

CONTRAST: Iodine based.
DESCRIPTION: Angiography allows INDICATIONS:

x-ray visualization of the large and • Detect tumors and arterial supply,
small arteries, veins, and their associ- extent of venous invasion, and tumor
ated branches of the abdominal vascularity
vasculature and organ parenchyma • Differentiate between tumors and cysts
after contrast-medium injection. This
• Detect nonmalignant tumors before
visualization is accomplished by the surgical resection
injection of contrast medium through
a catheter, which most commonly has • Allow infusion of thrombolytic drugs
been inserted into the femoral artery into an occluded artery
or vein and advanced through the • Aid in angioplasty, atherectomy, or
iliac artery and aorta into the organ- stent placement
specific artery or vein. Images of the • Detect artery stenosis, evidenced by
organ under study and associated vessel dilation, collateral vessels, or
vessels are displayed on a monitor and increased vascular pressure
recorded on film or stored electroni-
• Detect arterial occlusion, which may
cally for future viewing and evalua- be evidenced by a transection of the
tion. Patterns of circulation, organ artery caused by trauma or penetrating
function, and changes in vessel wall injury
appearance can be viewed to help
• Evaluate tumor vascularity before
diagnose the presence of vascular
surgery or embolization
abnormalities, aneurysm, tumor,
trauma, or lesions. The catheter used • Evaluate the vascular system of
to administer the contrast medium to prospective organ donors before
confirm the diagnosis of organ lesions surgery
may be used to deliver chemothera- • Detect thrombosis, arteriovenous
peutic drugs or different types of fistula, aneurysms, or emboli in
media to stop bleeding. Catheters abdominal vessels
with attached inflatable balloons and • Evaluate organ transplantation for
wire mesh stents are used to widen function or organ rejection
areas of stenosis and to keep the
• Evaluate placement of a shunt or
vessels open, frequently replacing
stent
surgery. Angiography is one of the
definitive tests for organ disease and
may be used to evaluate chronic RESULT
disease, evaluate organ failure, treat
arterial stenosis, differentiate a vascu- Normal Findings:
lar cyst from hypervascular cancers, • Normal structure, function, and
and evaluate the effectiveness of patency of abdominal organ vessels
medical or surgical treatment. ■ • Contrast medium normally circulates
throughout abdomen symmetrically Factors that may impair clear

and without interruption imaging:
• Gas or feces in the gastrointestinal tract
• No evidence of obstruction, variations
resulting from inadequate cleansing or
in number and size of vessels and
failure to restrict food intake before the
organs, malformations, cysts, or
study
tumors
• Retained barium from a previous radi-
Abnormal Findings: ologic procedure
• Abscess or inflammation • Metallic objects within the examina-
• Arterial aneurysm tion field (e.g., jewelry, earrings, dental
amalgams), which may inhibit organ
• Arterial stenosis, dysplasia, or organ visualization and can produce unclear
infarction images
• Arteriovenous fistula or other abnor- • Improper adjustment of the radi-
malities ographic equipment to accommodate
obese or thin patients, which can cause
• Congenital anomalies overexposure or underexposure and a
• Cysts or tumors poor-quality study
• Organ hematoma • Patients who are very obese, who may
exceed the weight limit for the equip-
• Trauma causing tears or other disrup- ment
tion
• Incorrect positioning of the patient,
which may produce poor visualization
INTERFERING FACTORS of the area to be examined
• Inability of the patient to cooperate or
This procedure is contraindicated
remain still during the procedure
for:
because of age, significant pain, or
• Patients with allergies to shellfish or mental status
iodinated dye. The contrast
medium used may cause a life- Other considerations:
threatening allergic reaction. Patients
• Failure to follow dietary restrictions
with a known hypersensitivity to
before the procedure may cause the
contrast medium may benefit from
procedure to be canceled or repeated.
premedication with corticosteroids or
the use of nonionic contrast medium. • Consultation with a physician should
occur before the procedure for radia-
• Patients with bleeding disorders. tion safety concerns regarding infants
• Patients who are pregnant or suspected of patients who are lactating.
of being pregnant, unless the potential • Risks associated with radiographic
benefits of the procedure far outweigh overexposure can result from frequent
the risks to the fetus and mother. x-ray procedures. Personnel in the
room with the patient should wear a
• Elderly and other patients who are protective lead apron, stand behind a
chronically dehydrated before shield, or leave the area while the
the test, because of their risk of examination is being done. Personnel
contrast-induced renal failure. working in the area where the exami-
• Patients who are in renal failure. nation is being done should wear
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.
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
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:
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Adrenal angiogram, adrenal arteriography.

AREA OF APPLICATION: Adrenal gland.
Angiography, Adrenal 61
DESCRIPTION: Adrenal angiography • Allow infusion of thrombolytic drugs

evaluates adrenal dysfunction by into an occluded artery
allowing x-ray visualization of the • Perform angioplasty, perform atherec-
large and small arteries of the adrenal tomy, or place a stent
gland vasculature and parenchyma.
• Detect arterial stenosis, evidenced by
This visualization is accomplished by vessel dilation, collateral vessels, or
the injection of contrast medium increased vascular pressure
through a catheter that has been
inserted into the femoral artery for • Detect arterial occlusion, evidenced by
a transection of the artery caused by
viewing the artery (arteriography) or
trauma or a penetrating injury
into the femoral vein for viewing the
veins (venography). After the catheter • Evaluate tumor vascularity before
is in place, a blood sample may be surgery or embolization
taken from the vein of each gland to • Detect thrombosis, arteriovenous
assess cortisol levels in determining a fistula, aneurysms, or emboli in vessels
diagnosis of Cushing’s syndrome or • Detect adrenal hyperplasia
the presence of pheochromocytoma.
After injection of the contrast • Collect blood samples from the vein
medium through the catheter, images for laboratory analysis
of the adrenal glands and associated
vessels surrounding the adrenal tissue RESULT
are displayed on a monitor and are
Normal Findings:
recorded on film or electronically.
• Normal structure, function, and
Patterns of circulation, adrenal func-
patency of adrenal vessels
tion, and changes in vessel wall
appearance can be viewed to help • Contrast medium circulating through-
diagnose the presence of vascular out the adrenal gland symmetrically
abnormalities, trauma, or lesions. and without interruption
This definitive test for adrenal disease • No evidence of obstruction, variations
may be used to evaluate chronic adre- in number and size of vessels and or-
nal disease, evaluate arterial or venous gans, malformations, cysts, or tumors
stenosis, differentiate an adrenal cyst
from adrenal tumors, and evaluate Abnormal Findings:
medical therapy or surgery of the • Adrenal adenoma
adrenal glands. ■ • Adrenal carcinoma
• Bilateral adrenal hyperplasia
INDICATIONS:
• Detect and determine the location of • Pheochromocytoma
adrenal tumors evidenced by arterial
supply, extent of venous invasion, and INTERFERING FACTORS
tumor vascularity
• Differentiate between adrenal tumors for:
and adrenal cysts
• Patients with allergies to shellfish or
• Detect nonmalignant tumors before iodinated contrast medium. The
surgical resection contrast medium used may cause
a life-threatening allergic reaction. Other considerations:

Patients with a known hyper-sensitivity • Failure to follow dietary restrictions
to contrast medium may benefit before the procedure may cause the
from premedication with corticos- procedure to be canceled or repeated.
teroids or the use of nonionic contrast
medium. • Consultation with a physician should
• Patients with bleeding disorders. tion safety concerns regarding infants
• Patients who are pregnant or suspected of patients who are lactating.
of being pregnant, unless the potential • Risks associated with radiographic
benefits of the procedure far outweigh overexposure can result from frequent
the risks to the fetus and mother. x-ray procedures. Personnel in the
• Elderly and other patients who are room with the patient should wear a
chronically dehydrated before protective lead apron, stand behind a
the test, because of their risk of shield, or leave the area while the
contrast-induced renal failure. examination is being done. Personnel
working in the area where the exami-
• Patients who are in renal failure. nation is being done should wear
badges that reveal their level of expo-
sure to radiation.
Factors that may impair clear
imaging:
resulting from inadequate cleansing or Nursing Implications and
failure to restrict food intake before the Procedure ● ● ● ● ● ● ● ● ● ● ●
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.
• 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
Angiography, Adrenal 63
(Glucophage) for non–insulin- osclerotic plaque, and throm-

dependent (type 2) diabetes should bophlebitis depending on the vessel
discontinue the drug on the day of used.
the test and continue to withhold it
for 48 hours after the test. Failure to
do so may result in lactic acidosis. Intratest:
➤ Determine date of last menstrual ➤ Have emergency life support equip-
period and possibility of pregnancy ment readily accessible.
in perimenopausal women. ➤ Have the patient void and put on a
➤ Ensure that food has been restricted gown without metallic closures.
for at least 8 hours before the proce- Remove all metallic objects, but
dure. allow the patient to wear dentures
➤ Instruct the patient to remove and hearing aid.
dentures and metallic objects, ➤ If the patient has a history of severe
including jewelry, before the test. allergic reactions to any substance
or drug, administer ordered prophy-
➤ Obtain a history of known hypersen-
lactic steroids or antihistamines
sitivity to iodine, seafood, or
before the procedure, and use
contrast medium from previous x-ray
nonionic contrast medium for the
procedures.
procedure.
➤ Using a pen, mark the site of the
complaints, medication usage, and
patient’s peripheral pulses before
known allergens.
angiography; this allows quicker and
➤ Obtain a history of the patient’s more consistent assessment of the
adrenal system and tests, treat- pulses after the procedure.
ments, surgeries, and procedures
➤ Place electrocardiographic elec-
previously performed. For other
trodes on the patient for cardiac
related tests, refer to the cardiovas-
monitoring. Establish baseline
cular and endocrine system tables.
rhythm; determine if the patient has
➤ Ascertain recent coagulation times, ventricular arrhythmias.
and obtain the results of other labo- ➤ Establish intravenous fluid line for
ratory tests as ordered. the injection of contrast medium,
➤ Take baseline vital signs and assess emergency drugs, and sedatives.
neurologic status and peripheral ➤ Administer a mild sedative as
pulses. ordered.
➤ The test is contraindicated in the ➤ If the patient is suspected of having
presence of atherosclerosis. a pheochromocytoma, administer
➤ Adrenal hemorrhage may occur from medication as ordered to prevent a
the pressure of the contrast medium potentially fatal hypertensive
on the gland tissue, leading to adre- episode.
nal insufficiency. ➤ Place the patient in the supine posi-
➤ In arteriography, severe hyperten- tion on an x-ray table. Cleanse and
sive crisis leading to death may drape the groin to create a sterile
occur if the patient has a pheochro- field.
mocytoma. Premedication may be ➤ A local anesthetic is injected at the
administered for several days before site, and a small incision is made or
the procedure to prevent life-threat- a needle inserted. The femoral artery
ening complications. is punctured and the guidewire
➤ Potential complications of the proce- inserted. The catheter is inserted
dure are hemorrhage, infection at over the guidewire and threaded into
the insertion site, cardiac arrhyth- the aorta and into the renal arteries
mias, embolism caused by the under fluoroscopy. For venography,
inadvertent dislodgment of an ather- the vein is punctured, and the
catheter is advanced into the adrenal to counteract the diuretic effects of

vein under fluoroscopic visualization. contrast medium.
➤ The contrast medium is injected, ➤ Advise the patient to immediately
and a rapid series of images is taken report symptoms such as fast
during and after the filling of the heart rate, difficulty breathing, skin
vessels to be examined. Delayed rash, itching, or decreased urinary
images may be taken to examine output.
the vessels after a time and to moni- ➤ Observe the catheter insertion site
tor the venous phase of the proce- for bleeding, inflammation, or
dure. Blood samples are obtained hematoma formation.
through the catheter for laboratory
examination in venographic studies. ➤ Instruct the patient to apply cold
compresses to the puncture site, as
➤ Ask the patient to breathe deeply to needed, to reduce discomfort or
relieve nausea. edema.
➤ Monitor the patient for complica- ➤ Monitor for absence of pulse distal
tions related to the contrast medium to catheter insertion site.
(e.g., allergic reaction, anaphylaxis,
bronchospasm). ➤ Assess neurologic status and vital
signs every 15 minutes for 2 hours
➤ The catheter is removed and a pres- or as directed.
sure dressing applied over the punc-
ture site for 5 to 10 minutes or ➤ Observe for a delayed allergic reac-
longer until bleeding has stopped. tion to contrast medium.
➤ Assess extremities for signs of ➤ A written report of the examination
ischemia caused by a catheter- is completed by a physician who
induced thrombus. specializes in this branch of medi-
cine. The report is sent to the order-
Post-test: ing provider, who discusses the
➤ Instruct the patient to resume taking ➤ Evaluate test results in relation
ordered medications that were to the patient’s symptoms and other
discontinued before the procedure. tests performed. Related diagnostic
Renal function should be assessed tests include computed tomog-
before metformin is restarted. raphy, magnetic resonance imaging,
➤ Instruct the patient to maintain bed positron emission tomography, and
rest for 4 to 6 hours after the proce- magnetic resonance angiography of
dure or as ordered, to resume previ- the abdomen; and adrenal imaging
ous diet, and to increase fluid intake done by nuclear medicine.
ANGIOGRAPHY, CORONARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Angiocardiography, cardiac angiography, cardiac

catheterization, cineangiocardiography, coronary arteriography.
AREA OF APPLICATION: Heart.
Angiography, Coronary 65
DESCRIPTION: Angiography allows • Evaluate disease associated with the

x-ray visualization of the heart, aorta, aortic arch
inferior vena cava, pulmonary artery • Allow infusion of thrombolytic drugs
and vein, and coronary arteries after into an occluded coronary artery
injection of contrast medium.
• Monitor pulmonary pressures and
Contrast medium is injected through cardiac output
a catheter, which has been inserted
into a peripheral vein for a right heart • Perform angioplasty, perform atherec-
catheterization or an artery for a left tomy, or place a stent
heart catheterization; through the
same catheter, cardiac pressures are RESULT
recorded. Images of the heart and Normal Findings:
associated vessels are displayed on a • Normal great vessels and coronary
monitor and are recorded on film or arteries
electronically. Patterns of circulation,
cardiac output, cardiac functions, and Abnormal Findings:
changes in vessel wall appearance can • Aortic atherosclerosis
be viewed to help diagnose the pres-
• Aortic dissection
ence of vascular abnormalities or
lesions. Pulmonary artery abnormali- • Aortitis
ties are seen with right heart views, • Aneurysms
and coronary artery and thoracic aorta
• Cardiomyopathy
abnormalities are seen with left heart
views. Coronary angiography is a • Congenital anomalies
definitive test for coronary artery • Coronary artery atherosclerosis and
disease, and it is useful for evaluating degree of obstruction
other types of cardiac abnormalities. ■
• Graft occlusion
• Pulmonary artery abnormalities
INDICATIONS:
• Detect narrowing of coronary vessels • Septal defects
or abnormalities of the great vessels
• Trauma causing tears or other disrup-
in patients with angina, syncope,
tion
abnormal electrocardiogram, hyper-
cholesteremia with chest pain, and • Tumors
persistent chest pain after revasculariza-
• Valvular disease
tion
• Quantify the severity of atheroscle- CRITICAL VALUES: N/A
rotic, occlusive coronary artery disease
• Evaluate cardiac valvular and septal INTERFERING FACTORS
defects
• Evaluate previous cardiac surgery or for:
other interventional procedures • Patients with allergies to shellfish or
• Evaluate cardiac muscle function iodinated dye. The contrast
medium used may cause a life-
• Evaluate ventricular aneurysms threatening allergic reaction. Patients
with a known hypersensitivity to • Risks associated with radiographic

contrast medium may benefit from overexposure can result from frequent
premedication with corticosteroids or x-ray procedures. Personnel in the
the use of nonionic contrast medium. room with the patient should wear a
protective lead apron, stand behind a
• Patients with bleeding disorders. shield, or leave the area while the
• Patients who are pregnant or suspected examination is being done. Personnel
of being pregnant, unless the potential working in the area where the exami-
benefits of the procedure far outweigh nation is being done should wear
the risk of radiation exposure to the badges that reveal their level of expo-
fetus. sure to radiation.
• Elderly and compromised patients who

are chronically dehydrated before
the test, because of their risk of Nursing Implications and
contrast-induced renal failure. Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients who are in renal failure.

Pretest:
imaging: ➤ Inform the patient that the proce-
• Inability of the patient to cooperate or dure will be performed by a physi-
cian and will take 1 to 2 hours.
because of age, significant pain, or ➤ Inform the patient that the proce-
mental status dure is not painful, but there may be
moments of discomfort.
• Metallic objects within the examina- ➤ Inform the patient that a burning and
tion field (e.g., jewelry or body rings), flushing sensation may be felt
which may inhibit organ visualization throughout the body during the
and can produce unclear images injection of contrast medium. For 5
minutes after the injection of the
• Improper adjustment of the radi- contrast medium, the patient may
ographic equipment to accommodate experience an urge to cough, flush-
obese or thin patients, which can cause ing, nausea, or a salty or metallic
overexposure or underexposure and a taste.
poor-quality study ➤ An informed consent needs to be
• Patients who are very obese, who may
exceed the weight limit for the equip- ➤ Instruct the patient regarding the
ment importance of lying motionless
throughout the procedure.
• Incorrect positioning of the patient, ➤ Instruct patient to avoid taking anti-
which may produce poor visualization coagulant medication or to reduce
of the area to be examined the dosage as ordered before the
procedure.
Other considerations: ➤ Patients receiving metformin
• Failure to follow dietary restrictions (Glucophage) for non–insulin-
before the procedure may cause the dependent (type 2) diabetes should
procedure to be canceled or repeated. discontinue the drug on the day of
• Consultation with the radiologist for 48 hours after the test. Failure to
should occur before the procedure do so may result in lactic acidosis.
for radiation safety concerns regard- ➤ Ensure that food and fluids have
ing infants and patients who are lactat- been restricted for at least 8 hours
ing. before the procedure.
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.
➤ Observe the catheter insertion branch of medicine sends a written

site for bleeding, inflammation, or report to the ordering provider, who
hematoma formation. discusses the results with the
➤ Monitor for absence of pulse distal patient.
to catheter insertion site. ➤ Evaluate test results in relation
➤ Assess neurologic status and vital to the patient’s symptoms and
signs every 15 minutes for 2 hours other tests performed. Related
or as directed. diagnostic tests include nuclear
imaging, computed tomography,
➤ Observe for a delayed allergic reac- magnetic resonance imaging, and
tion to contrast medium. positron emission tomography of
➤ A physician who specializes in this the heart.
ANGIOGRAPHY, MAGNETIC
RESONANCE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: MRA.
AREA OF APPLICATION: Vascular.
CONTRAST: Can be done with or without contrast (gadolinium).
DESCRIPTION: Magnetic resonance out the use of ionizing radiation or

imaging (MRI) uses a magnet and the interference of bone or surround-
radio waves to produce an energy ing tissue.
field that can be displayed as an Magnetic resonance angiography
image. The magnetic field causes the (MRA) is an application of MRI that
hydrogen atoms in tissue to line up, provides images of blood flow and
and when radio waves are directed diseased and normal blood vessels. In
toward the magnetic field, the atoms patients who are allergic to iodinated
absorb the radio waves and change contrast medium, MRA is used in
their position. When the radio waves place of angiography. MRA is partic-
are turned off, the atoms go back to ularly useful for visualizing vascular
their original position, this change in abnormalities, dissections, and other
the energy field is sensed by the pathology. Special imaging sequences
equipment, and an image is generated allow the visualization of moving
by the attached computer system. blood within the vascular system. Two
MRI produces cross-sectional images common techniques to obtain images
of the vessels in multiple planes with- of flowing blood are time-of-flight
Angiography, Magnetic Resonance 69
and phase-contrast MRA. In time-of- Abnormal Findings:

flight imaging, incoming blood • Coarctations
makes the vessels appear bright and • Dissections
surrounding tissue is suppressed. • Thrombosis within a vessel
Phase-contrast images are produced
• Tumor invasion of a vessel
by subtracting the stationary tissue
surrounding the vessels where the • Vascular abnormalities
blood is moving through vessels • Vessel stenosis
during the imaging, producing high- • Vessel occlusion
contrast images. MRA is the most
accurate technique for imaging blood CRITICAL VALUES: N/A
flowing in veins and small arteries
(laminar flow), but it does not accu- INTERFERING FACTORS
rately depict blood flow in tortuous
sections of vessels and distal to bifur- This procedure is contraindicated
for:
cations and stenosis. Swirling blood
may cause a signal loss and result in • Patients with certain ferrous metal
prosthetics, valves, aneurysm clips,
inadequate images, and the degree of
inner ear prostheses, or other metallic
vessel stenosis may be overestimated. objects
Images can be obtained in two-
dimensional (series of slices) or three- • Patients with metal in their body, such
dimensional sequences. ■ as shrapnel or ferrous metal in the eye
• Patients with cardiac pacemakers,
INDICATIONS: because the pacemaker can be
• Detect thoracic and abdominal vascu- deactivated by MRI
lar diseases
• Patients who are claustrophobic
• Identify congenital vascular diseases
• Patients who are pregnant or suspected
• Determine renal artery stenosis of being pregnant, unless the poten-
tial benefits of the procedure far
• Evaluate postoperative angioplasty sites
outweigh the risks to the fetus and
and bypass grafts
mother
• Detect pericardial abnormalities
• Detect peripheral vascular disease
imaging:
• Differentiate aortic aneurysms from
tumors near the aorta • Inability of the patient to cooperate or
• Evaluate cardiac chambers and because of age, significant pain, or
pulmonary vessels mental status
• Monitor and evaluate the effectiveness • Patients with extreme cases of claustro-
of medical or surgical treatment phobia, unless sedation is given before
the study
RESULT
Normal Findings: exceed the weight limit for the equip-
ment
• Normal blood flow in the area being
examined, including blood flow rate • Incorrect positioning of the patient,
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,
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Pulmonary angiography, pulmonary arteriography.

AREA OF APPLICATION: Pulmonary vasculature.
DESCRIPTION: Pulmonary angiogra- • Detect tumors; aneurysms; congenital

phy allows x-ray visualization of the defects; vascular changes associated
pulmonary vasculature after injection with emphysema, blebs, and bullae;
of an iodinated contrast medium into and heart abnormalities
the pulmonary artery or a branch of • Evaluate pulmonary circulation
this great vessel. Contrast medium is
• Determine the cause of recurrent or
injected through a catheter that has severe hemoptysis
been inserted into the vascular
system, usually through the femoral • Detect arteriovenous malformations or
vein. It is one of the definitive tests for aneurysms
pulmonary embolism, but it is also
useful for evaluating other types of RESULT
pulmonary vascular abnormalities. It
Normal Findings:
is definitive for peripheral pulmonary
artery stenosis, anomalous pulmonary • Normal pulmonary vasculature;
radiopaque iodine contrast medium
venous drainage, and pulmonary
should circulate symmetrically and
fistulae. Hemodynamic measure- without interruption through the
ments during pulmonary angiogra- pulmonary circulatory system.
phy can assist in the diagnosis of
pulmonary hypertension and cor Abnormal Findings:
pulmonale. ■ • Aneurysms
• Arterial hypoplasia or stenosis
INDICATIONS:
• Detect acute pulmonary embolism • Arteriovenous malformations
• Bleeding caused by tuberculosis, • Incorrect positioning of the patient,

bronchiectasis, sarcoidosis, or asper- which may produce poor visualization
gilloma of the area to be examined
• Inflammatory diseases • Metallic objects within the examina-
• Pulmonary embolism (acute or tion field (e.g., jewelry or body rings),
chronic) which may inhibit organ visualization
• Pulmonary sequestration and can produce unclear images
• Tumors Other considerations:
CRITICAL VALUES: N/A • Failure to follow dietary restrictions
INTERFERING FACTORS procedure to be canceled or repeated.
• Consultation with a physician should
This procedure is contraindicated occur before the procedure for radia-
for:
tion safety concerns regarding infants
• Patients with allergies to shellfish or of patients who are lactating.
medium used may cause a life- • Risks associated with radiographic
threatening allergic reaction. Patients overexposure can result from frequent
with a known hypersensitivity to x-ray procedures. Personnel in the
contrast medium may benefit from room with the patient should wear a
premedication with corticosteroids or protective lead apron, stand behind a
the use of nonionic contrast medium. shield, or leave the area while the
examination is being done. Personnel
• Patients who are pregnant or suspected working in the area where the exami-
of being pregnant, unless the potential nation is being done should wear
benefits of the procedure far outweigh badges that reveal their level of expo-
the risks to the fetus and mother. sure to radiation.
• Elderly and other patients who are
chronically dehydrated before
the test, because of their risk of
contrast-induced renal failure.
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
imaging: ➤ Inform the patient that the proce-
dure will be performed by a physi-
• Inability of the patient to cooperate or cian and will take 60 minutes.
because of age, significant pain, or ➤ Inform the patient that the proce-
dure is not painful, but there may be
mental status moments of discomfort.
• Improper adjustment of the radio- ➤ Inform the patient that a burning and
graphic equipment to accommodate flushing sensation may be felt
obese or thin patients, which can cause throughout the body during the
overexposure or underexposure and a injection of the contrast medium.
poor-quality study Also, for 5 minutes after the injec-
tion of the contrast medium, the
• Patients who are very obese, who may patient may experience an urge to
exceed the weight limit for the equip- cough, flushing, nausea, or a salty or
ment metallic taste.
Angiography, Pulmonary 73
➤ An informed consent needs to be ➤ Using a pen, mark the site of the

obtained and witnessed. patient’s peripheral pulses before
➤ Instruct the patient regarding the angiography; this allows quicker and
importance of lying motionless more consistent assessment of the
throughout the procedure. pulses after the procedure.
➤ Obtain a list of medications the ➤ Place electrocardiographic elec-
patient is taking. trodes on the patient for cardiac
monitoring. Establish baseline
➤ Instruct the patient to avoid taking rhythm; determine if the patient has
anticoagulant medication or to ventricular arrhythmias.
reduce the dosage as ordered
before the procedure. ➤ Establish intravenous fluid line for
the injection of contrast medium,
➤ Patients receiving metformin emergency drugs, and sedatives.
(Glucophage) for non–insulin-
dependent (type 2) diabetes should ➤ Administer a mild sedative as
discontinue the drug on the day of ordered.
the test and continue to withhold it ➤ Place the patient in the supine posi-
for 48 hours after the test. Failure to tion on an x-ray table. Cleanse the
do so may result in lactic acidosis. selected vein, and cover with a ster-
➤ Ensure that food and fluids have ile drape.
been restricted for at least 8 hours ➤ A local anesthetic is injected at the
before the procedure. site, and a small incision is made or
➤ Instruct the patient to remove a needle inserted. The catheter is
dentures, metallic objects, and valu- inserted into the femoral, brachial, or
ables before the test. jugular vein and threaded into the
inferior vena cava and right side of
➤ Obtain a history of known hypersen- the heart under fluoroscopy. From
sitivity to iodine, seafood, or the right ventricle, the catheter is
contrast medium from previous x-ray threaded into the pulmonary circula-
procedures. Obtain a history of tion. A rapid series of images is
ventricular arrhythmias or asthma. obtained, with at least two views
For other tests, refer to the respira- of each lung obtained after the
tory system table. contrast-medium injection.
➤ Ascertain recent coagulation times, ➤ Monitor the patient for complica-
blood urea nitrogen, and creatinine tions related to the contrast medium
values, as ordered. (e.g., allergic reaction, anaphylaxis,
➤ Complications of this procedure may bronchospasm) or to catheterization
include cardiac arrhythmias, reaction (e.g., arrhythmias, cardiac or vessel
to the iodinated contrast medium, perforation).
vascular perforation, and arterial ➤ The catheter is removed, and a pres-
infarct. sure dressing is applied over the
➤ Obtain and record baseline vital puncture site.
signs. ➤ Assess extremities for signs of
ischemia caused by a catheter-
Intratest: induced thrombus.
➤ Have emergency equipment readily Post-test:
accessible.
➤ If the patient has a history of severe ➤ Instruct the patient to resume
allergic reactions to any substance ordered medications that were
or drug, administer ordered prophy- discontinued before the procedure.
lactic steroids or antihistamines Renal function should be assessed
before the procedure. Use nonionic before metformin is restarted.
contrast medium for the procedure. ➤ Instruct the patient to maintain bed
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Renal angiogram, renal arteriography.

AREA OF APPLICATION: Kidney.
DESCRIPTION: Renal angiography can be viewed to help diagnose the

allows x-ray visualization of the large presence of vascular abnormalities,
and small arteries of the renal vascula- trauma, or lesions. This definitive test
ture and parenchyma or the renal for renal disease may be used to eval-
veins and their branches. Contrast uate chronic renal disease, renal fail-
medium is injected through a catheter ure, and renal artery stenosis;
that has been inserted into the differentiate a vascular renal cyst from
femoral artery or vein and advanced hypervascular renal cancers; and
through the iliac artery and aorta into evaluate renal transplant donors,
the renal artery or the inferior vena recipients, and the kidney after trans-
cava into the renal vein. Images of the plantation. ■
kidneys and associated vessels are
displayed on a monitor and recorded INDICATIONS:
on film or electronically. Patterns • Detect renal tumors as evidenced by
of circulation, renal function, or arterial supply, extent of venous inva-
changes in vessel wall appearance sion, and tumor vascularity
Angiography, Renal 75
• Differentiate between renal tumors organs, malformations, cysts, or

and renal cysts tumors
• Detect nonmalignant tumors before
Abnormal Findings:
surgical resection
• Abscess or inflammation
• Allow infusion of thrombolytic drugs
into an occluded artery • Arterial stenosis, dysplasia, or infarc-
tion
• Perform angioplasty, perform atherec-
tomy, or place a stent • Arteriovenous fistula or other abnor-
malities
• Detect renal artery stenosis as evidenced
by vessel dilation, collateral vessels, or • Congenital anomalies
increased renovascular pressure • Intrarenal hematoma
• Detect arterial occlusion as evidenced • Renal artery aneurysm
by a transection of the renal artery
caused by trauma or a penetrating • Renal cysts or tumors
injury • Trauma causing tears or other disrup-
• Evaluate tumor vascularity before tion
surgery or embolization
• Evaluate the renal vascular system of
prospective kidney donors before
surgery
INTERFERING FACTORS
• Detect thrombosis, arteriovenous fistu- This procedure is contraindicated
lae, aneurysms, or emboli in renal for:
vessels • Patients with allergies to shellfish or
• Evaluate postoperative renal transplan-
tation for function or organ rejection
• Detect small kidney or absence of a with a known hypersensitivity to
kidney contrast medium may benefit from
• Evaluate renal function in chronic
the use of nonionic contrast medium.
renal failure or end-stage renal disease
or hydronephrosis • Patients with bleeding disorders.
• Collect blood samples from renal vein • Patients who are pregnant or suspected
for renin analysis of being pregnant, unless the potential
benefits of the procedure far outweigh
RESULT the risks to the fetus and mother.
Normal Findings: chronically dehydrated before
• Normal structure, function, and the test, because of their risk of
patency of renal vessels contrast-induced renal failure.
• Contrast medium circulating through- • Patients who are in renal failure.
out the kidneys symmetrically and
without interruption Factors that may impair clear
• No evidence of obstruction, variations imaging:
in number and size of vessels and • Gas or feces in the gastrointestinal tract
resulting from inadequate cleansing or badges that reveal their level of expo-
failure to restrict food intake before the sure to radiation.
study
ologic procedure Nursing Implications and
• Inability of the patient to cooperate or Procedure ● ● ● ● ● ● ● ● ● ● ●

because of age, significant pain, or Pretest:
mental status ➤ Inform the patient that the physician
• Metallic objects within the examina- will take 1 to 2 hours to perform the
procedure.
tion field (e.g., jewelry, earrings, dental
amalgams), which may inhibit organ ➤ Inform the patient that the proce-
visualization and can produce unclear dure is not painful, but there may be
moments of discomfort.
images
➤ Inform the patient that a burning and
• Improper adjustment of the radi- flushing sensation may be felt
ographic equipment to accommodate throughout the body during injection
obese or thin patients, which can cause of the contrast medium. After the
overexposure or underexposure and a injection of the contrast medium,
poor-quality study the patient may experience an urge
to cough, flushing, nausea, or a salty
• Patients who are very obese, who may or metallic taste.
exceed the weight limit for the equip- ➤ An informed consent needs to be
ment obtained and witnessed.
• Incorrect positioning of the patient, ➤ Determine date of last menstrual
which may produce poor visualization period and possibility of pregnancy
of the area to be examined in perimenopausal women.
Other considerations: importance of lying motionless
• Failure to follow dietary restrictions throughout the procedure.
before the procedure may cause the ➤ Instruct patient to avoid taking anti-
procedure to be canceled or repeated. coagulant medication or to reduce
Failure to withhold dietary sodium or the dosage as ordered before the
procedure.
medications may interfere with accu-
rate analysis of blood sample for renin ➤ Patients receiving metformin
when done during renal venography. (Glucophage) for non–insulin-
dependent (type 2) diabetes should
• Consultation with a physician should discontinue the drug on the day of
occur before the procedure for radia- the test and continue to withhold it
tion safety concerns regarding infants for 48 hours after the test. Failure to
of patients who are lactating. do so may result in lactic acidosis.
➤ Ensure that food has been restricted
• Risks associated with radiographic for at least 8 hours before the proce-
overexposure can result from frequent dure.
x-ray procedures. Personnel in the ➤ Instruct the patient to remove
room with the patient should wear a dentures, metallic objects, and valu-
protective lead apron, stand behind a ables before the test.
shield, or leave the area while the ➤ Obtain a history of known hyper-
examination is being done. Personnel sensitivity to iodine, seafood, or
working in the area where the exami- contrast medium from previous x-ray
nation is being done should wear procedures.
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
needed, to reduce discomfort or ten report that is sent to the ordering

edema. provider, who discusses the results
➤ Monitor for absence of pulse distal with the patient.
to catheter insertion site. ➤ Evaluate test results in relation to
➤ Assess neurologic status and vital the patient’s symptoms and other
signs every 15 minutes for 2 hours tests performed. Related diagnostic
or as directed. tests include computed tomography
(CT) and magnetic resonance
➤ Observe for a delayed allergic reac- angiography of the kidneys; and
tion to contrast medium. positron emission tomography, CT,
➤ A physician who specializes in this and magnetic resonance imaging of
branch of medicine prepares a writ- the abdomen.
ANGIOTENSIN-CONVERTING
ENZYME
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Angiotensin-I-converting enzyme (ACE).

Conventional SI Units (Conversion

Age Units Factor 0.017)
0–2 y 5–83 U/L 0.09–1.41 Kat/L
3–7 y 8–76 U/L 0.14–1.29 Kat/L
8–14 y 6–89 U/L 0.10–1.51 Kat/L
Greater than 14 y 8–52 U/L 0.14–0.88 Kat/L
DESCRIPTION: Angiotensin-convert- aldosterone. Aldosterone is a hor-

ing enzyme (ACE) production occurs mone that helps the kidneys maintain
mainly in the epithelial cells of water balance by retaining sodium
the pulmonary bed. Smaller amounts and promoting the excretion of potas-
are found in blood vessels and sium.
renal tissue, where ACE converts ACE levels are used primarily in
angiotensin I to angiotensin II; this the evaluation of hypertension and
conversion helps regulate arterial active sarcoidosis, a granulomatous
blood pressure. Angiotensin II stimu- disease that can affect many organs,
lates the adrenal cortex to produce including the lungs. Serial levels are
Angiotensin-Converting Enzyme 79
useful in correlating the therapeutic • Connective tissue disease

response to corticosteroid treatment. • Gaucher’s disease
Increasing ACE levels with positive
gallium scans in sarcoidosis patients • Hansen’s disease (leprosy)
receiving steroids indicate a poor • Histoplasmosis and other fungal
response to therapy. Monitoring diseases
ACE levels may also have some • Hyperthyroidism (untreated)
utility in assessing the risk of
pulmonary damage in affected • Pulmonary fibrosis
patients receiving antineoplastic • Rheumatoid arthritis
agents. Thyroid hormones may play a
• Sarcoidosis
role in regulating ACE levels:
decreased levels have been noted in Decreased in:
patients with clinical hypothyroidism • Advanced pulmonary carcinoma
and anorexia nervosa, whereas
increased levels have been noted in • The period following corticosteroid
patients with hyperthyroidism. therapy for sarcoidosis
Elevations of serum ACE have been
reported in 20 to 30 percent of
patients with abnormal 1- INTERFERING FACTORS:
antitrypsin variants. ACE levels are • Drugs that may increase serum ACE
sometimes ordered on cerebrospinal levels include triiodothyronine.
fluid to evaluate patients with
• Drugs that may decrease serum
neurosarcoidosis. Results must be
ACE levels include captopril, cilaza-
interpreted with care because of pril, enalapril, fosinopril, lisinopril,
the nonspecificity of increased nicardipine, pentopril, perindopril,
and decreased ACE levels. ACE propranolol, quinapril, ramipril, and
is normally elevated in pediatric trandolapril.
patients and therefore is not a useful
• Prompt and proper specimen process-
marker in the evaluation of disease for ing, storage, and analysis are important
patients less than 20 years of age. ■ to achieve accurate results. Failure to
freeze sample if not tested immediately
INDICATIONS: may cause falsely decreased values
• Assist in establishing a diagnosis of because ACE degrades rapidly.
sarcoidosis
• Assist in the evaluation of Gaucher’s
disease Nursing Implications and
• Assist in the treatment of sarcoidosis Procedure ● ● ● ● ● ● ● ● ● ● ●
• Evaluate hypertension Pretest:

• Evaluate the severity and activity of ➤ Obtain a history of the patient’s
sarcoidosis complaints, including a list of known
allergens.
RESULT ➤ Obtain a history of the patient’s
endocrine, immune, musculoskele-
Increased in: tal, and respiratory systems, as well
• Bronchitis (acute and chronic) as results of previously performed
tests and procedures. For related be regulated. Educate patients with

tests, refer to the endocrine, low sodium levels that the major
immune, musculoskeletal, and respi- source of dietary sodium is found in
ratory system tables. table salt. Many foods such as milk
➤ Obtain a list of the medications the and other dairy products are also
patient is taking, including herbs, good sources of dietary sodium.
nutritional supplements, and nutra- Most other dietary sodium is
ceuticals. The requesting health care available through consumption of
practitioner and laboratory should be processed foods. Patients who need
advised if the patient regularly uses to follow low-sodium diets should
these products so that their effects be advised to avoid beverages such
can be taken into consideration as colas, ginger ale, Gatorade,
when reviewing results. lemon-lime sodas, and root beer.
Many over-the-counter medications,
➤ There are no food, fluid, or medica- including antacids, laxatives, anal-
tion restrictions unless by medical gesics, sedatives, and antitussives,
direction. contain significant amounts of
➤ Note the patient’s age. This test is sodium. The best advice is to
rarely ordered on patients less than emphasize the importance of read-
20 years old. ing all food, beverage, and medicine
➤ Review the procedure with the labels. In 1989, the Subcommi-
patient. ttee on the 10th Edition of the
Recommended Dietary Allowances
➤ Inform the patient that specimen (RDAs) established 500 mg as the
collection usually takes 5 to 10 recommended minimum limit for
minutes. dietary intake of sodium. There are
no RDAs established for potassium,
Intratest: but the estimated minimum intake
➤ Direct the patient to breathe for adults is 200 mEq/d. Potassium
normally and to avoid unnecessary is present in all plant and animal
movement. cells, making dietary replacement
fairly simple. A health care practi-
➤ Observe standard precautions and tioner or nutritionist should be
follow the general guidelines in consulted before considering the
Appendix A. use of salt substitutes.
➤ Perform a venipuncture, and collect ➤ Evaluate test results in relation to
the specimen in a 5-mL red- or tiger- the patient’s symptoms and other
top tube. tests performed. Related laboratory
➤ Label the specimen, and promptly tests include aldosterone, alkaline
transport it to the laboratory. phosphatase, 1-antitrypsin, 1-
antitrypsin phenotyping, arterial/
Post-test: alveolar oxygen ratio, anion gap,
blood gases, serum and urine
➤ Observe venipuncture site for bleed- calcium, electrolytes, erythrocyte
ing or hematoma formation. Apply sedimentation rate, urine protein,
pressure bandage. liver biopsy, lymph node biopsy,
➤ ACE levels affect the regulation of phosphorus, potassium, protein
fluid balance and electrolytes. electrophoresis, renin, rheumatoid
Dietary adjustment may be consid- factor, skin biopsy, sodium, and
ered if sodium allowances need to thyroid hormone levels.
Anion Gap 81
ANION GAP
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: AG, Agap.

SPECIMEN: Serum (1 mL) for electrolytes collected in a red- or tiger-top
tube. Plasma (1 mL) collected in green-top (heparin) tube is also acceptable.
REFERENCE VALUE: (Method: Anion gap is derived mathematically from

the direct measurement of sodium, chloride, and total carbon dioxide.)
There are differences between serum and plasma values for some elec-
trolytes. The reference ranges listed are based on serum values.

Age Units Factor 1)
Child 8–16 mEq/L 8–16 mmol/L
Adult 8–16 mEq/L 8–16 mmol/L
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
• Ketoacidosis caused by starvation,

high-protein/low-carbohydrate diet, Nursing Implications and
diabetes, and alcoholism Procedure ● ● ● ● ● ● ● ● ● ● ●
• Lactic acidosis Pretest:

• Poisoning (salicylate, methanol, ethyl- ➤ Obtain a history of the patient’s
ene glycol, or paraldehyde) complaints, including a list of known
allergens.
• Renal failure
• Uremia cardiovascular, endocrine, gastroin-
testinal, genitourinary, hematopoi-
Decreased in: etic, immune, and respiratory
systems, as well as results of previ-
• Hyperchloremia
ously performed tests and proce-
• Hypergammaglobulinemia (multiple dures. For other related tests, refer
myeloma) to the cardiovascular, endocrine,
gastrointestinal, genitourinary,
• Hypoalbuminemia hematopoietic, immune, and respira-
tory system tables.
• Hyponatremia (hyperviscosity syn-
dromes) ➤ Obtain a list of the medications the
patient is taking, including herbs,
TCO2 is commonly substituted for nutritional supplements, and
HCO3 in anion gap calculations. It is nutraceuticals. The requesting health
important to note the clinical signifi- care practitioner and laboratory
cance of excessive HCO3, which occurs should be advised if the patient
regularly uses these products so
in renal alkalosis, gastrointestinal alkalo-
sis, and excessive ingestion of exogenous consideration when reviewing
sources of alkali, the effects of which may results.
not be accurately reflected by the calcu-
lated anion gap. tion restrictions unless by medical
direction.
CRITICAL VALUES: N/A ➤ Review the procedure with the
patient.
INTERFERING FACTORS ➤ Inform the patient that specimen
• Drugs that can increase or decrease the collection takes approximately 5 to
anion gap include those listed in the 10 minutes.
individual electrolyte (i.e., sodium,
chloride, calcium, magnesium, and Intratest:
total carbon dioxide), total protein, ➤ Direct the patient to breathe
lactic acid, and phosphorus mono- normally and to avoid unnecessary
graphs. movement.
• Specimens should never be collected ➤ Observe standard precautions and
above an intravenous line because of follow the general guidelines in
the potential for dilution when the Appendix A. Perform a venipuncture,
specimen and the intravenous solution and collect the specimen in a 5-mL
combine in the collection container,
falsely decreasing the result. There is ➤ Label the specimen, and promptly
also the potential of contaminating the transport it to the laboratory.
sample with the substance of interest,
Post-test:
contained in the intravenous solution,
falsely increasing the result. ➤ Observe venipuncture site for bleed-
Anion Gap 83
ing or hematoma formation. Apply common finding in geriatric patients

pressure bandage. and patients with decreased renal
➤ Specific dietary considerations are function.
listed in the monographs on individ- ➤ Evaluate test results in relation
ual electrolytes (i.e., sodium, chlo- to the patient’s symptoms and
ride, calcium, and magnesium), total other tests performed. Related
protein, and phosphorus. laboratory tests include albumin,
➤ The anion gap can be used to blood gases, creatinine, electrolytes,
indicate the presence of dehydra- ethanol, glucose, ketones, lactic
tion. Evaluate the patient for signs acid, osmolality, protein, protein
and symptoms of dehydration. electrophoresis, salicylate, blood
Dehydration is a significant and urea nitrogen, and urinalysis.
ANTIARRHYTHMIC DRUGS: DIGOXIN,

DISOPYRAMIDE, FLECAINIDE,
LIDOCAINE, PROCAINAMIDE,
QUINIDINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Digoxin (Allocar, Cardioreg, Digacin, Lanocor,

Lanoxicaps, Lanoxin, Lenoxin, Purgoxin); disopyramide (Dicorynan,
Napamide, Norpace, Rhythmodan, Ritmilen); flecainide (Almartyn,
Tambocor); lidocaine (Anestacon, Baylocaine, Dalcaine, Dilocaine, Duo-Trach,
LidoPen, Lignocaine, Nervocaine, Norocaine, Octocaine, Xylocaine);
procainamide (Biocoryl, Novocainamidum, Novocamid, Procaine Amide
Hydrochloride, Procan SR, Pronestyl, Pronestyl SR, Retard, Rhythmin); quini-
dine (Biquin, Cardioquin, Cin-Quin, Kiditard, Kinidin, Quinaglute, Dura-
Tabs, Quinalan, Quinidex, Extentabs, Quini, Durules, Quinora, Systodin).
Route of Recommended
Drug Administration Collection Time
Digoxin Oral Trough: 12–24 h after dose
Never draw peak samples
Disopyramide Oral Trough: immediately before
next dose
Peak: 2–5 h after dose
Flecainide Oral Trough: immediately before
next dose
Peak: 3 h after dose
Lidocaine IV 15 min, 1 h, then every 24 h
Procainamide IV 15 min; 2, 6, 12 hours; then
every 24 h
Procainamide Oral Trough: immediately before
next dose
Peak: 75 min after dose
Quinidine sulfate Oral Trough: immediately before
next dose
Quinidine gluconate Oral Trough: immediately before
next dose
Quinidine polygalac- Oral Trough: immediately before
turonate next dose
IV intravenous.
Drug Therapeutic Volume of Protein
(Indication) Dose* SI Units Half-Life (h) Distribution (L/kg) Binding (%) Excretion

(Conversion Factor 1.28)
Digoxin 1.5–2.0 ng/mL 1.9–2.6 nmol/L 20–60 7 20–30 60% renal
(arrhythmias) 40% hepatic
Digoxin (CHF) 0.8–1.5 ng/mL 1.0–1.9 nmol/L

Disopyramide 2.8–3.2 g/mL 8.3–9.4 mol/L 4–10 0.7–0.9 50–80 50% renal
(atrial 50% hepatic
arrhythmias)
Disopyramide 3.3–7.5 g/mL 9.7–22.1 mol/L
(ventricular
arrhythmias)
Flecainide 0.2–1.0 g/mL 0.5–2.4 mol/L 7–27 5–13 30–60 30% renal
70% hepatic
Lidocaine 1.5–6.0 g/mL 6.4–26 mol/L 1.5–2 1–1.5 60–70 90% hepatic
Procainamide 4–10 g/mL 17–42 mol/L 2–6 2–4 10–20 50% renal
50% hepatic
N-acetyl 5–30 g/mL 18–108 mol/L 8
procainamide
Quinidine 2–5 g/mL 6–15 mol/L 6–8 2–3 80–90 10–30% renal
85
60–80% hepatic
CHF congestive heart failure.
DESCRIPTION: Cardiac glycosides are and trough collection times should

used in the prophylactic management be documented carefully in relation
and treatment of heart failure and to the time of medication administra-
ventricular and atrial arrhythmias. tion. ■
Because these drugs have narrow
therapeutic windows, they must be
monitored closely. The signs and IMPORTANT NOTE: This information
must be communicated clearly and accu-
symptoms of toxicity are often diffi-
rately to avoid misunderstanding of the
cult to distinguish from those of dose time in relation to the collection
cardiac disease. Patients with toxic time. Miscommunication between the
levels may show gastrointestinal, individual administering the medication
ocular, and central nervous system and the individual collecting the speci-
effects and disturbances in potassium men is the most frequent cause of
balance. subtherapeutic levels, toxic levels, and
Many factors must be considered misleading information used in the calcu-
in effective dosing and monitoring lation of future doses.
of therapeutic drugs, including
patient age, patient weight, interact- INDICATIONS:
ing medications, electrolyte balance, • Assist in the diagnosis and prevention
protein levels, water balance, condi- of toxicity
tions that affect absorption and • Monitor compliance to therapeutic
excretion, and the ingestion of regimen
substances (e.g., foods, herbals, vita- • Monitor patients who have a pace-
mins, and minerals) that can maker, who have impaired renal or
either potentiate or inhibit the hepatic function, or who are taking
intended target concentration. Peak interacting drugs
RESULT
Level Result
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Digoxin Renal impairment, CHF, elderly patients
Disopyramide Renal or hepatic impairment
Flecainide Renal or hepatic impairment, CHF
Lidocaine Hepatic impairment, CHF
Procainamide Renal impairment
Quinidine Hepatic impairment, CHF, elderly patients
CHF congestive heart failure.
CRITICAL VALUES: Adverse effects Digoxin: Greater Than 2.5 ng/mL

of subtherapeutic levels are important.
Care should be taken to investigate the Signs and symptoms of digoxin toxicity
signs and symptoms of too little and too include arrhythmias, anorexia, hyper-
much medication. kalemia, nausea, vomiting, diarrhea,
Antiarrhythmic Drugs: Digoxin, Disopyramide, Flecainide, Lidocaine, Procainamide, Quinidine 87
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.
Flecainide: Greater than 1 g/mL INTERFERING FACTORS:

• Drugs that may increase digoxin
Signs and symptoms of flecainide toxicity levels or increase risk of toxicity
include exaggerated pharmacologic include amiodarone, amphotericin B,
effects resulting in arrhythmia. Possible diltiazem, diclofenac, erythromycin,
interventions include discontinuing the propantheline, quinidine, spironolac-
medication as well as continuous ECG, tone, tetracycline, and verapamil.
respiratory, and blood pressure monitor-
ing. • Drugs that may decrease digoxin
levels include aluminum hydroxide
(antacids), cholestyramine, colestipol,
Lidocaine: Greater Than 9 g/mL
kaolin-pectin, metoclopramide, neo-
Signs and symptoms of lidocaine toxicity mycin, phenytoin, and sulfasalazine.
• 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.
• Drugs that may increase quinidine Procedure ● ● ● ● ● ● ● ● ● ● ●
levels or increase risk of toxicity

include amiodarone, cimetidine, vera- Pretest:
pamil, and thiazide diuretics.
• Drugs that may decrease quinidine complaints, including a list of known
levels include disopyramide, nifedi- allergens.
pine, phenobarbital, phenytoin, and ➤ Review results of previously
rifampin. performed tests and procedures. For
• Digitoxin cross-reacts with digoxin; cular system and therapeutic/toxicol-
results are falsely elevated if digoxin is ogy tables.
measured when the patient is taking ➤ Obtain a list of the medications
digitoxin. the patient is taking, including
• Digitalis-like immunoreactive sub- herbs, nutritional supplements, and
nutraceuticals. The requesting health
stances are found in the sera of some care practitioner and laboratory
patients who are not taking digoxin, should be advised if the patient
causing false-positive results. Patients regularly uses these products so
whose sera contain digitalis-like that their effects can be taken into
immunoreactive substances usually consideration when reviewing
have a condition related to salt and results.
fluid retention, such as renal failure, ➤ There are no food, fluid, or medica-
hepatic failure, low renin hypertension, tion restrictions unless by medical
and pregnancy. direction.
• Unexpectedly low digoxin levels may ➤ Review the procedure with the
patient.
be found in patients with thyroid
disease. ➤ Inform the patient that specimen
• Disopyramide may cause a decrease in 10 minutes.
Antiarrhythmic Drugs: Digoxin, Disopyramide, Flecainide, Lidocaine, Procainamide, Quinidine 89
Intratest: tance of following the medication

regimen and instructions regarding
➤ Direct the patient to breathe drug interactions. Instruct the
normally and to avoid unnecessary patient to report any unusual sensa-
movement. tions, such as dizziness or blurry
➤ Observe standard precautions and vision, immediately to his or her
follow the general guidelines in health care practitioner.
Appendix A. Consider recom- ➤ Instruct the patient to be prepared to
mended collection time around provide the pharmacist with a list of
dosing schedule. Perform a veni- other medications he or she is
puncture, and collect the specimen already taking in the event that the
in a 5-mL red-top tube. requesting health care practitioner
➤ Label the specimen, and promptly prescribes a medication.
transport it to the laboratory. ➤ Evaluate test results in relation
to the patient’s symptoms and
Post-test: other tests performed. Related
laboratory tests include alanine
➤ Observe venipuncture site for bleed- aminotransferase, albumin, alkaline
ing or hematoma formation. Apply phosphatase, aspartate aminotrans-
pressure bandage. ferase, creatinine, electrolytes, and
➤ Explain to the patient the impor- urea nitrogen.
ANTIBIOTIC DRUGS—
AMINOGLYCOSIDES: AMIKACIN,
GENTAMICIN, TOBRAMYCIN;
TRICYCLIC GLYCOPEPTIDE:
VANCOMYCIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS: Amikacin (Amikin); gentamicin (Garamycin, Genoptic,

Gentacidin, Gentafair, Gentak, Gentamar, Gentrasul, G-myticin, Oco-
Mycin, Spectro-Genta); tobramycin (Nebcin, Tobrex); vancomycin (Lyphocin,
Vancocin, Vancoled).
Antibiotic Type Administration Collection Time*
Aminoglycosides
Amikacin IV, IM Trough: immediately before
next dose
Peak: 30 min after 30-min IV
Gentamicin IV, IM Trough: immediately before
next dose
infusion
Tobramycin IV, IM Trough: immediately before
next dose
infusion
Tricyclic
glycopeptide
Vancomycin IV, PO Trough: immediately before
next 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.
Therapeutic Volume of Protein
Drug Dose* SI Units Half-Life (h) Distribution (L/kg) Binding (%) Excretion
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
Gentamicin
Trough Less than 2 Less than 4
g/mL mol/L

Tobramycin
Trough Less than 2 Less than 4
g/mL mol/L

Vancomycin
Trough 5–10 g/mL 3–7 mol/L
91
DESCRIPTION: The aminoglycoside herbals, vitamins, and minerals) that

antibiotics amikacin, gentamicin, can either potentiate or inhibit the
and tobramycin are used against intended target concentration. The
many gram-negative (Acinetobacter, most serious side effects of the
Citrobacter, Enterobacter, Escherichia aminoglycosides and vancomycin are
coli, Klebsiella, Proteus, Providencia, renal impairment and irreversible oto-
Pseudomonas, Salmonella, Serratia, toxicity (uncommon). Peak and
and Shigella) and some gram-positive trough collection times should be
(Staphylococcus aureus) pathogenic documented carefully in relation to
microorganisms. Aminoglycosides are the time of medication administra-
poorly absorbed through the gastroin- tion. ■
testinal tract and are most frequently
administered intravenously. IMPORTANT NOTE: This information
Vancomycin is a tricyclic glycopep- must be clearly and accurately communi-
tide antibiotic used against many cated to avoid misunderstanding of the
gram-positive microorganisms, such dose time in relation to the collection
time. Miscommunication between the
as staphylococci, Streptococcus pneu-
individual administering the medication
moniae, group A -hemolytic strepto- and the individual collecting the speci-
cocci, enterococci, Corynebacterium, men is the most frequent cause of
and Clostridium. Vancomycin has also subtherapeutic levels, toxic levels, and
been used in an oral form for the misleading information used in the calcu-
treatment of pseudomembranous lation of future doses. Some pharmacies
colitis resulting from Clostridium use a computerized pharmacokinetic
difficile infection. This approach is approach to dosing that eliminates the
less frequently used because of the need to be concerned about peak and
emergence of vancomycin-resistant trough collections; random specimens are
adequate.
enterococci.
Many factors must be considered
in effective dosing and monitoring of INDICATIONS:
therapeutic drugs, including patient • Assist in the diagnosis and prevention
of toxicity
age, patient weight, interacting med-
ications, electrolyte balance, protein • Monitor renal dialysis patients or
levels, water balance, conditions that patients with rapidly changing renal
affect absorption and excretion, and function
ingestion of substances (e.g., foods, • Monitor therapeutic regimen
RESULT
Level Result
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
Antibiotic Drugs—Aminoglycosides and Tricyclic Glycopeptide 93
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.
Drug Name Toxic Levels

Amikacin Peak greater than 35 g/mL, trough greater than 10 g/mL
Gentamicin Peak greater than 10 g/mL, trough greater than 2 g/mL
Tobramycin Peak greater than 10 g/mL, trough greater than 2 g/mL
Vancomycin Peak greater than 40 g/mL, trough greater than 10 g/mL
INTERFERING FACTORS tion restrictions unless by medical

• Drugs that may decrease aminoglyco- direction.
side efficacy include bleomycin, ➤ Review the procedure with the
daunorubicin, doxorubicin, and peni- patient.
cillins (e.g., carbenicillin, piperacillin). ➤ Inform the patient that specimen
• Obtain a culture before and after the 10 minutes.
first dose of aminoglycosides.
• The risks of ototoxicity and nephrotox- Intratest:
icity are increased by the concomitant ➤ Direct the patient to breathe
administration of aminoglycosides. normally and to avoid unnecessary
movement.
Nursing Implications and follow the general guidelines in Ap-
Procedure ● ● ● ● ● ● ● ● ● ● ● pendix A. Consider recommended
collection time around dosing sched-
Pretest: ule. Perform a venipuncture, and col-
lect the specimen in a 5-mL red-top
➤ Obtain a history of the patient’s tube.
complaints, including a list of known ➤ Label the specimen, and promptly
allergens. transport it to the laboratory.
➤ Review results of previously per-
formed tests and procedures. For Post-test:
related tests, refer to the genitouri-
nary and immune system and thera- ➤ Observe venipuncture site for bleed-
peutic/toxicology tables. ing or hematoma formation. Apply
➤ Obtain a list of the medications the pressure bandage.
patient is taking, including herbs, ➤ Explain to the patient the impor-
nutritional supplements, and tance of following the medication
nutraceuticals. The requesting health regimen and instructions regarding
care practitioner and laboratory food and drug interactions.
regularly uses such products so that the patient’s symptoms and other
their effects can be taken into tests performed. Related laboratory
consideration when reviewing tests include albumin, creatinine,
results. creatinine clearance, blood urea
➤ There are no food, fluid, or medica- nitrogen, and urinalysis.
ANTIBODIES, ANTICYTOPLASMIC
NEUTROPHILIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Cytoplasmic antineutrophil cytoplasmic antibody

(c-ANCA), perinuclear antineutrophil cytoplasmic antibody (p-ANCA).
REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative.
DESCRIPTION: There are two types • Differential diagnosis of ulcerative

of cytoplasmic neutrophil antibodies colitis
identified by their cellular staining
characteristics. c-ANCA (cytoplas-
RESULT
mic) is specific for proteinase 3 in Increased in:
neutrophils and monocytes and is • c-ANCA
found in the sera of patients with Wegener’s granulomatosis and its
Wegener’s granulomatosis. Wegener’s variants
disease includes granulomatous • p-ANCA
inflammation of the upper and lower
Alveolar hemorrhage
respiratory tract and vasculitis.
Angiitis and polyangiitis
p-ANCA (perinuclear) is specific for
Autoimmune liver disease
myeloperoxidase, elastase, and lacto-
Capillaritis
ferrin, as well as other enzymes
Churg-Strauss syndrome
in neutrophils. p-ANCA is present
in the sera of patients with pauci- Felty’s syndrome
immune necrotizing glomerulone- Inflammatory bowel disease
phritis. ■ Leukocytoclastic skin vasculitis
Necrotizing-crescentic
glomerulonephritis
INDICATIONS: Rheumatoid arthritis
• Distinguish between vasculitic disease Vasculitis
and the effects of therapy
• Assist in the diagnosis of Wegener’s Decreased in: N/A
granulomatosis and its variants
• Distinguish between biliary cirrhosis
and sclerosing cholangitis INTERFERING FACTORS: N/A
Antibodies, Anti-Glomerular Basement Membrane 95

Nursing Implications and collection takes approximately 5 to
Procedure ● ● ● ● ● ● ● ● ● ● ● 10 minutes.
Pretest:
Intratest:
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.
Post-test:
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.
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Goodpasture’s antibody, anti-GBM.

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

Negative.
DESCRIPTION: Autoimmune kidney nary, immune, and respiratory sys-

tem tables.
disease can result from the presence of
antibodies to renal glomerular base- ➤ Obtain a list of the medications the
ment membrane (GBM). Of patients tritional supplements, and nutraceu-
with anti-GBM, 10 to 20 percent ticals. The requesting health care
show false-negative results. ■ practitioner and laboratory should be
advised if the patient regularly uses
INDICATIONS: such products so that their effects
can be taken into consideration
• Detect the presence of anti-GBM anti- when reviewing results.
bodies to differentiate glomeru- ➤ There are no food, fluid, or medica-
lonephritis caused by anti-GBM from tion restrictions unless by medical
other causes of glomerulonephritis direction.
RESULT patient.
Increased in: ➤ Inform the patient that specimen
• Glomerulonephritis 10 minutes.
• Goodpasture’s disease
Intratest:
• Idiopathic pulmonary hemosiderosis
Decreased in: N/A normally and to avoid unnecessary
movement.
CRITICAL VALUES: N/A ➤ Observe standard precautions and
follow the general guidelines in Ap-
pendix A. Perform a venipuncture,
INTERFERING FACTORS: N/A and collect the specimen in a 5-mL
red-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Post-test:
Pretest:
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.
Antibodies, Antinuclear, Anti-DNA, and Anticentromere 97
ANTIBODIES, ANTINUCLEAR,
ANTI-DNA, AND ANTICENTROMERE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: ANA, Anti-DNA (Anti-ds DNA).
REFERENCE VALUE: (Method: Indirect fluorescent antibody for ANA and

anticentromere; enzyme-linked immunosorbent assay [ELISA] for Anti-
DNA )
ANA and anticentromere: titer of 1:40 or less
Anti-DNA: titer of less than 1:10
DESCRIPTION: Antinuclear antibod- bodies are detected using Hep-2

ies (ANA) are autoantibodies mainly (human epithelial cultured cells).
located in the nucleus of affected Anti-DNA antibodies can be detected
cells. The presence of ANA indicates using a Crithidia luciliae substrate.
systemic lupus erythematosus (SLE), Women are much more likely than
related collagen vascular diseases, and men to be diagnosed with SLE. ■
immune complex diseases. Antibodies
against cellular DNA are strongly INDICATIONS:
associated with SLE. Anticentromere • Assist in the diagnosis and evaluation
of SLE
antibodies are a subset of ANA.
Their presence is strongly associated • Evaluate suspected immune disorders,
with CREST syndrome (calcinosis, such as rheumatoid arthritis, systemic
Raynaud’s phenomenon, esophageal sclerosis, polymyositis, Sjögren’s syn-
dysfunction, sclerodactyly, telangiec- drome, and mixed connective tissue
disease
tasia). ANA and anticentromere anti-
RESULT
ANA Pattern Associated Antibody

Rim and/or homogeneous Double-stranded DNA
Single- or double-
stranded DNA
(Continued on following page)
ANA Pattern Associated Antibody

Homogeneous Histones
Speckled Sm (Smith) antibody
RNP
SS-B/La, SS-A/Ro
Diffuse speckled with positive mitotic figures Centromere
Nucleolar Nucleolar, RNP
ANA patterns are helpful in that certain conditions are frequently associated with
specific patterns, but the patterns are not diagnostic for a particular disease.
RNP ribonucleoprotein.
Increased in: mune and musculoskeletal systems

and results of previously performed
• Drug-induced lupus erythematosus tests and procedures. For related
tests, refer to the immune and mus-
• Lupoid hepatitis
culoskeletal system tables.
• Mixed connective tissue disease ➤ Obtain a list of the medications the
• Polymyositis
• Progressive systemic sclerosis ticals. The requesting health care
• Rheumatoid arthritis advised if the patient regularly uses
• Sjögren’s disease
• SLE when reviewing results.
Decreased in: N/A tion restrictions unless by medical
direction.
patient.
INTERFERING FACTORS: ➤ Inform the patient that specimen
• Drugs that may cause positive results collection takes approximately 5 to
include carbamazepine, chlorpro- 10 minutes.
mazine, ethosuximide, hydralazine,
isoniazid, mephenytoin, methyldopa, Intratest:
penicillins, phenytoin, primidone, ➤ Direct the patient to breathe
procainamide, and quinidine. normally and to avoid unnecessary
movement.
• A patient can have lupus and test ANA
negative. ➤ Observe standard precautions and
Nursing Implications and red-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
complaints, including a list of known ➤ Observe venipuncture site for bleed-
allergens. ing or hematoma formation. Apply
➤ Obtain a history of the patient’s im- pressure bandage.
Antibodies, Antiscleroderma 99
➤ Educate the patient, as appropriate, addressed on a continuous basis

regarding the importance of prevent- and may require significant changes
ing infection, which is a significant in lifestyle.
cause of death in immunosup- ➤ Evaluate test results in relation
pressed individuals. to the patient’s symptoms and
➤ Recognize anxiety related to test other tests performed. Related
results and offer support, as appro- laboratory tests include anticardi-
priate. Provide teaching and disease olipin antibody, antisclerodermal an-
information, as appropriate. Edu- tibodies, C3, C4, total complement,
cate the patient regarding access erythrocyte sedimentation rate, ex-
to counseling services. Collagen tractable nuclear antibodies, Jo-1 an-
and connective tissue diseases tibody, kidney biopsy, procainamide,
are chronic. As such, they must be rheumatoid factor, and skin biopsy.
ANTIBODIES, ANTISCLERODERMA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Progressive systemic sclerosis antibody, Scl-70

antibody.

REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative.
DESCRIPTION: Antiscleroderma anti- • CREST syndrome

bodies are associated with progressive • Progressive diffuse scleroderma
systemic sclerosis, a condition that af-
fects multiple systems, including the Decreased in: N/A
skin, gastrointestinal tract, lungs,
blood vessels, heart, and kidneys. CRITICAL VALUES: N/A
These antibodies are present in the
sera of patients with CREST syn- INTERFERING FACTORS: N/A
drome (calcinosis, Raynaud’s phe-
nomenon, esophageal dysfunction,
sclerodactyly, telangiectasia). ■ Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
INDICATIONS: Pretest:
• Assist in the diagnosis of scleroderma
RESULT complaints, including a list of known
allergens.
immune and musculoskeletal ➤ Observe standard precautions and

systems and results of previously follow the general guidelines in
performed tests and procedures. Appendix A. Perform a venipuncture,
For related tests, refer to the and collect the specimen in a 5-mL
immune and musculoskeletal red-top tube.
system tables. ➤ Label the specimen, and promptly
➤ Obtain a list of the medications the transport it to the laboratory.
nutritional supplements, and 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 ➤ Collagen diseases are chronic and
consideration when reviewing must be addressed on a continuous
results. basis. Significant changes in lifestyle
➤ There are no food, fluid, or medica- may be required. Recognize anxiety
tion restrictions unless by medical related to test results and offer
direction. support, as appropriate. Educate the
➤ Review the procedure with the patient regarding access to counsel-
patient. ing services.
➤ Inform the patient that specimen ➤ Evaluate test results in relation to
collection takes approximately 5 to the patient’s symptoms and other
10 minutes. tests performed. Related laboratory
tests include anticentromere anti-
Intratest: bodies, anti-DNA antibodies, antinu-
clear antibodies, Jo-1 antibody,
➤ Direct the patient to breathe Sjögren’s antibody, kidney biopsy,
normally and to avoid unnecessary skin biopsy, extractable nuclear anti-
movement. bodies, and rheumatoid factor.
ANTIBODIES, ANTISPERM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: N/A.
Result Sperm Bound by Immunobead (%)

Negative 0–15
Weak positive 16–30
Moderate positive 31–50
Strong positive 51–100
Antibodies, Antisperm 101
DESCRIPTION: A major cause of tritional supplements, and nutraceu-

infertility in men is blocked efferent
testicular ducts. As a result of the reab- advised if the patient regularly uses
sorption of sperm from the blocked these products so that their effects
ducts, antibodies against the sperm can be taken into consideration
may be produced over time and when reviewing results.
thereby may lower the patient’s fertil- ➤ There are no food, fluid, or medica-
tion restrictions unless by medical
ity. Semen and cervical mucus can also
direction.
be tested for antisperm antibodies. ■
patient. Inform the patient that addi-
INDICATIONS: tional specimens may be required.
• Evaluation of infertility Sensitivity to cultural and social
issues, as well as concern for
modesty, is important in providing
RESULT psychological support.
Increased in:
• Blocked testicular efferent duct 10 minutes.
• Postvasectomy
Intratest:
Decreased in: N/A ➤ Direct the patient to breathe
movement.
INTERFERING FACTORS: Appendix A. Perform a venipuncture,
• The patient should not ejaculate for 3 and collect the specimen in a 5-mL
to 4 days before specimen collection if red-top tube.
semen will be evaluated. ➤ Label the specimen, and promptly
• Sperm antibodies have been detected transport it to the laboratory.
in pregnant women and in women
Post-test:
with primary infertility.
pressure bandage.
Nursing Implications and ➤ Recognize anxiety related to test
Procedure ● ● ● ● ● ● ● ● ● ● ●
results. Provide teaching and infor-
mation regarding the clinical impli-
Pretest: cations of the test results, as
appropriate. Provide a supportive,
➤ Obtain a history of the patient’s nonjudgmental environment when
complaints, including a list of known assisting a patient through the
allergens. process of fertility testing. Educate
➤ Obtain a history of the patient’s the patient regarding access to coun-
immune and reproductive systems seling services, as appropriate.
and results of previously performed ➤ Evaluate test results in relation to the
tests and procedures. For related patient’s symptoms and other tests
tests, refer to the immune and performed. Related laboratory tests
reproductive system tables. include luteinizing hormone, proges-
➤ Obtain a list of the medications the terone, semen analysis, and testos-
patient is taking, including herbs, nu- terone.
ANTIBODIES, ANTISTREPTOLYSIN O
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Streptozyme, ASO.

REFERENCE VALUE: (Method: Nephelometry) Less than 200 IU/mL.
DESCRIPTION: Group A -hemolytic CRITICAL VALUES: N/A

streptococci secrete the enzyme strep-
tolysin O, which can destroy red INTERFERING FACTORS:
blood cells. The enzyme acts as an • Drugs that may decrease ASO titers
antigen and stimulates the immune include antibiotics and corticosteroids
because therapy suppresses antibody
system to develop streptolysin O anti-
response.
bodies. These antibodies occur within
1 month after the onset of a strepto-
coccal infection. Detection of the Nursing Implications and
antibody over several weeks strongly Procedure ● ● ● ● ● ● ● ● ● ● ●
suggests exposure to group A -

hemolytic streptococci. ■ Pretest:
INDICATIONS: ➤ Obtain a history of the patient’s

• Assist in establishing a diagnosis of allergens.
streptococcal infection
• Evaluate patients with streptococcal immune system and results of previ-
infections for the development of acute ously performed tests and proce-
rheumatic fever or nephritis dures. For related tests, refer to the
immune system table.
• Monitor response to therapy in strep- ➤ Obtain a list of the medications the
tococcal illnesses patient is taking, including herbs, nu-
RESULT ticals. The requesting health care
Increased in: advised if the patient regularly uses
• Endocarditis these products so that their effects
• Glomerulonephritis when reviewing results.
• Rheumatic fever ➤ There are no food, fluid, or medica-
• Scarlet fever direction.
Decreased in: N/A patient.
Antibodies, Antithyroglobulin and Antithyroid Peroxidase 103
➤ Inform the patient that specimen Post-test:

10 minutes. ➤ Observe venipuncture site for bleed-
Intratest: pressure bandage.
➤ Administer antibiotics as ordered,
➤ Direct the patient to breathe and instruct the patient in the impor-
normally and to avoid unnecessary tance of completing the entire
movement. course of antibiotic therapy even if
➤ Observe standard precautions and no symptoms are present.
follow the general guidelines in ➤ Evaluate test results in relation to
Appendix A. Perform a venipuncture, the patient’s symptoms and other
and collect the specimen in a 5-mL tests performed. Related laboratory
red-top tube. tests include anti-DNAse streptococ-
➤ Label the specimen, and promptly cal, rapid streptococcal screen, and
transport it to the laboratory. throat culture.
ANTIBODIES, ANTITHYROGLOBULIN
AND ANTITHYROID PEROXIDASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Thyroid antibodies, antithyroid peroxidase anti-

bodies (TPO antibodies were previously called thyroid antimicrosomal anti-
bodies).


Antibody Units Factor 1)
Antithyroglobulin Less than 0.3 U/mL Less than 0.3 kU/L
antibody
Antiperoxidase Less than 0.3 U/mL Less than 0.3 kU/L
antibody
DESCRIPTION: Thyroid antibodies destroy thyroid tissue as a result of

are mainly immunoglobulin G–type stimulation by lymphocytic killer
antibodies. Antithyroid peroxidase cells. These antibodies are present in
antibodies bind with microsomal hypothyroid and hyperthyroid condi-
antigens on cells lining the microso- tions. Antithyroglobulin antibodies
mal membrane. They are thought to are autoantibodies directed against
thyroglobulin. The function of this ➤ Obtain a history of the patient’s

antibody is unclear. Both tests are endocrine and immune system and
results of previously performed
normally requested together. ■ tests and procedures. For related
tests, refer to the endocrine and
INDICATIONS: immune system tables.
• Assist in confirming suspected inflam- ➤ Obtain a list of the medications
mation of thyroid gland the patient is taking, including
• Assist in the diagnosis of suspected herbs, nutritional supplements, and
nutraceuticals. The requesting
hypothyroidism caused by thyroid health care practitioner and labora-
tissue destruction tory should be advised if the
• Assist in the diagnosis of suspected patient regularly uses these prod-
thyroid autoimmunity in patients with ucts so that their effects can be
taken into consideration when re-
other autoimmune disorders viewing results.
RESULT ➤ Note any recent procedures that can
Increased in: ➤ There are no food, fluid, or medica-
• Autoimmune disorders tion restrictions unless by medical
direction.
• Graves’ disease
• Goiter patient.
• Hashimoto’s thyroiditis ➤ Inform the patient that specimen

• Idiopathic myxedema 10 minutes.
• Pernicious anemia
Intratest:
• Thyroid carcinoma
movement.
• Lithium may increase thyroid antibody red-top tube.
levels.
• Recent radioactive scans or radiation transport it to the laboratory.
within 1 week before the test can inter-
fere with test results when radioim-
Post-test:
Nursing Implications and pressure bandage.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Evaluate test results in relation to
Pretest: tests performed. Related laboratory
tests include complete blood count,
➤ Obtain a history of the patient’s thyroid biopsy, thyroid-stimulating
complaints, including a list of known hormone, free thyroxine, thyroxine,
allergens. and triiodothyronine.
Antibodies, Cardiolipin, Immunoglobulin G, and Immunoglobulin M 105
ANTIBODIES, CARDIOLIPIN,
IMMUNOGLOBULIN G, AND
IMMUNOGLOBULIN M
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Antiphospholipid antibody, lupus anticoagulant,

LA, ACA.

REFERENCE VALUE: (Method: Immunoassay, enzyme-linked immunosor-
bent assay [ELISA]) Negative.
DESCRIPTION: Cardiolipin antibody • Patients with lupus-like symptoms

is one of several identified antiphos- (often ANA negative)
pholipid antibodies. Antiphospho- • Placental infarction
lipid antibody syndrome is character-
• Recurrent fetal loss (strong association
ized by noninflammatory thrombosis
with two or more occurrences)
of blood vessels. These antibodies are
found in individuals with lupus ery- • Recurrent venous and arterial throm-
thematosus, lupus-related conditions, boses
infectious diseases, drug reactions,
Decreased in: N/A
and sometimes fetal loss. Cardiolipin
antibodies are often found in associa-
tion with lupus anticoagulant. ■ CRITICAL VALUES: N/A
INDICATIONS: INTERFERING FACTORS: Cardiolipin

• Assist in the diagnosis of antiphospho- antibody is partially cross-reactive with
lipid antibody syndrome syphilis reagin antibody and lupus anti-
coagulant. False-positive rapid plasma
reagin results may occur.
RESULT
Increased in:
• Chorea Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Drug reactions
• Epilepsy Pretest:
• Infectious diseases ➤ Obtain a history of the patient’s

• Mitral valve endocarditis allergens.
➤ Obtain a history of the patient’s Intratest:

hematopoietic, immune, and repro-
ductive systems and results of previ- ➤ Direct the patient to breathe nor-
ously performed tests and proce- mally and to avoid unnecessary
dures. For related tests, refer to the movement.
hematopoietic, immune, and repro- ➤ Observe standard precautions and
ductive system tables. follow the general guidelines in Ap-
➤ Obtain a list of the medications the pendix A. Perform a venipuncture,
patient is taking, including herbs, nu- and collect the specimen in a 5-mL
tritional supplements, and nutraceu- red-top tube.
ticals. The requesting health care ➤ Label the specimen, and promptly
practitioner and laboratory should be transport it to the laboratory.
these products so that their effects Post-test:
when reviewing results. ➤ Observe venipuncture site for bleed-
pressure bandage.
direction. ➤ Evaluate test results in relation to
➤ Review the procedure with the pa- tests performed. Related laboratory
tient. tests include antinuclear antibodies,
➤ Inform the patient that specimen complete blood count, fibrinogen,
collection takes approximately 5 to protein C, protein S, syphilis serol-
10 minutes. ogy, and Sjögren antibodies.
ANTIBODIES, GLIADIN
(IMMUNOGLOBULIN G
AND IMMUNOGLOBULIN A)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Endomysial antibodies, gliadin (IgG and IgA)

antibodies, EMA.

Gliadin Conventional DESCRIPTION: Gliadin is a water-

Antibody Units soluble protein found in the gluten of
IgA Less than 5 U
wheat, rye, oats, and barley. The
IgG Less than 57 U intestinal mucosa of certain individu-
als does not digest gluten, allowing a
Antibodies, Gliadin (IgG and IgA) 107
toxic buildup of gliadin. Antibodies

to gliadin form and result in damage
to the intestinal mucosa. In severe
Procedure ● ● ● ● ● ● ● ● ● ● ●
cases, intestinal mucosa can be lost;

Pretest:
lactose intolerance compounds the
condition. Immunoglobulin G (IgG) ➤ Obtain a history of the patient’s
and immunoglobulin A (IgA) gliadin complaints, including a list of known
allergens.
antibodies are detectable in the serum
➤ Obtain a history of the patient’s gas-
of patients with gluten-sensitive
trointestinal and immune systems
enteropathy. ■ and results of previously performed
INDICATIONS: tests, refer to the gastrointestinal
• Assist in the diagnosis of asymptomatic and immune system tables.
gluten-sensitive enteropathy in some ➤ Obtain a list of foods and medica-
patients with dermatitis herpetiformis tions the patient is taking, including
herbs, nutritional supplements, and
• Assist in the diagnosis of gluten-
sensitive enteropathies care practitioner and laboratory
• Assist in the diagnosis of nontropical should be advised if the patient reg-
sprue ularly uses these products so that
their effects can be taken into con-
• Monitor dietary compliance of patients sideration when reviewing results.
with gluten-sensitive enteropathies ➤ There are no food, fluid, or medica-
RESULT direction.
Increased in: patient.
• Asymptomatic gluten-sensitive en- ➤ Inform the patient that specimen
teropathy collection takes approximately 5 to
• Celiac disease 10 minutes.
• Dermatitis herpetiformis Intratest:

• Nontropical sprue ➤ Direct the patient to breathe nor-
mally and to avoid unnecessary
Decreased in: N/A movement.
CRITICAL VALUES: N/A follow the general guidelines in Ap-
INTERFERING FACTORS: and collect the specimen in a 5-mL
• Conditions other than gluten-sensitive red-top tube.
enteropathy can result in elevated anti- ➤ Label the specimen, and promptly
body levels without corresponding transport it to the laboratory.
histologic evidence. These conditions
include Crohn’s disease, postinfection Post-test:
malabsorption, and food protein intol-
erance. ➤ Observe venipuncture site for bleed-
• A negative IgA gliadin result, especially pressure bandage.
with a positive IgG gliadin result in an ➤ Recognize anxiety related to test
untreated patient, does not rule out results and offer support. Provide
active gluten-sensitive enteropathy. teaching and information regarding
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.
REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative or
titer less than 1:20.
D ESCRIPTION : Antimitochondrial • Thyroid disease (occasionally)

antibodies are found in 90 percent of
patients with primary biliary cirrhosis Decreased in: N/A
(PBC). PBC is identified most fre-
quently in women age 35 to 60 CRITICAL VALUES: N/A
years. ■
INTERFERING FACTORS: N/A
INDICATIONS:
• Assist in the diagnosis of PBC
• Assist in the differential diagnosis of Nursing Implications and
chronic liver disease Procedure ● ● ● ● ● ● ● ● ● ● ●
RESULT Pretest:
Increased in: complaints, including a list of known
• PBC allergens.
• Hepatitis (alcoholic, viral) hepatobiliary and immune systems,
• Rheumatoid arthritis (occasionally) as well as results of previously
• Systemic lupus erythematosus (occa- related tests, refer to the hepatobil-
sionally) iary and immune system tables.
Antibody, Anti–Smooth Muscle 109
➤ Obtain a list of the medications the ➤ The presence of antimitochondrial

patient is taking, including herbs, nu- antibodies may be associated with
tritional supplements, and nutraceu- liver disease. Dietary recommenda-
ticals. The requesting health care tions may be indicated and vary
practitioner and laboratory should be depending on the severity of the
advised if the patient regularly uses condition. A low-protein diet may be
these products so that their effects in order if the liver cannot process
can be taken into consideration the end products of protein metabo-
when reviewing results. lism. A diet of soft foods may be
➤ There are no food, fluid, or medica- required if esophageal varices have
tion restrictions unless by medical developed. Ammonia levels may be
direction. used to determine whether protein
should be added to or reduced from
➤ Review the procedure with the pa- the diet. Patients should be encour-
tient. aged to eat simple carbohydrates
➤ Inform the patient that specimen and emulsified fats (as in homoge-
collection takes approximately 5 to nized milk or eggs), as opposed
10 minutes. to complex carbohydrates (e.g.,
starch, fiber, and glycogen [animal
Intratest: carbohydrates]) and complex fats,
which would require additional bile
➤ Direct the patient to breathe to emulsify it so that it could be
normally and to avoid unnecessary used. Observe the cirrhotic patient
movement. carefully for the development of
➤ Observe standard precautions and ascites; if ascites develops, pay
follow the general guidelines in Ap- strict attention to fluid and elec-
pendix A. Perform a venipuncture, trolyte balance.
and collect the specimen in a 5-mL ➤ Evaluate test results in relation to
red-top tube. the patient’s symptoms and other
➤ Label the specimen, and promptly tests performed. Related laboratory
transport it to the laboratory. tests include albumin, alkaline phos-
phatase, ammonia, anticytoplasmic
Post-test: neutrophilic antibodies, antinuclear
antibodies, anti–smooth muscle anti-
➤ Observe venipuncture site for bleed- bodies, bilirubin, electrolytes, liver
ing or hematoma formation. Apply biopsy, and -glutamyl transpepti-
pressure bandage. dase.
ANTIBODY, ANTI–SMOOTH MUSCLE

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SYNONYM/ACRONYM: ASMA.
REFERENCE VALUE: (Method: Indirect fluorescent antibody) Negative.
DESCRIPTION: Anti–smooth muscle ➤ Review the procedure with the

patient.
antibodies are autoantibodies found
in high titers in the sera of patients ➤ Inform the patient that specimen
with autoimmune diseases of the liver 10 minutes.
and bile duct. ■
Intratest:
INDICATIONS: ➤ Direct the patient to breathe
• Differential diagnosis of liver disease normally and to avoid unnecessary
movement.
RESULT ➤ Observe standard precautions and
Increased in:
• Autoimmune hepatitis red-top tube.
• Chronic active viral hepatitis ➤ Label the specimen, and promptly
Post-test:
Decreased in: N/A
CRITICAL VALUES: N/A pressure bandage.
➤ The presence of anti–smooth
INTERFERING FACTORS: N/A muscle antibodies may be associ-
Nursing Implications and and vary depending on the severity
of the condition. A low-protein diet
Procedure ● ● ● ● ● ● ● ● ● ● ●
may be in order if the liver cannot
process the end products of protein
Pretest: metabolism. A diet of soft foods may
➤ Obtain a history of the patient’s be required if esophageal varices
complaints, including a list of known have developed. Ammonia levels
allergens. may be used to determine whether
protein should be added to or
➤ Obtain a history of the patient’s reduced from the diet. Patients
hepatobiliary and immune systems, should be encouraged to eat simple
as well as results of previously carbohydrates and emulsified fats
performed tests and procedures. For (as in homogenized milk or eggs), as
related tests, refer to the hepatobil- opposed to complex carbohydrates
iary and immune system tables. (e.g., starch, fiber, and glycogen
➤ Obtain a list of the medications the [animal carbohydrates]) and complex
patient is taking, including herbs, nu- fats, which would require additional
tritional supplements, and nutraceu- bile to emulsify it so that it could be
ticals. The requesting health care used. Observe the cirrhotic patient
practitioner and laboratory should be carefully for the development of
advised if the patient regularly uses ascites; if ascites develops, pay
these products so that their effects strict attention to fluid and elec-
can be taken into consideration trolyte balance.
when reviewing results. ➤ Evaluate test results in relation to the
➤ There are no food, fluid, or medica- patient’s symptoms and other tests
tion restrictions unless by medical performed. Related laboratory tests
direction. include alkaline phosphatase, ammo-
Antibody, Jo-1 111
nia, antimitochondrial antibody, anti- hepatitis serology, serum protein

nuclear antibody, aspartate amino- electrophoresis, and prothrombin
transferase, liver biopsy, bilirubin, time.
ANTIBODY, Jo-1
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SYNONYM/ACRONYM: Antihistidyl transfer tRNA synthase.

REFERENCE VALUE: (Method: Immunoassay) Negative.

DESCRIPTION: Jo-1 is an autoanti- Procedure ● ● ● ● ● ● ● ● ● ● ●
body found in the sera of some anti-
nuclear antibody–positive patients. Pretest:
Compared to the presence of other
autoantibodies, the presence of Jo-1 complaints, including a list of known
suggests a more aggressive disease allergens.
course and a higher risk of mortality. ➤ Obtain a history of the patient’s im-
The clinical effects of this autoanti- mune and musculoskeletal systems,
body include acute onset, fever, dry as well as results of previously per-
and cracked skin on the hands, Ray- formed tests and procedures. For re-
lated tests, refer to the immune and
naud’s phenomenon, and arthritis. ■ musculoskeletal system tables.
INDICATIONS: patient is taking, including herbs, nu-
• Test for idiopathic inflammatory my- tritional supplements, and nutraceu-
opathies ticals. The requesting health care
RESULT advised if the patient regularly uses
Increased in: can be taken into consideration
• Dermatomyositis when reviewing results.
• Polymyositis tion restrictions unless by medical
direction.
Decreased in: N/A
patient.
CRITICAL VALUES: N/A ➤ Inform the patient that specimen
INTERFERING FACTORS: N/A 10 minutes.
Intratest: ing or hematoma formation. Apply

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 include alanine aminotrans-
follow the general guidelines in ferase, aldolase, antinuclear anti-
Appendix A. Perform a venipuncture, body, aspartate aminotransferase,
and collect the specimen in a 5-mL creatine kinase, urine creatinine, ery-
red-top tube. throcyte sedimentation rate, ex-
➤ Label the specimen, and promptly tractable nuclear antibodies, lactate
transport it to the laboratory. dehydrogenase and isoenzymes,
muscle biopsy, myoglobin, rheuma-
Post-test: toid factor, scleroderma antibody,
Sjögren’s antibodies, and skin
➤ Observe venipuncture site for bleed- biopsy.
ANTICONVULSANT DRUGS:
CARBAMAZEPINE, ETHOSUXIMIDE,
PHENOBARBITAL, PHENYTOIN,
PRIMIDONE, VALPROIC ACID
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SYNONYMS/ACRONYM: Carbamazepine (Carbategretal, Carbazep, Epitrol,

Tegretol); ethosuximide (Suxinutin, Zarontin, Zartalin); phenobarbital
(Barbita, Comizial, Fenilcal, Gardenal, Luminal, Phenemal, Phenobarb,
phenobarbitone, Stental Extentabs); phenytoin (Antisacer, Dilantin,
Dintoina, Diphenylan Sodium, Ditan, Epanutin, Epinal, Fenytoin); primi-
done (Desoxyphenobarbital, Hexamidinum, Majsolin, Mylepsin, Mysoline,
Primaclone, Prysolin); valproic acid (Depakene, Depakote, Depamide,
dipropylacetic acid, Epilim, Ergenyl, Leptilan, Valkote).

Drug Route of Administration
Carbamazepine* Oral
Ethosuximide* Oral
Phenobarbital* Oral
Phenytoin* Oral
Primidone* Oral
Valproic Acid* Oral
* Recommended collection time trough: immediately before next dose
(at steady state) or at a consistent sampling time.
Carbamazepine 4–12 g/mL 17–51 mol/L 15–40 0.8–1.8 60–80 Hepatic
Ethosuximide 40–100 283–708 25–70 0.7 0–5 Renal
g/mL mol/L
Phenobarbital Adult: 20–40 Adult: 86–172 50–140 0.5–1.0 L/kg 40–50 80%
g/mL mol/L Hepatic
Child: 15–30 Child: 65–129 20% Renal
g/mL mol/L

Phenytoin 10–20 g/mL 40–79 mol/L Adult: 0.6–0.7 85–95 Hepatic
20–40
Child: 10
Primidone Adult: 5–12 Adult: 23–55 4–12 0.5–1.0 0–20 Hepatic
g/mL mol/L
Child: 7–10 Child: 32–46
g/mL mol/L

Valproic Acid 50–100 347–693 8–15 0.1–0.5 85–95 Renal
g/mL mol/L
113
DESCRIPTION: Anticonvulsants are CRITICAL VALUES: It is important

used to reduce the frequency and to note the adverse effects of subther-
severity of seizures for patients with apeutic levels. Care must be taken to
epilepsy. Carbamazepine is also used investigate the signs and symptoms of too
for controlling neurogenic pain in little and too much medication.
trigeminal neuralgia and diabetic
neuropathy and for treating for bipo- Carbamazepine: Greater than
lar disease and other neurologic and 12 g/mL
psychiatric conditions. Signs and symptoms of carbamazepine
Many factors must be considered toxicity include respiratory depression,
in effective dosing and monitoring of seizures, stupor, and possible coma.
therapeutic drugs, including patient Possible interventions include gastric
age, patient weight, interacting med- lavage (contraindicated if ileus is pres-
ications, electrolyte balance, protein ent); airway protection; administration of
fluids and vasopressors for hypotension;
levels, water balance, conditions that
treatment of seizures with diazepam,
affect absorption and excretion, and phenobarbital, or phenytoin; cardiac
foods, herbals, vitamins, and minerals monitoring; monitoring of vital signs;
that can either potentiate or inhibit and discontinuing the medication.
the intended target concentration. ■ Emetics are contraindicated.
INDICATIONS: Ethosuximide: Greater than

• Assist in the diagnosis of and preven-
tion of toxicity 150 g/mL
• Monitor compliance to therapeutic Signs and symptoms of ethosuximide

regimen toxicity include nausea, vomiting, and
lethargy. Possible interventions include
RESULT administration of activated charcoal,
administration of saline cathartic and
Level Response gastric lavage (contraindicated if ileus is
present), airway protection, hourly
Normal levels Therapeutic
assessment of neurologic function, and
effect
discontinuing the medication.
Subtherapeutic Adjust dose as
levels indicated
Toxic levels Adjust dose as Phenobarbital: Greater than
indicated 40 g/mL
Carbamazepine Hepatic
Signs and symptoms of phenobarbital
impairment
toxicity include cold, clammy skin;
Ethosuximide Hepatic
ataxia; central nervous system depression;
impairment
hypothermia; hypotension; cyanosis;
Phenobarbital Hepatic
Cheyne-Stokes respiration; tachycardia;
impairment
possible coma; and possible renal impair-
Phenytoin Hepatic
ment. Possible interventions include gas-
impairment
tric lavage, administration of activated
Primidone Hepatic
charcoal with cathartic, airway protec-
impairment
tion, possible intubation and mechanical
Valproic acid Renal
ventilation (especially during gastric
impairment
lavage if there is no gag reflex), monitor-
Anticonvulsant Drugs 115
ing for hypotension, and discontinuing barbital drugs, furosemide, primidone,

the medication. salicylates, and valproic acid.
Phenytoin: Greater than • Phenobarbital may affect the metabo-

lism of other drugs, increasing
40 g/mL their effectiveness, such as beta
Signs and symptoms of phenytoin toxic- blockers, chloramphenicol, cortico-
ity include double vision, nystagmus, steroids, doxycycline, griseofulvin,
lethargy, central nervous system depres- haloperidol, methylphenidate, pheno-
sion, and possible coma. Possible inter- thiazines, phenylbutazone, propoxy-
ventions include airway support, phene, quinidine, theophylline, tri-
electrocardiographic monitoring, admin- cyclic antidepressants, and valproic
istration of activated charcoal, gastric acid.
lavage with warm saline or tap water,
• Phenobarbital may affect the metabo-
administration of saline or sorbitol
lism of other drugs, decreasing their
cathartic, and discontinuing the medica-
effectiveness, such as chloramphenicol,
tion.
cyclosporine, ethosuximide, oral anti-
coagulants, oral contraceptives, pheny-
Primidone: Greater than
toin, and theophylline.
12 g/mL
• Phenobarbital is an active metabolite
Signs and symptoms of primidone toxic- of primidone, and both drug levels
ity include ataxia, anemia, and central should be monitored while the patient
nervous system depression. Possible in- is receiving primidone to avoid either
terventions include airway protection, toxic or subtherapeutic levels of both
treatment of anemia with vitamin B12 medications.
and folate, and discontinuing the med-
ication. • Drugs that may increase phenytoin lev-
els or increase the risk of pheny-
Valproic Acid: Greater than toin toxicity include amiodarone, aza-
200 g/mL propazone, carbamazepine, cimetidine,
chloramphenicol, disulfiram, ethanol,
Signs and symptoms of valproic acid tox- fluconazole, halothane, ibuprofen,
icity include numbness, tingling, weak- imipramine, levodopa, miconazole,
ness, and mental changes. Possible inter- metronidazole, nifedipine, phenylbuta-
ventions include administration of zone, sulfonamides, tricyclic antide-
activated charcoal and naloxone and dis- pressants, trazodone, and trimetho-
continuing the medication. prim. Small changes in formulation
(i.e., changes in brand) also may in-
INTERFERING FACTORS crease phenytoin levels or increase the
• Drugs that may increase carbamazepine risk of phenytoin toxicity.
levels or increase risk of toxicity include
cimetidine, danazol, diltiazem, erythro- • Drugs that may decrease phenytoin
mycin, isoniazid, propoxyphene, levels include bleomycin, carba-
triacetyloleandomycin, valproic acid, mazepine, cisplatin, disulfiram, folic
and verapamil. acid, intravenous fluids contain-
ing glucose, nitrofurantoin, oxacillin,
• Drugs that may decrease carba- rifampin, salicylates, and vinblastine.
mazepine levels include phenobarbital,
phenytoin, and primidone. • Primidone decreases the effectiveness
of oral anticoagulants.
• Drugs that may increase phenobarbital
levels or increase risk of toxicity include • Drugs that may increase valproic acid
levels or increase risk of toxicity include Intratest:

dicumarol, phenylbutazone, and high
➤ Direct the patient to breathe nor-
doses of salicylate. mally and to avoid unnecessary
• Drugs that may decrease valproic movement.
acid levels include carbamazepine, ➤ Observe standard precautions and
phenobarbital, phenytoin, and primi- follow the general guidelines in Ap-
done pendix A. Review dosing schedule to
ensure that peak and trough speci-
mens are ordered to be collected at
the appropriate time. Perform a
Nursing Implications and venipuncture, and collect the speci-
Procedure ● ● ● ● ● ● ● ● ● ● ● men in a 5-mL red-top tube.
complaints, including a list of known Post-test:
➤ Review results of previously per- ing or hematoma formation. Apply
formed tests and procedures. For re- pressure bandage.
lated tests, refer to the hepatobiliary ➤ Explain to the patient the impor-
system and therapeutic/toxicology tance of following the medication
tables. regimen and instructions regarding
➤ Obtain a list of medications the pa- food and drug interactions.
tient is taking, including herbs, nutri- ➤ Instruct the patient to immediately
tional supplements, and nutraceuti- report any unusual sensations, such
cals. The requesting health care as dizziness or disturbances in
practitioner and laboratory should be vision, to his or her health care prac-
advised if the patient regularly uses titioner.
can be taken into consideration ➤ Instruct the patient to be prepared to
when reviewing results. list to the pharmacist the other
medications he or she is already
➤ There are no food, fluid, or medica- taking in the event that the request-
tion restrictions unless by medical ing health care practitioner gives the
direction. patient a prescription to be filled.
➤ 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 albumin, electrolytes,
10 minutes. and protein.
ANTIDEOXYRIBONUCLEASE-B,
STREPTOCOCCAL
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SYNONYMS/ACRONYM: ADNase-B, AntiDNase-B titer, antistreptococcal

DNase-B titer, streptodornase.
Antideoxyribonuclease-B, Streptococcal 117

Age Normal Results ➤ Obtain a history of the patient’s

immune system and results of previ-
Preschoolers Less than ously performed tests and proce-
61 U dures. For related tests, refer to the
School-age Less than immune system table.
children 171 U ➤ Obtain a list of the medications the
Adults Less than patient is taking, including herbs, nu-
86 U tritional supplements, and nutraceu-
DESCRIPTION: The presence of these products so that their effects
streptococcal DNase antibodies is an can be taken into consideration
indicator of recent infection, espe- when reviewing results.
cially if a rise in antibody titer can be ➤ There are no food, fluid, or medica-
shown. This test is more sensitive direction.
than the antistreptolysin-O test. A
rise in titer of two or more dilution patient.
increments between acute and conva- ➤ Inform the patient that each speci-
lescent specimens is clinically signifi- men collection takes approximately
cant. ■ 5 to 10 minutes.
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.
RESULT follow the general guidelines in Ap-
Increased in: and collect the specimen in a 5-mL
• Streptococcal infections (systemic) red-top tube.
Decreased in: N/A transport it to the laboratory.
CRITICAL VALUES: N/A Post-test:

INTERFERING FACTORS: N/A ing or hematoma formation. Apply
pressure bandage.
➤ Administer analgesics and antibi-
Nursing Implications and otics as ordered, and instruct the pa-
Procedure ● ● ● ● ● ● ● ● ● ● ●
tient in the importance of complet-
ing the entire course of antibiotic
therapy even if no symptoms are
Pretest: present.
➤ Obtain a history of the patient’s ➤ Inform the patient that a convales-
complaints, including a list of known cent specimen may be requested in
allergens. 7 to 10 days.
➤ Evaluate test results in relation to tests include antistreptolysin-O anti-

the patient’s symptoms and other body, rapid streptococcal screen,
tests performed. Related laboratory and throat culture.
ANTIDEPRESSANT DRUGS:
AMITRYPTYLINE, NORTRIPTYLINE,
DIAZEPAM, DOXEPIN, IMIPRAMINE,
DESIPRAMINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Monoamine oxidase (MAO) inhibitors, tricyclic

antidepressants: amitryptyline (Elavil, Endep, Etrafon, Limbitrol, Triavil);
nortriptyline (Allegron, Aventyl, Norval, Pamelor); doxepin (Adapin, Co-
Dax, Novoxapin, Sinequan, Triadapin); imipramine (Berkomine,
Dimipressin, Iprogen, Janimine, Presamine, Tofranil); desipramine
(Norpramin). Benzodiazepine derivatives: diazepam (Aliseum, Alupram,
Atensine, Lamra, Solis, Stesolid, Tensium, Valium, Valrelease, Vatran, Vivol,
Zetran).
Amitriptyline Oral Trough: immediately before next
dose (at steady state)
Nortriptyline Oral Trough: immediately before next
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
Imipramine Oral Trough: immediately before next
Desipramine Oral Trough: immediately before next
REFERENCE VALUE: (Method: Chromatography for amitryptyline,

nortriptyline, diazepam, and doxepin; immunoassay for imipramine and
desipramine)
Amitryptyline 120–250 433–903 17–40 10–36 85–95 Hepatic
ng/mL nmol/L
Nortriptyline 50–150 190–570 20–90 15–23 90–95 Hepatic
ng/mL nmol/L
Diazepam 100–1000 0.35–3.5 20–50 1.0–1.5 96–99 Hepatic
ng/mL mol/L

Combined doxepin 150–251 540–900 10–25 10–30 75–85 Hepatic
and desmethyl- ng/mL nmol/L
doxepin
Imipramine 150–250 536–892 6–28 9–23 60–95 Hepatic
ng/mL nmol/L

Desipramine 75–300 281–1125 6–28 9–23 60–95 Hepatic
ng/mL nmol/L
119
DESCRIPTION: Diazepam is a benzo- • Monitor compliance to therapeutic

diazepine derivative used for sedation. regimen
The other sedative drugs listed are re-
ferred to as tricyclic antidepressants. RESULT
MAO inhibitors are classified as hy- Level Response
drazines and nonhydrazines. They are
prescribed for the treatment of neu-
effect
rotic or atypical depression. MAO in- Subtherapeutic Adjust dose as
hibitors should be used with caution levels indicated
in patients with hyperthyroidism and Toxic levels Adjust dose as
in patients with diabetes who take in- indicated
sulin or antidiabetic medications. Nu- Amitryptyline Hepatic
merous drug interactions occur with impairment
the cyclic antidepressants. Nortriptyline Hepatic
Many factors must be considered impairment
in effective dosing and monitoring of Diazepam Renal or
hepatic
therapeutic drugs, including patient
impairment
age, patient weight, interacting med- Doxepin Hepatic
ications, electrolyte balance, protein impairment
levels, water balance, conditions that Imipramine Hepatic
affect absorption and excretion, and impairment
foods, herbals, vitamins, and minerals Desipramine Hepatic
that can either potentiate or inhibit impairment
the intended target concentration.
Peak and trough collection times
CRITICAL VALUES: It is important
should be documented carefully in re- to note the adverse effects of subther-
lation to the time of medication ad- apeutic levels of antidepressants. Care
ministration. ■ must be taken to investigate signs and
symptoms of too little and too much
IMPORTANT NOTE: This information medication.
must be clearly and accurately communi-
cated to avoid misunderstanding of the Benzodiazepine-Derivative
dose time in relation to the collection Antidepressants:
time. Miscommunication between the
individual administering the medication • Diazepam and N-desmethyldiazepam:
and the individual collecting the speci- Greater than 3000 ng/mL
men is the most frequent cause of • Diazepam and nordiazepam: Greater
subtherapeutic levels, toxic levels, and than 5000 ng/mL
misleading information used in calcula- Signs and symptoms of diazepam or
tion of future doses. diazepam-derivative toxicity include
ataxia, convulsions, diminished reflexes,
INDICATIONS: confusion, respiratory depression, slurred
• Assist in the diagnosis and prevention speech, somnolence, and possible coma.
of toxicity Possible interventions include adminis-
• Evaluate overdose, especially in combi- tration of activated charcoal, gastric
nation with ethanol (Note: Doxepin lavage with saline or tap water, airway
abuse is unusual) protection, monitoring for central nerv-
Antidepressant Drugs 121
ous system depression, and seizure pre- advised if the patient regularly uses
cautions. Emetics are contraindicated. these products so that their effects
Tricyclic Antidepressants: when reviewing results.
• 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
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,
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.
ANTIDIURETIC HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Vasopressin, arginine vasopressin hormone, ADH.

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

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

Osmolality* Hormone* Factor 0.926)
270–280 mOsm/kg Less than 1.5 pg/mL Less than 1.4 pmol/L
280–285 mOsm/kg Less than 2.5 pg/mL Less than 2.3 pmol/L
285–290 mOsm/kg 1–5 pg/mL 0.9–4.6 pmol/L
DESCRIPTION: Antidiuretic hor- INDICATIONS:

mone (ADH) is formed by the hypo- • Evaluate polyuria or altered serum
thalamus and stored in the posterior osmolality to identify possible alter-
pituitary gland. ADH is released in ations in ADH secretion as the cause.
response to increased serum osmolal- • Detect central nervous system trauma,
ity or decreased blood volume. When surgery, or disease that may lead to
the hormone is active, small amounts impaired ADH secretion.
of concentrated urine are produced; • Differentiate neurogenic (central)
in its absence, large amounts of dilute diabetes insipidus from nephrogenic
urine are produced. Although a 1 per- diabetes insipidus by decreased ADH
cent change in serum osmolality stim- levels in neurogenic diabetes insipidus
ulates ADH secretion, blood volume or elevated levels in nephrogenic
must decrease by approximately 10 diabetes insipidus if normal feedback
percent for ADH secretion to be in- mechanisms are intact.
duced. Psychogenic stimuli, such as • Assist in the diagnosis of known or sus-
stress, pain, and anxiety, may also pected malignancy associated with syn-
stimulate ADH release, but the mech- drome of inappropriate ADH secretion
anism is unclear. ■ (SIADH), such as oat cell lung cancer,
Antidiuretic Hormone 123
thymoma, lymphoma, leukemia, pan- INTERFERING FACTORS

creatic carcinoma, prostate gland carci- • Drugs that may increase ADH levels
noma, and intestinal carcinoma; ele- include barbiturates, carbamazepine,
vated ADH levels indicate the presence chlorpropamide, chlorthalidone,
of this syndrome. cisplatin, clofibrate, ether, furose-
• Assist in the diagnosis of known or sus- mide, haloperidol, hydrochloro-
pected pulmonary conditions associ- thiazide, lithium, methyclothiazide,
ated with SIADH, such as tuberculo- narcotic analgesics, phenothiazides,
sis, pneumonia, and positive-pressure polythiazide, tolbutamide, tricyclic an-
mechanical ventilation. tidepressants, vidarabine, vinblastine,
and vincristine.
RESULT • Drugs that may decrease ADH levels
include clonidine, demeclocycline,
Increased in: ethanol, lithium carbonate, and pheny-
• Acute intermittent porphyria toin.
• Brain tumor • Recent radioactive scans or radiation
• Disorders involving the central nervous within 1 week before the test can inter-
system, thyroid gland, and adrenal fere with test results when radioim-
gland munoassay is the test method.
• Ectopic production (systemic • ADH exhibits diurnal variation, with

neoplasm) highest levels of secretion occurring at
night; first morning collection is
• Guillain-Barré syndrome recommended.
• Nephrogenic diabetes insipidus • ADH secretion is also affected by
• Pain, stress, or exercise posture, with higher levels measured
while upright.
• Pneumonia
• Pulmonary tuberculosis
• SIADH Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Tuberculosis meningitis
Pretest:
Decreased in:
• Nephrotic syndrome ➤ Obtain a history of the patient’s
• Pituitary (central) diabetes insipidus allergens.
• Psychogenic polydipsia ➤ Obtain a history of the patient’s en-
docrine and genitourinary systems,
as well as results of previously per-
CRITICAL VALUES: Effective treatment formed tests and procedures. For re-
of SIADH depends on identifying lated tests, refer to the endocrine
and resolving the cause of increased and genitourinary system tables.
ADH production. Signs and symptoms
of SIADH are the same as those
for hyponatremia, including irritability, tritional supplements, and nutraceu-
tremors, muscle spasms, convulsions, and ticals. The requesting health care
neurologic changes. The patient has practitioner and laboratory should
enough sodium, but it is diluted in excess be advised if the patient regularly
retained water. uses these products so that their
effects can be taken into considera- Appendix A. Perform a venipuncture,

tion when reviewing results. and collect the specimen in a 5-mL
➤ Note any recent procedures that can lavender-top tube.
interfere with test results. ➤ Label the specimen, and promptly
➤ There are no food, fluid, or medica- transport it to the laboratory.
direction. Post-test:
➤ Review the procedure with the ➤ Observe venipuncture site for bleed-
patient. ing or hematoma formation. Apply
➤ Inform the patient that specimen pressure bandage.
collection takes approximately 5 to ➤ Inform the patient, as appropriate,
10 minutes. that treatment may include diuretic
therapy and fluid restriction to
Intratest: successfully eliminate the excess
water.
➤ The patient should be encouraged to
be calm and in a sitting position for ➤ Evaluate test results in relation to
specimen collection. the patient’s symptoms and other
➤ Direct the patient to breathe tests include serum and urine elec-
normally and to avoid unnecessary trolytes, serum and urine osmolality,
movement. serum and urine sodium, thyroid-
➤ Observe standard precautions and stimulating hormone, urea nitrogen,
follow the general guidelines in uric acid, and urinalysis.
ANTIGENS/ANTIBODIES,
ANTI–EXTRACTABLE NUCLEAR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: La antibodies, Ro antibodies, SS-A antibodies,

SS-B antibodies, ENA.

DESCRIPTION: The extractable nu- INDICATIONS:

clear antigens (ENAs) include ribonu- • Assist in the diagnosis of mixed
cleoprotein (RNP), Smith (Sm), SS- connective tissue disease
A/Ro, and SS-B/La antigens. ENAs
• Assist in the diagnosis of Sjögren’s
and antibodies to them are found in
syndrome
various combinations in individuals
with combinations of overlapping • Assist in the diagnosis of systemic
rheumatologic symptoms. ■ lupus erythematosus (SLE)
Antigens/Antibodies, Anti Extractable Nuclear 125
RESULT cals. The requesting health care

Increased in: advised if the patient regularly uses
• Anti-SS-A/Ro–positive patients have can be taken into consideration
photosensitivity. when reviewing results.
• Anti-RNP is associated with mixed ➤ There are no food, fluid, or medica-
connective tissue disease. tion restrictions unless by medical
direction.
• Anti-SS-A and anti-SS-B are helpful in ➤ Review the procedure with the pa-
antinuclear antibody (ANA)–negative tient.
cases of SLE.
• Anti-SS-A/ANA–positive, anti-SS- collection takes approximately 5 to
B–negative patients are likely to have 10 minutes.
nephritis.
Intratest:
• Anti-SS-A/anti-SS-B–positive sera are
found in patients with neonatal lupus. ➤ Direct the patient to breathe
• Anti-SS-A–positive patients may also movement.
have antibodies associated with ➤ Observe standard precautions and
antiphospholipid syndrome. follow the general guidelines in Ap-
• Anti-SS-A/La is associated with pendix A. Perform a venipuncture,
primary Sjögren’s syndrome. red-top tube.
• Anti-SS-A/Ro is a predictor of congen- ➤ Label the specimen, and promptly
ital heart block in neonates born to transport it to the laboratory.
mothers with SLE.
Post-test:
Decreased in: N/A
➤ Educate the patient, as appropriate,
INTERFERING FACTORS: N/A in the importance of preventing in-
fection, which is a significant cause
of death in immunosuppressed indi-
Nursing Implications and viduals.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Recognize anxiety related to test re-
sults and offer support. Provide
Pretest: teaching and disease information, as
appropriate. Educate the patient re-
➤ Obtain a history of the patient’s garding access to counseling serv-
complaints, including a list of known ices. Collagen and connective tissue
allergens. diseases are chronic; as such, they
➤ Obtain a history of the patient’s im- must be addressed on a continuous
mune and musculoskeletal systems, basis and may require significant
as well as results of previously per- changes in lifestyle.
formed tests and procedures. For re- ➤ Evaluate test results in relation
lated tests, refer to the immune and to the patient’s symptoms and other
musculoskeletal system tables. tests performed. Related laboratory
➤ Obtain a list of medications the pa- tests include anticardiolipin antibod-
tient is taking, including herbs, nutri- ies, anti-DNA antibodies, ANA, and
tional supplements, and nutraceuti- scleroderma antibody.
ANTIPSYCHOTIC DRUGS AND

ANTIMANIC DRUGS: HALOPERIDOL,
LITHIUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Antipsychotic drugs: haloperidol (Dozic, Fortunan,

Haldol); antimanic drugs: lithium (Cibalith-S, Eskalith, Lithane, Lithobid,
Lithonate, Lithotabs).
Haloperidol Oral Peak: 3–6 h
Lithium Oral 12 h after dose
REFERENCE VALUE: (Method: Chromatography for haloperidol; ion selec-

tive electrode for lithium)
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.
DESCRIPTION: Haloperidol is an Many factors must be considered

antipsychotic tranquilizer used for the in effective dosing and monitoring of
following indications: acute and therapeutic drugs, including patient
chronic psychotic disorders, Tourette’s age, patient weight, interacting med-
syndrome, and hyperactive children ications, electrolyte balance, protein
with severe behavioral problems. levels, water balance, conditions that
Lithium is used in the treatment of affect absorption and excretion, and
manic depression. foods, herbals, vitamins, and minerals
Antipsychotic Drugs and Antimanic Drugs 127
that can either potentiate or inhibit city include hypotension, respiratory

the intended target concentration. depression, and extrapyramidal neuro-
Peak collection times should be docu- muscular reactions. Possible interven-
mented carefully in relation to the tions include emesis (contraindicated in
time of medication administration. ■ the absence of gag reflex or central nerv-
ous system depression or excitation),
IMPORTANT NOTE: This information administration of ipecac cathartic, and
must be clearly and accurately communi- gastric lavage followed by administration
cated to avoid misunderstanding of the of activated charcoal and saline cathartic.
dose time in relation to the collection
time. Miscommunication between the Lithium: Greater than 1.5 mEq/L
individual administering the medication Signs and symptoms of lithium toxicity
and the individual collecting the speci- include ataxia, coarse tremors, muscle
men is the most frequent cause of weakness, vomiting, diarrhea, confusion,
subtherapeutic levels, toxic levels, and convulsions, stupor, T-wave flattening,
misleading information used in calcula- loss of consciousness, and possible coma.
tion of future doses. Possible interventions include adminis-
tration of activated charcoal, gastric
INDICATIONS: lavage, and administration of intravenous
• Assist in the diagnosis and prevention fluids with diuresis.
of toxicity
• Monitor compliance to therapeutic INTERFERING FACTORS:
regimen • Haloperidol may increase levels of
tricyclic antidepressants and increase
RESULT the risk of lithium toxicity.
• Drugs that may increase lithium levels
Level Response include thiazide diuretics, angiotensin-
Normal levels Therapeutic converting enzyme inhibitors, and
effect some nonsteroidal anti-inflammatory
Subtherapeutic Adjust dose as drugs.
levels indicated • Drugs and substances that may
Toxic levels Adjust dose as decrease lithium levels include acetazo-
indicated lamide, theophylline, osmotic diuret-
Haloperidol Hepatic ics, and caffeine.
impairment
Lithium Renal
impairment
Procedure ● ● ● ● ● ● ● ● ● ● ●
CRITICAL VALUES: It is important

to note the adverse effects of subther- Pretest:
apeutic levels. Care must be taken to ➤ Obtain a history of the patient’s
investigate signs and symptoms of not complaints, including a list of known
enough medication and too much allergens.
medication. ➤ Review results of tests and proce-
dures previously performed. For
Haloperidol: Greater than related tests, refer to the genitouri-
nary and hepatobiliary system and
42 ng/mL therapeutic/toxicology tables.
Signs and symptoms of haloperidol toxi- ➤ Obtain a list of medications the
patient is taking, including herbs, nu- Post-test:

ticals. The requesting health care ➤ Explain to the patient the impor-
practitioner and laboratory should be tance of following the medication
advised if the patient regularly uses regimen and instructions regarding
these products so that their effects food and drug interactions.
can be taken into consideration ➤ Instruct the patient receiving
when reviewing results. haloperidol to immediately report
➤ There are no food, fluid, or medica- any unusual symptoms (e.g., blurred
tion restrictions unless by medical vision, dry eyes) to the requesting
direction. health care practitioner.
➤ Review the procedure with the ➤ Instruct the patient receiving lithium
patient. to immediately report any unusual
symptoms (e.g., nausea, vomiting,
diarrhea, dizziness, visual distur-
bances) to the requesting health
10 minutes.
care practitioner.
Intratest: ➤ Instruct the patient to be prepared to
list to the pharmacist the other med-
➤ Direct the patient to breathe ications he or she is already taking in
normally and to avoid unnecessary the event that the requesting health
movement. care practitioner prescribes a med-
➤ Observe standard precautions and ication.
follow the general guidelines in Ap- ➤ Evaluate test results in relation to
pendix A. Consider recommended the patient’s symptoms and other
collection time around dosing sched- tests performed. Patients receiving
ule. Perform a venipuncture, and col- lithium should be monitored espe-
lect the specimen in a 5-mL red-top cially for albumin, calcium, creati-
tube. nine, glucose, magnesium, potas-
➤ Label the specimen, and promptly sium, sodium, and blood urea
transport it to the laboratory. nitrogen.
ANTITHROMBIN III
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Heparin cofactor assay, AT-III.

SPECIMEN: Plasma (1 mL) collected in blue-top (sodium citrate) tube.
REFERENCE VALUE: (Method: Radioimmunodiffusion)
SI Units
Conventional Units (Conversion Factor 10)
Immunologic assay 21–30 mg/dL 210–300 mg/L
Antithrombin III 129
SI Units
Conventional Units (Conversion Factor 0.01)
Functional assay 85–115% of standard 0.85–1.15
DESCRIPTION: Antithrombin III • Drugs that may increase AT-III levels

(AT-III) can inhibit thrombin and include anabolic steroids, gemfibrozil,
factors IX, X, XI, and XII. It is a and warfarin.
heparin cofactor, interacting with • Drugs that may decrease AT-III levels
heparin and thrombin. AT-III acts to include asparaginase, heparin, estro-
increase the rate of thrombin neutral- gens, gestodene, and oral contracep-
ized or inhibited, and it decreases the tives.
total quantity of thrombin inhibited. • Placement of the tourniquet for longer
Patients with low levels show some than 1 minute can result in venous
level of resistance to heparin therapy. ■ stasis and changes in the concentration
of the plasma proteins to be measured.
INDICATIONS: Platelet activation may also occur
• Investigate tendency for thrombosis under these conditions, resulting in
erroneous measurements.
RESULT
Increased in: Nursing Implications and
• Acute hepatitis Procedure ● ● ● ● ● ● ● ● ● ● ●
• Inflammation
Pretest:
• Menstruation
• Obstructive jaundice complaints, including a list of known
allergens.
• Renal transplant
• 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
• Disseminated intravascular coagula-
tion these products so that their effects
• Liver transplant or partial hepatectomy can be taken into consideration
• Nephrotic syndrome ➤ There are no food, fluid, or medica-
• Pulmonary embolism tion restrictions unless by medical
direction.
patient.
collection takes approximately 5 to ent concentrations of sodium citrate

10 minutes. preservative are added to blue-top tubes
for coagulation studies: 3.2 percent and
Intratest: 3.8 percent. The National Committee for
➤ Direct the patient to breathe Clinical Laboratory Standards (NCCLS)
normally and to avoid unnecessary guideline for sodium citrate is 3.2
movement. percent. Laboratories establish reference
➤ Observe standard precautions and ranges for coagulation testing based on
follow the general guidelines in numerous factors, including sodium
Appendix A. Perform a venipuncture, citrate concentration, test equipment,
and collect the specimen in a 5-mL and test reagents. Inquire from the
blue-top tube. When multiple speci- laboratory as to which concentration is
mens are drawn, the blue-top tube used.
should be collected after sterile (i.e.,
blood culture) and red-top tubes.
When coagulation testing is the only
Post-test:
work to be done, an extra red-top ➤ Observe venipuncture site for bleed-
tube should be collected before the ing or hematoma formation. Apply
blue-top tube to avoid contaminating pressure bandage.
the specimen with tissue thrombo-
plastin.
➤ Label the specimen, and promptly tests performed. Some related labo-
transport it to the laboratory. ratory tests include partial thrombo-
plastin time, protein C, protein S,
IMPORTANT NOTE: Presently two differ- and vitamin K.
1-ANTITRYPSIN AND
1-ANTITRYPSIN PHENOTYPING
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: 1-antitrypsin: A1AT, 1-AT, AAT; 1-antitrypsin

phenotyping: A1AT phenotype, 1-AT phenotype, AAT phenotype, Pi
phenotype.
SPECIMEN: Serum (1 mL) for 1-antitrypsin (1-AT) and serum (2 mL)

for 1-AT phenotyping collected in a red- or tiger-top tube.
REFERENCE VALUE: (Method: Rate nephelometry for 1-AT, isoelectric

focusing/high-resolution electrophoresis for 1-AT phenotyping)
1-Antitrypsin and 1-Antitrypsin Phenotyping 131
1-Antitrypsin
SI Units
(Conversion
0–1 mo 124–348 mg/dL 1.24–3.48 g/L
2–6 mo 111–297 mg/dL 1.11–2.97 g/L
7 mo–2 y 95–251 mg/dL 0.95–2.51 g/L
3 y–19 y 110–279 mg/dL 1.10–2.79 g/L
Adult 126–226 mg/dL 1.26–2.26 g/L
1-Antitrypsin Phenotyping than 80% of ZZ-deficient individuals

ultimately develop chronic lung or
There are three major protease inhibitor liver disease. It is important to iden-
phenotypes:
tify inherited deficiencies early in life.
MM—Normal
Typically, 1-AT–deficient patients
SS—Intermediate; heterozygous
have circulating levels less than 50
ZZ—Markedly abnormal; mg/dL. Patients who have 1-AT val-
homozygous
ues less than 140 mg/dL should be
The total level of measurable 1-AT
varies with genotype. The effects of 1- phenotyped.
AT deficiency depend on the patient’s Elevated levels are found in normal
personal habits, but are most severe in individuals when an inflammatory
patients who smoke tobacco. process, such as rheumatoid arthritis,
bacterial infection, neoplasm, and
vasculitis, is present. Decreased levels
DESCRIPTION: 1-AT is the main are found in affected patients with
glycoprotein produced by the liver. Its chronic obstructive pulmonary dis-
inhibitory function is directed against ease (COPD) and in children with
proteolytic enzymes, such as trypsin, cirrhosis of the liver. Decreased 1-AT
elastin, and plasmin, released by alve- levels also may be elevated into the
olar macrophages and bacteria. In the normal range in heterozygous 1-
absence of 1-AT, functional tissue is AT–deficient patients during concur-
destroyed by proteolytic enzymes and rent infection, pregnancy, estrogen
replaced with excessive connective therapy, steroid therapy, cancer, and
tissue. Emphysema develops at an postoperative periods. Homozygous
earlier age in 1-AT–deficient emphy- 1-AT–deficient patients do not show
sema patients than in other emphy- such an elevation. ■
sema patients. 1-AT deficiency is
passed on as an autosomal-recessive INDICATIONS:
trait. Inherited deficiencies are associ- • Assist in establishing a diagnosis of
COPD
ated early in life with development of
lung and liver disorders. In the pedi- • Assist in establishing a diagnosis of
atric population, the ZZ phenotype liver disease
usually presents as liver disease, • Detect hereditary absence or deficiency
cholestasis, and cirrhosis. Greater of 1-AT

allergens.
• Acute and chronic inflammatory hepatobiliary and respiratory system
conditions and results of previously performed
• Carcinomas tests, refer to the hepatobiliary and
respiratory system tables.
• Estrogen therapy
• Postoperative recovery patient is taking, including herbs, nu-
• Pregnancy ticals. Oral contraceptives should be
• Steroid therapy withheld 24 hours before the speci-
men is collected, although this re-
• Stress (extreme physical) striction should first be confirmed
with the person ordering the test.
Decreased in: The requesting health care practi-
• COPD tioner and laboratory should be ad-
vised if the patient regularly uses
• Homozygous 1-AT–deficient patients these products so that their effects
• Liver disease (severe) when reviewing results.
• Liver cirrhosis (child) ➤ There are no food, fluid, or medica-
• Malnutrition direction.
• Nephrotic syndrome ➤ Review the procedure with the
patient.
collection usually takes approxi-
INTERFERING FACTORS: mately 5 to 10 minutes.
• 1-AT is an acute-phase reactant
protein, and any inflammatory process Intratest:
elevates levels. If a serum C-reactive
protein is performed simultaneously normally and to avoid unnecessary
and is positive, the patient should be movement.
retested for 1-AT in 10 to 14 days.
• Rheumatoid factor causes false-positive follow the general guidelines in
elevations. Appendix A. Perform a venipuncture,
• Drugs that may increase serum 1-AT red- or tiger-top tube.
levels include aminocaproic acid, estro- ➤ Label the specimen, and promptly
gen therapy, oral contraceptives (high- transport it to the laboratory.
dose preparations), oxymetholone,
streptokinase, tamoxifen, and typhoid Post-test:
vaccine.
pressure bandage.
Procedure ● ● ● ● ● ● ● ● ● ● ●
medication as directed by the health
care practitioner.
Pretest:
➤ Educate the patient with abnormal
➤ Obtain a history of the patient’s findings in preventive measures for
Apolipoprotein A 133
protection of the lungs (e.g., avoid ➤ Malnutrition is commonly seen in 1-

contact with persons who have res- AT–deficient patients with severe
piratory or other infections; avoid the respiratory disease for many rea-
use of tobacco; avoid areas having sons, including fatigue, lack of ap-
highly polluted air; and avoid work petite, and gastrointestinal distress.
environments with hazards such as Research has estimated that the
fumes, dust, and other respiratory daily caloric intake required for
pollutants). respiration in patients with COPD
➤ Instruct the affected patient in deep is 10 times higher than that required
breathing and pursed-lip breathing to of normal individuals. Inadequate
enhance breathing patterns as ap- nutrition can result in hypo-
propriate. Inform the patient of phosphatemia, especially in the
smoking cessation programs, as ap- respirator-dependent patient. During
propriate. periods of starvation, phosphorus
leaves the intracellular space and
➤ Recognize anxiety related to test re-
moves outside the tissue, resulting
sults and offer support. Provide
in dangerously decreased phospho-
teaching and information regarding
rus levels. Adequate intake of vita-
the clinical implications of the test
mins A and C is important to prevent
results, as appropriate. Because de-
pulmonary infection and to decrease
creased 1-AT can be an inherited
the extent of lung tissue damage.
disorder, it may be appropriate to
The importance of following the pre-
recommend resources for genetic
scribed diet should be stressed to
counseling if levels less than 140
the patient and caregiver.
mg/dL are reported. It may also be
appropriate to inform the patient ➤ Water balance must be closely
that 1-AT phenotype testing can monitored in 1-AT–deficient
be performed on family members patients with COPD. Fluid retention
to determine the homozygous or can lead to pulmonary edema.
heterozygous nature of the defi- ➤ Evaluate test results in relation to
ciency. the patient’s symptoms and other
➤ Inform the patient of the importance tests performed. Related laboratory
of medical follow-up, and suggest tests include arterial/alveolar oxygen
ongoing support resources to assist ratio, angiotensin-converting en-
the patient in coping with chronic zyme, anion gap, blood gases, elec-
illness and possible early death. trolytes, osmolality, and phosphorus.
APOLIPOPROTEIN A
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Apo A.
REFERENCE VALUE: (Method: Immunonephelometry)
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
DESCRIPTION: Apolipoprotein A Increased in:

(Apo A), the major component of • Familial hyper--lipoproteinemia
high-density lipoprotein (HDL), is • Weight reduction
synthesized in the liver and intes-
tines. Apolipoproteins assist in the Decreased in:
regulation of lipid metabolism by ac- • A--lipoproteinemia
tivating and inhibiting enzymes re-
• Cholestasis
quired for this process. Apo A-I acti-
vates the enzyme lecithin-cholesterol • Chronic renal failure
acyltransferase (LCAT), whereas Apo • Diabetes (uncontrolled)
A-II inhibits LCAT. The apolipopro-
teins also help keep lipids in solution • Diet high in carbohydrates or polyun-
saturated fats
as they circulate in the blood and di-
rect the lipids toward the correct tar- • Familial deficiencies of related enzymes
get organs and tissues in the body. It and lipoproteins
is believed that Apo A measurements • Hepatocellular disorders
may be more important than HDL
• Hypertriglyceridemia
cholesterol measurements as a predic-
tor of coronary artery disease (CAD). • Nephrotic syndrome
There is an inverse relationship be- • Premature coronary heart disease
tween Apo A levels and risk for
developing CAD. Because of difficul- • Smoking
ties with method standardization,
the above-listed reference ranges
should be used as a rough guide INTERFERING FACTORS:
in assessing abnormal conditions. • Drugs and substances that may in-
Values for African-Americans are 5 crease Apo A levels include anticon-
to 10 mg/dL higher than values for vulsants, beclobrate, bezafibrate,
whites. ■ ciprofibrate, estrogens, furosemide, lo-
vastatin, pravastatin, prednisolone,
INDICATIONS: simvastatin, and ethanol (abuse).
• Evaluation for risk of CAD • Drugs that may decrease Apo A levels
include androgens, beta blockers, di-
RESULT uretics, and probucol.
Apolipoprotein A 135

Nursing Implications and pendix A. Perform a venipuncture,
Procedure ● ● ● ● ● ● ● ● ● ● ● and collect the specimen in a 5-mL
Pretest: ➤ Label the specimen, and promptly
➤ Obtain a history of the patient’s transport it to the laboratory.
allergens. Post-test:
➤ Obtain a history of the patient’s car- ➤ Observe venipuncture site for bleed-
diovascular system and results of ing or hematoma formation. Apply
previously performed tests and pro- pressure bandage.
cedures. For related tests, refer to ➤ Instruct the patient to resume usual
the cardiovascular system table. diet as directed by the health care
➤ Obtain a list of medications the pa- practitioner.
tient is taking, including herbs, nutri- ➤ Decreased Apo A levels may be as-
tional supplements, and nutraceuti- sociated with CAD. Nutritional ther-
cals. The requesting health care apy is recommended for individuals
practitioner and laboratory should be identified to be at high risk for devel-
advised if the patient regularly uses oping CAD. Overweight patients
these products so that their effects should be encouraged to achieve a
can be taken into consideration normal weight. The American Heart
when reviewing results. Association Step 1 and Step 2 diets
➤ The patient should abstain from food may be helpful in achieving a goal of
for 6 to 12 hours before specimen reducing total cholesterol and triglyc-
collection. eride levels. The Step 1 diet empha-
➤ There are no fluid or medication sizes a reduction in foods high in
restrictions unless by medical direc- saturated fats and cholesterol. Red
tion. meats, eggs, and dairy products are
the major sources of saturated fats
➤ Review the procedure with the and cholesterol. If triglycerides are
patient. also elevated, the patient should be
➤ Inform the patient that specimen advised to eliminate or reduce alco-
collection takes approximately 5 to hol and simple carbohydrates from
10 minutes. the diet. The Step 2 diet recom-
mends stricter reductions.
Intratest: ➤ Evaluate test results in relation
➤ Ensure that the patient complied to the patient’s symptoms and
with dietary pretesting restrictions. other tests performed. Related
laboratory tests include apolipopro-
➤ Direct the patient to breathe nor- tein B, total cholesterol, HDL choles-
mally and to avoid unnecessary terol, low-density lipoprotein choles-
movement. terol, lipoprotein electrophoresis,
➤ Observe standard precautions and and triglycerides.
APOLIPOPROTEIN B
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Apo B.
REFERENCE VALUE: (Method: Immunonephelometry)
SI Units
(Conversion
Newborn–5 y 11–31 mg/dL 0.11–0.31 g/L
5–17 y
Male 47–139 mg/dL 0.47–1.39 g/L
Female 41–96 mg/dL 0.41–0.96 g/L
Adult
Male 46–174 mg/dL 0.46–1.74 g/L
Female 46–142 mg/dL 0.46–1.42 g/L
DESCRIPTION: Apolipoprotein B Increased in:

(Apo B), the major component of the • Anorexia nervosa
low-density lipoproteins (chylomi- • Cushing’s syndrome
crons, LDL, and very-low-density • Diabetes
lipoprotein), is synthesized in the liver
and intestines. Apolipoproteins assist • Dysglobulinemia
in the regulation of lipid metabolism • Emotional stress
by activating and inhibiting enzymes • Hepatic disease
required for this process. The apoli-
• Hepatic obstruction
poproteins also help keep lipids in
solution as they circulate in the blood • Hyperlipoproteinemias
and direct the lipids toward the correct • Hypothyroidism
target organs and tissues in the body. ■ • Infantile hypercalcemia
INDICATIONS: • Nephrotic syndrome
• Evaluation for risk of coronary artery • Porphyria
disease (CAD)
• Pregnancy
RESULT • Premature CAD
Apolipoprotein B 137
• Renal failure ➤ Obtain a history of the patient’s car-

diovascular system and results of
• Werner’s syndrome previously performed tests and pro-
cedures. For related tests, refer to
Decreased in: the cardiovascular system table.
➤ Obtain a list of medications the pa-
• Alpha lipoprotein deficiency (Tangier
tient is taking, including herbs, nutri-
disease) tional supplements, and nutraceuti-
• Acute stress (burns, illness) cals. The requesting health care
• Chronic anemias advised if the patient regularly uses
• Chronic pulmonary disease can be taken into consideration
• Familial deficiencies of related enzymes when reviewing results.
and lipoproteins ➤ The patient should abstain from food
for 6 to 12 hours before specimen
• Hyperthyroidism collection.
• Inflammatory joint disease ➤ There are no fluid or medication
restrictions unless by medical direc-
• Intestinal malabsorption tion.
• Malnutrition ➤ Review the procedure with the
patient.
• Myeloma
• Reye’s syndrome collection takes approximately 5 to
10 minutes.
• Weight reduction
Intratest:
CRITICAL VALUES: N/A ➤ Ensure that the patient complied
with dietary pretesting restrictions.
• Drugs that may increase Apo B levels normally and to avoid unnecessary
include amiodarone, androgens, beta movement.
blockers, catecholamines, cyclosporine, ➤ Observe standard precautions and
diuretics, ethanol (abuse), etretinate, follow the general guidelines in
glucogenic corticosteroids, oral contra- Appendix A. Perform a venipuncture,
ceptives, and phenobarbital. and collect the specimen in a 5-mL
• Drugs that may decrease Apo B levels
include fibrates, beclobrate, cholestyra- ➤ Label the specimen, and promptly
mine, captopril, ketanserin, lovastatin, transport it to the laboratory.
niacin, nifedipine, pravastatin, pra-
Post-test:
zosin, probucol, and simvastatin.
pressure bandage.
Procedure ● ● ● ● ● ● ● ● ● ● ●
practitioner.
Pretest:
➤ Increased Apo B levels may be asso-
➤ Obtain a history of the patient’s ciated with CAD. Nutritional therapy
complaints, including a list of known is recommended for individuals iden-
allergens. tified to be at high risk for developing
CAD. Overweight patients should be advised to eliminate or reduce alco-

encouraged to achieve a normal hol and simple carbohydrates from
weight. The American Heart Associa- the diet. The Step 2 diet recom-
tion Step 1 and Step 2 diets may be mends stricter reductions.
helpful in achieving a goal of reducing ➤ Evaluate test results in relation to
total cholesterol and triglyceride the patient’s symptoms and other
levels. The Step 1 diet emphasizes a tests performed. Related laboratory
reduction in foods high in saturated tests include apolipoprotein A, total
fats and cholesterol. Red meats, cholesterol, high-density lipoprotein
eggs, and dairy products are the cholesterol, LDL cholesterol, lipopro-
major sources of saturated fats and tein electrophoresis, and triglyc-
cholesterol. If triglycerides are also erides.
elevated, the patient should be
ARTHROGRAM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Joint study.

AREA OF APPLICATION: Shoulder, elbow, wrist, hip, knee, ankle, temporo-
mandibular joint.
CONTRAST: Iodinated or gadolinium.
DESCRIPTION: An arthrogram evalu- the contour of the joint. After brief

ates the cartilage, ligaments, and bony exercise of the joint, radiographs or
structures that compose a joint. After magnetic resonance images (MRIs)
local anesthesia is administered to the are obtained. Arthrograms are used
area of interest, a fluoroscopically primarily for assessment of persistent,
guided small-gauge needle is inserted unexplained joint discomfort. ■
into the joint space. Fluid in the joint
space is aspirated and sent to the labo- INDICATIONS:
ratory for analysis. Contrast medium • Evaluate pain, swelling, or dysfunction
is inserted into the joint space to of a joint
outline the soft tissue structures and • Monitor disease progression
Arthrogram 139
RESULT Factors that may impair clear

imaging:
Normal Findings: • Inability of the patient to cooperate or
• Normal bursae, menisci, ligaments, remain still during the procedure
and articular cartilage of the joint because of age, significant pain, or
(note: the cartilaginous surfaces and mental status
menisci should be smooth, without • Metallic objects within the examina-
evidence of erosion, tears, or disinte- tion field (e.g., jewelry, earrings, dental
gration) amalgams), which may inhibit organ
visualization and can produce unclear
Abnormal Findings: images
• Arthritis
• Improper adjustment of the radi-
• Cysts ographic equipment to accommodate
• Diseases of the cartilage (chondro- overexposure or underexposure and a
malacia) poor-quality study
• Injury to the ligaments • Patients who are very obese, who may
• Joint derangement exceed the weight limit for the equip-
ment
• Meniscal tears or laceration
• Muscle tears which may produce poor visualization
• Osteochondral fractures
• Osteochondritis dissecans Other considerations:
• Synovitis • Consultation with a physician should
• Synovial tumor tion safety concerns regarding infants
of patients who are lactating.
INTERFERING FACTORS • Risks associated with radiographic
overexposure can result from frequent
x-ray procedures. Personnel in the
for:
• Patients who are pregnant or suspected shield, or leave the area while the
of being pregnant, unless the potential examination is being done. Personnel
benefits of the procedure far outweigh working in the area where the exami-
the risks to the fetus and mother. nation is being done should wear
• Patients with bleeding disorders, active badges that reveal their level of expo-
arthritis, or joint infections. sure to radiation.
medium used may cause a life- Nursing Implications and
threatening allergic reaction. Patients Procedure ● ● ● ● ● ● ● ● ● ● ●
with a known hypersensitivity to the

medium may benefit from premedica- Pretest:
tion with corticosteroids or the use of a ➤ Inform the patient about the
nonionic contrast medium. purpose of the procedure, various
positions to assume, and the need is exercised to help distribute the

for the patient to hold his or her contrast medium.
breath periodically. ➤ X-rays or MRIs are taken of the joint.
➤ Obtain a history of the patient’s joint ➤ The patient is instructed to inhale
problems and the results of previ- deeply and hold his or her breath
ously performed tests, surgery, ther- while the x-ray film is taken, and
apy, injury, medication usage, and then to exhale after the film is taken.
to the musculoskeletal system Post-test:
table.
➤ A physician performs this procedure, ➤ Inform the patient that further exam-
which lasts 30 minutes. inations may be needed to evaluate
disease progression and to deter-
➤ There are no food, fluid, or medica- mine the need for a change in ther-
tion restrictions. apy.
➤ Inform the patient that discomfort ➤ Answer any questions or concerns
may be experienced when the voiced by the patient or family.
contrast medium is injected.
➤ Assess the joint for swelling after
➤ An informed consent needs to be the test. Apply ice as needed.
➤ Instruct the patient to use a mild
Intratest: analgesic (aspirin, acetaminophen),
as ordered, if there is discomfort.
➤ Clothing and metallic objects are ➤ Advise the patient to avoid strenu-
removed from the joint to be exam- ous activity until approved by the
ined. physician.
➤ Patients are given a gown and robe ➤ Instruct the patient to notify the
to wear. health care provider if he or she
➤ When x-rays are used, lead protec- experiences fever or increased
tion is placed over the gonads to pain, drainage, warmth, edema, or
prevent their irradiation. swelling of the joint.
➤ Place the patient on the table in a ➤ Inform the patient that noises from
supine position. the joint after the procedure are
➤ The skin surrounding the joint is common and should disappear 24 to
aseptically cleaned and anes- 48 hours after the procedure.
thetized. ➤ A physician who specializes in this
➤ A small-gauge needle is inserted branch of medicine sends a written
into the joint space. report to the ordering health care
provider, who discusses the results
➤ Any fluid in the space is aspirated with the patient.
and sent to the laboratory for analy-
sis. ➤ Evaluate test results in relation
to the patient’s symptoms and
➤ Contrast medium is inserted into the other tests performed. Related diag-
joint space with fluoroscopic guid- nostic tests include MRIs, x-rays,
ance. and bone scans of the joint in ques-
➤ The needle is removed, and the joint tion.
Arthroscopy 141
ARTHROSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
AREA OF APPLICATION: Joints.
CONTRAST: None.
DESCRIPTION: Arthroscopy provides • Remove loose objects

direct visualization of a joint through • Evaluate meniscal, patellar, condylar,
the use of a fiberoptic endoscope. The extrasynovial, and synovial injuries or
arthroscope has a light, fiberoptics, diseases of the knee
and lenses; it connects to a monitor,
• Detect torn ligament or tendon
and the images are recorded for future
study and comparison. This proce- • Monitor effectiveness of therapy
dure is used for inspection of joint
structures, performance of a biopsy, RESULT
and surgical repairs to the joint.
Normal Findings:
Meniscus removal, spur removal, and
• Normal muscle, ligament, cartilage,
ligamentous repair are some of the synovial, and tendon structures of the
surgical procedures that may be joint
performed. This procedure is most
commonly performed to diagnose Abnormal Findings:
athletic injuries and acute or chronic • Arthritis
joint disorders. Because arthroscopy
• Chondromalacia
allows direct visualization, degenera-
tive processes can be accurately • Cysts
differentiated from injuries. A local • Degenerative joint changes
anesthetic allows the arthroscope to
be inserted through the skin with • Ganglion or Baker’s cyst
minimal discomfort. This procedure • Gout or pseudogout
may also be done under a spinal or • Joint tumors
general anesthetic, especially if
surgery is anticipated. ■ • Loose bodies
• Meniscal disease
INDICATIONS:
• Evaluate the presence of gout • Osteoarthritis
• Evaluate the extent of arthritis • Osteochondritis
• Evaluate joint pain and damaged carti- • Rheumatoid arthritis

lage • Subluxation, fracture, or dislocation
• Synovitis
• 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.
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.
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
Aspartate Aminotranspeptidase 143
extremity to the proximal portion to Post-test:

drain as much blood from the limb
as possible. ➤ Advise the patient to avoid strenu-
ous activity involving the joint until
➤ A pneumatic tourniquet placed approved by the physician.
around the proximal portion of the
limb is inflated, and the elastic band- ➤ Inform the patient to resume normal
age is removed. diet and medications.
➤ As an alternative to a tourniquet, a ➤ Instruct the patient to take an
mixture of lidocaine with epineph- analgesic for joint discomfort after
rine and sterile normal saline may be the procedure; ice bags may be
instilled into the joint to help reduce used to reduce postprocedure
bleeding. swelling.
➤ The joint is placed in a 45º angle, and ➤ Monitor the patient’s circulation and
a local anesthetic is administered. sensations in the joint area.
➤ A small incision is made in the skin ➤ Emphasize that any fever as well as
in the lateral or medial aspect of the excessive bleeding, difficulty breath-
joint. ing, incision site redness, swelling,
➤ The arthroscope is inserted into the and tenderness must be reported to
joint spaces. The joint is manipulated the physician.
as it is visualized. Added puncture ➤ To reduce swelling, instruct the
sites may be needed to provide a full patient to elevate the joint when
view of the joint. sitting and to avoid overbending of
➤ Biopsy or treatment can be per- the joint.
formed at this time, and photo- ➤ Inform the patient to shower after 48
graphs should be taken for future hours but to avoid a tub bath until
reference. after his or her appointment with the
➤ After inspection, specimens may be physician.
obtained for cytologic and microbio- ➤ A physician who specializes in this
logic study. All specimens are placed branch of medicine provides a writ-
in appropriate containers, labeled ten report to the ordering health care
properly, and promptly sent to the provider, who discusses the results
laboratory. with the patient.
➤ The joint is irrigated, and the arthro- ➤ Evaluate procedure results in rela-
scope is removed. Manual pressure tion to the patient’s symptoms and
is applied to the joint to remove other tests performed. Related diag-
remaining irrigation solution. nostic tests include magnetic reso-
nance imaging, x-rays, and bone
➤ The incision sites are sutured, and a scans of the joint.
pressure dressing is applied.
➤ Gloves and gowns are worn through-
out the procedure.
ASPARTATE AMINOTRANSPEPTIDASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYMS: Serum glutamic-oxaloacetic transaminase, AST,

SGOT.

REFERENCE VALUE: (Method: Spectrophotometry, enzymatic at 37ºC)
SI Units
(Conversion
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
DESCRIPTION: Aspartate amino- myocardial infarction (note: AST rises

transferase (AST) is an enzyme that within 6 to 8 hours, peaks at 24 to 48
catalyzes the reversible transfer of an hours, and declines to normal within
amino between aspartate and - 72 to 96 hours)
ketoglutaric acid. It was formerly • Compare serially with alanine amino-
known as serum glutamic-oxaloacetic transferase levels to track the course of
transaminase (SGOT). AST exists in hepatitis
large amounts in liver and myocardial • Monitor response to therapy with
cells and in smaller but significant potentially hepatotoxic or nephrotoxic
amounts in skeletal muscle, kidneys, drugs
pancreas, and the brain. Serum AST • Monitor response to treatment for
rises when there is cellular damage to various disorders in which AST may be
the tissues where the enzyme is found. elevated, with tissue repair indicated by
AST values greater than 500 U/L are declining levels
usually associated with hepatitis and
other hepatocellular diseases in an RESULT
acute phase. AST levels are very
elevated at birth and decrease with Significantly increased in (greater
age. Note: Measurement of AST in than five times normal levels):
evaluation of myocardial infarction • Acute hepatitis
has been replaced by more sensitive • Acute hepatocellular disease
tests, such as creatine kinase–MB • Acute pancreatitis
fraction (CK-MB) and troponin. ■
• Shock
INDICATIONS: Moderately increased in (three to
• Assist in the diagnosis of disorders or five times normal levels):
injuries involving the tissues where
AST is normally found • Biliary tract obstruction
• Assist (formerly) in the diagnosis of • Cardiac arrhythmias
Aspartate Aminotranspeptidase 145
• Chronic hepatitis nine, ranitidine, retinol, ritodrine, sul-

fonylureas, tetracyclines, tobramycin,
• Congestive heart failure
and verapamil.
• Dermatomyositis
• Hemolysis falsely increases AST values.
• Liver tumors
• Muscular dystrophy
Slightly increased in (two to three Procedure ● ● ● ● ● ● ● ● ● ● ●
times normal):
Pretest:
• Cerebrovascular accident
• 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
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
benzodiazepines, chlorothiazide, chlor-
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.
• 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.
Post-test: ➤ Increased AST levels may be associ-

ated with coronary artery disease
➤ Observe venipuncture site for bleed- (CAD). Nutritional therapy is recom-
ing or hematoma formation. Apply mended for individuals identified to
pressure bandage. be at high risk for CAD. Overweight
patients should be encouraged to
➤ Increased AST levels may be associ- achieve a normal weight. The Ameri-
ated with liver disease. Dietary can Heart Association Step 1 and
recommendations may be indicated Step 2 diets may be helpful in
and vary depending on the condition achieving a goal of reducing total
and its severity. Currently, there are cholesterol and triglyceride levels.
no specific medications that can be The Step 1 diet emphasizes a reduc-
given to cure hepatitis, but elimination in foods high in saturated fats
tion of alcohol ingestion and a diet and cholesterol. Red meats, eggs,
optimized for convalescence are and dairy products are the major
commonly included in the treatment sources of saturated fats and choles-
plan. A high-calorie, high-protein, terol. If triglycerides are also ele-
moderate-fat diet with a high fluid vated, the patient should be advised
intake is often recommended for to eliminate or reduce alcohol and
patients with hepatitis. Treatment of simple carbohydrates from the diet.
cirrhosis is different; a low-protein The Step 2 diet recommends stricter
diet may be in order if the patient’s reductions.
liver can no longer process the end
products of protein metabolism. A ➤ Instruct the patient to immediately
diet of soft foods may be required if report chest pain and changes in
esophageal varices have developed. breathing pattern to the health care
Ammonia levels may be used to practitioner.
determine whether protein should ➤ Evaluate test results in relation to
be added to or reduced from the the patient’s symptoms and other
diet. Patients should be encouraged tests performed. Related laboratory
to eat simple carbohydrates and tests include acetaminophen, albu-
emulsified fats (as in homogenized min, alkaline phosphatase, alanine
milk or eggs), as opposed to com- aminotransferase, 1-antitrypsin/
plex carbohydrates (e.g., starch, phenotyping, ammonia, antimito-
fiber, and glycogen [animal carbohy- chondrial antibody, bilirubin, liver
drates]) and complex fats, which biopsy, ethanol, ferritin, -glutamyl-
would require additional bile to transferase, hepatitis antigens and
emulsify it so that it could be used. antibodies, iron/total iron-binding ca-
The cirrhotic patient should be pacity, protein, and prothrombin
observed carefully for the develop- time if liver disease is suspected;
ment of ascites, in which case fluid and creatine kinase, lactate dehydro-
and electrolyte balance requires genase, magnesium, and troponin I
strict attention. if myocardial infarction is suspected.
ATRIAL NATRIURETIC FACTOR

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

peptide, ANF, ANH.
Atrial Natriuretic Factor 147
SPECIMEN: Plasma (1 mL) collected in a chilled, lavender-top tube.

Conventional Units SI Units (Conversion Factor 1)

20–77 pg/mL 20–77 ng/L
DESCRIPTION: Atrial natriuretic INTERFERING FACTORS:

factor (ANF) is a hormone secreted • Drugs that may increase ANF levels
from cells in the right atrium of the include atenolol, candoxatril, capto-
heart when right atrial pressure pril, carteolol, dopamine, morphine,
increases. The release of this cardiac oral contraceptives, vasopressin, and
verapamil.
peptide is stimulated by increases in
the stretch of the atrial wall caused by • Drugs that may decrease ANF levels
an increase in blood pressure or blood include clonidine, prazosin, and ura-
volume. ANF receptors are also stim- pidil.
ulated by elevated sodium levels. This • Recent radioactive scans or radiation
extremely potent hormone enhances within 1 week before the test can inter-
salt and water excretions by blocking fere with test results when radioim-
aldosterone and renin secretion. ANF munoassay is the test method.
inhibits angiotensin II and vaso-
pressin, resulting in vasodilation and a
decrease in blood volume and blood Nursing Implications and
pressure. ■ Procedure ● ● ● ● ● ● ● ● ● ● ●
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.
• Asymptomatic cardiac volume over- cardiovascular system and results of
load previously performed tests and
• CHF to the cardiovascular system table.
• Elevated cardiac filling pressure ➤ Obtain a list of medications the pa-
• Paroxysmal atrial tachycardia tional supplements, and nutraceuti-
cals. The requesting health care
Decreased in: N/A practitioner and laboratory should be
CRITICAL VALUES: N/A these products so that their effects
can be taken into consideration and collect the specimen in a chilled,

when reviewing results. 5-mL lavender-top tube.
➤ Instruct the patient to fast for 6 to 12 ➤ Label the specimen, and promptly
hours before the test and to avoid transport it to the laboratory. The
taking medications that interfere tightly capped sample should be
with test results, as directed by the placed in an ice slurry immediately
health care practitioner. Note: Drugs after collection. Information on the
such as beta-blocking agents, cal- specimen label can be protected
cium antagonists, cardiac glycosides, from water in the ice slurry if the
and vasodilators can affect results. specimen is first placed in a protec-
➤ Note any recent procedures that tive plastic bag.
may interfere with test results.
➤ Review the procedure with the Post-test:
patient.
➤ Inform the patient that specimen ing or hematoma formation. Apply
collection takes approximately 5 to pressure bandage.
10 minutes.
➤ Overweight patients with high blood
➤ Prepare an ice slurry in a cup or plas- pressure should be encouraged
tic bag to have on hand for immedi- to achieve a normal weight. Other
ate transport of the specimen to the changeable risk factors warranting
laboratory. patient education include strategies
to safely decrease sodium intake, in-
Intratest: crease physical activity, decrease al-
cohol consumption, eliminate to-
➤ Ensure that the patient complied bacco use, and decrease cholesterol
with dietary preparation and other levels.
➤ Direct the patient to breathe the patient’s symptoms and other
normally and to avoid unnecessary tests performed. Related laboratory
movement. tests include aldosterone, antiar-
➤ Observe standard precautions and rhythmic drugs, antidiuretic hor-
follow the general guidelines in mone, calcium, electrolytes, and
Appendix A. Perform a venipuncture, renin.
BACTERIAL CULTURE, ANAL/

GENITAL, EAR, EYE, SKIN,
AND WOUND
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Bacterial Culture, Anal/Genital, Ear, Eye, Skin, and Wound 149
SPECIMEN: Sterile fluid or swab from affected area placed in transport

media tube provided by laboratory.
REFERENCE VALUE: (Method: Culture aerobic and/or anaerobic on selected

media; DNA probe assays are available for identification of Neisseria gonor-
rhoeae.) Negative: no growth of pathogens.
DESCRIPTION: When indicated by otics to which organisms are suscep-

patient history, anal cultures may be tible to ensure an effective treatment
performed to isolate the organism plan. ■
responsible for sexually transmitted
disease. INDICATIONS
Ear and eye cultures are performed
to isolate the organism responsible for Anal/genital:
chronic or acute infectious disease of • Assist in the diagnosis of sexually trans-
the ear and eye. mitted diseases
Skin and soft tissue samples from
• Determine the cause of genital itching
infected sites must be collected care-
or purulent drainage
fully to avoid contamination from the
surrounding normal skin flora. Skin • Determine effective antimicrobial ther-
and tissue infections may be caused apy specific to the identified pathogen
by both aerobic and anaerobic organ-
isms. Therefore, a portion of the Ear:
sample should be placed in aerobic • Isolate and identify organisms respon-
and anaerobic transport media. Care sible for ear pain, drainage, or changes
must be taken to use transport media in hearing
that is approved by the laboratory • Isolate and identify organisms respon-
performing the testing. sible for outer-, middle-, or inner-ear
A wound culture involves collect- infection
ing a specimen of exudates, drainage, • Determine effective antimicrobial ther-
or tissue so that the causative organ- apy specific to the identified pathogen
ism can be isolated and pathogens
identified. Specimens can be obtained Eye:
from superficial and deep wounds.
• Isolate and identify pathogenic micro-
Optimally, specimens should be
organisms responsible for infection of
obtained before antibiotic use. The the eye
method used to culture and grow the
organism depends on the suspected • Determine effective antimicrobial ther-
infectious organism. There are trans- apy specific to identified pathogen
port media specifically for bacterial
Skin:
agents. The laboratory will select
the appropriate media for suspect • Isolate and identify organisms respon-
organisms. The laboratory will initi- sible for skin eruptions, drainage, or
ate antibiotic sensitivity testing if other evidence of infection
indicated by test results. Sensiti- • Determine effective antimicrobial ther-
vity testing identifies the antibi- apy specific to the identified pathogen
Sterile fluids: Skin

• Isolate and identify organisms before Commonly identified organisms include
surrounding tissue becomes infected Bacteroides, Clostridium, Corynebac-
terium, Pseudomonas, Staphylococci, and
• Determine effective antimicrobial
group A Streptococci.
therapy specific to the identified
pathogen
Sterile fluids
Wound: Commonly identified pathogens include

Bacteroides, Enterococcus spp., E. coli,
• Detect abscess or deep-wound infec- Pseudomonas aeruginosa, and Peptostrepto-
tious process coccus spp.
• Determine if an infectious agent is the
cause of wound redness, warmth, or Wound
edema with drainage at a site Aerobic and anaerobic microorganisms
• Determine presence of infectious can be identified in wound culture
agents in a stage 3 and stage 4 decubi- specimens. Commonly identified organ-
tus ulcer isms include Clostridium perfringens,
Klebsiella, Proteus, Pseudomonas, Staphylo-
• Isolate and identify organisms respon- coccus aureus, and group A Streptococcus.
sible for the presence of pus or other
exudate in an open wound CRITICAL VALUES: N/A
• Determine effective antimicrobial ther-
apy specific to the identified pathogen INTERFERING FACTORS:
• Failure to collect adequate specimen,
improper collection or storage tech-
RESULT nique, and failure to transport speci-
men in a timely fashion are causes for
Positive findings in: specimen rejection.
Anal/Endocervical/Genital • Pretest antimicrobial therapy will
delay or inhibit the growth of
Infections or carrier states caused by the pathogens.
following organisms: Gardnerella vagi-
nalis, N. gonorrhoeae, toxin-producing • Testing specimens more than 1 hour
strains of Staphylococcus aureus, and after collection may result in decreased
Treponema pallidum. growth or nongrowth of organisms.
Ear
Commonly identified organisms include
Escherichia coli, Proteus spp., Pseudomonas
Procedure ● ● ● ● ● ● ● ● ● ● ●
aeruginosa, Staphylococcus aureus, and -

Pretest:
hemolytic Streptococcus.
Eye complaints, including a list of known
allergens.
Commonly identified organisms include ➤ Obtain a history of the patient’s
Haemophilus influenzae, H. aegyptius, N. immune system and, as appropriate,
gonorrhoeae, Pseudomonas aeruginosa, a history of sexual activity, as well as
Staphylococcus aureus, and Streptococcus results of previously performed
pneumoniae. tests and procedures. For related
Bacterial Culture, Anal/Genital, Ear, Eye, Skin, and Wound 151
tests, refer to the immune and Genital

reproductive system tables.
➤ Obtain a list of the medications Female patient
herbs, nutritional supplements, and ➤ Position the patient on the gyneco-
nutraceuticals. The requesting health logic examination table with the feet
care practitioner and laboratory up in stirrups. Drape the patient’s
should be advised if the patient legs to provide privacy and reduce
regularly uses these products so chilling.
that their effects can be taken into ➤ Cleanse the external genitalia and
consideration when reviewing perineum from front to back with
results. towelettes provided in culture kit.
➤ Note any recent procedures that can Using a Culturette swab, obtain a
interfere with test results. sample of the lesion or discharge
from the urethra or vulva. Place the
➤ There are no food or fluid restrictions swab in the Culturette tube, and
unless by medical direction. squeeze the bottom of the tube to
➤ Review the procedure with the release the transport medium.
patient. Sensitivity to cultural and Ensure that the end of the swab is
social issues, as well as concern for immersed in the medium.
modesty, is important in providing ➤ To obtain a vaginal and endocervical
psychological support. culture, insert a water-lubricated vagi-
➤ Instruct female patients not to nal speculum, and apply pressure to
douche for 24 hours before a cervi- the speculum to express exudate
cal or vaginal specimen is to be from the cervix. Insert the swab into
obtained. the cervical orifice and rotate the
swab to collect the secretions
➤ Inform the patient that specimen containing the microorganisms.
collection takes approximately 5 to Remove and place in the appropriate
10 minutes. culture medium. Material from the
vagina can be collected by moving a
Intratest: swab along the sides of the vaginal
mucosa. The swab is removed and
➤ Direct the patient to breathe then placed in a tube of saline
normally and to avoid unnecessary medium.
movement.
➤ Observe standard precautions and Male patient
follow the general guidelines in ➤ To obtain a urethral culture, cleanse
Appendix A. the penis (retracting the foreskin),
compress to express discharge from
Anal the urethra, and insert a swab into
➤ Place the patient in a lithotomy or the urethral orifice to obtain a
side-lying position and drape for sample of the discharge. Place the
privacy. Insert the swab 1 inch into swab in the Culturette tube, and
the anal canal and rotate, move it squeeze the bottom of the tube to
from side-to-side to allow it to come release the transport medium.
into contact with the microorgan- Ensure that the end of the swab is
isms. Remove the swab. Place the immersed in the medium.
swab in the Culturette tube, and
squeeze the bottom of the tube to
Ear
release the transport medium. ➤ Cleanse the area surrounding the
Ensure that the end of the swab is site with a swab containing cleaning
immersed in the medium. Repeat solution to remove any contaminat-
with a clean swab if the swab is ing material or flora that have
pushed into feces. collected in the ear canal. If needed,
remove any cerumen that has Sterile fluid

collected.
➤ Refer to related body fluid mono-
➤ Insert a Culturette swab approxi- graphs (i.e., amniotic fluid, cere-
mately 1/4 inch into the external ear brospinal fluid, pericardial fluid,
canal. Rotate the swab in the area peritoneal fluid, pleural fluid, synovial
containing the exudate. Carefully fluid) for specimen collection.
remove the swab, ensuring that it
does not touch the side or opening Wound
of the ear canal.
➤ Place the patient in a comfortable
➤ Place the swab in the Culturette tube, position, and drape the site to be
and squeeze the bottom of the tube cultured. Cleanse the area around
to release the transport medium. the wound to remove flora indige-
Ensure that the end of the swab is nous to the skin.
immersed in the medium. ➤ Place a Culturette swab in a superfi-
cial wound where the exudate is the
Eye most excessive without touching
the wound edges. Place the swab in
➤ Pass a moistened swab over the the Culturette tube, and squeeze the
appropriate site, avoiding eyelid and bottom of the tube to release the
eyelashes unless those areas are transport medium. Ensure that the
selected for study. Collect any visible end of the swab is immersed in the
pus or other exudate. Place the swab medium. Use more than one swab
in the Culturette tube, and squeeze and Culturette tube to obtain speci-
the bottom of the tube to release the mens from other areas of the
transport medium. Ensure that the wound.
end of the swab is immersed in the ➤ To obtain a deep wound specimen,
medium. insert a sterile syringe and needle
➤ An appropriate health care practi- into the wound and aspirate the
tioner should perform procedures drainage. Following aspiration, inject
requiring eye scrapings. the material into a tube containing
an anaerobic culture medium.
Skin General
➤ Using a sterile scalpel, scrape the ➤ Label the specimen, including speci-
skin from several areas of the men source (left or right as appropri-
affected site. If indicated, select the ate), patient age and gender, date
dark, moist areas of the folds of the and time of collection, and current
skin and outer growing edges of the antibiotic therapy (if any). Promptly
infection where microorganisms are transport the specimen to the labo-
most likely to flourish. Place the ratory. Do not freeze the specimen
scrapings in a Petri dish or spread on or allow it to dry.
a slide. Aspirate any fluid from a
pustule or vesicle using a sterile Post-test:
needle and tuberculin syringe. Flush
the exudate into a Petri dish or sterile
collection tube. If the lesion is not Anal/endocervical/genital
fluid filled, open the lesion with a ➤ Inform the patient that final results
scalpel and swab the area with a ster- may take from 24 hours to 4 weeks,
ile cotton-tipped swab. Place the depending on the test performed.
swab in the Culturette tube, and
squeeze the bottom of the tube to ➤ Advise the patient to avoid sexual
release the transport medium. contact until test results are avail-
Ensure that the end of the swab is able.
immersed in the medium. ➤ Instruct in vaginal suppository and
Bacterial Culture, Blood 153
douche procedures and administra- vitamin C) to promote wound heal-

tion of topical medication to treat ing.
specific conditions, as indicated.
➤ Inform infected patients that all General
sexual partners must be tested for
the microorganism. ➤ Emphasize the importance of report-
➤ Inform the patient that positive ing continued signs and symptoms
culture findings for certain organ- of the infection.
isms must be reported to a local ➤ Inform the patient that a repeat
health department official, who will culture may be needed in 1 week
question him or her regarding sexual after completion of the antimicrobial
partners. regimen.
➤ Offer support, as appropriate, to pa- ➤ Advise the patient that final test re-
tients who may be the victims of sults may take 24 to 72 hours de-
rape or sexual assault. Educate the pending on the organism suspected,
patient regarding access to counsel- but that antibiotic therapy may be
ing services. Provide a nonjudgmen- started immediately. Administer an-
tal, nonthreatening atmosphere for tibiotics as ordered, and instruct the
discussing the risks of sexually patient in the importance of com-
transmitted diseases. It is also im- pleting the entire course of antibiotic
portant to discuss problems the pa- therapy even if no symptoms are
tient may experience (e.g., guilt, de- present.
pression, anger). ➤ Evaluate test results in relation to
Wound tests performed. Related laboratory
➤ Instruct in wound care and nutri- tests include relevant tissue biop-
tional requirements (e.g., protein, sies and Gram stain.
BACTERIAL CULTURE, BLOOD

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Whole blood collected in bottles containing standard aerobic
and anaerobic culture media; 10 to 20 mL for adult patients or 1 to 5 mL
for pediatric patients.
REFERENCE VALUE: (Method: Growth of organisms in standard culture

media identified by radiometric or infrared automation, or by manual read-
ing of subculture.) Negative: no growth of pathogens.
DESCRIPTION: Blood cultures are infections, rapidly progressing tissue

collected whenever bacteremia or sep- infection, postoperative wound sepsis,
ticemia is suspected. Although mild and indwelling venous or arterial
bacteremia is found in many infec- catheter
tious diseases, a persistent, continu- • Evaluate intermittent or continuous
ous, or recurrent bacteremia indicates temperature elevation of unknown
a more serious condition that may re- origin
quire immediate treatment. Early de- • Evaluate persistent, intermittent fever
tection of pathogens in the blood may associated with a heart murmur
aid in making clinical and etiologic
• Evaluate a sudden change in pulse and
diagnoses. temperature with or without chills and
Blood culture involves the intro- diaphoresis
duction of a specimen of blood into
artificial aerobic and anaerobic • Evaluate suspected bacteremia after
invasive procedures
growth culture medium. The culture
is incubated for a specific length of • Identify the cause of shock in the post-
time, at a specific temperature, and operative period
under other conditions suitable for
the growth of pathogenic microor- RESULT
ganisms. Pathogens enter the blood- Positive findings in:
stream from soft-tissue infection sites, • Bacteremia or septicemia: Aerobacter,
contaminated intravenous lines, or Bacteroides, Brucella, Clostridium
invasive procedures (e.g., surgery, perfringens, enterococci, Escherichia coli
tooth extraction, cystoscopy). A and other coliform bacilli, Haemophilus
blood culture may also be done with influenzae, Klebsiella, Listeria monocyto-
an antimicrobial removal device genes, Pseudomonas aeruginosa, Salmo-
(ARD). This involves transferring nella, Staphylococcus aureus, Staphylo-
coccus epidermidis, and -hemolytic
some of the blood sample into a spe-
Streptococcus.
cial vial containing absorbent resins
that remove antibiotics from the sam- • Plague
ple before the culture is performed. • Malaria (by special request, a stained
The laboratory will initiate antibiotic capillary smear would be examined)
sensitivity testing if indicated by test
• Typhoid fever
results. Sensitivity testing identifies
the antibiotics to which the organisms Note: Candida albicans is a yeast that
are susceptible to ensure an effective can cause disease and can be isolated by
treatment plan. ■ blood culture.
INDICATIONS: CRITICAL VALUES: Positive findings

• Determine sepsis in the newborn as a must be immediately communicated to
result of prolonged labor, early rupture the primary health care practitioner.
of membranes, maternal infection, or
neonatal aspiration INTERFERING FACTORS:
• Evaluate chills and fever in patients • Pretest antimicrobial therapy will delay
with infected burns, urinary tract or inhibit growth of pathogens.
Bacterial Culture, Blood 155
• Contamination of the specimen by the Intratest:

skin’s resident flora may invalidate
interpretation of test results. ➤ Direct the patient to breathe
• An inadequate amount of blood or movement.
number of blood specimens drawn for ➤ Observe standard precautions and
examination may invalidate interpreta- follow the general guidelines in
tion of results. Appendix A.
• Specimens that are tested more than 1 ➤ The high risk for infecting a patient
hour after collection may result in by venipuncture can be decreased
decreased growth or nongrowth of by using an aseptic technique during
specimen collection.
organisms.
➤ The contamination of blood cultures
• Negative findings do not ensure the by skin and other flora can also be
absence of infection. dramatically reduced by careful
preparation of the puncture site and
collection containers before speci-
men collection. Cleanse the rubber
Nursing Implications and stoppers of the collection containers
Procedure ● ● ● ● ● ● ● ● ● ● ●
with the appropriate disinfectant as
recommended by the laboratory,
allow to air-dry, and cleanse with
Pretest:
70% alcohol. Once the vein has
➤ Obtain a history of the patient’s been located by palpation, cleanse
complaints, including a list of known the site with 70% alcohol followed
allergens. by swabbing with an iodine solution.
The iodine should be swabbed in a
circular concentric motion, moving
immune system, as well as results
outward or away from the puncture
of previously performed tests and
site. The iodine should be allowed to
completely dry before the sample is
to the immune system table.
collected. If the patient is sensitive
➤ Obtain a list of the medications the to iodine, a double alcohol scrub or
patient is taking, including herbs, green soap may be substituted.
nutritional supplements and
➤ If collection is performed by directly
drawing the sample into a culture
tube, fill the aerobic culture tube
first.
that their effects can be taken into ➤ If collection is performed using a
consideration when reviewing syringe, transfer the blood sample
results. directly into each culture bottle.
➤ There are no food or fluid restrictions ➤ More than three sets of cultures per
unless by medical direction. day do not significantly add to the
likelihood of pathogen capture.
➤ Establish whether the patient is Capture rates are more likely
sensitive to iodine. affected by obtaining a sufficient
➤ Review the procedure with the volume of blood per culture.
patient. Inform the patient that ➤ The use of ARDs or resin bottles is
multiple specimens may be required costly and controversial with respect
at timed intervals. to their effectiveness versus stan-
➤ Inform the patient that specimen dard culture techniques. They may
collection takes approximately 5 to be useful in selected cases, such as
10 minutes. when septicemia or bacteremia is
Disease Suspected Recommended Collection

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

apy has been initiated. antibiotic therapy even if no symp-
➤ Label the specimen, and promptly toms are present.
transport it to the laboratory. ➤ Inform the patient that preliminary
results should be available in 24 to
Post-test: 72 hours, but final results are not
➤ Cleanse the iodine from the collec- available for 5 to 7 days.
tion site. ➤ Instruct the patient to report fever,
➤ Observe the venipuncture site for chills, and other signs and symp-
bleeding or hematoma formation. toms of acute infection to the health
Apply a pressure bandage. care practitioner.
➤ Instruct the patient to resume usual ➤ Evaluate test results in relation to
medication as directed by the health the patient’s symptoms and other
care practitioner. tests performed. A related labora-
➤ Instruct the patient in the antimicro- tory test is the complete blood
bial regimen and in the importance count.
BACTERIAL CULTURE, SPUTUM

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

SPECIMEN: Sputum (10 to 15 mL).
Bacterial Culture, Sputum 157
REFERENCE VALUE: (Method: Aerobic culture on selective and enriched

media; microscopic examination of sputum by Gram stain.) The presence of
normal upper respiratory flora should be expected. Tracheal aspirates and
bronchoscopy samples can be contaminated with normal flora, but transtra-
cheal aspiration specimens should show no growth. Normal respiratory flora
include Neisseria catarrhalis, Candida albicans,diphtheroids, -hemolytic
Streptococcus, and some staphylococci. The presence of normal flora does not
rule out infection. A normal Gram stain of sputum contains polymor-
phonuclear leukocytes, alveolar macrophages, and a few squamous epithelial
cells.
DESCRIPTION: This test involves squamous cells or absence of polymor-

collecting a sputum specimen so the phonuclear leukocytes
pathogen can be isolated and identi-
fied. The test results will reflect the RESULT:
• The major difficulty in evaluating
type and number of organisms pres-
results is in distinguishing organisms
ent in the specimen, as well as the infecting the lower respiratory tract
antibiotics to which the identified from organisms that have colonized
pathogenic organisms are susceptible. but not infected the lower respiratory
Sputum collected by expectoration or tract. Review of the Gram stain assists
suctioning with catheters and by in this process. The presence of greater
bronchoscopy cannot be cultured for than 25 squamous epithelial cells per
anaerobic organisms; instead transtra- low-power field (lpf ) indicates oral
cheal aspiration or lung biopsy must contamination, and the specimen
be used. The laboratory will initiate should be rejected. The presence of
many polymorphonuclear neutrophils
antibiotic sensitivity testing if indi-
and few squamous epithelial cells indi-
cated by test results. Sensitivity test- cates that the specimen was collected
ing identifies antibiotics to which the from an area of infection and is satis-
organisms are susceptible to ensure an factory for further analysis.
effective treatment plan. ■
• Bacterial pneumonia can be caused by
INDICATIONS: Streptococcus pneumoniae, Haemophilus
influenzae, staphylococci, and some
Culture: gram-negative bacteria. Other patho-
gens that can be identified by culture
• Assist in the diagnosis of respiratory are Corynebacterium diphtheriae, Kleb-
infections, as indicated by the presence siella pneumoniae, and Pseudomonas
or absence of organisms in culture aeruginosa. Some infectious agents,
such as C. diphtheriae, are more fastid-
Gram Stain: ious in their growth requirements and
• Assist in the differentiation of gram- cannot be cultured and identified with-
positive from gram-negative bacteria in out special treatment. Suspicion of in-
respiratory infection fection by less commonly identified
and/or fastidious organisms must be
• Assist in the differentiation of sputum communicated to the laboratory to en-
from upper respiratory tract secretions, sure selection of the proper procedure
the latter being indicated by excessive required for identification.
CRITICAL VALUES: N/A ➤ Address concerns about pain related

to the procedure. Explain that a
INTERFERING FACTORS: sedative and/or anesthetic will be
administered before the procedure
• Contamination with oral flora may
to promote relaxation and reduce
invalidate results. discomfort during the procedure,
• Specimen collection after antibiotic and that general anesthesia will be
therapy has been initiated may result in administered for open biopsy. At-
ropine is usually given before bron-
inhibited or no growth of organisms.
choscopy examinations to reduce
bronchial secretions and prevent va-
gally induced bradycardia. Meperi-
Nursing Implications and dine (Demerol) or morphine may be
Procedure ● ● ● ● ● ● ● ● ● ● ● given as a sedative. Lidocaine is
sprayed in the patient’s throat to re-
Pretest: duce discomfort caused by the pres-
ence of the tube.
complaints, including a list of known ➤ Assess if the patient has an allergy
allergens. to local anesthetics, and inform the
health care practitioner accordingly.
➤ Obtain a history of the patient’s im-
mune and respiratory system, as ➤ Ensure that the patient is not allergic
well as results of previously per- to anesthesia before bronchoscopy
formed tests and procedures. For re- procedure is performed under gen-
lated tests, refer to the immune and eral anesthesia.
respiratory system tables. ➤ Obtain written and informed consent
➤ Obtain a list of the medications the before administering any medica-
patient is taking, including herbs, nu- tions prior to the biopsy or bron-
tritional supplements and nutraceuti- coscopy procedure.
cals. The requesting health care ➤ Assist with mouth care (i.e., rinsing
practitioner and laboratory should be mouth with water), if needed, before
advised if the patient is regularly us- collection so as not to contaminate
ing these products so their effects the specimen by oral secretions.
➤ Inform the patient that the test helps
identify organisms that cause respi-
➤ Note any recent procedures that can ratory tract infections. Emphasize
interfere with test results. that sputum and saliva are not the
➤ Ensure that the patient has fasted same.
and refrained from consuming liq- ➤ Assist in providing extra fluids,
uids since midnight the previous unless contraindicated, and proper
night if bronchoscopy is to be per- humidification to decrease tenacious
formed. secretions. Inform the patient that
➤ If the specimen is collected by increasing fluid intake before retiring
expectoration or tracheal suctioning, on the night before the test aids in
there are no food, fluid, or medica- liquefying secretions and may make
tion restrictions (except antibiotics) it easier to expectorate in the morn-
unless by medical direction. ing. Also explain that humidifying
➤ Reassure the patient that he or she inspired air also helps liquefy secre-
will be able to breathe during the tions.
procedure if specimen collected is ➤ Instruct the patient to brush the
accomplished via suction method. teeth or rinse the mouth before ob-
Ensure that oxygen has been admin- taining the specimen, to avoid ex-
istered 20 to 30 minutes before the cessive contamination of the speci-
procedure if the specimen is to be men with organisms normally found
obtained by tracheal suctioning. in the mouth.
Bacterial Culture, Sputum 159
➤ 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
previous procedure is followed ➤ Instruct the patient to perform

except that the suction catheter is mouth care after the specimen has
passed through the existing endotra- been obtained.
cheal or tracheostomy tube rather ➤ Provide comfort measures and treat-
than through the nostril. The patient ment as needed, such as antiseptic
should be hyperoxygenated before gargles, inhalants, and warm moist
and after the procedure in accor- applications. A cool beverage may
dance with usual protocols for aid in relieving throat irritation
suctioning these patients. caused by coughing or suctioning.
➤ Provide sterile sputum collection ➤ Instruct the patient to notify some-
containers. Label the specimen, and one immediately if difficulty in
promptly transport it to the labora- breathing or swallowing or if bleed-
tory. It is advisable to note antimi- ing occurs.
crobial therapy on the collection
container. ➤ Observe the patient’s color and
respiratory rate. Administer oxygen,
as necessary.
Post-test: ➤ Administer analgesics and antibi-
➤ Monitor vital signs and compare otics as ordered and instruct the pa-
with baseline values. tient in the importance of complet-
➤ Note the color, consistency, and therapy even if no symptoms are
volume of the specimen collected. present.
➤ Instruct the patient to resume usual ➤ Evaluate test results in relation to
diet and medication as directed by the patient’s symptoms and other
the health care practitioner. tests performed. Related laboratory
➤ If bronchoscopy has been per- tests include acid-fast culture and
formed, inform the patient to drink smear, arterial/alveolar oxygen ratio,
liquids or eat food only after the gag lung biopsy, blood gases, complete
reflex returns. blood count, and Gram stain.
BACTERIAL CULTURE, STOOL

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Fresh random stool collected in a clean plastic container.
REFERENCE VALUE: (Method: Culture on selective media for identification
of pathogens usually to include Salmonella, Shigella, Escherichia coli
O157:H7, Yersinia enterocolitica, and Campylobacter; latex agglutination or
enzyme immunoassay for Clostridium A and B toxins) Negative: No growth
of pathogens. Normal fecal flora is 96 to 99 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.
Bacterial Culture, Stool 161
DESCRIPTION: Stool culture involves food or the presence of toxin confirmed

collecting a sample of feces so that in the stool specimen).
organisms present can be isolated and
identified. Certain bacteria are CRITICAL VALUES: N/A
normally found in feces. However,
when overgrowth of these organisms • A rectal swab does not provide an
occurs or pathologic organisms are adequate amount of specimen for eval-
present, diarrhea or other signs and uating the carrier state and should be
symptoms of systemic infection avoided in favor of a standard stool
occur. These symptoms are the result specimen.
of damage to the intestinal tissue by • A rectal swab should never be submit-
the pathogenic organisms. Routine ted for Clostridium toxin studies.
stool culture normally screens for a Specimens for Clostridium toxins
small number of common pathogens, should be refrigerated if they are not
such as Campylobacter, Salmonella, immediately transported to the labora-
and Shigella. Identification of other tory as toxins degrade rapidly.
bacteria is initiated by special request • A rectal swab should never be submit-
or upon consultation with a microbi- ted for Campylobacter culture. Excessive
ologist when there is knowledge of exposure of the sample to air or room
special circumstances. The laboratory temperature may damage this type of
will initiate antibiotic sensitivity test- bacteria so that they will not grow in the
ing if indicated by test results. culture.
Sensitivity testing identifies the • Therapy with antibiotics before speci-
antibiotics to which organisms are men collection may decrease the type
susceptible to ensure an effective and the amount of bacteria.
treatment plan. ■ • Failure to transport the culture within
1 hour of collection or urine contami-
INDICATIONS: nation of the sample may affect results.
• Assist in establishing a diagnosis for
diarrhea of unknown etiology • Barium and laxatives used less than 1
week before the test may reduce bacte-
• Identify pathogenic organisms causing rial growth.
gastrointestinal disease and carrier
states
RESULT
Procedure ● ● ● ● ● ● ● ● ● ● ●
Positive findings in:

Pretest:
• Bacterial infection: Aeromonas spp.,
Bacillus cereus, Campylobacter, Clostrid- ➤ Obtain a history of the patient’s
ium, E. coli including serotype
allergens.
O157:H7, Plesiomonas shigelloides, Sal-
monella, Shigella, Yersinia, and Vibrio. ➤ Obtain a history of the patient’s
travel to foreign countries.
Isolation of Staphylococcus aureus may
indicate infection or a carrier state. ➤ Obtain a history of the patient’s gas-
trointestinal and immune systems,
• Botulism: Clostridium botulinum (the recent dietary history, and results of
bacteria must also be isolated from the previously performed tests and pro-
cedures. For related tests, refer to ➤ If collecting the specimen by rectal

the gastrointestinal and immune swab, insert swab past the patient’s
system tables. anal sphincter. Rotate the swab,
➤ Obtain a list of the medications the allowing 15 to 30 seconds for the
patient is taking (especially antibi- specimen to absorb on the swab,
otics), including herbs, nutritional withdraw it, and place in media
supplements, and nutraceuticals. container provided by the laboratory.
The requesting health care practi- ➤ Label the specimen, note any antibi-
tioner and laboratory should be otics the patient may be taking and
advised if the patient regularly uses the appearance of the specimen on
these products so that their effects the label, and promptly transport the
can be taken into consideration specimen to the laboratory.
➤ Note any recent procedures that can Post-test:
interfere with test results. Hold
antibiotics, by medical direction, until ➤ Instruct the patient to resume usual
after specimen has been collected. medication as directed by the health
➤ There are no food or fluid restrictions care practitioner.
unless by medical direction. ➤ Advise the patient that final test
➤ Review the procedure with the results may take up to 72 hours but
patient. that antibiotic therapy may be
started immediately. Instruct the
Intratest: patient about the importance of
completing the entire course of
➤ Observe standard precautions and antibiotic therapy even if no symp-
follow the general guidelines in toms are present. Note: antibiotic
Appendix A. therapy is frequently contraindicated
➤ Collect a stool specimen directly into for Salmonella infection unless the
a clean container. If the patient infection has progressed to a
requires a bedpan, make sure it is systemic state.
clean and dry and use a tongue ➤ Evaluate test results in relation to
blade to transfer the specimen to the patient’s symptoms and other
the container. Make sure represen- tests performed. Related laboratory
tative portions of the stool are sent tests include fecal analysis, and ova
for analysis. and parasites.
BACTERIAL CULTURE, THROAT

OR NASAL PHARYNGEAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Routine throat culture.

SPECIMEN: Throat or nasal pharyngeal swab.
REFERENCE VALUE: (Method: Aerobic culture) No growth.
Bacterial Culture, Throat or Nasal Pharyngeal 163
DESCRIPTION: The routine throat Streptococci are generally available within

culture is a commonly ordered test to 24 to 48 hours. Cultures that report of
screen for the presence of Group A - normal respiratory flora are issued after
hemolytic Streptococci. S. pyogenes is 48 hours. Culture results of no growth
for Corynebacterium require 72 hours to
the organism that most commonly
report; 48 hours are required to report
causes acute pharyngitis. The more negative Neisseria cultures.
dangerous sequelae of scarlet fever,
rheumatic heart disease, and glomeru- CRITICAL VALUES: N/A
lonephritis are less frequently seen
because of the early treatment of infec- INTERFERING FACTORS:
tion at the pharyngitis stage. There are • Contamination with oral flora may
a number of other bacterial agents invalidate results.
responsible for pharyngitis. Specific • Specimen collection after antibiotic
cultures can be set up to detect therapy has been initiated may result in
other pathogens such as Bordetella, inhibited or nongrowth of organisms.
Corynebacteria, Haemophilus, or Neis-
seria if they are suspected or by special
request from the health care practi- Nursing Implications and
tioner. Corynebacterium diphtheriae is Procedure ● ● ● ● ● ● ● ● ● ● ●
the causative agent of diphtheria.

Neisseria gonorrhoeae is a sexually Pretest:
transmitted pathogen. In children, a ➤ Obtain a history of the patient’s
positive throat culture for Neisseria complaints, including a list of known
allergens.
usually indicates sexual abuse. The
laboratory will initiate antibiotic ➤ Obtain a history of the patient’s im-
mune and respiratory system, as
sensitivity testing if indicated by test well as results of previously per-
results. Sensitivity testing identifies formed tests and procedures. For re-
the antibiotics to which the organisms lated tests, refer to the immune and
are susceptible to ensure an effective respiratory system tables.
treatment plan. ■ ➤ Obtain a list of the medications
INDICATIONS: herbs, nutritional supplements, and
• Assist in the diagnosis of bacterial
infections such as tonsillitis, diphthe- should be advised if the patient regu-
ria, gonorrhea, or pertussis larly uses these products so that their
• Assist in the diagnosis of upper respira- effects can be taken into considera-
tion when reviewing results.
tory infections resulting in bronchitis,
pharyngitis, croup, and influenza ➤ Note any recent therapies or proce-
dures that can interfere with test
• Isolate and identify Group A - results.
hemolytic Streptococci as the cause of ➤ There are no food, fluid, or medica-
strep throat, acute glomerulonephritis, tion restrictions (except antibiotics)
scarlet fever, or rheumatic fever unless by medical direction.
RESULT: Reports on cultures that are patient. In cases of acute epiglottitis,
positive for Group A -hemolytic do not swab the throat unless you
are equipped to establish an alterna- on the collection container. Promptly

tive airway if needed. transport the specimen to the labo-
➤ The time it takes to collect a proper ratory.
specimen varies according to the
level of cooperation of the patient. Post-test:
Intratest: medication as directed by the health
➤ Observe standard precautions and care practitioner.
follow the general guidelines in ➤ Instruct the patient to perform
Appendix A. mouth care after the specimen has
➤ To collect the throat culture, tilt the been obtained.
patient’s head back. Swab both ➤ Provide comfort measures and treat-
tonsillar pillars and oropharynx with ment such as antiseptic gargles,
the sterile Culturette. A tongue inhalants, and warm moist applica-
depressor can be used to ensure tions as needed. A cool beverage
that contact with the tongue and may aid in relieving throat irritation
uvula is avoided. caused by coughing or suctioning.
➤ A nasopharyngeal specimen is ➤ Instruct the patient to notify some-
collected through the use of a flexi- one immediately if difficulty in
ble probe inserted through the nose breathing or swallowing or if bleed-
and directed toward the back of the ing occurs.
throat. ➤ Administer analgesics and antibiotics
➤ Place the swab in the Culturette as ordered and instruct the patient in
tube and squeeze the bottom of the the importance of completing the
Culturette tube to release the liquid entire course of antibiotic therapy
transport medium. Ensure that the even if no symptoms are present.
end of the swab is immersed in the ➤ Evaluate test results in relation to
liquid transport medium. the patient’s symptoms and other
➤ Label the collection container and tests performed. Related laboratory
include the specimen site. It is advis- tests include complete blood count
able to note antimicrobial therapy and group A streptococcal screen.
BACTERIAL CULTURE, URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Urine (5 mL) collected in a sterile plastic collection container.
REFERENCE VALUE: (Method: Culture on selective and enriched media)
Negative: no growth.
Bacterial Culture, Urine 165
DESCRIPTION: A urine culture • Monitor the response to UTI treat-

involves collecting a urine specimen ment
so that the organism causing disease
can be isolated and identified. Urine RESULT
can be collected by clean catch,
urinary catheterization, or suprapubic
aspiration. The severity of the infec- • UTIs
tion or contamination of the speci-
men can be determined by knowing Negative findings in:
the type and number of organisms • N/A
(colonies) present in the specimen.
The laboratory will initiate sensitivity CRITICAL VALUES: N/A
testing if indicated by test results.
Sensitivity testing identifies the INTERFERING FACTORS:
antibiotics to which the organisms are • Antibiotic therapy initiated before
susceptible to ensure an effective specimen collection may produce false-
treatment plan. negative results.
Commonly detected organisms • Improper collection techniques may

are those normally found in the result in specimen contamination.
genitourinary tract, including • Specimen storage for longer than 30
enterococci, Escherichia coli, minutes at room temperature or 24
Klebsiella, Proteus, and hours at refrigerated temperature may
Pseudomonas. A culture result in overgrowth of bacteria and
showing multiple organisms false-positive results.
indicates a contaminated
specimen. • Results of urine culture are often inter-
Colony counts of 100,000/mL or preted along with routine urinalysis
more indicate urinary tract findings.
infection (UTI).
• Discrepancies between culture and
Colony counts of 1000/mL or less urinalysis may be reason to recollect
suggest contamination the specimen.
resulting from poor collection
technique.
Colony counts between 1000 and
10,000/mL may be significant Nursing Implications and
depending on a variety of Procedure ● ● ● ● ● ● ● ● ● ● ●
factors including patient’s age,

gender, number of types of Pretest:
organisms present, method of
specimen collection, and ➤ Obtain a history of the patient’s
presence of antibiotics. ■ complaints, including a list of known
allergens.
• Assist in the diagnosis of suspected genitourinary and immune systems,
UTI as well as results of previously
• Determine the sensitivity of significant related tests, refer to the genitouri-
organisms to antibiotics nary and immune system tables.
➤ Obtain a list of the medications the Indwelling catheter:

tritional supplements, and nutraceu- ➤ Empty drainage tube of urine. It may
ticals. The requesting health care be necessary to clamp off the
practitioner and laboratory should be catheter for 15 to 30 minutes before
advised if the patient regularly uses specimen collection. Cleanse speci-
these products so that their effects men port with antiseptic swab, and
can be taken into consideration then aspirate 5 mL of urine with a
when reviewing results. 21- to 25-gauge needle and syringe.
Transfer urine to a sterile container.
➤ Hold antibiotics, by medical direc-
tion, until after specimen has been Urinary catheterization:
collected.
➤ Place female patient in lithotomy
➤ There are no food or fluid restrictions position or male patient in supine
unless by medical direction. position. Using sterile technique,
➤ Review the procedure with the open the straight urinary catheteriza-
patient. Instruct the patient on clean- tion kit and perform urinary catheter-
catch procedure and provide neces- ization. Place the retained urine in a
sary supplies. sterile specimen container.
collection depends on patient coop- Suprapubic aspiration:
eration and usually takes approxi- ➤ Place the patient in a supine posi-
mately 5 to 10 minutes. tion. Cleanse the area with antisep-
tic and drape with sterile drapes. Us-
Intratest: ing sterile technique, insert needle
and remove sterile sample. Place
the returned sample in a sterile
specimen container. Place a dry,
Appendix A.
sterile dressing over the site.
Clean-catch specimen: ➤ Do not collect urine from the pouch
from the patient with a urinary diver-
➤ Instruct the male patient to (1) thor- sion (e.g., ileal conduit). Instead,
oughly wash his hands, (2) cleanse perform catheterization through the
the meatus, (3) void a small amount stoma.
into the toilet, and (4) void directly
into the specimen container. General:
➤ Instruct the female patient to (1)
thoroughly wash her hands; (2)
transport it to the laboratory. Indi-
cleanse the labia from front to back;
cate on the label the date and time
(3) while keeping the labia sepa-
of collection, method of specimen
rated, void a small amount into the
collection, and any medications the
toilet; and (4) without interrupting
patient has taken that may interfere
the urine stream, void directly into
with test results.
the specimen container.
Pediatric urine collector: Post-test:

➤ Appropriately cleanse the genital ➤ Instruct the patient to resume usual
area and allow the area to dry. Re- medication as directed by the health
move the covering over the adhesive care practitioner.
strips on the collector bag and apply ➤ Instruct the patient to report symp-
over the genital area. Diaper the toms such as pain related to tissue
child. When specimen is obtained, inflammation, pain or irritation during
place the entire collection bag in a void, bladder spasms, or alterations
sterile urine container. in urinary elimination.
Barium Enema 167
➤ Observe for signs of inflammation if ➤ UTIs are more common in women

the specimen is obtained by supra- who use diaphragm–spermicide
pubic aspiration. contraception. These patients can be
➤ Instruct patient to begin antibiotic educated, as appropriate, in the
therapy, as prescribed and instruct proper insertion and removal of the
the patient in the importance of contraceptive device to avoid recur-
completing the entire course of rent UTI.
antibiotic therapy even if no symp- ➤ Evaluate test results in relation
toms are present. to the patient’s symptoms and
➤ Instruct patient on the proper tech- other tests performed. Related labo-
nique for wiping the perineal area ratory tests include Gram stain,
(front to back) after a bowel move- urinalysis, and white blood cell
ment. count.
BARIUM ENEMA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Air-contrast barium enema, double-contrast

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

CONTRAST: Barium sulfate, air, iodine mixture.
DESCRIPTION: This radiologic exam- containing blood or mucus, and for

ination of the colon, distal small visualizing polyps, diverticula, and
bowel, and occasionally the appendix tumors. A barium enema may be ther-
follows installation of barium using a apeutic; it may reduce an obstruction
rectal tube inserted into the rectum or caused by intussusception, or telescop-
an existing ostomy. The patient must ing of the intestine. Barium enema
retain the barium while a series of should be performed before an upper
radiographs are obtained. Visualiza- gastrointestinal study or barium swal-
tion can be improved by using air or low. ■
barium as the contrast medium
(double-contrast study). A combina- INDICATIONS:
tion of x-ray and fluoroscopy tech- • Determine the cause of rectal bleeding,
blood, pus, or mucus in feces
niques is used to complete the study.
This test is especially useful in the • Evaluate unexplained weight loss,
evaluation of patients experiencing anemia, or a change in bowel pattern
lower abdominal pain, changes in • Identify and locate benign or malig-
bowel habits, or the passage of stools nant polyps or tumors
• Evaluate suspected inflammatory acute ulcerative colitis, acute divertic-

process, congenital anomaly, motility ulitis, megacolon, or suspected rupture
disorder, or structural change of the colon.

RESULT: imaging:
• Normal size, filling, shape, position, because of age, significant pain, or
and motility of the colon mental status
• Normal filling of the appendix and • Metallic objects within the examina-
terminal ileum tion field (e.g., jewelry or body rings),
which may inhibit organ visualization
Abnormal Findings: and can produce unclear images
• Appendicitis
• Colorectal cancer ographic equipment to accommodate
• Congenital anomalies obese or thin patients, causing overex-
posure or underexposure and poor-
• Crohn’s disease quality study
• Diverticular disease • Inability of the patient to tolerate
• Fistulas introduction of or retention of barium,
air, or both in the bowel
• Gastroenteritis
• Granulomatous colitis resulting from inadequate cleansing or
• Hirschsprung’s disease failure to restrict food intake before the
study
• Intussusception
• Perforation of the colon • Retained barium from a previous radi-
ological procedure
• Polyps
• Spasm of the colon, which can mimic
• Sarcoma the radiographic signs of cancer (note:
• Sigmoid torsion the use of IV glucagon minimizes
spasm)
• Sigmoid volvulus
• Stenosis exceed the weight limit for the equip-
• Tumors ment
• Ulcerative colitis • Incorrect positioning of the patient,
This procedure is contraindicated Other considerations:
for: • Ensure that this procedure is per-
• Patients that are pregnant or suspected formed before an upper gastrointesti-
of being pregnant, unless the potential nal study or barium swallow.
• Ensure that the patient followed
the risks to the fetus and mother.
dietary restrictions before the proce-
• Patients with intestinal obstruction, dure; failure to do so may cause the
Barium Enema 169
procedure to be canceled or repeated. ➤ The 30- to 60-minute procedure is

done by a physician and/or technolo-
• Consultation with a physician should gist.
occur before the procedure for radia- ➤ Instruct the patient to eat a low-
tion safety concerns regarding infants residue diet for several days before
of patients who are lactating. the procedure, to consume only
clear liquids the evening before the
test, and to withhold food and fluids
overexposure can result from frequent for 8 hours before the test.
➤ Inform the patient that a laxative and
cleansing enema may be needed
protective lead apron, stand behind a the day before the procedure, with
shield, or leave the area while the cleansing enemas on the morning of
examination is being done. Badges that the procedure, depending on the
reveal the level of exposure to radiation institution’s policy.
should be worn by persons working in ➤ Determine date of last menstrual
the area where the examination is being period and possibility of pregnancy
done. in perimenopausal women.
• Possible complications of barium ➤ Instruct patients with a colostomy to
enema include perforation of the follow the same dietary preparation,
take laxatives the evening before,
colon, water intoxication, barium and perform colostomy irrigation
granulomas, and rarely, intraperitoneal before the study.
and extraperitoneal extravasation of
➤ Assess for completion of bowel
barium and barium embolism. preparation according to the institu-
tion’s procedure.
Intratest:
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
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.
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Esophagram, video swallow, esophagus x-ray, swal-

lowing function, esophagography.
AREA OF APPLICATION: Esophagus.

CONTRAST: Barium sulfate, water-soluble iodinated contrast.
Barium Swallow 171
DESCRIPTION: This radiologic exam- filling, patency, and shape of the

ination of the esophagus evaluates esophagus
motion and anatomic structures of
Abnormal Findings:
the esophageal lumen by recording
• Acute or chronic esophagitis
images of the lumen while the patient
swallows a barium solution of milk- • Achalasia
shake consistency and chalky taste. • Benign or malignant tumors
The procedure uses fluoroscopic and
cineradiographic techniques. The • Chalasia
barium swallow is often performed as • Diverticula
part of an upper gastrointestinal series • Esophageal ulcers
or cardiac series and is indicated for
patients with a history of dysphagia • Esophageal varices
and regurgitation. In patients with • Hiatal hernia
esophageal reflux, the radiologist may
• Perforation of the esophagus
identify reflux of the barium from the
stomach back into the esophagus. • Strictures or polyps
Muscular abnormalities such as acha-
lasia, as well as diffuse esophageal INTERFERING FACTORS:
spasm, can be easily detected with this This procedure is contraindicated
procedure. ■ for:
INDICATIONS: of being pregnant, unless the potential
• Determine the cause of dysphagia, benefits of the procedure far outweigh
heartburn, or regurgitation the risks to the fetus and mother
• Evaluate suspected esophageal motility • Patients with intestinal obstruction or
disorders suspected esophageal rupture, unless
• Detect esophageal reflux, tracheoe- water-soluble iodinated contrast
sophageal fistulas, and varices medium is used
• Evaluate suspected polyps, strictures, • Patients with suspected tracheoe-
Zenker’s diverticula, tumor, or inflam- sophageal fistula, unless barium is used
mation
• Determine the type and location of imaging:
foreign bodies within the pharynx and
esophagus • Inability of the patient to cooperate or
• Confirm the integrity of esophageal because of age, significant pain, or
anastomoses in the postoperative mental status
patient
RESULT tion field (e.g., jewelry, earrings, and/or
dental amalgams), which may inhibit
Normal Findings: organ visualization and can produce
unclear images
• Normal peristalsis through the esopha-
gus into the stomach with normal size, • Improper adjustment of the radi-
ographic equipment to accommodate lated tests, refer to the gastrointesti-

obese or thin patients, which can cause nal system table.
overexposure or underexposure and ➤ A physician and/or technologist
poor-quality study performs the procedure, which lasts
15 to 30 minutes.
➤ Instruct the patient to withhold food
exceed the weight limit for the equip- and fluids for 8 hours before the
ment test.
• Incorrect positioning of the patient, ➤ No pain is associated with the study.
which may produce poor visualization ➤ Determine date of last menstrual
of the area to be examined period and possibility of pregnancy
in perimenopausal women.
Other considerations:
• A potential complication of a barium Intratest:
swallow is barium-induced fecal ➤ Remove any clothing and metallic
impaction. objects from the esophageal area.
• Ensure that the procedure is done after ➤ Give the patient a gown and robe to
cholangiography and barium enema. wear.
➤ Remove any wires connected to
• Consultation with a physician should electrodes, if allowed.
➤ Place the patient on the x-ray table in
a supine position or have the patient
of patients who are lactating. stand in front of an x-ray fluoroscopy
• Risks associated with radiographic screen.
overexposure can result from frequent ➤ An initial image is taken and the
x-ray procedures. Personnel in the room patient is stood in front of a fluo-
with the patient should wear a protec- roscopy screen and is asked to swal-
tive lead apron, stand behind a shield, low a barium solution with or
without a straw.
or leave the area while the examination
is being done. Badges that reveal the ➤ Images are taken at different angles
level of exposure to radiation should be and positions to aid in the evaluation
of patient’s problem.
worn by persons working in the area
where the examination is being done. ➤ The patient may be asked to drink
additional barium to complete the
study. Swallowing the additional
barium evaluates the passage of
Nursing Implications and barium from the esophagus into the
Procedure ● ● ● ● ● ● ● ● ● ● ● stomach.
➤ Return the patient to a comfortable
Pretest: position; help the patient from the x-
ray table to a chair or stretcher.
purpose of the procedure and the
need to swallow contrast medium. Post-test:
➤ Obtain a history of the patient’s ➤ Instruct the patient to resume food,
complaints and a list of medications fluids, and medications withheld
taken. before the procedure.
➤ Obtain a history of the patient’s ➤ Inform the patient of the possible
esophageal and gastrointestinal sys- need for further examinations to
tems, as well as the results of previ- evaluate and determine the need for
ously performed tests, surgeries, a change in therapy or progression
therapies, and procedures. For re- of the disease process.
Bilirubin and Bilirubin Fractions 173
➤ Unless contraindicated, instruct the ➤ A physician specializing in this

patient to take a mild laxative and branch of medicine will send a report
increase fluid intake (four glasses) to to the ordering health care provider,
aid in elimination of barium. who will discuss the results with the
➤ Instruct the patient that stools will patient.
be white or light in color for 2 to 3 ➤ Evaluate test results in relation to
days. If the patient is unable to elim- the patient’s symptoms and other
inate the barium, or if stools do not tests performed. Related diagnostic
return to normal color, the patient tests include endoscopy, computed
should notify the physician. tomography and magnetic reso-
➤ Determine if the patient or family nance imaging of the neck, and
members have any further ques- thyroid scan.
tions or concerns.
BILIRUBIN AND BILIRUBIN

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

bilirubin, delta bilirubin, TBil.

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

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

Bilirubin Units Factor 17.1)
Total bilirubin
Newborn–1 d 1.4–8.7 mg/dL 24–149 mol/L
1–2 d 3.4–11.5 mg/dL 58–97 mol/L
3–5 d 1.5–12.0 mg/dL 26–205 mol/L
1 mo–adult 0.3–1.2 mg/dL 5–21 mol/L
Unconjugated
bilirubin Less than 1.1 mg/dL Less than 19 mol/L
Conjugated bilirubin Less than 0.3 mg/dL Less than 5 mol/L
Delta bilirubin Less than 0.2 mg/dL Less than 3 mol/L
DESCRIPTION: Bilirubin is a byprod- Erythroblastosis fetalis

uct of heme catabolism from aged red The post–blood transfusion period,
blood cells. Bilirubin is primarily when a number of units are
rapidly infused or in the case of
produced in the liver, spleen, and bone
a delayed transfusion reaction
marrow. Total bilirubin is the sum of
Hematoma
unconjugated bilirubin, monoglu-
Hemolytic anemias
curonide and diglucuronide, conju-
Pernicious anemia
gated bilirubin, and albumin-bound
delta bilirubin. Unconjugated biliru- Physiologic jaundice of the
newborn
bin is carried to the liver by albumin,
Red blood cell enzyme
where it becomes conjugated. In the
abnormalities (i.e., G-6-PD,
small intestine, conjugated bilirubin pyruvate kinase, spherocytosis)
converts to urobilinogen and then to
• Hepatic jaundice—bilirubin conjuga-
urobilin. Urobilin is then excreted in
tion failure
the feces. Increases in bilirubin levels
Crigler-Najjar syndrome
can result from prehepatic and/or
posthepatic conditions, making frac- • Hepatic jaundice—disturbance in
tionation useful in determining the bilirubin transport
cause of the increase in total bilirubin Dubin-Johnson syndrome
(preconjugation transport failure)
levels. Delta bilirubin has a longer
half-life than the other bilirubin frac- Gilbert’s disease (postconjugation
transport failure)
tions and therefore remains elevated
during convalescence after the other • Hepatic jaundice—liver damage or
fractions have decreased to normal necrosis
levels. When bilirubin concentration Alcoholism
increases the yellowish pigment Cholangitis
deposits in skin and sclera. This Cholestatic drug reactions
increase in yellow pigmentation is Cholecystitis
termed jaundice or icterus. ■ Cirrhosis
Hepatitis
INDICATIONS: Hepatocellular damage
• Assist in the differential diagnosis of Infectious mononucleosis
obstructive jaundice
• Posthepatic jaundice
• Assist in the evaluation of liver and
Advanced tumors of the liver
biliary disease
Biliary obstruction
• Monitor the effects of drug reactions
on liver function • Other conditions
Anorexia or starvation
• Monitor jaundice in newborn patients
Breast milk jaundice
• Monitor the effects of phototherapy on Hypothyroidism
jaundiced newborns
Decreased in: N/A
RESULT
CRITICAL VALUES: Sustained
Increased in: hyperbilirubinemia can result in brain
• Prehepatic (hemolytic) jaundice damage. Kernicterus refers to the depo-
Bilirubin and Bilirubin Fractions 175
sition of bilirubin in the basal ganglia cephaloridine, cephalothin, chlorpro-

and brainstem nuclei. There is no exact mazine, chlorpropamide, dinitrophe-
level of bilirubin that puts infants nol, ibuprofen, insulin, isoniazid, levo-
at risk for developing kernicterus. dopa, mefenamic acid, melphalan,
Symptoms of kernicterus in infants methotrexate, methyldopa, penicillins,
include lethargy, poor feeding, upward phenacetin, procainamide, quinidine,
deviation of the eyes, and seizures. quinine, rifampin, stibophen, sulfon-
Generally, levels in excess of 15 to 20 amides, and tolbutamide.
mg/dL are reason for intervention. • Bilirubin is light sensitive. Therefore,
Intervention may include early frequent the collection container should be suit-
feedings to stimulate gastrointestinal ably covered to protect the specimen
motility, phototherapy, and exchange from light between the time of collec-
transfusion. tion and analysis.
• Drugs that may increase bilirubin levels Nursing Implications and
by causing cholestasis include ami- Procedure ● ● ● ● ● ● ● ● ● ● ●
tryptyline, anabolic steroids, andro-
gens, benzodiazepines, chlorothiazide, Pretest:
chlorpropamide, dapsone, erythromy-
cin, estrogens, ethionamide, gold salts, ➤ Obtain a history of the patient’s
imipramine, mercaptopurine, nitrofu- complaints, including a list of known
allergens.
rans, oral contraceptives, penicillins,
phenothiazines, progesterone, propo- ➤ Obtain a history of the patient’s he-
xyphene, sulfonamides, tamoxifen, and patobiliary system, as well as results
tolbutamide. procedures. For related tests, refer
• Drugs that may increase bilirubin levels to the hepatobiliary system table.
by causing hepatocellular damage ➤ Obtain a list of the medications the
include acetaminophen (toxic), acetyl- patient is taking, including herbs, nu-
salicylic acid, allopurinol, amiodarone, tritional supplements, and nutraceu-
anabolic steroids, anticonvulsants, ticals. The requesting health care
asparaginase, azithromycin, bromocrip- practitioner and laboratory should be
tine, captopril, cephalosporins, chlo- these products so their effects can
ramphenicol, clindamycin, clofibrate, be taken into consideration when re-
danazol, enflurane, ethambutol, viewing results.
ethionamide, fenofibrate, fluconazole, ➤ There are no food, fluid, or medica-
fluoroquinolones, foscarnet, genta- tion restrictions unless by medical
micin, indomethacin, interferon, direction.
interleukin-2, low-molecular-weight ➤ Review the procedure with the
heparin, levamisole, levodopa, linco- patient.
mycin, monoamine oxidase inhibitors,
methyldopa, naproxen, nifedipine, collection takes approximately 5 to
nitrofurans, oral contraceptives, pro- 10 minutes.
benecid, procainamide, quinine, raniti-
dine, retinol, ritodrine, sulfonylureas, Intratest:
tetracyclines, tobramycin, and vera-
➤ Direct the patient to breathe nor-
pamil.
mally and to avoid unnecessary
• Drugs that may increase bilirubin levels movement.
by causing hemolysis include ampho- ➤ Observe standard precautions and
tericin B, carbamazepine, carbutamide, follow the general guidelines in Ap-
pendix A. Perform a venipuncture, to eat simple carbohydrates and

and collect the specimen in a 5-mL emulsified fats (as in homogenized
red- or tiger-top tube. milk or eggs), as opposed to complex
➤ Label, protect from light, and carbohydrates (e.g., starch, fiber, and
promptly transport the specimen to glycogen [animal carbohydrates])
the laboratory. and complex fats, which would
require additional bile to emulsify it
so that it could be used. The cirrhotic
Post-test: patient should be carefully observed
➤ Observe venipuncture site for bleed- for the development of ascites, in
ing or hematoma formation. Apply which case, fluid and electrolyte
pressure bandage. balance requires strict attention. The
alcoholic patient should be encour-
➤ Increased bilirubin levels may be aged to avoid alcohol and also to seek
associated with liver disease. Dietary appropriate counseling for substance
recommendations may be indicated abuse.
depending on the condition and
severity of the condition. Currently, ➤ Intervention for hyperbilirubinemia
for example, there are no specific in the neonatal patient may include
medications that can be given to early frequent feedings (to stimulate
cure hepatitis, but elimination of gastrointestinal motility), photother-
alcohol ingestion and a diet opti- apy, and exchange transfusion.
mized for convalescence are comm- ➤ Evaluate test results in relation to
only included in the treatment plan. A the patient’s symptoms and other
high-calorie, high-protein, moderate- tests performed. Related laboratory
fat diet with a high fluid intake is often tests include alanine aminotrans-
recommended for the patient with ferase, albumin, alkaline phos-
hepatitis. Treatment of cirrhosis is phatase, 1-antitrypsin/phenotyping,
different because a low-protein diet ammonia, amylase, antimitochon-
may be in order if the patient’s liver drial antibody, anti–smooth muscle
has lost the ability to process the end antibody, aspartate aminotrans-
products of protein metabolism. A ferase, cholesterol, coagulation
diet of soft foods may also be factor assays, complete blood count,
required if esophageal varices have copper, -glutamyl transpeptidase,
developed. Ammonia levels may be hepatitis serologies, infectious
used to determine whether protein mononucleosis screen, lipase, liver
should be added or reduced from the biopsy, protein, prothrombin time,
diet. Patients should be encouraged and urinalysis.
BIOPSY, BLADDER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Bladder tissue or cells.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination of
tissue) No abnormal tissue or cells.
Biopsy, Bladder 177
DESCRIPTION: A urologist performs ➤ Obtain a history of the patient’s

genitourinary and immune systems,
a biopsy of the bladder during cysto-
any bleeding disorders, and results
scopic examination. The procedure is of previously performed tests and
usually carried out under general procedures, especially bleeding
anesthesia. After the bladder is filled time, clotting time, complete blood
with saline for irrigation, the bladder count, partial thromboplastin time,
platelets, and prothrombin time. For
and urethra are examined by direct related tests, refer to the genitouri-
and lighted visualization using a nary and immune system tables.
cystoscope. A sample of suspicious ➤ Obtain a list of the medications the
bladder tissue is then excised and patient is taking, including anticoagu-
examined macroscopically and micro- lant therapy drugs, acetylsalicylic
scopically to determine the presence acid, herbs, and nutraceuticals
known to affect coagulation. These
of cell morphology and tissue abnor- products should be discontinued 14
malities. ■ days before dental or surgical proce-
dures. The requesting health care
INDICATIONS: practitioner and laboratory should be
• Assist in confirmation of malignant advised if the patient regularly uses
lesions of the bladder or ureter, espe- these products so their effects can
cially if tumor is seen by radiological be taken into consideration when
examination reviewing results.
➤ There are no medication restrictions
• Assist in the evaluation of cases in unless by medical direction. Prophy-
which symptoms such as hematuria lactic antibiotics may be adminis-
persist after previous treatment (e.g., tered before or after the procedure in
removal of polyps or kidney stones) certain cases.
• Monitor existing recurrent benign ➤ Instruct the patient that nothing
should be taken by mouth if general
lesions for malignant changes
or spinal anesthesia will be used.
Clear liquids may be permitted, by
RESULT: Positive findings in neoplasm of medical direction, if a local anes-
the bladder or ureter. thetic will be used for the procedure.
CRITICAL VALUES: N/A patient. Sensitivity to cultural and
social issues, as well as concern for
INTERFERING FACTORS: modesty, is important in providing
• This test is contraindicated in patients psychological support.
with an acute infection of the ➤ Inform patients that they may expe-
bladder, urethra, or prostate. rience back pain and burning or pres-
• This test is contraindicated in sure in the genital area during and
after the procedure.
patients with bleeding disorders.
➤ Address concerns about pain related
to the procedure. Explain that a seda-
tive may be administered to promote
Nursing Implications and relaxation during the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Inform the patient that if a local
anesthetic is used, the patient may
Pretest: experience the urge to urinate.
➤ Obtain a history of the patient’s ➤ Assess if the patient has an allergy
complaints, including a list of known to local anesthetics, and inform the
allergens. health care practitioner accordingly.
➤ Confirm nonallergy to anesthesia ➤ After open biopsy, monitor vital

before the procedure is performed signs every 15 minutes for 1 hour,
under general anesthesia. then every 2 hours for 4 hours, and
➤ Obtain written and informed consent as ordered. Take temperature every
before administering any medica- 4 hours for 24 hours.
tions prior to the procedure. ➤ After local anesthesia, monitor vital
➤ Inform the patient that the proce- signs and compare with baseline
dure is performed under sterile values.
conditions by a surgeon. Specimen ➤ Monitor fluid intake and output for
collection takes approximately 30 to 24 hours. Instruct the patient how to
45 minutes. do this if the patient is an outpatient.
➤ Encourage fluid intake of 3000 mL in
Intratest: 24 hours, unless contraindicated by
➤ Record baseline vital signs. another medical condition.
➤ Ensure that the patient has complied ➤ Apply heat to the lower abdomen to
with pretesting dietary restrictions. relieve pain and muscle spasms if
approved by medical direction.
follow the general guidelines in ➤ Inform the patient that blood may be
Appendix A. seen in the urine after the first or
second postprocedural voiding.
normally and to avoid unnecessary ➤ Instruct the patient to report any
movement while a local anesthetic further changes in urinary pattern,
is administered into the urethra, volume, or appearance.
before insertion of the cystoscope. ➤ Instruct the patient to immediately
➤ Place the patient in a lithotomy posi- report pain, chills, or fever indicative
tion on the examination table (with of risk of infection, hemorrhage, or
the feet up in stirrups). Drape the perforation of the bladder as a result
patient’s legs. Clean the external of cystoscopy.
genitalia with a suitable antiseptic ➤ If ordered, administer analgesic and
solution. prophylactic antibiotic.
➤ Once the cystoscope is inserted, the ➤ Assist the patient in alleviating
bladder is irrigated with saline. A discomfort by administering warm
tissue sample is removed using a sitz bath or hip bath.
cytology brush or biopsy forceps.
Catheters may be used to obtain ➤ Recognize anxiety related to test
samples from the ureter. results and offer support. Provide
➤ Place the specimens in the appropri- the clinical implications of the test
ate containers. Label the specimen, results, as appropriate. Educate the
indicating site location, and promptly patient regarding access to counsel-
transport it to the laboratory. ing services.
➤ Instruct the patient to resume usual tests performed. Related laboratory
diet as directed by the health care tests include routine urinalysis and
practitioner. urine bladder cancer test.
Biopsy, Bone 179
BIOPSY, BONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Bone tissue.
REFERENCE VALUE: (Method: Microscopic study of bone samples) No
abnormal tissue or cells.
DESCRIPTION: Biopsy is the excision is contraindicated in patients with bleed-

of a sample of tissue that can be ing disorders.
analyzed microscopically to determine
cell morphology and the presence of Nursing Implications and
tissue abnormalities. This test is used Procedure ● ● ● ● ● ● ● ● ● ● ●
to assist in confirming the diagnosis of

cancer when clinical symptoms or x- Pretest:
rays are suspicious. After surgical inci- ➤ Obtain a history of the patient’s
sion to reveal the affected area, bone complaints, including a list of known
biopsy is obtained. An alternative allergens.
collection method is needle biopsy, in ➤ Obtain a history of the patient’s im-
mune and musculoskeletal systems,
which a plug of bone is removed using
a special serrated needle. ■ of previously performed tests and
procedures, especially complete
INDICATIONS: bleeding time, complete blood
• Differentiation of a benign from a count, clotting time, partial thrombo-
malignant bone lesion plastin time, platelets, and pro-
thrombin time. For related tests,
• Radiographic evidence of a bone lesion refer to the immune and muscu-
loskeletal system tables.
RESULT ➤ Obtain a list of the medications the
patient is taking, including anticoag-
Abnormal findings in: ulant therapy, acetylsalicylic acid,
herbs, and nutraceuticals known to
• Ewing’s sarcoma affect coagulation. These products
• Multiple myeloma should be discontinued 14 days be-
fore dental or surgical procedures.
• Osteoma The requesting health care practi-
tioner and laboratory should be ad-
• Osteosarcoma vised that the patient regularly uses
these products so their effects can
CRITICAL VALUES: N/A be taken into consideration when re-
viewing results.
INTERFERING FACTORS: This procedure ➤ Open biopsy: Explain that foods and
fluids are restricted after midnight Needle biopsy:

the day before the open biopsy
surgery. ➤ Assist the patient into a comfortable
position in which the biopsy site
➤ Needle biopsy: There are usually no can be supported and exposed.
restrictions on food or fluids before Cleanse the skin with an antiseptic
needle biopsy. solution. Administer local anesthetic
➤ There are no medication restrictions and protect the site with sterile
unless by medical direction. drapes. A small incision is made and
➤ Review the procedure with the the biopsy needle is inserted to
patient. Sensitivity to cultural and remove the specimen.
social issues, as well as concern for ➤ Place tissue samples in formalin so-
modesty, is important in providing lution. Ensure that the specimen is
psychological support. properly labeled, indicating site loca-
➤ Assess if the patient has an allergy tion, especially left or right; promptly
to local anesthetics, and inform transport the specimen to the labo-
the health care practitioner accord- ratory.
ingly.
➤ Inform the patient that a general
Post-test:
anesthetic will be administered be- ➤ Instruct the patient to resume usual
fore the open biopsy. Ensure nonal- diet as directed by the health care
lergy to anesthesia is confirmed be- practitioner.
fore procedure performed under
➤ After open biopsy, monitor vital
general anesthesia.
signs every 15 minutes for 1 hour,
➤ Obtain written and informed con- then every 2 hours for 4 hours, and
sent before administering any med- as ordered. Take temperature every
ications prior to the procedure. 4 hours for 24 hours.
➤ Inform the patient that the proce- ➤ After local anesthesia, monitor vital
dure is performed by a surgeon, that signs and compare with baseline
it usually takes about 30 minutes to values.
complete, and that sutures may be
➤ Inspect biopsy site for excessive
necessary to close the site.
bleeding.
➤ Instruct the patient in the care and
Intratest: assessment of the site. Instruct
the patient to report any redness,
edema, bleeding, or pain at the
with pretesting dietary restrictions
biopsy site. Instruct the patient to
before the open biopsy procedure.
keep the site clean and change the
➤ Observe standard precautions and dressing as needed.
➤ Administer mild analgesic and antibi-
Appendix A.
otic therapy as ordered. Remind the
➤ It may be necessary to shave and patient of the importance of com-
perform an orthopedic skin prepara- pleting the entire course of antibiotic
tion before needle biopsy. therapy, even if signs and symptoms
➤ Administer premedication as di- disappear before completion of ther-
rected. apy.
➤ Inform the patient of a follow-up
Open biopsy: appointment for removal of sutures,
➤ Record baseline vital signs. After a if indicated.
surgical incision is complete, the ➤ Recognize anxiety related to test
surgeon locates the suspected results and offer support. Provide
lesion and removes sufficient tissue teaching and information regarding
for analysis. the clinical implications of the test
Biopsy, Bone Marrow 181
results, as appropriate. Educate the biopsy; calcium; urine calcium;

patient regarding access to counsel- complete blood count; cortisol; im-
ing services. munofixation electrophoresis; im-
➤ Evaluate test results in relation to munoglobulin A, G, and M; parathy-
the patient’s symptoms and other roid hormone; phosphorus; urine
tests performed. Related laboratory and serum protein electrophoresis;
tests include alkaline phosphatase; urine and serum total protein; urinal-
2-microglobulin; bone marrow ysis; and vitamin D.
BIOPSY, BONE MARROW

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

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

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

Erythrocyte precursors 18–32%
Myeloblasts 0–2%
Promyelocytes 2–6%
Myelocytes 9–17%
Metamyelocytes 7–25%
Bands 10–16%
Neutrophils 18–28%
Eosinophils and precursors 1–5%
Basophils and precursors 0–1%
Monocytes and precursors 1–5%
Lymphocytes 9–19%
Plasma cells 0–1%
DESCRIPTION: This test involves the Increased neutrophils (total):

removal of a small sample of bone • Acute myeloblastic leukemia
marrow by aspiration, needle biopsy,
or open surgical biopsy for a complete • Myeloid (chronic) leukemias
hematological analysis. The marrow is
a suspension of blood, fat, and devel- Decreased neutrophils (total):
oping blood cells, which is evaluated • Aplastic anemia
for morphology and examined for all
stages of maturation; iron stores; and • Leukemias (monocytic and lympho-
blastic)
M:E cells. Sudan B and periodic
acid–Schiff (PAS) stains can be per-
formed for microscopic examination Increased lymphocytes:
to differentiate the types of leukemia, • Aplastic anemia
although flow cytometry and cytoge-
netics have become more commonly • Lymphatic leukemia
used techniques for this purpose. ■ • Lymphomas
• Lymphosarcoma
INDICATIONS:
• Determine marrow differential (pro- • Mononucleosis
portion of the various types of cells • Viral infections
present in the marrow) and M:E
• Evaluate abnormal results of complete Increased plasma cells:
blood count or white blood cell count
with differential showing increased • Cancer
numbers of leukocyte precursors • Cirrhosis of the liver
• Evaluate hepatomegaly or spleno- • Connective tissue disorders
megaly
• Hypersensitivity reactions
• Identify bone marrow hyperplasia or
hypoplasia • Infections
• Monitor effects of exposure to bone • Macroglobulinemia
marrow depressants
• Ulcerative colitis
• Monitor bone marrow response to
chemotherapy or radiation therapy
Increased megakaryocytes:
RESULT • Hemorrhage
• Infections
Increased reticulocytes:
• Increasing age
• Compensated red blood cell (RBC)
loss • Megakaryocytic myelosis
• Response to vitamin B12 therapy • Myeloid leukemia
• Pneumonia
Decreased reticulocytes:
• Polycythemia vera
• Aplastic crisis of sickle-cell disease or
hereditary spherocytosis • Thrombocytopenia
Biopsy, Bone Marrow 183
Decreased megakaryocytes: • This procedure is contraindicated in

patients with known bleeding
• Agranulocytosis
disorders.
• Cirrhosis of the liver
• Pernicious aplastic anemia
• Radiation therapy Procedure ● ● ● ● ● ● ● ● ● ● ●
• 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.
• 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
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
• Hemolytic anemia
Increased eosinophils:
direction.
• Bone marrow cancer ➤ Review the procedure with the
patient. Sensitivity to cultural and
• Lymphadenoma
• 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
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.
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.
➤ 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.
Biopsy, Breast 185
BIOPSY, BREAST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Breast tissue or cells.
tissue) No abnormal cells or tissue.
DESCRIPTION: Fine-needle and open complaints, including a list of known

allergens.
biopsies of the breast have become
more commonly ordered in recent ➤ Obtain a history of the patient’s
immune and reproductive systems,
years as increasing emphasis on early any bleeding disorders, and results
detection of breast cancer has become of previously performed tests and
stronger. Breast biopsies are used to procedures, especially bleeding
assist in the identification and prog- time, clotting time, complete blood
count, partial thromboplastin time,
nosis of breast cancer. ■
platelets, and prothrombin time.
For related tests, refer to the
INDICATIONS: immune and reproductive system
• Evidence of breast lesion by palpation, tables.
mammography, or ultrasound ➤ Obtain a list of the medications the
• Observable breast changes such as patient is taking, including anticoag-
“peau d’orange” skin, scaly skin of the ulant therapy, acetylsalicylic acid,
herbs, and nutraceuticals known
areola, drainage from the nipple, or
to affect coagulation. It is recom-
ulceration of the skin mended that use be discontinued 14
days before dental or surgical proce-
RESULT: Positive findings in carcinoma dures. The requesting health care
of the breast. practitioner and laboratory should be
CRITICAL VALUES: N/A these products so their effects can
INTERFERING FACTORS: This procedure reviewing results.
is contraindicated in patients with ➤ Needle biopsy: There are no food,
bleeding disorders. fluid, or medication restrictions
before needle biopsy unless by
medical direction.
Nursing Implications and ➤ Open biopsy: Food and fluids are
restricted for at least 12 hours
Procedure ● ● ● ● ● ● ● ● ● ● ●
before an open biopsy.
Pretest: ➤ Review the procedure with the
➤ Obtain a history of the patient’s social issues, as well as concern for
modesty, is important in providing imen is properly labeled, indicating

psychological support. location, especially left or right
➤ Address concerns about pain related breast; promptly transport the speci-
to the procedure and discuss the men to the laboratory.
possibility of administering a seda-
tive to promote relaxation during the Post-test:
procedure. ➤ Instruct the patient to resume usual
➤ Assess if the patient has an allergy diet and medication, if withheld, as
to local anesthetics, and inform the directed by the health care practi-
health care practitioner accordingly. tioner.
➤ Ensure nonallergy to anesthesia ➤ After open biopsy, monitor vital
before the open biopsy procedure is signs every 15 minutes for 1 hour,
performed under general anesthe- then every 2 hours for 4 hours, and
sia. as ordered. Take temperature every
➤ Obtain written and informed consent 4 hours for 24 hours.
before administering any medica- ➤ After local anesthesia, monitor vital
tions prior to the procedure. signs, and compare with baseline
➤ In certain cases, administer prophy- values.
lactic antibiotics before or after the ➤ Instruct the patient in proper cleans-
procedure. ing of the site. Stress the impor-
➤ Inform the patient that specimen tance of a follow-up appointment for
collection takes approximately 20 to suture removal.
30 minutes. ➤ Instruct the patient to report exces-
sive bleeding, redness, edema, or
Intratest: pain at the biopsy site.
➤ Observe standard precautions and ➤ Administer analgesics and antibiotics
follow the general guidelines in as ordered, and instruct the patient
Appendix A. in the importance of complet-
Open biopsy: therapy, even if no symptoms are
present.
➤ Instruct and educate the patient
with pretesting dietary restrictions
how to perform monthly breast
before open biopsy. Record baseline
self-examination and emphasize,
vital signs. The specimen is obtained
as appropriate, the importance of
by surgical excision.
having a mammogram performed
Needle biopsy: annually.
➤ Recognize anxiety related to test
➤ Assist the patient into a supine posi- results and offer support. Provide
tion and cleanse the biopsy site with teaching and information regarding
an antiseptic. Record baseline vital the clinical implications of the test
signs. Inject the local anesthetic and results, as appropriate. Educate the
protect the biopsy site with sterile patient regarding access to counsel-
drapes. Direct the patient to breathe ing services.
movement. A needle is inserted into ➤ Evaluate test results in relation to the
the mass and tissue, and fluid is patient’s symptoms and other tests
aspirated. performed. Related laboratory tests
include cancer antigen 15-3, HER-
➤ Apply a sterile dressing to the site. 2/neu oncoprotein, estrogen and
➤ Place the specimens in the appropri- progesterone receptors, and carci-
ate containers. Ensure that the spec- noembryonic antigen.
Biopsy, Cervical 187
BIOPSY, CERVICAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Cervical tissue.
REFERENCE VALUE: (Method: Microscopic examination of tissue cells) No
abnormal cells or tissue.
DESCRIPTION: Biopsy is the excision • Cervical dysplasia

of a sample of tissue that can be • Cervical polyps
analyzed microscopically to deter-
mine cell morphology and the pres- CRITICAL VALUES: N/A
ence of tissue abnormalities. The
cervical biopsy is used to assist in INTERFERING FACTORS:
confirmation of cancer when screen- • The test is contraindicated in cases
ing tests are positive. Cervical biopsy of acute pelvic inflammatory
is obtained using an instrument that disease, cervicitis, or bleeding
disorders.
punches into the tissue and retrieves a
tissue sample. Schiller’s test entails • This test should not be performed
applying an iodine solution to the while the patient is menstruating.
cervix. Normal cells pick up the
iodine and stain brown. Abnormal
cells do not pick up any color. Punch Nursing Implications and
biopsy results may indicate the need Procedure ● ● ● ● ● ● ● ● ● ● ●
for a cone biopsy of the cervix. Cone

Pretest:
biopsy is a surgical procedure requir-
ing general anesthesia. ■ ➤ Obtain a history of the patient’s
allergens.
INDICATIONS:
• Follow-up to abnormal Papanicolaou ➤ Obtain a history of the patient’s im-
mune and reproductive systems,
(Pap) smear, Schiller’s test, or
colposcopy of previously performed tests and
• Suspected cervical malignancy procedures, especially bleeding
time, clotting time, complete blood
RESULT platelets, and prothrombin time. For
related tests, refer to the immune
Positive findings in: and reproductive system tables.
• Carcinoma in situ ➤ Obtain a list of the medications the
patient is taking, including anticoag- Cone biopsy:

ulant therapy, acetylsalicylic acid,
herbs, and nutraceuticals known to ➤ Ensure that the patient has complied
affect coagulation. These products with dietary preparation and other
should be discontinued 14 days pretesting restrictions before open
before dental or surgical procedures. biopsy. Record baseline vital signs.
The requesting health care practi- The specimen is obtained by surgi-
tioner and laboratory should be cal excision.
advised if the patient regularly uses Cervical biopsy:
be taken into consideration when ➤ Cleanse the external genitalia with
reviewing results. an antiseptic solution. Direct the pa-
➤ Cervical biopsy: There are no food, tient to breathe normally and to
fluid, or medication restrictions avoid unnecessary movement.
before needle biopsy unless by Swab the cervix with 3% acetic acid
medical direction. before insertion of the colposcope.
Biopsy forceps are inserted and the
➤ Cone biopsy: Food and fluids are tissue samples are obtained.
restricted for at least 12 hours
➤ Place the specimens in the appropri-
before an open biopsy.
ate containers containing formalin
➤ Review the procedure with the solution. Label the specimen, indi-
patient. Sensitivity to cultural and cating site location, and promptly
social issues, as well as concern for transport it to the laboratory.
modesty, is important in providing
➤ Bleeding is common and is con-
psychological support.
trolled by cautery or silver nitrate ap-
➤ Address concerns about pain related plication. The health care practitioner
to the procedure. may insert a tampon after the specu-
➤ Encourage the use of relaxation and lum is removed if bleeding persists.
controlled breathing during the
procedure to aid in reducing discom- Post-test:
fort. ➤ After general anesthesia for cone
➤ Confirm nonallergy to anesthesia biopsy, monitor vital signs and
before the cone biopsy procedure is compare with baseline values.
performed under general anesthe- ➤ Observe for bleeding.
sia.
➤ Instruct the patient to expect a gray-
➤ Obtain written and informed green vaginal discharge for several
consent before administering any days, to avoid strenuous activity for
medications prior to the procedure. 8 to 24 hours, to avoid douching or
➤ Inform the patient that specimen intercourse for 2 weeks or as in-
collection takes approximately 20 to structed by the health care practi-
30 minutes. Specimen collection will tioner, and to report excessive
be performed by a health care prac- bleeding to the health care practi-
titioner. tioner.
➤ Recognize anxiety related to test re-
Intratest: sults and offer support. Provide
➤ Have patient remove clothes below the clinical implications of the test
the waist. Assist the patient into a results, as appropriate. Educate the
lithotomy position on a gynecologic patient regarding access to counsel-
examination table with feet in stir- ing services.
rups. Drape the patient’s legs. ➤ Evaluate test results in relation to
➤ Observe standard precautions and the patient’s symptoms and other
follow the general guidelines in tests performed. A related labora-
Appendix A. tory test is the Pap smear.
Biopsy, Chorionic Villus 189
BIOPSY, CHORIONIC VILLUS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Chorionic villus tissue.
REFERENCE VALUE: (Method: Tissue culture) Normal karyotype.
DESCRIPTION: This test is used to genetic disorders. Generally, the labora-

detect fetal abnormalities caused by tory provides detailed interpretive infor-
numerous genetic disorders. The mation regarding the specific chromo-
advantage over amniocentesis is that some abnormality detected.
it can be performed as early as the
eighth week of pregnancy, permitting CRITICAL VALUES: N/A
earlier decisions regarding termina-
tion of pregnancy. However, unlike INTERFERING FACTORS:
amniocentesis this test will not detect • The test is contraindicated in the
neural tube defects. ■ patient with a history of or in the pres-
ence of incompetent cervix.
INDICATIONS:
• Assist in the diagnosis of in utero meta-
bolic disorders such as cystic fibrosis or Nursing Implications and
other errors of lipid, carbohydrate, or Procedure ● ● ● ● ● ● ● ● ● ● ●
amino acid metabolism

Pretest:
• Detect abnormalities in the fetus of
women of advanced maternal age ➤ Obtain a history of the patient’s
• Determine fetal gender when the allergens.
mother is a known carrier of a sex-
➤ Obtain a history of the patient’s re-
linked abnormal gene that could be productive system, as well as re-
transmitted to male offspring, such as sults of previously performed tests
hemophilia or Duchenne’s muscular and procedures. For related tests,
dystrophy refer to the reproductive system
table.
• Evaluate fetus in families with a history
of genetic disorders, such as Down ➤ Obtain a list of the medications the
syndrome, Tay-Sachs disease, chromo- patient takes, including herbs, nutri-
tional supplements, and nutraceuti-
some or enzyme anomalies, or inher- cals. The requesting health care
ited hemoglobinopathies practitioner and laboratory should be
RESULT such products so their effect can be
taken into consideration when re-
Abnormal karyotype: Numerous viewing results.
➤ 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.
patient. Sensitivity to cultural and Post-test:
modesty, is important in providing ➤ Monitor maternal and fetal vital
psychological support. signs and compare with baseline
values.
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.
Biopsy, Intestinal 191
BIOPSY, INTESTINAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Intestinal tissue or cells.
DESCRIPTION: Intestinal biopsy is CRITICAL VALUES: N/A

the excision of a tissue sample from
the small intestine for microscopic INTERFERING FACTORS:
analysis to determine cell morphology • Barium swallow within 48 hours of
and the presence of tissue abnormali- small intestine biopsy affects results.
ties. This test assists in confirming the • This procedure is contraindicated in
diagnosis of cancer or intestinal disor- patients with bleeding disorders
ders. Biopsy specimen is usually and aortic arch aneurysm.
obtained during endoscopic examina-
tion. ■
INDICATIONS: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Assist in the diagnosis of various intes-
tinal disorders, such as lactose and Pretest:
other enzyme deficiencies, celiac
disease, and parasitic infections ➤ Obtain a history of the patient’s
• Confirm suspected intestinal malig- allergens.
nancy ➤ Obtain a history of the patient’s
gastrointestinal and immune sys-
• Confirm suspicious findings during tems, any bleeding disorders, and
endoscopic visualization of the intes- results of previously performed
tinal wall tests and procedures, especially
bleeding time, clotting time, com-
RESULT plete blood count, partial thrombo-
plastin time, platelets, and pro-
Abnormal findings in: thrombin time. For related tests,
refer to the gastrointestinal and im-
• Cancer mune system tables.
• Celiac disease ➤ Obtain a list of the medications the
• Lactose deficiency ulant therapy, acetylsalicylic acid,
• Parasitic infestation herbs, and nutraceuticals known to
affect coagulation. These products
• Tropical sprue should be discontinued 14 days be-
fore dental or surgical procedures. breathe normally and to avoid unnec-

The requesting health care practi- essary movement.
tioner and laboratory should be ad- ➤ A local anesthetic is sprayed into the
vised if the patient regularly uses throat. A protective tooth guard and
these products so their effects can a bite block may be placed in the
be taken into consideration when re- mouth.
viewing results.
➤ The flexible endoscope is passed
➤ Note any recent procedures that can into and through the mouth, and
interfere with test results. the patient is asked to swallow.
➤ There are no medication restrictions Once the endoscope passes into
unless by medical direction. the esophagus, assist the patient
➤ Explain that food and fluids are into the left lateral position. A
restricted for 6 to 8 hours before the suction device is used to drain
test. saliva.
➤ Review the procedure with the ➤ The esophagus, stomach, and duo-
patient. Sensitivity to cultural and denum are visually examined as the
social issues, as well as concern for endoscope passes through each
modesty, is important in providing section. A biopsy specimen can be
psychological support. taken from any suspicious sites.
➤ Address concerns about pain related ➤ Tissue samples are obtained by
to the procedure. Explain that a inserting a cytology brush or biopsy
sedative may be administered to forceps through the endoscope.
promote relaxation during the proce- ➤ When the examination and tissue
dure. removal are complete, the endo-
➤ Determine if the patient has an scope and suction device are with-
allergy to local anesthetics, and drawn and the tooth guard and bite
inform the health care practitioner block are removed.
accordingly. ➤ Place tissue samples in formalin
➤ Obtain written and informed solution. Label the specimen, indi-
consent before administering cating site location, and promptly
any medications prior to the proce- transport it to the laboratory.
dure.
Post-test:
➤ Remove full or partial dentures.
Inform the health care practitioner if ➤ Instruct the patient to resume usual
the patient has any crowns or caps diet as directed by the health care
on the teeth. practitioner.
➤ Inform the patient that the proce- ➤ After local anesthesia, monitor vital
dure is performed by a surgeon and signs and compare with baseline
usually takes about 60 minutes to values. Assess and record breath
complete. sounds and characteristics of respi-
ration.
Intratest: ➤ Note any chest pain, upper abdomi-
➤ Ensure that the patient has complied nal pain, pain on swallowing, diffi-
with pretesting dietary restrictions. culty breathing, or expectoration of
blood. Report these to the health
➤ Record baseline vital signs. care practitioner immediately.
➤ Observe standard precautions and ➤ Instruct the patient not to eat or
follow the general guidelines in drink until the anesthesia has worn
Appendix A. off. Assess the patient’s ability to
➤ Administer ordered premedication. swallow before allowing liquids or
➤ Assist the patient into a semireclin- solid foods.
ing position. Direct the patient to ➤ Instruct the patient to maintain a
Biopsy, Kidney 193
side-lying position for 2 hours after ➤ Evaluate test results in relation to

the procedure to prevent aspiration the patient’s symptoms and other
of secretions. tests performed. Related labora-
➤ Recognize anxiety related to test tory tests include albumin, calcium,
results and offer support. Provide electrolytes, D-xylose tolerance,
teaching and information regarding gliadin antibodies, fecal analysis,
the clinical implications of the test fecal fat, folic acid, iron/total iron-
results, as appropriate. Educate the binding capacity, lactose tolerance,
patient regarding access to counsel- ova and parasites, prothrombin time,
ing services. vitamin B12, and vitamin D.
BIOPSY, KIDNEY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Renal biopsy.

SPECIMEN: Kidney tissue or cells.
DESCRIPTION: Kidney or renal systemic lupus erythematosus or other

biopsy is the excision of a tissue immunologic disorders
sample from the kidney for micro- • Monitor progression of nephrotic
scopic analysis to determine cell syndrome
morphology and the presence of
• Monitor renal function after transplan-
tissue abnormalities. This test assists tation
in confirming a diagnosis of cancer
found on x-ray or ultrasound or to
diagnose certain inflammatory or RESULT
immunologic conditions. Biopsy
specimen is usually obtained either
percutaneously or after surgical inci- • Acute and chronic poststreptococcal
glomerulonephritis
sion. ■
• Amyloidosis infiltration
INDICATIONS: • Cancer
• Assist in confirming suspected renal
malignancy • Disseminated lupus erythematosus
• Assist in the diagnosis of the cause of • Goodpasture’s syndrome
renal disease
• Immunologic rejection of transplanted
• Determine extent of involvement in kidney
• Nephrotic syndrome should be taken by mouth beginning

the night before the procedure.
• Pyelonephritis ➤ Review the procedure with the
• Renal venous thrombosis patient. Sensitivity to cultural and
modesty is important in providing
CRITICAL VALUES: N/A psychological support.
INTERFERING FACTORS: to the procedure. Explain that a
• This procedure is contraindicated in sedative may be administered to
bleeding disorders, advanced promote relaxation during the proce-
renal disease, uncontrolled dure.
hypertension, or solitary kidney ➤ Assess if the patient has an allergy
(except transplanted kidney). to local anesthetics and inform
the health care practitioner accord-
• Obesity and severe spinal deformity ingly.
can make percutaneous biopsy impos- ➤ Confirm nonallergy to anesthesia
sible. before open biopsy procedure per-
formed under general anesthesia.
➤ Obtain written and informed con-
Nursing Implications and sent before administering any med-
ications prior to the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: dure is performed by a surgeon
under sterile conditions using a local
➤ Obtain a history of the patient’s anesthetic (e.g., lidocaine) and that
genitourinary and immune system specimen collection takes approxi-
including a list of known allergens. mately 40 to 60 minutes.
➤ Obtain a history of bleeding disor-
ders, as well as results of previously Intratest:
performed tests and procedures, ➤ Ensure that the patient has complied
especially bleeding time, clotting with dietary restrictions before open
time, complete blood count, partial biopsy.
thromboplastin time, platelets, and
prothrombin time. For related tests, ➤ Direct the patient to breathe nor-
refer to the genitourinary and mally and to avoid unnecessary
immune system tables. movement.
➤ Obtain a list of the medications the ➤ Observe standard precautions and
patient takes, including anticoagu- follow the general guidelines in
lant therapy, acetylsalicylic acid, Appendix A.
herbals, and nutraceuticals known to ➤ Administer ordered premedication.
should be discontinued 14 days Open biopsy:
before dental or surgical procedures.
➤ Record baseline vital signs. After
administration of anesthesia, a surgi-
tioner and laboratory should be
cal incision is made, suspicious
areas located, and tissue samples
such products so their effect can be
collected.
taken into consideration when
reviewing results. Percutaneous needle biopsy:
➤ Assist the patient into a prone posi-
unless by medical direction.
tion. Cleanse the site with antisep-
➤ Instruct the patient that nothing tic. A local anesthetic is injected and
Biopsy, Kidney 195
a sterile field is prepared. A sandbag intake unless contraindicated by

may be placed under the abdomen another medical condition.
to aid in moving the kidneys to the ➤ Instruct the patient to immediately
desired position. Instruct the patient report symptoms such as backache,
to take a deep breath and hold it flank pain, shoulder pain, lighthead-
while the needle is inserted. As the edness, burning on urination, hema-
needle enters the kidney, instruct turia, chills, or fever, which may
the patient to exhale. The needle is indicate the presence of infection,
rotated to obtain a plug of tissue, hemorrhage, or inadvertent puncture
and then removed. of other internal organs.
➤ Place the specimens in the appropri- ➤ Observe the needle site or incision
ate containers. Label the specimen, for bleeding.
indicating site location, especially
left or right; promptly transport the ➤ Observe the patient for other signs
specimen to the laboratory. of distress including hypotension
and tachycardia.
➤ Apply manual pressure for 5 to 20
minutes, and then apply a pressure ➤ After percutaneous biopsy, instruct
dressing. the patient to stay in bed lying on
the affected side for at least 30
minutes with a pillow or sandbag
Post-test: under the site to prevent bleeding.
➤ Instruct the patient to resume usual The patient also needs to remain on
diet as directed by the health care bed rest for 24 hours.
practitioner. ➤ Instruct the patient to avoid strenu-
➤ After open biopsy, monitor vital ous activity, sports, and heavy lifting
signs every 15 minutes for 1 hour, for 2 weeks after the procedure.
then every 2 hours for 4 hours, and ➤ Recognize anxiety related to test
as ordered. Take temperature every results and offer support. Provide
4 hours for 24 hours. teaching and information regarding
➤ After local anesthesia, monitor vital the clinical implications of the test
signs and compare with baseline results, as appropriate. Educate the
values. patient regarding access to counsel-
ing services.
➤ Inform the patient that blood may be
seen in the urine after the first or ➤ Evaluate test results in relation to
second postprocedural voiding. the patient’s symptoms and other
➤ Monitor fluid intake and output for tests include albumin, aldosterone,
24 hours. Instruct the patient how to antiglomerular basement membrane
do this if the patient is an outpatient. antibody, 2-microglobulin, creati-
➤ Instruct the patient to report any nine, creatinine clearance, osmolal-
changes in urinary pattern or volume ity, urine osmolality, potassium,
or any unusual appearance of the urine potassium, protein, urine pro-
urine. If urinary volume is less than tein, renin, sodium, urine sodium,
200 mL in the first 8 hours, encour- urea nitrogen, urinalysis, and urine
age the patient to increase fluid cytology.
BIOPSY, LIVER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Liver tissue or cells.
DESCRIPTION: Liver biopsy is the • Hepatic involvement with systemic

excision of a tissue sample from the lupus erythematosus, sarcoidosis, or
liver for microscopic analysis to deter- amyloidosis
mine cell morphology and the pres- • Hepatitis
ence of tissue abnormalities. This test
• Parasitic infestations (e.g., amebiasis,
is used to assist in confirming a diag- malaria, visceral larva migrans)
nosis of cancer or certain disorders of
the hepatic parenchyma. Biopsy spec- • Reye’s syndrome
imen is usually obtained either percu- • Wilson’s disease
taneously or after surgical incision. ■
INDICATIONS:
• Assist in confirming suspected hepatic INTERFERING FACTORS: This proce-
malignancy dure is contraindicated in patients
with bleeding disorders, suspected
• Assist in confirming suspected hepatic
vascular tumor of the liver, ascites that
parenchymal disease
may obscure proper insertion site for
• Assist in diagnosing the cause of needle biopsy, subdiaphragmatic or right
persistently elevated liver enzymes, hemothoracic infection, or biliary tract
hepatomegaly, or jaundice infection.
RESULT
Positive findings in: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Benign tumor
Pretest:
• Cancer
• 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
Biopsy, Liver 197
hepatobiliary and immune system, Needle biopsy should take about 15

any bleeding disorders, and results minutes.
procedures, especially bleeding Intratest:
count, partial thromboplastin time, ➤ Ensure that the patient has complied
platelets, and prothrombin time. For with dietary restrictions before open
related tests, refer to the hepatobil- biopsy.
iary and immune system tables. ➤ Instruct the patient to avoid cough-
➤ Obtain a list of the medications the ing or straining, as this may increase
patient is taking, including anticoag- intra-abdominal pressure.
ulant therapy, acetylsalicylic acid, ➤ Administer ordered premedication
herbs, and nutraceuticals known to 30 to 60 minutes before the proce-
affect coagulation. These products dure.
before dental or surgical procedures. ➤ Observe standard precautions and
The requesting health care practi- follow the general guidelines in
tioner and laboratory should be Appendix A.
these products so their effects can Open biopsy:
be taken into consideration when ➤ Record baseline vital signs. After
reviewing results. administration of anesthesia, a surgi-
➤ There are no medication restrictions cal incision is made, suspicious
unless by medical direction. areas are located, and tissue
samples collected.
➤ Explain that food and fluids are
restricted beginning midnight of the
day before the test. Percutaneous needle biopsy:
➤ Review the procedure with the ➤ Help the patient to a supine or left
patient. Sensitivity to cultural and lateral position with the right hand
social issues, as well as concern for under the head. Record baseline
modesty, is important in providing vital signs. After the site has been
psychological support. cleansed with antiseptic, a local
anesthetic is injected and a sterile
field is prepared. The patient is
instructed to take a deep breath,
sedative and/or anesthetic will be
exhale forcefully, and hold the breath
administered before the procedure
while the needle is inserted under
to promote relaxation during the
sterile conditions. The needle is
percutaneous biopsy, and that
rotated to obtain a core of liver
general anesthesia will be adminis-
tissue and then removed. Once the
tered for open biopsy.
needle is removed, the patient may
➤ Assess if the patient has an allergy breathe. A pressure dressing is then
to local anesthetics, and inform the applied.
➤ Place tissue samples in formalin
➤ Ensure that nonallergy to anesthesia solution. Label the specimen, indi-
is confirmed before the open biopsy cating site location, and promptly
procedure is performed under transport it to the laboratory.
general anesthesia.
➤ Obtain written and informed con- Post-test:
sent before administering any med-
ications prior to the procedure. ➤ Instruct the patient to resume usual
practitioner.
dure is performed by a surgeon
under sterile conditions and usually ➤ After open biopsy, monitor vital
takes about 90 minutes to complete. signs every 15 minutes for 1 hour,
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: Transbronchial lung biopsy, open lung biopsy.

SPECIMEN: Lung tissue or cells.
tissue) No abnormal tissue or cells; no growth in culture.
DESCRIPTION: A biopsy of the lung passes through a bronchoscope to

is performed to obtain lung tissue for obtain the specimen. In a trans-
examination of pathologic features. catheter bronchial brushing, a brush
The specimen can be obtained trans- is inserted through the bronchoscope.
bronchially or by open lung biopsy. In In an open lung biopsy, the chest is
a transbronchial biopsy, forceps pass opened and a small thoracic incision
through the bronchoscope to obtain is made to remove tissue from the
the specimen. In a transbronchial chest wall. Lung biopsies are used to
needle aspiration biopsy, a needle differentiate between infection and
Biopsy, Lung 199
other sources of disease indicated by

initial radiology studies, computed
tomography scans, or sputum analy-
Procedure ● ● ● ● ● ● ● ● ● ● ●
sis. Specimens are cultured to detect Pretest:

pathogenic organisms or directly
examined for the presence of malig- complaints, including a list of known
nant cells. ■ allergens.
INDICATIONS: immune and respiratory systems,
• Assist in the diagnosis of lung cancer any bleeding disorders, and results
• Assist in the diagnosis of fibrosis and procedures, especially bleeding
degenerative or inflammatory diseases time, clotting time, complete blood
of the lung count, partial thromboplastin time,
• Assist in the diagnosis of sarcoidosis related tests, refer to the immune
and respiratory system tables.
RESULT ➤ Obtain a list of the medications the
Abnormal findings in: ulant therapy, acetylsalicylic acid,
• Amyloidosis herbs, and nutraceuticals known to
• Cancer should be discontinued 14 days
• Granulomas The requesting health care practi-
• Infections caused by Blastomyces, tioner and laboratory should be
Histoplasma, Legionella spp., and
Pneumocystis carinii be taken into consideration when
• Sarcoidosis reviewing results.
• Systemic lupus erythematosus unless by medical direction.
• Tuberculosis ➤ Instruct the patient to fast and
refrain from taking liquids beginning
CRITICAL VALUES: midnight of the day before the bron-
choscopy or open lung biopsy proce-
• Shortness of breath, cyanosis, or rapid dure is to be performed.
pulse during the procedure must be ➤ Review the procedure with the
reported immediately. patient. Sensitivity to cultural and
• Any postprocedural decrease in breath modesty, is important in providing
sounds noted at the biopsy site should psychological support.
be reported immediately.
INTERFERING FACTORS: sedative and/or anesthetic will be
• Conditions such as vascular anomalies administered before the procedure
of the lung, bleeding abnormali- to promote relaxation and reduce
ties, or pulmonary hypertension discomfort during the procedure.
may increase the risk of bleeding. General anesthesia will be adminis-
tered for open biopsy. Atropine is
• Conditions such as bullae or cysts and usually given before bronchoscopy
respiratory insufficiency increase examinations to reduce bronchial se-
the risk of pneumothorax. cretions and prevent vagally induced
bradycardia. Meperidine (Demerol) Bronchoscopy:

or morphine may be given as a seda-
tive. Lidocaine is sprayed in the pa- ➤ Record baseline vital signs. The
tient’s throat to reduce discomfort patient is positioned in relation to
caused by the presence of the tube. the type of anesthesia being used.
For general anesthesia, the patient is
➤ Assess if the patient has an allergy placed in a supine position with the
to local anesthetics, and inform the neck hyperextended. If local anes-
health care practitioner accordingly. thesia is used, the patient is seated
➤ Ensure that nonallergy to anesthesia while the tongue and oropharynx are
is confirmed before the open biopsy sprayed and swabbed with anes-
procedure is performed under thetic. The patient is then helped to
general anesthesia. a supine or side-lying position and
the bronchoscope is inserted. After
➤ Obtain written and informed inspection, the tissue samples are
consent before administering any collected from suspicious sites by
medications prior to the procedure. bronchial brush or biopsy forceps.
➤ Inform the patient that the fine-
needle biopsy procedure will be Open biopsy:
performed by a surgeon under ster-
ile conditions and will take approxi- ➤ Record baseline vital signs. The
mately 30 minutes. A bronchoscopy patient is prepared for thoracotomy
usually takes 15 to 30 minutes. under general anesthesia in the
operating room. Tissue specimens
are collected from suspicious sites.
Intratest: A chest tube is inserted after the
➤ Ensure that the patient is in compli- procedure.
ance with pretesting dietary restric- ➤ Carefully observe the patient for any
tions. Direct the patient to breathe signs of respiratory distress during
normally and to avoid unnecessary the procedure.
movement, because coughing or
sudden movements could result in ➤ Place specimen from needle aspira-
perforation of the lung. tion or brushing on clean glass
microscope slides. Place tissue or
➤ Observe standard precautions and aspirate specimens in appropriate
follow the general guidelines in sterile container for culture or appro-
Appendix A. priate fixative container for histologic
➤ Administer any ordered premedica- studies.
tion 30 to 60 minutes before the ➤ Label the specimen, indicating site
procedure. location, especially left or right;
promptly transport the specimen to
Needle biopsy: the laboratory.
➤ Assist patient to a sitting position
with arms on a pillow over a bed Post-test:
table. Record baseline vital signs. ➤ After general anesthesia, monitor
Clean site with antiseptic, administer vital signs every 15 minutes for 1
anesthesia, and drape area with ster- hour, then every 2 hours for 4 hours,
ile towels. Instruct patient to remain and as ordered. Take temperature
still and to avoid coughing during the every 4 hours for 24 hours.
procedure. The needle is inserted
through the posterior chest wall and ➤ After local anesthesia, monitor vital
into the intercostal space. The needle signs and compare with baseline
is rotated to obtain the sample and values.
then withdrawn. Pressure is applied ➤ Instruct the patient not to eat or
to the site, and a pressure dressing is drink until the effects of the anes-
applied. thesia have worn off and the gag
Biopsy, Lymph Node 201
reflex has returned to avoid acciden- ➤ Emergency resuscitation equipment

tal aspiration. should be readily available if the
➤ Instruct the patient to resume usual vocal cords become spastic after
diet as directed by the health care intubation. Some hoarseness is
practitioner. expected after intubation.
➤ Observe the patient for hemoptysis, ➤ Instruct the patient to use lozenges
difficulty breathing, cough, air hun- or gargle for throat discomfort.
ger, or absent breathing sounds over ➤ Inform the patient of smoking cessa-
the affected area. Monitor chest tion programs as appropriate.
tube patency and drainage after a
thoracotomy. ➤ Inform the patient of the importance
of medical follow-up. Recognize anx-
➤ Evaluate the patient for symptoms
iety related to test results and pro-
indicating the development of pneu-
vide support. Provide teaching and
mothorax, such as dyspnea, tachyp-
information regarding the clinical im-
nea, anxiety, decreased breathing
plications of the test results. Edu-
sounds, or restlessness. A chest x-
cate the patient regarding access to
ray may be ordered to check for the
counseling services, as appropriate.
presence of this complication.
Malnutrition is commonly seen in
➤ Evaluate the patient for symptoms patients with severe respiratory dis-
of empyema, such as fever, tachy- ease for numerous reasons includ-
cardia, malaise, or elevated white ing fatigue, lack of appetite, and gas-
blood cell count. trointestinal distress. Adequate
➤ Observe the patient’s sputum for intake of vitamins A and C are also
blood if a biopsy was taken, because important to prevent pulmonary in-
large amounts of blood may indi- fection and to decrease the extent
cate the development of a problem; of lung tissue damage. The impor-
a small amount of streaking is tance of following the prescribed
expected. Evaluate the patient for diet should be stressed to the pa-
signs of bleeding such as tachycar- tient/caregiver.
dia, hypotension, or restlessness. ➤ Evaluate test results in relation
➤ Instruct the patient to remain in a to the patient’s symptoms and
semi-Fowler’s position after bron- other tests performed. Related labo-
choscopy or fine needle aspiration to ratory tests include arterial/alveolar
maximize ventilation. Semi-Fowler’s oxygen ratio, antiglomerular base-
position is a semisitting position ment membrane antibody, blood
with the knees flexed and supported gases, complete blood count,
by pillows on the bed or examination culture and Gram/acid-fast stain,
table. cytology, and sputum findings.
BIOPSY, LYMPH NODE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Lymph node tissue or cells.

DESCRIPTION: Lymph node biopsy is • Infectious mononucleosis

the excision of a tissue sample from • Lymph involvement of systemic
one or more lymph nodes for micro- diseases (e.g., systemic lupus erythe-
scopic analysis to determine cell matosus, sarcoidosis)
morphology and the presence of tissue
• Lymphangitis
abnormalities. This test assists in
confirming a diagnosis of cancer, diag- • Lymphogranuloma venereum
nosing disorders causing systemic • Malignancy (e.g., lymphomas, leu-
illness, or determining the stage of kemias)
metastatic cancer. A biopsy specimen
• Metastatic disease
is usually obtained either by needle
biopsy or after surgical incision. Biop- • Parasitic infestation (e.g., pneumoco-
sies are most commonly performed on niosis)
the following types of lymph nodes:
cervical nodes, which drain the face
and scalp; axillary nodes, which drain INTERFERING FACTORS: This procedure
the arms, breasts, and upper chest; is contraindicated in patients with
and inguinal nodes, which drain the bleeding disorders.
legs, external genitalia, and lower
abdominal wall. ■
• Assist in confirming suspected fungal

or parasitic infections of the lymphatics Pretest:
• Assist in confirming suspected malig- ➤ Obtain a history of the patient’s
nant involvement of the lymphatics complaints, including a list of known
allergens.
• Determine the stage of metastatic
cancer immune and musculoskeletal sys-
• Differentiate between benign and tems, any bleeding disorders, and
results of previously performed tests
malignant disorders that may cause
and procedures, especially bleeding
lymph node enlargement time, clotting time, complete blood
• Evaluate persistent enlargement of one count, partial thromboplastin time,
or more lymph nodes for unknown
reasons and musculoskeletal system tables.
RESULT ➤ Obtain a list of the medications that
the patient is taking, including antico-
Abnormal findings in: agulant therapy, acetylsalicylic acid,
• Chancroid affect coagulation. These products
• Fungal infection (e.g., cat scratch should be discontinued 14 days
disease) before dental or surgical procedures.
• Immunodeficiency tioner and laboratory should be
Biopsy, Lymph Node 203
advised if the patient regularly uses Open biopsy:

be taken into consideration when ➤ Record baseline vital signs. After
reviewing results. administration of local anesthetic (for
surface nodes) or general anesthesia
➤ There are no medication restrictions (for deeper nodes), a surgical incision
unless by medical direction. is made; the suspicious nodes are
➤ Explain that food and fluids are then located, grasped with forceps,
restricted beginning at midnight of and removed. The site is closed and a
the day before the open biopsy sterile dressing is applied.
procedure. There are usually no such
restrictions before needle biopsy. Percutaneous needle biopsy:
➤ Review the procedure with the ➤ Assist the patient to a position that
patient. Sensitivity to cultural and exposes the affected node. Record
social issues, as well as concern for baseline vital signs. After the site has
modesty, is important in providing been cleansed with antiseptic solu-
psychological support. tion, a local anesthetic is injected and
➤ Address concerns about pain related a sterile field is prepared. The node is
to the procedure. Explain that a grasped with the fingers, and a
sedative will be administered to needle (with attached syringe) is
promote relaxation and reduce inserted directly into the node. The
discomfort during percutaneous node is aspirated to collect the spec-
needle biopsy, and a general anes- imen. A sterile dressing is applied.
thetic will be administered before ➤ Label the specimen, indicating site
the open biopsy. location, and promptly transport it to
➤ Assess if the patient has an allergy the laboratory.
to local anesthetics, and inform
the health care practitioner accord- Post-test:
ingly.
➤ Confirm nonallergy to anesthesia diet as directed by the health care
before the open biopsy procedure is practitioner.
performed under general anesthe-
sia.
signs every 15 minutes for 1 hour,
➤ Obtain written and informed and then every 2 hours for 4 hours,
consent before administering any and as ordered. Take temperature
medications prior to the procedure. every 4 hours for 24 hours.
➤ Inform the patient that it may be ➤ After local anesthesia, monitor vital
necessary to shave the site before signs and compare with baseline
specimen collection. values.
➤ Inform the patient that the proce- ➤ Inspect biopsy site for excessive
dure is performed under sterile bleeding.
conditions by a surgeon and usually
➤ Instruct the patient in the care and
takes about 30 minutes to complete.
assessment of the site. Instruct the
Needle biopsy should take about 15
patient to keep the site clean and
minutes.
change the dressing as needed to
avoid risk of infection resulting from
Intratest: altered skin integrity.
➤ Ensure that the patient has complied ➤ Instruct the patient to report any
with pretesting dietary restrictions. redness, edema, bleeding, or pain at
➤ Observe standard precautions and the biopsy site.
follow the general guidelines in ➤ Administer a mild analgesic as
Appendix A. ordered.
➤ Administer ordered premedication. ➤ Recognize anxiety related to test
results and offer support. Provide fluid analysis; Chlamydia serology;

teaching and information regarding culture for bacteria/fungus; com-
the clinical implications of the test plete blood count; cytomegalo-
results, as appropriate. Educate the virus serology; Gram stain; HIV-1/
patient regarding access to counsel- HIV-2 serology; immunofixation
ing services. electrophoresis; immunoglobulins
➤ Evaluate test results in relation A, G, and M; infectious mononu-
to the patient’s symptoms and cleosis screen; rheumatoid factor;
other tests performed. Related total protein; total protein elec-
laboratory tests include CD4/ trophoresis; and toxoplasmosis
CD8 enumeration; cerebrospinal serology.
BIOPSY, MUSCLE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Muscle tissue or cells.
DESCRIPTION: Muscle biopsy is the RESULT

excision of a tissue sample from one
of many muscles for microscopic Abnormal findings in:
analysis to determine cell morphology • Alcoholic myopathy
and the presence of tissue abnormali- • Amyotrophic lateral sclerosis
ties. This test is used to confirm a
diagnosis of neuropathy or myopathy • Duchenne’s muscular dystrophy
and to diagnose parasitic infestation. • Fungal infection
A biopsy specimen is usually obtained
from the deltoid or gastrocnemius • Myasthenia gravis
muscle after a surgical incision. ■ • Myotonia congenita
INDICATIONS: • Parasitic infestation

• Assist in confirming suspected fungal • Polymyalgia rheumatica
infection or parasitic infestation of the
muscle • Polymyositis
• Assist in diagnosing the cause of
neuropathy or myopathy
• Assist in the diagnosis of Duchenne’s INTERFERING FACTORS:
muscular dystrophy • If electromyography is performed
Biopsy, Muscle 205
before muscle biopsy, residual inflam- to promote relaxation and reduce

mation may lead to false-positive discomfort during the procedure.
biopsy results. ➤ Assess if the patient has an allergy
to local anesthetics, and inform the
• This procedure is contraindicated health care practitioner accordingly.
in patients with bleeding disor-
➤ Obtain written and informed con-
ders. sent before administering any med-
ications prior to the procedure.
➤ Inform the patient that it may be
Nursing Implications and necessary to shave the site before
Procedure ● ● ● ● ● ● ● ● ● ● ● specimen collection.
➤ Inform the patient the procedure will
Pretest: be performed under sterile condi-
➤ Obtain a history of the patient’s tions by a surgeon and that it usually
complaints, including a list of known takes about 15 minutes to complete.
allergens. Sutures may be necessary to close
the site.
mune and musculoskeletal systems,
Intratest:
of previously performed tests and ➤ Record baseline vital signs.
procedures, especially bleeding
movement.
For related tests, refer to the im- ➤ Observe standard precautions and
mune and musculoskeletal system follow the general guidelines in
tables. Appendix A.
➤ Obtain a list of the medications the ➤ Administer ordered premedication.
patient is taking, including anticoag- ➤ Assist the patient to a supine posi-
ulant therapy, acetylsalicylic acid, tion (for deltoid biopsy) or prone
herbs, and nutraceuticals known to position (for gastrocnemius biopsy).
➤ Cleanse the site with antiseptic solu-
tion and drape with sterile drapes.
After infiltration with local anes-
thetic, a small incision is made over
the muscle and a small bit of muscle
is grasped with forceps. The area is
closed with sutures or similar mate-
rial and a sterile dressing is applied.
reviewing results.
➤ Place tissue samples in normal
➤ Note any recent procedures that can
saline solution. Label the specimen,
indicating site location, and promptly
patient. Sensitivity to cultural and ➤ After local anesthesia, monitor vital
social issues, as well as concern for signs and compare with baseline
modesty, is important in providing values.
psychological support. ➤ Inspect biopsy site for excessive
➤ Address concerns about pain related bleeding.
to the procedure. Inform the patient ➤ Instruct the patient in the care
that a sedative will be administered and assessment of the site. Instruct
the patient to report any redness, ➤ Inform the patient of a follow-up

edema, bleeding, or pain at the bi- appointment for removal of sutures,
opsy site. Instruct the patient to if indicated.
keep the site clean and change the ➤ Recognize anxiety related to test re-
dressing as needed to avoid risk of sults and offer support. Provide
infection resulting from altered skin teaching and information regarding
integrity. the test results, as appropriate. Edu-
➤ Inform the patient that the site will cate the patient regarding access to
be sore and tender and that move- counseling services.
ment will be difficult for several ➤ Evaluate test results in relation to
days. the patient’s symptoms and other
➤ Administer mild analgesic and antibi- tests performed. Related laboratory
otic therapy as ordered. Remind the tests include acetylcholine receptor
patient of the importance of com- antibody, aldolase, antinuclear anti-
pleting the entire course of antibiotic bodies, antithyroglobulin antibodies,
therapy, even if signs and symptoms creatine kinase and isoenzymes,
disappear before completion of Jo-1 antibody, myoglobin, and
therapy. rheumatoid factor.
BIOPSY, PROSTATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Prostate tissue.
REFERENCE VALUE: (Method: Microscopic examination of tissue cells) No
abnormal cells or tissue.
DESCRIPTION: Biopsy of the prostate CRITICAL VALUES: N/A

gland is performed to identify cancer-
ous cells, especially if serum prostate- INTERFERING FACTORS:
specific antigen is increased. ■ • This test is contraindicated in
patients with bleeding disorders.
INDICATIONS: • The various sampling approaches
• Evaluate prostatic hypertrophy of have individual drawbacks that
unknown etiology should be considered: transur-
• Investigate suspected cancer of the ethral sampling does not always ensure
prostate that malignant cells will be included in
the specimen, whereas transrectal sam-
RESULT: Positive findings in prostate pling carries the risk of perforating the
cancer. rectum and creating a channel through
Biopsy, Prostate 207
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
➤ Have the patient void before the
Procedure ● ● ● ● ● ● ● ● ● ● ●
procedure. Administer enemas if
ordered.
Pretest:
➤ 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.
any bleeding disorders, and results Intratest:
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.
ulant therapy, acetylsalicylic acid, Transurethral approach:
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:
direction. ➤ Assist the patient into a Sims’ posi-
tion. A rectal examination is
performed to locate suspicious
nodules. A biopsy needle guide is
placed at the biopsy site, and the
modesty is important in providing
biopsy needle is inserted through
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
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
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Skin 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
Biopsy, Skin 209
• Evaluate suspicious skin lesions ➤ Obtain a list of the medications the

RESULT ulant therapy, acetylsalicylic acid,
Abnormal findings in: affect coagulation. These products
• Basal cell carcinoma before dental or surgical procedures.
• Cysts The requesting health care practi-
• Dermatitis advised if the patient regularly uses
• Dermatofibroma these products so their effects can
• Keloids reviewing results.
• Malignant melanoma ➤ There are no food, fluid, or medica-
• Pemphigus direction.
• Pigmented nevi ➤ Review the procedure with the
• Neurofibroma social issues, as well as concern for
• Seborrheic keratosis modesty, is important in providing
• Skin involvement in systemic lupus
erythematosus, discoid lupus erythe- to the procedure. Inform the patient
matosus, and scleroderma that a local anesthetic will be admin-
• Squamous cell carcinoma istered before the procedure.
➤ Assess if the patient has an allergy
• Warts to local anesthetics, and inform the
CRITICAL VALUES: N/A ➤ Obtain written and informed con-
sent before administering any med-
INTERFERING FACTORS: This procedure ications prior to the procedure.
is contraindicated in patients with ➤ Inform the patient that it may be
bleeding disorders. necessary to shave the site before
Nursing Implications and dure is performed under sterile
Procedure ● ● ● ● ● ● ● ● ● ● ● conditions by a surgeon, that it
usually takes about 30 minutes to
Pretest: complete, and that sutures may be
necessary to close the site.
allergens. Intratest:
➤ Obtain a history of the patient’s ➤ Record baseline vital signs.
immune and musculoskeletal sys- ➤ Assist the patient into a comfortable
tems, any bleeding disorders, and position in which the biopsy site can
results of previously performed be supported and exposed.
bleeding time, clotting time, com- ➤ Observe standard precautions and
plete blood count, partial thrombo- follow the general guidelines in
plastin time, platelets, and pro- Appendix A.
thrombin time. For related tests, ➤ Cleanse the skin with an antiseptic
refer to the immune and muscu- solution. Direct the patient to
loskeletal system tables. breathe normally and to avoid unnec-
essary movement. Administer local ➤ Inspect biopsy site for excessive

anesthetic and protect the site with bleeding.
sterile drapes. ➤ Instruct the patient in the care and
➤ Curettage: The skin is scraped with a assessment of the site. Instruct the
curette to obtain specimen. patient to report any redness,
➤ Shaving or excision: A scalpel is edema, bleeding, or pain at the
used to remove a portion of the biopsy site. Instruct the patient to
lesion that protrudes above the keep the site clean and to change
epidermis. If the lesion is to be the dressing as needed to avoid risk
excised, the incision is made as of infection resulting from altered
wide and as deep as needed to skin integrity.
ensure that the entire lesion is ➤ Administer mild analgesic and antibi-
removed. Bleeding is controlled with otic therapy as ordered. Remind the
external pressure to the site. Large patient of the importance of com-
wounds are closed with sutures. An pleting the entire course of antibiotic
adhesive bandage is applied when therapy, even if signs and symptoms
excision is complete. disappear before completion of ther-
➤ Punch biopsy: A small, round punch apy.
about 4 to 6 mm in diameter is ➤ If indicated, inform the patient of a
rotated into the skin to the desired follow-up appointment for the
depth. The cylinder of skin is pulled removal of sutures.
upward with forceps and separated ➤ Recognize anxiety related to test
at its base with a scalpel or scissors. results and offer support. Provide
If needed, sutures are applied. A teaching and information regarding
sterile dressing is applied over the the clinical implications of the test
site. results, as appropriate. Educate the
➤ Place tissue samples in formalin patient regarding access to counsel-
solution. Label the specimen, indi- ing services.
cating site location, and promptly ➤ Evaluate test results in relation to
transport it to the laboratory. the patient’s symptoms and other
Post-test: tests include allergen-specific im-
munoglobulin E (IgE), IgE, antinu-
➤ After local anesthesia, monitor vital clear antibody, skin culture, eosino-
signs and compare with baseline phil count, and erythrocyte sedimen-
values. tation rate.
BIOPSY, THYROID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Thyroid gland tissue or cells.
Biopsy, Thyroid 211
DESCRIPTION: Thyroid biopsy is the ➤ Obtain a history of the patient’s

endocrine and immune systems,
excision of a tissue sample for micro-
scopic analysis to determine cell of previously performed tests and
morphology and the presence of procedures, especially bleeding
tissue abnormalities. This test assists time, clotting time, complete blood
in confirming a diagnosis of cancer or count, partial thromboplastin time,
determining the cause of persistent For related tests, refer to the
thyroid symptoms. A biopsy speci- endocrine and immune system
men can be obtained by needle aspi- tables.
ration or by surgical excision. ■ ➤ Obtain a list of the medications the
INDICATIONS: ulant therapy, acetylsalicylic acid,
• Assist in the diagnosis of thyroid herbs, and nutraceuticals known to
cancer or benign cysts or tumors
• Determine the cause of inflammatory before dental or surgical procedures.
thyroid disease The requesting health care practi-
• Determine the cause of hyperthy- advised if the patient regularly uses
roidism these products so their effects can
• Evaluate enlargement of the thyroid reviewing results.
gland
RESULT ➤ Explain that food and fluids are not
usually restricted for a needle biopsy
Positive findings in: but are restricted for 6 to 8 hours
• Benign thyroid cyst before open biopsy.
• Granulomatous thyroiditis
patient.
• Hashimoto’s thyroiditis ➤ Assess if the patient has an allergy
• Nontoxic nodular goiter health care practitioner accordingly.
• Thyroid cancer ➤ Inform the patient that open biopsy
is performed under sterile conditions
CRITICAL VALUES: N/A by a surgeon. Ensure nonallergy to
anesthesia is confirmed before the
open biopsy procedure is performed
INTERFERING FACTORS: This procedure
under general anesthesia.
is contraindicated in patients with
bleeding disorders. ➤ Obtain written and informed
consent before administering any
Nursing Implications and collection by needle biopsy takes
Procedure ● ● ● ● ● ● ● ● ● ● ● approximately 15 minutes. Speci-
mens collected by open biopsy take
Pretest: about 30 minutes.
allergens. ➤ Ensure that the patient has complied
with dietary restrictions before open Post-test:

biopsy.
➤ Administer ordered sedation. Assist diet as directed by the health care
the patient to a comfortable posi- practitioner.
tion.
➤ Observe standard precautions and signs every 15 minutes for 1 hour,
follow the general guidelines in and then every 2 hours for 4 hours,
Appendix A. and as ordered. Take temperature
➤ Cleanse the biopsy site with an anti- every 4 hours for 24 hours.
septic solution, and drape the area ➤ After local anesthesia, monitor vital
with sterile towels. signs and compare with baseline
values.
Open biopsy:
➤ Instruct the patient in the care
➤ Record baseline vital signs. After and assessment of the site. Instruct
administration of general anesthe- the patient to report any bleed-
sia, a surgical incision is made, ing, redness, edema, or pain at the
suspicious areas are located, and site.
tissue samples are collected. ➤ Instruct the patient to return for
suture removal as indicated.
Needle biopsy:
➤ Recognize anxiety related to test
➤ Direct the patient to breathe results and offer support. Provide
normally and to avoid unnecessary teaching and information regarding
movement. Instruct the patient not the clinical implications of the test
to swallow when the local anes- results, as appropriate. Educate the
thetic is injected. The biopsy needle patient regarding access to counsel-
is inserted and a sample is obtained. ing services.
Pressure is applied to the site, and a ➤ Evaluate test results in relation to
sterile dressing is applied. the patient’s symptoms and other
➤ Place tissue samples in formalin tests performed. Related laboratory
solution. Label the specimen, indi- tests include antithyroglobulin
cating site location, and promptly antibodies, thyroid-stimulating hor-
transport it to the laboratory. mone, and free thyroxine.
BLADDER CANCER MARKERS,

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

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

immunochromatographic for Bard BTA)
Bladder Cancer Markers, Urine 213
NMP22: Less than 10 units/mL other trauma to the bladder or urinary

Bard BTA: Negative tract may cause falsely elevated values.
Active urinary tract infection, renal or
bladder calculi, gross hemolysis, and
DESCRIPTION: Cystoscopy is still positive leukocyte dipstick may also
considered the gold standard for cause false-positive results.
detection of bladder cancer, but other
noninvasive tests are being developed
including several urine assays Nursing Implications and
approved by the Food and Drug Procedure ● ● ● ● ● ● ● ● ● ● ●
Administration. Compared to cyto-

logic studies, these assays are believed Pretest:
to be more sensitive but less specific ➤ Obtain a history of the patient’s
for detecting transitional cell carci- complaints, including a list of known
noma. allergens.
NMP22: Nuclear matrix proteins genitourinary and immune systems,
(NMPs) are involved in the as well as results of previously
regulation and expression of performed tests and procedures.
various genes. The NMP For related tests, refer to the
identified as NuMA is abundant genitourinary and immune system
in bladder tumor cells. The tables.
dying tumor cells release the ➤ Obtain a list of the medications the
soluble NMP into the urine. patient is taking, including herbs, nu-
This assay is quantitative. tritional supplements, and nutraceu-
Bladder tumor antigen (BTA): A ticals. The requesting health care
human complement factor practitioner and laboratory should be
H–related protein (hCFHrp) is advised if the patient regularly uses
thought to be produced by these products so their effects can
bladder tumor cells as be taken into consideration when re-
protection from the body’s viewing results.
natural immune response. The ➤ There are no food, fluid, or medica-
bladder tumor antigen is tion restrictions unless by medical
released from tumor cells into direction.
the urine. This assay is ➤ Review the procedure with the
qualitative. ■ patient.
INDICATIONS: collection takes approximately 5
• Detection of bladder carcinoma minutes.
• Management of recurrent bladder
cancer Intratest:
RESULT: Increased in bladder carcinoma. follow the general guidelines in
Appendix A.
CRITICAL VALUES: N/A ➤ Obtain urine specimen in a clean
plastic collection container. Label
INTERFERING FACTORS: the specimen, and promptly trans-
• NMP22: Any condition that results in port it to the laboratory.
inflammation of the bladder or urinary
tract may cause falsely elevated values. Post-test:
• Bard BTA: Recent surgery, biopsy, or ➤ Recognize anxiety related to test
results and offer support. Provide ➤ Evaluate test results in relation to

teaching and information regarding the patient’s symptoms and other
the clinical implications of the test tests performed. Related laboratory
results, as appropriate. Educate the tests include bladder biopsy and
patient regarding access to counsel- urine cytology.
ing services.
BLEEDING TIME
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Mielke bleeding time, Simplate bleeding time,

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

REFERENCE VALUE: (Method: Timed observation of incision)
Template: 2.5 to 10 minutes • Fibrinogen disorders
Ivy: 2 to 7 minutes
• Glanzmann’s thrombasthenia
There are slight differences in the
disposable devices used to make the inci- • Hereditary telangiectasia
sion. Although the Mielke or Template
bleeding time is believed to offer greater • Liver disease
standardization to a fairly subjective • Macroglobulinemia
procedure, both methods are thought to
be of equal sensitivity and reproducibility. • Some myeloproliferative disorders
• Renal disease
DESCRIPTION: Bleeding time assesses
• Thrombocytopenia
platelet and capillary function. ■
• von Willebrand’s disease
INDICATIONS:
• Assess platelet and capillary function Decreased in: N/A
• Evaluate ecchymosis, unexplained
bleeding or bruising, and tendency to
bleed CRITICAL VALUES: N/A
• Screen for coagulopathy INTERFERING FACTORS:
• Drugs that may prolong bleeding
RESULT: time include acetylsalicylic acid,
This test does not predict excessive bleed- aminocaproic acid, ampicillin, aspara-
ing during a surgical procedure. ginase, carbenicillin, cefoperazone,
cilostazol, dextran, diltiazem, ethanol,
Prolonged in: flurbiprofen, fluroxene, halothane,
• Bernard-Soulier syndrome heparin, ketorolac, mezlocillin, mox-
Bleeding Time 215
alactam, nafcillin, naproxen, nifedi- ➤ Inform the patient that specimen

pine, nonsteroidal anti-inflammatory collection takes approximately 2 to
drugs, penicillin, piroxicam, pli- 15 minutes.
camycin, propranolol, streptokinase,
sulindac, ticarcillin, tolmetin, uroki- Intratest:
nase, valproic acid, and warfarin. ➤ Direct the patient to breathe
• Drugs that may decrease bleeding time normally and to avoid unnecessary
include desmopressin and erythropoi- movement.
etin. ➤ Ensure that the patient has complied
with pretesting restrictions.
• The test should not be performed on ➤ Observe standard precautions and
patients who must be restrained, follow the general guidelines in
have excessively cold or edema- Appendix A.
tous arms, have a platelet count less ➤ Place a blood pressure cuff on the
than 50,000/mm3, have an infectious arm above the elbow and inflate to
skin disease, or cannot have a blood 40 mm Hg. Cleanse the site with
pressure cuff placed on the arm. alcohol and wait until it is air-dry.
Hold skin taut. Avoid superficial
veins and use bleeding time device
to make a parallel incision about 3
Nursing Implications and mm deep into the muscular outside
Procedure ● ● ● ● ● ● ● ● ● ● ● area of the forearm distal to the
antecubital fossa (in the direction of
Pretest: wrist to elbow). Start stopwatch
immediately. At 30-second intervals,
➤ Obtain a history of the patient’s blot the incision site, in a clockwise
complaints, including a list of known fashion, on the edge of a piece of
allergens. filter paper. The test concludes when
➤ Obtain a history of the patient’s the bleeding stops or if bleeding
hematopoietic system, as well as continues longer than 15 minutes.
results of previously performed tests Bleeding time is determined by
and procedures. For related tests, adding the total number of blots on
refer to the hematopoietic system the filter paper (30 seconds or 0.5
table. minutes.
patient is taking, including herbs, Post-test:
nutritional supplements, and nutra- ➤ Instruct the patient to resume usual
ceuticals. The requesting health care medication as directed by the health
practitioner and laboratory should be care practitioner.
these products so their effects can ➤ Observe the incision site for bleed-
be taken into consideration when ing. It may be necessary to place a
reviewing results. dressing or butterfly bandage on the
site after the test.
➤ There are no food or fluid restrictions
unless by medical direction. ➤ Inform the patient with a bleeding
disorder of the importance of taking
➤ The test should not be performed precautions against bruising and
until a minimum of 10 days after the bleeding. These precautions may
last dose of any medication contain- include the use of soft-bristle tooth-
ing acetylsalicylic acid. brush, use of an electric razor, avoid-
➤ Review the procedure with the ance of constipation, avoidance of
patient. Inform the patient that scar- acetylsalicylic acid and similar prod-
ring, keloid formation, or infection ucts, and avoidance of intramuscular
may occur. injections.
➤ Evaluate test results in relation to the Related laboratory tests include clot
patient’s symptoms and other tests. retraction and platelet count.
BLOOD GASES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Arterial blood gases (ABGs), venous blood gases,

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

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

Arterial 7.11–7.36 7.35–7.45
Venous 7.25–7.45 7.32–7.43
Capillary 7.32–7.49 7.35–7.45
Scalp 7.25–7.40 N/A
SI units (conversion factor 1).
SI Units SI Units SI Units
(Conversion (Conversion (Conversion
pCO2 Arterial Factor 0.133) Venous Factor 0.133) Capillary Factor 0.133)
Birth, cord, 32–66 mm Hg 4.3–8.8 kPa 27–49 mm Hg 3.6–6.5 kPa — —
full term
Adult/child 35–45 mm Hg 4.66–5.98 kPa 41–51 mm Hg 5.4–6.8 kPa 26–41 mm Hg 3.5–5.4 kPa
SI Units SI Units SI Units

pO2 Arterial Factor 0.133) Venous Factor 0.133) Capillary Factor 0.133)
Birth, cord, 8–24 mm Hg 1.1–3.2 kPa 17–41 mm Hg 2.3–5.4 kPa — —
full term
Adult/child 80–95 mm Hg 10.6–12.6 kPa 20–49 mm Hg 2.6–6.5 kPa 80–95 mm Hg 10.6–12.6 kPa
217
Arterial Venous Capillary

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

Birth, cord, 40–90% 40–70% —
full term
Adult/child 95–99% 70–75% 95–98%
SI Units (conversion factor .01)
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
BE Arterial SI Units mmol/L (Conversion Factor 1)

Birth, cord, full term (10)–(2) mEq/L
Adult/child (2)–(
3) mEq/L
DESCRIPTION: Blood gas analysis is gen ions (H

) in the body. A pH less
used to evaluate respiratory function than 7.35 indicates acidosis. A pH
and provide a measure for determin- greater than 7.45 indicates alkalosis.
ing acid-base balance. Respiratory, Changes in the ratio of free hydrogen
renal, and cardiovascular system func- ions to bicarbonate will result in a
tions are integrated in order to main- compensatory response from the
tain normal acid-base balance. lungs or kidneys to restore proper
Therefore, respiratory or metabolic acid-base balance.
disorders may cause abnormal blood pCO2 is an important indicator of
gas findings. The blood gas measure- ventilation. The level of pCO2
ments commonly reported are pH, is controlled primarily by the lungs
partial pressure of carbon dioxide in and is referred to as the respiratory
the blood (pCO2), partial pressure of component of acid-base balance. The
oxygen in the blood (pO2), bicarbon- main buffer system in the body is the
ate (HCO3), O2 saturation, and bicarbonate–carbonic acid system.
base excess (BE) or base deficit (BD). Bicarbonate (HCO3) is an important
pH reflects the number of free hydro- alkaline ion that participates along
Blood Gases 219
with other anions such as hemoglobin, without subjecting the patient to an

proteins, and phosphates to neutralize arterial puncture with its associated
acids. For the body to maintain proper risks.
balance, there must be a ratio of 20 As seen in the table of reference
parts bicarbonate to one part carbonic ranges, pO2 is lower in infants than in
acid (20:1). Carbonic acid level is indi- children and adults owing to the
rectly measured by pCO2. Bicarbonate respective level of maturation of the
level is indirectly measured by the lungs at birth. pO2 tends to trail off
total carbon dioxide content (tCO2). after age 30 years, by approximately 3
Carbonic acid levels are not measured to 5 mm Hg per decade as the organs
directly, but can be estimated because age and begin to lose elasticity. There
it is 3 percent of the pCO2. Bicarbon- is a formula that can be used to
ate can also be calculated from these approximate the relationship between
numbers once the carbonic acid value age and pO2:
has been obtained because of the 20:1 pO2 104 (age 0.27).
ratio. For example, if the pCO2 was Like carbon dioxide, oxygen is
40, the carbonic acid would be 1.2 carried in the body in a dissolved and
(3% 40) and the HCO3 would be combined (oxyhemoglobin) form.
24 (20 1.2). The main acid in the Oxygen content is the sum of the
acid-base system is carbonic acid. It dissolved and combined oxygen.
is the metabolic or nonrespiratory The oxygen-carrying capacity of
component of the acid-base system the blood indicates how much oxy-
and is controlled by the kidney. Bicar- gen could be carried if all the hemo-
bonate levels can either be measured globin were saturated with oxygen.
directly or estimated from the tCO2 Percent oxygen saturation is oxygen
in the blood. BE/BD reflects the content divided by oxygen content
amount of anions available in the times 100.
blood to help buffer changes in pH. Specimens other than arterial spec-
A BD (negative BE) indicates meta- imen are often ordered when oxygen
bolic acidosis, whereas positive BE measurements are not needed or
indicates metabolic alkalosis. when the information regarding
Extremes in acidosis are generally oxygen can be obtained by noninva-
more life threatening than alkalosis. sive techniques such as pulse oxime-
Acidosis can develop either very try. Capillary blood is satisfactory for
quickly (e.g., cardiac arrest) or over a most purposes for pH and pCO2; the
longer period of time (e.g., renal fail- use of capillary pO2 is limited to the
ure). Infants can develop acidosis very exclusion of hypoxia. Measurements
quickly if they are not kept warm and involving oxygen are usually not
given enough calories. Children with useful when performed on venous
diabetes tend to go into acidosis more samples; arterial blood is required to
quickly than do adults who have been accurately measure pO2 and oxygen
dealing with the disease over a longer saturation. There is considerable
period of time. In many cases a evidence that prolonged exposure to
venous or capillary specimen is satis- high levels of oxygen can result in
factory to obtain the necessary infor- injury, such as retinopathy of prema-
mation regarding acid-base balance turity in infants or the drying of
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.
Acid-Base Disturbance pH pCO2 pO2 BE

Respiratory Acidosis
Uncompensated Decreased Increased Normal Normal
Compensated Normal Increased Increased Increased
Respiratory Alkalosis
Uncompensated Increased Decreased Normal Normal
Compensated Normal Decreased Decreased Decreased
Metabolic (Nonrespiratory) Acidosis
Uncompensated Decreased Normal Decreased Decreased
Compensated Normal Decreased Decreased Decreased
Metabolic (Nonrespiratory) Alkalosis
Uncompensated Increased Normal Increased Increased
Compensated Normal Increased Increased Increased
RESULT: to be retained in the blood. This results

• Acid-base imbalance is determined by in an increase of circulating carbonic
evaluating pH, pCO2, and HCO3 acid and a corresponding decrease in
values. pH less than 7.35 reflects an pH (respiratory acidosis). Acute respi-
acidic state, whereas pH greater than ratory acidosis can occur in acute
7.45 reflects alkalosis. pCO2 and pulmonary edema, severe respiratory
HCO3 determine whether the imbal- infections, bronchial obstruction,
ance is respiratory or nonrespiratory. pneumothorax, hemothorax, open
Because a patient may have more than chest wounds, opiate poisoning, respi-
one imbalance and may also be in the ratory depressant drug therapy, and
process of compensating, the interpre- inhalation of air with a high CO2
tation of blood gas values may not content. Chronic respiratory acidosis
always seem straightforward. can be seen in patients with asthma,
pulmonary fibrosis, emphysema,
• Respiratory conditions that interfere bronchiectasis, and respiratory depres-
with normal breathing will cause CO2 sant drug therapy. Alternately, respira-
Blood Gases 221
tory conditions that increase the Excessive artificial ventilation

breathing rate will cause CO2 to be Fever
removed from the alveoli more rapidly Hyperventilation
than it is being produced. This will Hysteria
result in an alkaline pH. Acute respira-
Salicylate intoxication
tory alkalosis may be seen in anxiety,
hysteria, hyperventilation, pulmonary
embolus, and an increase in artificial Decreased:
ventilation. Chronic respiratory alkalo- • pH (metabolic acidosis):
sis may be seen in high fever, adminis- Decreased formation of acids:
tration of drugs (e.g., salicylate and diabetic ketoacidosis, high-
sulfa) that stimulate the respiratory fat/low-carbohydrate diets
system, hepatic coma, hypoxia of Decreased excretion of H
:
high altitude, and central nervous acquired (e.g., drugs,
system (CNS) lesions or injury that hypercalcemia), Addison’s
result in stimulation of the respiratory disease, Fanconi’s syndrome,
center. inherited (e.g., cystinosis,
Wilson’s disease), renal failure,
• Metabolic (nonrespiratory) conditions renal tubular acidosis
that cause the excessive formation or
Increased acid intake
decreased excretion of organic or inor-
ganic acids result in metabolic acidosis. Increased loss of alkaline body
fluids: diarrhea, excess
Some of these conditions include
potassium, fistula
ingestion of salicylates, ethylene glycol,
and methanol, as well as uncontrolled • pH (respiratory acidosis):
diabetes, starvation, shock, renal Asthma
disease, diarrhea, and biliary or pancre- Bronchoconstriction
atic fistula. Metabolic alkalosis results
Drugs depressing the respiratory
from conditions that increase pH, as system
can be seen in excessive intake of
Emphysema
antacids to treat gastritis or peptic
ulcer, excessive administration of Pneumonia
HCO3, loss of stomach acid caused Pulmonary edema
by protracted vomiting, cystic fibrosis,
or potassium and chloride deficiencies. Increased:
• pO2:
Increased:
Hyperbaric oxygenation
• pH (metabolic alkalosis):
Hyperventilation
Alkali ingestion (excessive)
Gastric suctioning Decreased:
Potassium depletion: Cushing’s • pO2:
disease, diarrhea, diuresis,
Decreased alveolar gas exchange:
excessive vomiting, excessive
cancer, compression or resection
ingestion of licorice, inadequate
of lung, respiratory distress
potassium intake, potassium-
syndrome (newborns),
losing nephropathy, steroid
sarcoidosis
administration
Decreased ventilation or perfusion:
• pH (respiratory alkalosis): asthma, bronchitis,
CNS lesions or injuries that cause bronchiectasis, cancer, croup,
stimulation of the respiratory cystic fibrosis (mucoviscidosis),
center emphysema, granulomata,
pneumonia, pulmonary Fever

infarction, shock Head injury
Hypoxemia: anesthesia, cardiac Hyperthermia
disorders, carbon monoxide Hyperventilation
exposure, high altitudes, near
drowning, presence of abnormal Salicylate intoxication
hemoglobins • tCO2 (metabolic acidosis):
Hypoventilation: cerebrovascular Diabetic ketoacidosis
incident, drugs depressing the Renal disease
respiratory system, head injury
Right to left shunt: congenital heart Increased:
disease, intrapulmonary
• HCO3:
venoarterial shunting
Anoxia
Increased: Metabolic alkalosis
• pCO2 (respiratory acidosis): Respiratory acidosis
Acute intermittent porphyria
Decreased:
Asthma
Bronchitis
• HCO3:
Hypocapnia
Cardiac disorders
Metabolic acidosis
Congestive heart failure
Respiratory alkalosis
Cystic fibrosis
Depression of respiratory center Increased:
Electrolyte disturbances (severe) • O2 saturation:
Emphysema Hyperbaric oxygenation
Hypothyroidism (severe) Hypocapnia
Near drowning Hypothermia
Pneumonia Oxygen therapy
Pneumothorax Respiratory alkalosis
Poliomyelitis
Pulmonary edema Decreased:
Pulmonary tuberculosis • O2 saturation:
Respiratory failure Anemia (severe)
Respiratory disorders Anorexia
Tumor Anoxia
• tCO2 (metabolic alkalosis): Atelectasis
Alkali ingestion (excessive) Carbon monoxide poisoning
Hypochloremic states Cardiac disorders
Hypokalemic states Congenital heart defects
Salicylate intoxication COPD
Shock Fever
Vomiting Head injury
Hypercapnia
Decreased: Near drowning
• pCO2 (respiratory alkalosis): Pleural effusion
Anxiety Poisoning
Blood Gases 223
Pneumonia INTERFERING FACTORS:

Pneumothorax • Drugs that may cause an increase in
Pulmonary embolism pH include antacids, acetylsalicylic
Respiratory distress syndrome acid (initially), carbenicillin, carbenox-
(adult and neonatal) olone, ethacrynic acid, glycyrrhiza
Sarcoidosis (licorice), laxatives, mafenide, and
sodium bicarbonate.
Increased: • Drugs that may cause a decrease in pH
• Base excess: Metabolic alkalosis include acetazolamide, acetylsalicylic
acid (long term or high doses), citrates,
Decreased: dimethadione, ether, ethylene glycol,
• Base excess: Metabolic acidosis fluorides, mercury compounds (laxa-
tives), methylenedioxyamphetamine,
CRITICAL VALUES: paraldehyde, and xylitol.
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
• Drugs that may cause an increase in risk of bleeding, especially in patients

pCO2 include acetylsalicylic acid, who have bleeding disorders or are
aldosterone bicarbonate, carbenicillin, taking medications for a bleeding
carbenoxolone, corticosteroids, dexa- disorder.
methasone, ethacrynic acid, laxatives
(chronic abuse), and x-ray contrast • Recent blood transfusion may produce
agents. misleading values.
• Drugs that may cause a decrease in • Specimens with extremely elevated

pCO2 include acetazolamide, acetylsal- white blood cell counts will undergo
icylic acid ethamivan, neuromuscular misleading decreases in pH resulting
relaxants (secondary to postoperative from cellular metabolism, if transport
hyperventilation), NSD 3004 (arterial to the laboratory is delayed.
long-acting carbonic anhydrase in- • Specimens collected soon after a
hibitor), theophylline, tromethamine, change in inspired oxygen has occurred
and xylitol. will not accurately reflect the patient’s
• Drugs that may cause an increase in oxygenation status.
pO2 include theophylline and uroki- • Specimens collected within 20 to 30
nase. minutes of respiratory passage suction-
• Drugs that may cause a decrease in ing or other respiratory therapy will
pO2 include althesin, barbiturates, not be accurate.
GM-CSF, isoproterenol, and meperi-
• Excessive differences in actual body
dine.
temperature relative to normal body
• Samples for blood gases are obtained temperature will not be reflected in
by arterial puncture, which carries a the results. Temperature affects the
amount of gas in solution. Blood gas • Specimens should be placed in ice

analyzers measure samples at 37 C slurry immediately after collection
(98.6 F); therefore, if the patient is hy- because blood cells continue to carry
perthermic or hypothermic, it is im- out metabolic processes in the speci-
portant to notify the laboratory of the men after it has been removed from the
patient’s actual body temperature at patient. These natural life processes can
the time the specimen was collected. affect pH, pO2, pCO2, and the other
Fever will increase actual pO2 and calculated values in a short period of
pCO2 values; therefore the uncorrected time. The cold temperature provided
values measured at 37 C will be falsely by the ice slurry will slow down but
decreased. Hypothermia decreases ac- not completely stop metabolic changes
tual pO2 and pCO2 values; therefore occurring in the sample over time.
the uncorrected values measured at Iced specimens not analyzed within
37 C will be falsely increased. 60 minutes of collection should be
rejected for analysis.
• A falsely increased O2 saturation may
occur because of elevated levels of
carbon monoxide in the blood.
• O2 saturation is a calculated parameter Procedure ● ● ● ● ● ● ● ● ● ● ●
based on an assumption of 100 percent

hemoglobin A. Values may be mislead- Pretest:
ing when hemoglobin variants with
different oxygen dissociation curves are complaints, including a list of known
present. Hemoglobin S will cause a allergens.
shift to the right, indicating decreased
➤ Obtain a history of the patient’s car-
oxygen binding. Fetal hemoglobin and diovascular and respiratory systems,
methemoglobin will cause a shift to the any bleeding disorders, and results
left, indicating increased oxygen bind- of tests and procedures previously
ing. performed, especially bleeding time,
clotting time, complete blood count,
• Excessive amounts of heparin in the partial thromboplastin time, plate-
sample may falsely decrease pH, lets, and prothrombin time. For other
pCO2, and pO2. related tests, refer to the cardiovas-
cular and respiratory system tables.
• Citrates should never be used as an
anticoagulant in evacuated collection ➤ Obtain a list of the medications the
tubes for venous blood gas determina- ulant therapy, acetylsalicylic acid,
tions because citrates will cause a herbs, and nutraceuticals known to
marked analytic decrease in pH. affect coagulation. It is recom-
mended that use of these products
• Air bubbles or blood clots in the speci- be discontinued 14 days before
men are cause for rejection. Air dental or surgical procedures. The
bubbles in the specimen can falsely requesting health care practitioner
elevate or decrease the results depend- and laboratory should be advised if
ing on the patient’s blood gas status. If the patient is regularly using these
an evacuated tube is used for venous products so their effects can be
blood gas specimen collection, the tube taken into consideration when
must be removed from the needle reviewing results.
before the needle is withdrawn from ➤ Note any recent procedures that can
the arm or else the sample will be interfere with test results.
contaminated with room air. ➤ There are no food, fluid, or medica-
Blood Gases 225
tion restrictions unless by medical or other natural products that may

direction. prolong bleeding from the puncture
➤ Record the patient’s temperature. site.
➤ Indicate the type of oxygen, mode of ➤ Prepare an ice slurry in a cup or plas-
oxygen delivery, and delivery rate as tic bag to have ready for immediate
part of the test requisition process. transport of the specimen to the
laboratory.
➤ If the sample is to be collected by
radial artery puncture, perform Intratest:
an Allen test before puncture
to ensure that the patient has ➤ Direct the patient to breathe
adequate collateral circulation to the normally and to avoid unnecessary
hand if thrombosis of the radial movement.
artery occurs after arterial puncture. ➤ Observe standard precautions and
The modified Allen test is performed follow the general guidelines in
as follows: extend the patient’s wrist Appendix A.
over a rolled towel. Ask the patient
to make a fist with the hand Arterial
extended over the towel. Use the
second and third fingers to locate ➤ Perform an arterial puncture and
the pulses of the ulnar and radial collect the specimen in an air-
arteries on the palmar surface of the free heparinized syringe. There is no
wrist. The thumb should not be used demonstrable difference in results
to locate these arteries because it between samples collected in plas-
has a pulse. Compress both arteries tic syringes and samples collected in
and ask the patient to open and glass syringes. It is very important
close the fist several times until the that no room air be introduced into
palm turns pale. Release pressure the collection container because the
on the ulnar artery only. Color should gases in the room and in the sample
return to the palm within 5 seconds will begin equilibrating immediately.
if the ulnar artery is functioning. This The end of the syringe must be stop-
is a positive Allen test, and blood pered immediately after the needle
gases may be drawn from the radial is withdrawn and removed. Samples
artery site. The Allen test should should be mixed gently but thor-
then be performed on the opposite oughly to ensure proper mixing of
hand. The hand to which color is the heparin with the sample, which
restored fastest has better circula- will prevent the formation of small
tion and should be selected for spec- clots leading to rejection of the sam-
imen collection. ple. Label the specimen and prompt-
ly transport it to the laboratory. The
tightly capped sample should be
patient and advise rest for 30
placed in an ice slurry immediately
minutes before specimen collection.
after collection. Information on the
Be sure to explain to the patient that
specimen label can be protected
an arterial puncture may be painful.
from water in the ice slurry by first
The site may be anesthetized with
placing the specimen in a protective
1% to 2% lidocaine before puncture.
plastic bag.
Assess if the patient has an allergy
to local anesthetics, and inform the Venous
➤ Inform the patient that specimen ➤ Central venous blood is collected in
collection usually takes 10 to 15 a heparinized syringe.
minutes. The person collecting the ➤ Venous blood collected percuta-
specimen should be notified before- neously by venipuncture in a 5-mL
hand if the patient is receiving anti- green-top (heparin) tube (for adult
coagulant therapy, or taking aspirin patients) or a heparinized micro-
tainer (for pediatric patients) may be specimen, and promptly transport it

used. Observe standard precautions to the laboratory.
and follow the general guidelines in
Appendix A. The vacuum collection Cord blood
tube must be removed from the ➤ The sample may be collected di-
needle before the needle is removed rectly from the cord, using a syringe.
from the patient’s arm. Samples Label the specimen and promptly
should be mixed gently but thor- transport it to the laboratory. The
oughly to ensure proper mixing of tightly capped sample should be
the heparin with the sample, which placed in an ice slurry immediately
will prevent the formation of small after collection. Information on the
clots leading to rejection of the specimen label can be protected
sample. Label the specimen, and from water in the ice slurry by first
promptly transport it to the labora- placing the specimen in a protective
tory. The tightly capped sample plastic bag.
should be placed in an ice slurry im-
mediately after collection. Informa- Scalp sample
tion on the specimen label can be
protected from water in the ice ➤ Samples for scalp pH may be col-
slurry by first placing the specimen lected anaerobically before delivery
in a protective plastic bag. in special, scalp-sample collection
capillaries and transported immedi-
Capillary ately to the laboratory for analysis.
Some hospitals recommend that
➤ Perform a capillary puncture and col-
fleas be added to the scalp tube be-
lect the specimen in two 250-L he-
fore the ends are capped. See pre-
parinized capillaries (scalp or heel for
ceding capillary collection for discus-
neonatal patients) or a heparinized
sion of fleas.
microtainer (for pediatric patients).
Observe standard precautions and
follow the general guidelines in Ap- Post-test:
pendix A. The capillaries should be ➤ Pressure should be applied to the
filled as much as possible and puncture site for at least 5 minutes
capped on both ends. Some hospi- in the unanticoagulated patient and
tals recommend that metal “fleas” for at least 15 minutes in the case of
be added to the capillary tube before a patient receiving anticoagulant
the ends are capped. During trans- therapy. Observe puncture site for
port a magnet can be moved up and bleeding or hematoma formation.
down the outside of the capillary Apply pressure bandage.
tube to facilitate mixing and prevent
the formation of clots, which would ➤ Observe the patient for signs or
cause rejection of the sample. It is symptoms of respiratory acidosis,
important to inform the laboratory or such as dyspnea, headache, tachy-
respiratory therapy staff of the num- cardia, pallor, diaphoresis, apprehen-
ber of fleas used so the fleas can be sion, drowsiness, coma, hyperten-
accounted for and removed before sion, or disorientation.
the sample is introduced into the ➤ Teach the patient breathing exer-
blood gas analyzers. Fleas left in the cises to assist with the appropriate
sample may damage the blood gas exchange of oxygen and carbon diox-
equipment if allowed to enter the an- ide.
alyzer. Microtainer samples should ➤ Administer oxygen, if appropriate.
be mixed gently but thoroughly to
ensure proper mixing of the heparin ➤ Teach the patient how to properly
with the sample, which will prevent use the incentive spirometer device
the formation of small clots leading or mininebulizer, if ordered.
to rejection of the sample. Label the ➤ Observe the patient for signs or
Blood Groups and Antibodies 227
symptoms of respiratory alkalosis, gastrointestinal distress. Research

such as tachypnea, restlessness, ag- has estimated that the daily caloric
itation, tetany, numbness, seizures, intake required for respiration of pa-
muscle cramps, dizziness, or tingling tients with COPD is ten times higher
fingertips. than that of normal individuals. Inad-
equate nutrition can result in hy-
➤ Instruct the patient to breathe
pophosphatemia, especially in the
deeply and slowly; performing this
respirator-dependent patient. During
type of breathing exercise into a
periods of starvation, phosphorus
paper bag decreases hyperventila-
leaves the intracellular space and
tion and quickly helps the patient’s
moves outside the tissue, resulting
breathing return to normal.
in dangerously decreased phospho-
➤ Observe the patient for signs or rus levels. Adequate intake of vita-
symptoms of metabolic acidosis, mins A and C is also important to
such as rapid breathing, flushed prevent pulmonary infection and to
skin, nausea, vomiting, dysrhyth- decrease the extent of lung tissue
mias, coma, hypotension, hyperven- damage. The importance of follow-
tilation, and restlessness. ing the prescribed diet should be
➤ Observe the patient for signs or stressed to the patient and/or care-
symptoms of metabolic alkalosis, giver.
such as shallow breathing, weak- ➤ Water balance needs to be closely
ness, dysrhythmias, tetany, hy- monitored in COPD patients. Fluid
pokalemia, hyperactive reflexes, and retention can lead to pulmonary
excessive vomiting. edema.
➤ Abnormal blood gas values may be ➤ Evaluate test results in relation to
associated with diseases of the res- the patient’s symptoms and other
piratory system. Malnutrition is com- tests performed. Related laboratory
monly seen in patients with severe tests include arterial/alveolar oxygen
respiratory disease for reasons in- ratio, anion gap, electrolytes, osmo-
cluding fatigue, lack of appetite, and lality, phosphorus, and lactic acid.
BLOOD GROUPS AND ANTIBODIES

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

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

collected in a lavender-top (ethylenediaminetetra-acetic acid [EDTA]) tube.
REFERENCE VALUE: (Method: FDA-licensed reagents with glass slides, glass

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

Blood (with any That React at 37 C or React at Room
Type ABO) with Antiglobulin Temperature or Below
A Positive Kell Lewis
B Negative Duffy P
AB Kidd MN
O S Cold agglutinins
s
U
DESCRIPTION: Blood typing is a se- incompatible cells. ABO and Rh test-

ries of tests that include the ABO and ing is also performed as a prenatal
Rh blood-group system performed to screen in pregnant women to identify
detect surface antigens on red blood the risk of hemolytic disease of the
cells by an agglutination test and newborn. Although most of the anti-
compatibility tests to determine anti- A and anti-B activity resides in the
bodies against these antigens. The immunoglobulin M (IgM) class of
major antigens in the ABO system are immunoglobulins, some activity rests
A and B, although AB and O are also with IgG. Anti-A and anti-B antibod-
common phenotypes. The patient ies of the IgG class coat the red blood
with A antigens has type A blood; the cells without immediately affecting
patient with B antigens has type B their viability and can readily cross
blood. The patient with both A and B the placenta, resulting in hemolytic
antigens has type AB blood (universal disease of the newborn. Individuals
recipient); the patient with neither A with type O blood frequently have
nor B antigens has type O blood more IgG anti-A and anti-B; thus,
(universal donor). Blood type is ge- ABO hemolytic disease of the new-
netically determined. After 6 months born will affect infants of type O
of age, individuals develop serum an- mothers almost exclusively (unless the
tibodies that react with A or B antigen newborn is also type O).
absent from their own red blood cells. Major antigens of the Rh system
These are called anti-A and anti-B an- are D (or Rho), C, E, c, and e.
tibodies. Individuals whose red blood cells
In ABO blood typing, the patient’s possess D antigen are called Rh-
red blood cells mix with anti-A and positive; those who lack D antigen are
anti-B sera, a process known as for- called Rh-negative, no matter what
ward grouping. The process then re- other Rh antigens are present. Indi-
verses, and the patient’s serum mixes viduals who are Rh-negative produce
with type A and B cells in reverse anti-D antibodies when exposed to
grouping. Rh-positive cells by either transfu-
Generally, only blood with the sions or pregnancy. These anti-D
same ABO and Rh group as the re- antibodies cross the placenta to the
cipient is transfused because the fetus and can cause hemolytic disease
anti-A and anti-B antibodies are of the newborn or transfusion reac-
strong agglutinins that cause a rapid, tions if Rh-positive blood is adminis-
complement-mediated destruction of tered. ■
Blood Groups and Antibodies 229
INDICATIONS: • Identify the patient’s ABO and Rh

• Determine ABO and Rh compatibility blood type, especially before a pro-
of donor and recipient before transfu- cedure in which blood loss is a
sion threat or blood replacement may be
needed
• Determine anti-D antibody titer of
Rh-negative mothers after sensitization
by pregnancy with an Rh-positive fetus RESULT :
• Determine the need for immunosup- • ABO system: A, B, AB, or O specific to
pressive therapy (e.g., with RhoGAM) person
when an Rh-negative woman delivers
• Rh system: positive or negative specific
or aborts an Rh-positive fetus
to person
• Identify donor ABO and Rh blood
type for stored blood • Cross-matching: compatibility be-
tween donor and recipient
• Identify maternal and infant ABO and
Rh blood types to predict risk of • Incompatibility indicated by clumping
hemolytic disease of the newborn (agglutination) of red blood cells
Alternative Transfusion Group and

Type of PACKED CELL UNITS in
Group Order of Preference If Patient’s Own
and Type Incidence (%) Group and Type Not Available
O Positive 37.4 O Negative
O Negative 6.6 None
A Positive 35.7 A Negative, O Positive, O Negative
A Negative 6.3 O Negative, O Positive, A Positive
B Positive 8.5 B Negative, O Positive, O Negative
B Negative 1.5 O Negative, O Positive, B Positive
AB Positive 3.4 AB Negative, A Positive, B Positive, A
Negative, B Negative, O Positive, O
Negative
AB Negative 0.6 A Negative, B Negative, O Negative,
AB Positive, A Positive, B Positive, O
Positive
Rh Type
Rh Positive 85–90
Rh Negative 10–15
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
further development of signs and symp- tritional supplements, and nutraceu-

toms. Administration of epinephrine ticals. The requesting health care
may be ordered. practitioner and laboratory should be
Possible interventions in a more severe advised if the patient regularly uses
transfusion reaction may include imme- be taken into consideration when re-
diate cessation of infusion, notification of viewing results.
the health care practitioner, keeping the
➤ Note any recent procedures that
intravenous (IV) line open with saline or could interfere with test results.
lactated Ringer solution, collection of
red- and lavender-top tubes for post- ➤ There are no food, fluid, or medica-
transfusion work-up, collection of urine, direction.
monitoring vital signs every 5 minutes,
ordering additional testing if DIC is ➤ Although correct patient identifica-
tion is important for test specimens,
suspected, maintaining patent airway it is crucial when blood is collected
and blood pressure, and administering for type and cross-match. Therefore,
mannitol. additional requirements are neces-
sary, including verifying name, social
INTERFERING FACTORS: security number, hospital number,
• Drugs including levodopa, methyl- date, and blood bank number on
dopa, and methyldopate hydrochloride requisition and specimen labels;
cause a false-positive in Rh typing. completing and applying a wrist
band on the arm with the same
• Recent administration of blood, blood information; and placing labels with
products, dextran, or IV contrast the same information and blood
medium causes cellular aggregation bank number on blood sample
resembling agglutination in ABO tubes.
typing. ➤ Review the procedure with the
patient.
• Abnormal proteins, cold agglutinins,
and bacteremia may interfere with test- collection takes approximately 5 to
ing. 10 minutes.
• Testing does not detect every antibody
and may miss the presence of a weak Intratest:
antibody. ➤ Direct the patient to breathe
movement.
Nursing Implications and ➤ Observe standard precautions and
Procedure ● ● ● ● ● ● ● ● ● ● ●
Appendix A.
Pretest: ➤ Perform a venipuncture, collect the
specimen in a 5-mL red- and
➤ Obtain a history of the patient’s lavender-top tube.
allergens. ➤ Label the specimen, and promptly
mune and hematopoietic systems, Post-test:
formed tests and procedures. For re- ➤ Observe venipuncture site for bleed-
lated tests, refer to the immune and ing or hematoma formation. Apply
hematopoietic system tables. pressure bandage.
➤ Obtain a list of the medications the ➤ Inform patient of blood and Rh type,
patient is taking, including herbs, nu- and advise the patient to record the
Blood Pool Imaging 231
information on a card or other docu- ➤ Evaluate test results in relation

ment normally carried. to the patient’s symptoms and
➤ Inform women who are Rh-negative other tests performed. Related
to inform the health care practitioner laboratory tests include direct
of their Rh-negative status if they and indirect antiglobulin, bilirubin,
become pregnant or need a transfu- cold agglutinin, haptoglobin, and
sion. urinalysis.
BLOOD POOL IMAGING

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

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

CONTRAST: Intravenous radioactive material.
DESCRIPTION: Multigated blood for first-pass studies. Studies detect

pool imaging (MUGA; also known as abnormalities in heart wall motion at
cardiac blood pool scan) is used to diag- rest or with exercise, ejection fraction,
nose cardiac abnormalities involving ventricular dilation, stroke volume,
the left ventricle and myocardial and cardiac output. The MUGA
wall abnormalities by imaging the procedure, performed with the heart
blood within the cardiac chamber in motion, is used to obtain multiple
rather than the myocardium. The images of the heart in contraction and
ventricular blood pool can be imaged relaxation during an R-to-R cardiac
during the initial transit of a periph- cycle. The resulting images can be
erally injected, intravenous bolus of displayed in a cinematic mode to
radionuclide (first-pass technique) or visualize cardiac function. Repetitive
when the radionuclide has reached data acquisitions are possible during
equilibrium concentration. The graded levels of exercise, usually a
patient’s electrocardiogram (ECG) is bicycle ergometer or handgrip, to
synchronized to the gamma camera assess ventricular functional response
imager and computer and thereby to exercise.
termed “gated.” For multigated stud- After the administration of sublin-
ies, technetium-99m (Tc-99m) gual nitroglycerin; the MUGA scan
pertechnetate is injected after an can evaluate the effectiveness of the
injection of pyrophosphate, allowing drug on ventricular function. Heart
the labeling of circulating red blood shunt imaging is done in conjunction
cells; Tc-99m sulfur colloid is used with a resting MUGA scan to obtain
ejection fraction and assess regional Abnormal Findings:

wall motion. • Abnormal wall motion (akinesia or
First-pass cardiac flow study is dyskinesia)
done to study heart chamber disor- Ischemic areas are hypokinetic
ders including left-to-right and right- Infarcted areas are akinetic
to-left shunts, determine both right • Cardiac hypertrophy
and left ventricular ejection fractions,
• Cardiac ischemia
and assess blood flow through the
great vessels. The study uses a jugular • Enlarged left ventricle
or antecubital vein injection of the • Myocardial infarction
radionuclide. ■
INDICATIONS:
• Determine ischemic coronary artery This procedure is contraindicated
disease for:
• Aid in the diagnosis of myocardial • Testing is contraindicated in patients
infarction with hypersensitivity to the radionu-
clide and in pregnancy and lactation
• Aid in the diagnosis of true or false unless the benefits of performing the
ventricular aneurysms test greatly outweigh the risks.
• Aid in the diagnosis of valvular heart
• Dipyridamole testing is not performed
disease and determine the optimal time
in patients with anginal pain at rest or
for valve replacement surgery
in patients with severe atherosclerotic
• Quantitate cardiac output by calculat- coronary vessels.
ing global or regional ejection fraction
• Chemical stress with vasodilators
• Evaluate ventricular size, function, and should not be done to patients having
wall motion after an acute episode or asthma; bronchospasm can occur.
in chronic heart disease
• Determine drug cardiotoxicity to stop Factors that may impair clear
therapy before development of conges- imaging:
tive heart failure • Inability of the patient to cooperate or
• Determine cardiomyopathy
• Differentiate between chronic obstruc- mental status
tive pulmonary disease and left ventric-
ular failure • Metallic objects within the examina-
tion field (e.g., jewelry, earrings, and/or
• Detect left-to-right shunts and deter- dental amalgams), which may inhibit
mine pulmonary-to-systemic blood organ visualization and can produce
flow ratios, especially in children unclear images
RESULT • Improper adjustment of the radi-

ographic equipment to accommodate
Normal Findings: obese or thin patients, which can cause
overexposure or underexposure and
• Normal wall motion, ejection fraction
poor-quality study
(55 to 65 percent), coronary blood
flow, ventricular size and function, and • Patients who are very obese, who may
symmetry in contractions of the left exceed the weight limit for the equip-
ventricle ment
Blood Pool Imaging 233
• Incorrect positioning of the patient, takes approximately 30 to 60

which may produce poor visualization minutes for the examination.
of the area to be examined ➤ Reassure the patient that radioactive
material poses no radioactive hazard
• Conditions such as chest wall trauma, and rarely produces side effects.
cardiac trauma, angina that is difficult
to control, significant cardiac arrhyth- ➤ Inform the patient when the proce-
mias, or a recent cardioversion procedure will be done.
dure may affect test results. ➤ The results of the procedure are
interpreted by a physician. The
Other considerations: patient’s physician will discuss the
• Atrial fibrillation and extrasystoles
invalidate the procedure. ➤ Obtain pertinent history of cardiac
tests, other diagnostic procedure
• Suboptimal cardiac stress or patient results, laboratory test results,
exhaustion, preventing maximum medication usage, present cardiac
heart rate testing, will affect results conditions or abnormalities, and
when the procedure is done in therapy received for cardiac condi-
conjunction with exercise testing. tion. For related tests, refer to the
cardiovascular system table.
• Consultation with a physician should ➤ Obtain a history of hypersensitivity
occur before the procedure for radia- to radioactive materials injected.
➤ Complete the informed consent
document, when required.
• Risks associated with radiographic ➤ Tell the patient to wear walking
overexposure can result from frequent shoes for the treadmill or bicycle
x-ray procedures. Personnel in the exercise. Emphasize to the patient
room with the patient should wear a the importance of reporting fatigue,
protective lead apron, stand behind a pain, or shortness of breath.
shield, or leave the area while the ➤ Ask the patient to lie very still during
examination is being done. Badges that the procedure, as movement will
reveal the level of exposure to radiation produce unclear images.
should be worn by persons working in ➤ Restrict food for 4 hours, and
the area where the examination is being medications for 24 hours before the
done. test as ordered by the physician.
Intratest:
Nursing Implications and ➤ Ensure that the patient has complied
Procedure ● ● ● ● ● ● ● ● ● ● ●
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.
➤ The radionuclide is administered ➤ Observe the patient for up to 60

intravenously and after 1 minute minutes after the procedure for
scanning is done to obtain views of possible reaction to the radionuclide
the heart in the anterior, oblique, and or complications from the proce-
lateral views. Between 12 and 64 dure.
images are obtained reflecting the
➤ Advise the patient to drink fluids to
motion of heart over the entire
eliminate the radionuclide from the
cardiac cycle.
body, unless otherwise contraindi-
➤ When done under exercise condi- cated.
tions, the patient is assisted onto
➤ Instruct the patient to wash hands
the treadmill or bicycle ergometer
with soap and water after each void-
and is exercised to a calculated 80 to
ing for 24 hours.
85 percent of the maximum heart
rate as determined by the protocol ➤ Instruct the patient to resume
selected. Images are done at each normal activity and diet, unless
exercise level and begun immedi- otherwise indicated.
ately after injection of the radionu- ➤ A written report of the examination
clide. will be completed by a physician
➤ If nitroglycerin is given, a cardiologist who specializes in this branch of
assessing the baseline MUGA scan medicine. The report is sent to the
injects the medication and records ordering health care provider who
another scan, and then repeats this will discuss the results with the
procedure until blood pressure patient.
reaches the desired level. ➤ Inform the patient that abnormalities
➤ Patients who cannot exercise are of the heart scan can indicate the
given dipyridamole before the need for further studies, including
radionuclide is injected. cardiac catheterization and echocar-
diography.
➤ Patient movement during the proce-
dure will affect the results and make ➤ If possible, pregnant health care
interpretation difficult. workers should avoid caring for a
patient who has had a nuclear medi-
cine procedure for the first 24 hours.
Post-test:
➤ Monitor ECG tracings and compare the patient’s symptoms and other
with baseline readings until stable. tests performed. Related diagnostic
➤ Observe the injection site for tests include echocardiography and
redness, swelling, or hematoma. myocardial perfusion scan.
BONE MINERAL DENSITOMETRY

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

QCT, RA.
Bone Mineral Densitometry 235
Dual-energy x-ray DEXA machines is approximately

absorptiometry (DEXA, DXA): one-tenth that of a standard chest
Two x-rays of different energy x-ray.
levels measure bone mineral
The BMD values measured by the
density and predict risk of
fracture. various techniques cannot be directly
Single-energy x-ray compared. Therefore, they are stated
absorptiometry (SXA): A in terms of standard deviation (SD)
single-energy x-ray measures units. The patient’s T-score is the
bone density at peripheral sites. number of SD units above or below
Quantitative computerized the average BMD in young adults. A
tomography (QCT): QCT is Z-score is the number of SD units
used to examine the lumbar above or below the average value for a
vertebrae. It measures trabecular
person of the same age as the meas-
and cortical bone density.
Results are compared to a ured patient. For most BMD read-
known standard. This test is the ings, one SD is equivalent to 10 to 12
most expensive and involves the percent of the average young-normal
highest radiation dose of all BMD value. A T-score of 2.5 is
techniques. therefore equivalent to a bone mineral
Radiographic absorptiometry loss of 30 percent when compared to
(RA): A standard x-ray of the a young adult. ■
hand. Results are compared to a
known standard.
INDICATIONS:
Ultrasound densitometry: Osteoporosis is a condition characterized
Studies bone mineral content in by low BMD, which results in increased
peripheral densitometry sites
risk of fracture. The National Osteoporo-
such as the heel or wrist. It is
sis Foundation (NOF) estimates that 4 to
not as precise as x-ray
techniques, but less expensive 6 million postmenopausal women in the
than other techniques. United States have osteoporosis, and an
additional 13 to 17 million (30 to 50
percent) have low bone density at the hip.
AREA OF APPLICATION: It is estimated that one of every two
Lumbar spine, heel, hip, wrist, women will experience a fracture as a
whole body. result of low bone mineral content in her
lifetime. The measurement of BMD gives
CONTRAST: None. the best indication of risk for a fracture.
The lower the BMD, the greater the risk
of fracture. The most common fractures
DESCRIPTION: Bone mineral density are those of the hip, vertebrae, and distal
(BMD) can be measured at any of forearm. Bone mineral loss is a disease of
several body sites including spine, the entire skeleton and not restricted to
hip, wrist, and heel. Machines to the areas listed. The effect of the fractures
measure BMD include computerized has a wide range of results, from complete
tomography (CT), radiographic ab- recovery to chronic pain, disability, and
possible death.
sorptiometry, ultrasound, single-
energy x-ray absorptiometry (SXA), • Determine the mineral content of
and most commonly, dual-energy bone
x-ray absorptiometry (DEXA). The • Establish a diagnosis of osteoporosis
radiation exposure from SXA and • Predict future fracture risk
• 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
• Evaluate bone demineralization associ- poor-quality study
ated with immobilization
RESULT: exceed the weight limit for the equip-
• T-score estimates the actual fracture ment
risk compared to young adults.
• 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-
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.
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
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.

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

because of age, significant pain, or As a result of altered BMD,
mental status not the BMD testing process:
• Metallic objects within the examina- ➤ Vertebral fractures may cause
Bone Mineral Densitometry 237
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.
➤ Possible increased dependency on normally and to avoid unnecessary
family for basic care may occur. movement.
Pretest:
Post-test:
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.
BONE SCAN
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SYNONYMS/ACRONYM: Bone imaging, radionuclide bone scan, bone

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

CONTRAST: Intravenous radioactive material (diphosphonate compounds),
usually combined with technetium-99m.
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
Bone Scan 239
• 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
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
• 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.
imaging: room with the patient should wear 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
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.
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.
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
Bronchoscopy 241
days. She should be instructed to ➤ Tell all caregivers to wear gloves

express the milk and discard it when discarding urine for 48 hours
during the 3-day period to prevent after the procedure. Wash gloved
cessation of milk production. hands with soap and water before
➤ No other radionuclide tests should removing gloves. Then wash un-
be scheduled for 24 to 48 hours after gloved hands after the gloves are re-
this procedure. moved.
➤ Inform the patient to immediately ➤ Evaluate test results in relation to
flush the toilet after each voiding the patient’s symptoms and other
after the procedure and to meticu- tests performed. Related diagnostic
lously wash hands with soap and tests include x-rays, CT, and MRI of
water after each voiding for 48 hours the area in question.
BRONCHOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Flexible bronchoscopy.

AREA OF APPLICATION: Bronchial tree, larynx, trachea.
CONTRAST: None.
DESCRIPTION: This procedure pro- including the lobar, segmental, and

vides direct visualization of the subsegmental bronchi, while main-
larynx, trachea, and bronchial tree by taining effective gas exchange. Rigid
means of either a rigid or a flexible bronchoscopy is preferred when large
bronchoscope. A fiberoptic broncho- volumes of blood or secretions need
scope with a light incorporated is to be aspirated, when foreign bodies
guided into the tracheobronchial tree. are to be removed, when large-sized
A local anesthetic may be used to biopsy specimens are to be obtained,
allow the scope to be inserted through and for most bronchoscopies in chil-
the mouth or nose into the trachea dren.
and into the bronchi. The patient The flexible fiberoptic broncho-
must breathe during insertion and scope has a smaller lumen that is
with the scope in place. The purpose designed to allow for visualization of
of the procedure is both diagnostic all segments of the bronchial tree. The
and therapeutic. accessory lumen of the bronchoscope
The rigid bronchoscope allows is used for tissue biopsy, bronchial
visualization of the larger airways, washings, instillation of anesthetic
agents and medications, and to obtain or possible adverse sequelae to tube

specimens with brushes for cytologic placement
examination. In general, fiberoptic
bronchoscopy is less traumatic to the RESULT
surrounding tissues than the larger
rigid bronchoscopes. Fiberoptic bron- Normal Findings:
choscopy is performed under local • Normal larynx, trachea, bronchi, bron-
anesthesia; patient tolerance is better chioles, and alveoli
for fiberoptic bronchoscopy than for Abnormal Findings:
rigid bronchoscopy. ■ • Abscess
• Bronchial diverticulum
INDICATIONS:
• Determine etiology of persistent • Bronchial stenosis
cough, hemoptysis, hoarseness, unex-
plained chest x-ray abnormalities, • Bronchogenic cancer
and/or abnormal cytologic findings in • Coccidioidomycosis, histoplasmosis,
sputum blastomycosis, phycomycosis
• Evaluate respiratory distress and • Foreign bodies
tachypnea in an infant to rule out
tracheoesophageal fistula or other • Inflammation
congenital anomaly • Interstitial pulmonary disease
• Detect end-stage bronchogenic cancer • Opportunistic lung infections (e.g.,
• Treat lung cancer through instillation pneumocystitis, nocardia, cytomegalo-
of chemotherapeutic agents, implanta- virus)
tion of radioisotopes, or laser palliative • Strictures
therapy
• Tuberculosis
• Identify hemorrhagic and inflamma-
tory changes in Kaposi’s sarcoma • Tumors
• Detect lung infections and inflamma- INTERFERING FACTORS

tion
• Remove foreign body This procedure is contraindicated
for:
• Determine extent of smoke-inhalation • Patients with bleeding disorders, espe-
or other traumatic injury cially those associated with uremia and
• Evaluate airway patency; aspirate deep cytotoxic chemotherapy
or retained secretions • Patients with pulmonary hypertension
• Identify bleeding sites and remove clots • Patients with cardiac conditions or
within the tracheobronchial tree dysrhythmias
• Evaluate possible airway obstruction in • Patients with disorders that limit
patients with known or suspected sleep extension of the neck
apnea
• Patients with severe obstructive
• Intubate patients with cervical spine tracheal conditions
injuries or massive upper airway edema
• Patients with or having the potential
• Evaluate endotracheal tube placement for respiratory failure; introduction of
Bronchoscopy 243
the bronchoscope alone may cause a 10 ➤ Obtain a history of patient’s com-

to 20 mm Hg drop in PaO2 plaints, including allergies or sensi-
tivities to anesthetics, analgesics,
Factors that may impair a medication usage, and antibiotics
complete examination: and known or suspected pulmonary
disorders.
remain still during the procedure ➤ Obtain a history of the patient’s res-
piratory system, as well as results of
previously performed tests, thera-
mental status pies, procedures, and surgeries. For
• Metallic objects within the examina- related tests, refer to the respiratory
tion field (e.g., jewelry, earrings, and/or system table.
dental amalgams), which may inhibit ➤ Obtain a written and informed con-
organ visualization and can produce sent for the procedure before ad-
unclear images ministering medication.
➤ Determine previous abnormalities in
laboratory test results, particularly
ographic equipment to accommodate hematologic or coagulation tests.
poor-quality study Intratest:
exceed the weight limit for the equip- pretesting restrictions.
ment
➤ Keep resuscitation equipment on
• Incorrect positioning of the patient, hand in the case of respiratory
which may produce poor visualization impairment or laryngospasm after
of the area to be examined the procedure.
➤ Avoid using morphine sulfate in
Other considerations: those with asthma or other
• Hypoxemic or hypercapnic states pulmonary disease. This drug can
require continuous oxygen administra- further exacerbate bronchospasms
and respiratory impairment.
tion.
➤ Have patient remove dentures,
• Failure to follow dietary restrictions contact lenses, eyeglasses, and
before the procedure may cause the jewelry. Notify the physician if the
procedure to be canceled or repeated. patient has permanent crowns on
teeth. Have the patient remove
clothing and change into a gown for
the procedure.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Provide mouth care to reduce oral
bacterial flora.
Pretest: Rigid bronchoscopy:
➤ Inform the patient that the proce- ➤ The patient is placed in the supine
dure is performed in an endoscopy position and a general anesthetic is
suite by a physician. The procedure administered. The patient’s neck is
is performed under local anesthesia hyperextended, and the lightly lubri-
and takes approximately 30 to 45 cated bronchoscope is inserted
minutes. orally and passed through the glottis.
➤ Instruct the patient to refrain from The patient’s head is turned or repo-
food and fluids for 6 to 8 hours sitioned to aid visualization of vari-
before the test. ous segments.
➤ After inspection, the bronchial brush, ➤ After inspection, specimens may be

suction catheter, biopsy forceps, obtained for cytologic and microbio-
laser, and electrocautery devices are logic study. All specimens are placed
introduced to obtain specimens for in appropriate containers, properly
cytologic or microbiologic study or labeled, and promptly sent to the
for therapeutic procedures. laboratory.
➤ If a bronchial washing is performed, ➤ After the procedure, the broncho-
small amounts of solution are in- scope is removed. Patients who
stilled into the airways and removed. had local anesthesia are placed
These specimens are placed in la- in a semi-Fowler’s position to
beled containers and promptly sent recover.
to the laboratory.
➤ After the procedure, the broncho-
Post-test:
scope is removed and the patient is
placed in a side-lying position with ➤ The patient should remain in a semi-
the head slightly elevated. Fowler’s position on either side until
vital signs revert to preprocedure
Fiberoptic bronchoscopy: levels.
➤ The patient is placed in a sitting po- ➤ Instruct the patient not to attempt to
sition while the tongue and orophar- swallow saliva until the gag reflex
ynx is sprayed or swabbed with local has returned, but to expectorate
anesthetic. When loss of sensation saliva into an emesis basin.
is adequate, the client is placed in a ➤ Emphasize that any excessive bleed-
supine position. The fiberoptic scope ing, difficulty breathing, changes in
can be introduced through the nose, sputum, excessive coughing after
the mouth, endotracheal tube, a tra- biopsy, or pain must be reported to
cheostomy tube, or a rigid broncho- the physician immediately.
scope. Most common insertion is
through the nose. Clients with copi- ➤ A physician specializing in this
ous secretions or massive hemo- branch of medicine will send a writ-
ptysis, or in whom airway complica- ten report of the examination to the
tions are more likely, may be intu- ordering health care provider who
bated before the bronchoscopy. will discuss the results with the
Additional local anesthetic is applied patient.
through the scope as it approaches ➤ Evaluate procedure results in rela-
the vocal cords and the carina, elimi- tion to the patient’s symptoms and
nating reflexes in these sensitive other tests performed. Related diag-
areas. The fiberoptic approach allows nostic tests include chest x-ray, com-
visualization of airway segments puted tomography and magnetic
without having to move the patient’s resonance imaging of the chest, and
head through various positions. lung scan.
C-PEPTIDE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Connecting peptide insulin, insulin C-peptide,

proinsulin C-peptide.
C-Peptide 245


0.78–1.8 ng/mL 0.26–0.63 nmol/L
DESCRIPTION: C-peptide is a biolog- • Evaluate hypoglycemia.

ically inactive peptide formed when
beta cells of the pancreas convert RESULT
proinsulin to insulin. Most of C-
Increased in:
peptide is secreted by the kidneys. C-
peptide levels usually correlate with • Endogenous hyperinsulinism
insulin levels and provide a reliable • Islet cell tumor
indication of how well the beta cells
secrete insulin. Release of C-peptide is • Non–insulin-dependent (type 2)
not affected by exogenous insulin diabetes
administration. C-peptide values • Oral hypoglycemic medication
double after stimulation with glucose • Pancreas or beta cell transplants
or glucagon. An insulin–C-peptide
ratio less than 1.0 indicates endoge- • Renal failure
nous insulin secretion, whereas a ratio
Decreased in:
of greater than 1.0 indicates an excess
of exogenous insulin. ■ • Factitious hypoglycemia
INDICATIONS: • Insulin-dependent (type 1) diabetes
• Assist in the diagnosis of insulinoma: • Pancreatectomy

Serum levels of insulin and C-peptide
are elevated. CRITICAL VALUES: N/A
• Detect suspected factitious cause of INTERFERING FACTORS:
hypoglycemia (excessive insulin
administration): C-peptide levels do • Drugs that may increase C-peptide
not increase with serum insulin levels. levels include betamethasone, chloro-
quine, danazol, deferoxamine, ethinyl
• Determine beta cell function when estradiol, oral contraceptives, pred-
insulin antibodies preclude accurate nisone, and rifampin.
measurement of serum insulin produc-
tion. • Drugs that may decrease C-peptide
levels include atenolol and calcitonin.
• Distinguish between insulin-
dependent (type 1) and non– • Recent radioactive scans or radiation
insulin-dependent (type 2) diabetes within 1 week before the test can inter-
(with C-peptide–stimulating test): fere with test results when radioim-
Patients with diabetes whose C-peptide munoassay is the test method.
stimulation level is greater than 18 • C-peptide and endogenous insulin
ng/mL can be managed without levels do not always correlate in obese
insulin treatment. patients.

Procedure ● ● ● ● ● ● ● ● ● ● ●
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.
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.
C-Reactive Protein 247
C-REACTIVE PROTEIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CRP.
REFERENCE VALUE: (Method: High-sensitivity immunoassay, nephelometry)
High-sensitivity immunoassay 0.08–3.10 g/mL

(cardiac applications)
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
DESCRIPTION: C-reactive protein studies are in progress to confirm

(CRP) is a glycoprotein produced by the correlation and to establish
the liver in response to acute inflam- standardized reference ranges for this
mation. The CRP assay is a nonspe- purpose. ■
cific test that determines the presence
(not the cause) of inflammation; it is INDICATIONS:
often ordered in conjunction with • Assist in the differential diagnosis of
erythrocyte sedimentation rate (ESR). appendicitis and acute pelvic inflam-
CRP assay is a more sensitive and matory disease
rapid indicator of the presence of an • Assist in the differential diagnosis of
inflammatory process than ESR. CRP Crohn’s disease and ulcerative colitis
disappears from the serum rapidly
• Assist in the differential diagnosis of
when inflammation has subsided.
rheumatoid arthritis and uncompli-
The inflammatory process and its cated systemic lupus erythematosus
association with atherosclerosis make (SLE)
the presence of CRP, as detected by
highly sensitive CRP assays, a poten- • Assist in the evaluation of coronary
artery disease
tial marker for coronary artery
disease. It is believed that the inflam- • Detect the presence or exacerbation of
matory process may instigate the inflammatory processes
conversion of a stable plaque to a • Monitor response to therapy for
weaker one that can rupture and autoimmune disorders such as
occlude an artery. Several major rheumatoid arthritis
RESULT process in connective or other

tissues.
cardiovascular and immune
• Acute bacterial infections systems, as well as results of previ-
• Crohn’s disease dures. For related tests, refer to the
• Inflammatory bowel disease cardiovascular and immune system
tables.
• Myocardial infarction ➤ Obtain a list of the medications the
• Pregnancy (second half ) patient is taking, including herbs,
• Rheumatic fever nutraceuticals. The requesting health
• Rheumatoid arthritis should be advised if the patient
• SLE regularly uses these products so
Decreased in: N/A
results.
CRITICAL VALUES: N/A tion restrictions unless by medical
direction.
• Drugs that may decrease CRP levels patient.
include aurothiomalate, methotrexate, ➤ Inform the patient that specimen
nonsteroidal anti-inflammatory drugs, collection takes approximately 5 to
oral contraceptives (progestogen 10 minutes.
effect), penicillamine, pentopril, and
sulfasalazine. Intratest:
• Nonsteroidal anti-inflammatory drugs, ➤ Direct the patient to breathe
salicylates, and steroids may cause normally and to avoid unnecessary
false-negative results because of movement.
suppression of inflammation. ➤ Observe standard precautions and
• Falsely elevated levels may occur with Appendix A. Perform a venipuncture,
the presence of an intrauterine device. and collect the specimen in a 5-mL
• Lipemic samples that are turbid in
appearance may be rejected for analysis ➤ Label the specimen, and promptly
when nephelometry is the test method.
Post-test:
Nursing Implications and ➤ Observe venipuncture site for bleed-
Procedure ● ● ● ● ● ● ● ● ● ● ●
pressure bandage.
Pretest: ➤ Evaluate test results in relation to
➤ Obtain a history of the patient’s tests performed. Related laboratory
complaints, including a list of known tests include creatine kinase and
allergens. The patient may complain isoenzymes, ESR, homocysteine,
of pain related to the inflammatory troponin, and white blood cell count.
CA 125 249
CA 125
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carbohydrate antigen 125, cancer antigen 125.


Less than 35 U/mL Less than 35 kU/L
DESCRIPTION: CA 125, a glycopro- • First-trimester pregnancy

tein present in normal endometrial • Menses
tissue, appears in the blood when
• Ovarian abscess
natural endometrial protective barri-
ers are destroyed, as occurs in cancer • Pelvic inflammatory disease
or endometriosis. Persistently rising • Peritonitis
levels indicate a poor prognosis, but
Decreased in:
absence of the tumor marker does not
rule out tumor presence. Levels may • Effective therapy or removal of the
also rise in pancreatic, liver, colon, tumor
breast, and lung cancers. It is not
useful as a screening test. ■ CRITICAL VALUES: N/A
INDICATIONS: INTERFERING FACTORS: N/A

• Assist in the diagnosis of carcinoma of
the cervix and endometrium Nursing Implications and
• Assist in the diagnosis of ovarian cancer Procedure ● ● ● ● ● ● ● ● ● ● ●
• Monitor response to treatment of ovar- Pretest:

ian cancer
RESULT allergens.
• Breast, colon, endometrial, liver, lung, as well as results of previously
ovarian, and pancreatic cancer performed tests and procedures. For
• Endometriosis and reproductive system tables.
➤ Obtain a list of the medications Appendix A. Perform a venipuncture,

the patient is taking, including and collect the specimen in a 5-mL
herbs, nutritional supplements, and red-top tube.
nutraceuticals. The requesting health ➤ Label the specimen, and promptly
care practitioner and laboratory transport it to the laboratory.
regularly uses these products so Post-test:
that their effects can be taken
into consideration when reviewing ➤ Observe venipuncture site for bleed-
results. ing or hematoma formation. Apply
tion restrictions unless by medical ➤ Recognize anxiety related to test
direction. results and offer support. Provide
➤ Review the procedure with the teaching and information regarding
patient. the clinical implications of the test
results, as appropriate. Educate the
➤ Inform the patient that specimen patient regarding access to counsel-
collection takes approximately 5 to ing services.
10 minutes.
➤ Inform the patient that serial speci-
Intratest: mens may be requested at regular
intervals.
➤ Direct the patient to breathe ➤ Evaluate test results in relation to
normally and to avoid unnecessary the patient’s symptoms and other
movement. tests performed. Related laboratory
➤ Observe standard precautions and tests include breast biopsy, CA 19-9,
follow the general guidelines in and CA 15-3.
CA 15-3
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carbohydrate antigen 15-3, cancer antigen 15-3.

REFERENCE VALUE: (Method: Immunoradiometric)

DESCRIPTION: CA 15-3 monitors than 38 U/mL), a more recently appro-

patients for recurrence of breast carci- ved protein marker, is replacing CA
noma. CA 27.29 (reference range less 15-3 in some reference laboratories. ■
CA 15-3 251
INDICATIONS: Monitor recurrent carci- ➤ Note any recent procedures that can
noma of the breast interfere with test results.
RESULT tion restrictions unless by medical
direction.
Increased in: Recurrent carcinoma ➤ Review the procedure with the
of the breast patient.
Decreased in: Effective therapy or collection takes approximately 5 to
removal of the tumor 10 minutes.
CRITICAL VALUES: N/A Intratest:

INTERFERING FACTORS: Recent radioac- normally and to avoid unnecessary
tive scans or radiation within 1 week movement.
before the test can interfere with test ➤ Observe standard precautions and
results when radioimmunoassay is the follow the general guidelines in
test method. Appendix A. Perform a venipuncture,
red-top tube.
Nursing Implications and ➤ Label the specimen, and promptly
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: Post-test:
➤ 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.
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.
CA 19-9
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carbohydrate antigen 19-9, cancer antigen 19-9.

REFERENCE VALUE: (Method: Immunoradiometric)

DESCRIPTION: CA 19-9 is used to CRITICAL VALUES: N/A

monitor patients with various types of
cancer. ■ INTERFERING FACTORS:
INDICATIONS: within 1 week before the test can inter-
• Monitor effectiveness of therapy fere with test results when radioim-
• Monitor gastrointestinal, head and
neck, and gynecologic carcinomas
• Predict recurrence of cholangiocarci- Nursing Implications and
noma Procedure ● ● ● ● ● ● ● ● ● ● ●
• Predict recurrence of stomach, pancre-

atic, colorectal, gallbladder, liver, and Pretest:
urothelial carcinomas ➤ Obtain a history of the patient’s
RESULT allergens.
Increased in: gastrointestinal and immune
• Gastrointestinal, head and neck, and ously performed tests and proce-
gynecologic carcinomas dures. For related tests, refer to the
• Recurrence of stomach, pancreatic, gastrointestinal and immune system
colorectal, gallbladder, liver, and tables.
urothelial carcinomas ➤ Obtain a list of the medications
• Recurrence of cholangiocarcinoma herbs, nutritional supplements, and
Decreased in: care practitioner and laboratory
• Effective therapy or removal of the regularly uses these products so
tumor that their effects can be taken
Calcitonin and Calcitonin Stimulation Tests 253
into consideration when reviewing ➤ Label the specimen, and promptly

results. transport it to the laboratory.
interfere with test results. Post-test:
➤ There are no food, fluid, or medica- ➤ Observe venipuncture site for bleed-
tion restrictions unless by medical ing or hematoma formation. Apply
direction. pressure bandage.
➤ Review the procedure with the ➤ Recognize anxiety related to test
patient. results and offer support. Provide
➤ Inform the patient that specimen teaching and information regarding
collection takes approximately 5 to the clinical implications of the test
10 minutes. results, as appropriate. Educate the
ing services.
Intratest:
➤ Inform the patient that serial speci-
➤ Direct the patient to breathe mens may be requested at regular
normally and to avoid unnecessary intervals.
movement. ➤ Evaluate test results in relation to
follow the general guidelines in tests performed. Related laboratory
Appendix A. Perform a venipuncture, tests include biopsy of suspect
and collect the specimen in a 5-mL tissue, CA 15-3, CA 125, and carci-
red-top tube. noembryonic antigen.
CALCITONIN AND CALCITONIN

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

Medication Recommended
Procedure Administered Collection Times
Calcium and Calcium, 2 mg/kg IV 4 calcitonin levels—baseline 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
SI Units
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
Maximum Response
After Pentagastrin
Stimulation
DESCRIPTION: Calcitonin, also • Evaluate altered serum calcium levels

called thyrocalcitonin, is secreted by • Monitor response to therapy for
the parafollicular or C cells of the medullary thyroid carcinoma
thyroid gland in response to elevated • Predict recurrence of medullary
serum calcium levels. Calcitonin thyroid carcinoma
antagonizes the effects of parathyroid • Screen family members of patients
hormone and vitamin D so that with medullary thyroid carcinoma (20
calcium continues to be laid down in percent have a familial pattern)
bone rather than reabsorbed into the
blood. Calcitonin also increases RESULT
renal clearance of magnesium and
inhibits tubular reabsorption of phos- Increased in:
phates. The net result is that calci- • Alcoholic cirrhosis
tonin decreases the serum calcium
• C-cell hyperplasia
level. The pentagastrin (Peptavlon)
provocation test and the calcium • Cancer of the breast, lung, and
pentagastrin provocation test are pancreas
useful for diagnosing medullary • Carcinoid syndrome
thyroid cancer. ■ • Chronic renal failure
• Ectopic secretion (especially neuroen-
INDICATIONS: docrine origins)
• Assist in the diagnosis of hyperparathy- • Hypercalcemia (any cause)
roidism • Medullary thyroid cancer
• Assist in the diagnosis of medullary • Pancreatitis
thyroid cancer • Pernicious anemia
Calcitonin and Calcitonin Stimulation Tests 255
• Pregnancy (late) ➤ Note any recent procedures that can

• Pseudohypoparathyroidism
➤ There are no fluid or medication
• Thyroiditis restrictions unless by medical direc-
tion.
• Zollinger-Ellison syndrome
➤ The patient should fast 10 to 12
hours before specimen collection.
Decreased in: N/A
patient.
INTERFERING FACTORS: 10 minutes; a few extra minutes is
• Drugs that may increase calcitonin required to administer the stimula-
levels include calcium, epinephrine, tion tests.
estrogens, glucagon, pentagastrin,
sincalide, and oral contraceptives. Intratest:
• Recent radioactive scans or radiation ➤ Ensure that the patient has complied
within 1 week before the test can inter- with dietary preparations and other
fere with test results when radioim- pretesting restrictions.
munoassay is the test method. ➤ Direct the patient to breathe
movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
and collect the specimen in a chilled
Pretest: 5-mL red- or tiger-top tube.
complaints, including a list of known transport it to the laboratory.
allergens.
endocrine, genitourinary, and
musculoskeletal systems, as well as ➤ Observe venipuncture site for bleed-
results of previously performed ing or hematoma formation. Apply
tests and procedures. For related pressure bandage.
tests, refer to the endocrine, geni- ➤ Instruct the patient to resume usual
tourinary, and musculoskeletal diet as directed by the health care
system tables. practitioner.
➤ Obtain a list of medications the ➤ Evaluate test results in relation to
patient is taking, including herbs, the patient’s symptoms and other
nutritional supplements, and nutra- tests performed. Related laboratory
ceuticals. The requesting health care tests include adrenocorticotropin,
practitioner and laboratory should be calcium, catecholamines, carci-
advised if the patient regularly uses noembrionic antigen (CEA), com-
these products so that their effects plete blood count, magnesium,
can be taken into consideration metanephrines, urine phosphorus,
when reviewing results. thyroid biopsy, and vitamin D.
CALCIUM, IONIZED
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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.
REFERENCE VALUE: (Method: Ion-selective electrode)
SI Units
Whole blood
Cord blood 5.20–5.84 mg/dL 1.30–1.46 mmol/L
Adult 4.60–5.08 mg/dL 1.12–1.32 mmol/L
Plasma
Adult 4.12–4.92 mg/dL 1.03–1.23 mmol/L
Serum
Cord blood 5.20–6.40 mg/dL 1.30–1.60 mmol/L
Adult 4.64–5.28 mg/dL 1.16–1.32 mmol/L
DESCRIPTION: Calcium is the most by vitamin D. Compared to total

abundant cation in the body and calcium level, ionized calcium is a
participates in almost all vital body better measurement of calcium
processes. (See other calcium mono- metabolism. Ionized calcium levels
graphs.) Circulating calcium is found are not influenced by protein concen-
in the free or ionized form; bound to trations, as seen in patients with
organic anions such as lactate, phos- chronic renal failure, nephrotic
phate, or citrate; and bound to syndrome, malabsorption, and multi-
proteins such as albumin. Ionized ple myeloma. Levels are also not
calcium is the physiologically active affected in patients with metabolic
form of circulating calcium. About acid-base balance disturbances.
half of the total amount of calcium Elevations in ionized calcium may be
circulates as free ions that participate seen when the total calcium is
in blood coagulation, neuromuscular normal. Measurement of ionized
conduction, intracellular regulation, calcium is useful to monitor patients
glandular secretion, and control of undergoing cardiothoracic surgery or
skeletal and cardiac muscle contractil- organ transplantation. It is also useful
ity. Calcium levels are regulated in the evaluation of patients in cardiac
largely by the parathyroid glands and arrest. ■
Calcium, Ionized 257
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.
• Patients on ethylenediaminetetra- ➤ Inform the patient that specimen

acetic acid (EDTA) therapy (chelation) collection takes approximately 5 to
may show falsely decreased calcium 10 minutes.
values.
Intratest:
• Specimens should never be collected
above an intravenous (IV) line because ➤ Direct the patient to breathe
of the potential for dilution when the movement.
specimen and the IV solution combine
in the collection container, falsely ➤ Observe standard precautions and
decreasing the result. There is also the Appendix A. Perform a venipuncture,
potential of contaminating the sample and without using a tourniquet, col-
with the substance of interest, lect the specimen in a heparinized
contained in the IV solution, falsely syringe. The specimen must be
increasing the result. maintained in an anaerobic environ-
ment; the cork should not be
removed from the tube at any point
in the collection process.
Procedure ● ● ● ● ● ● ● ● ● ● ●
transport it to the laboratory. The
tightly capped sample should be
Pretest: placed in an ice slurry immediately
➤ Obtain a history of the patient’s after collection. Information on the
complaints, including a list of known specimen label can be protected
allergens. from water in the ice slurry if the
specimen is first placed in a protec-
tive plastic bag.
cardiovascular, endocrine, and geni-
tourinary systems, as well as results
of previously performed tests and Post-test:
procedures. For related tests, refer ➤ Observe venipuncture site for bleed-
to the cardiovascular, genitourinary, ing or hematoma formation. Apply
and endocrine system tables. pressure bandage.
➤ Obtain a list of the medications ➤ Patients with abnormal calcium
the patient is taking, including values should be informed that daily
herbs, nutritional supplements, and intake of calcium is important even
nutraceuticals. The requesting health though body stores in the bones can
care practitioner and laboratory be called on to supplement circulat-
should be advised if the patient ing levels. Dietary calcium can be
regularly uses these products so obtained from animal or plant
that their effects can be taken sources. Milk and milk products,
into consideration when reviewing sardines, clams, oysters, salmon,
results. rhubarb, spinach, beet greens, broc-
➤ Note any recent procedures that coli, kale, tofu, legumes, and forti-
could interfere with test results. fied orange juice are high in calcium.
➤ There are no food, fluid, or medica- Milk and milk products also contain
tion restrictions unless by medical vitamin D and lactose, which assist
direction. calcium absorption. Cooked vegeta-
bles yield more absorbable calcium
➤ Review the procedure with the than raw vegetables. Patients
patient. The patient should be should be informed of the sub-
instructed to lie quietly for 30 stances that can inhibit calcium
minutes before specimen collection. absorption by irreversibly binding to
➤ Prepare an ice slurry for specimen some of the calcium, making it
transport. unavailable for absorption, such as
Calcium, Serum 259
oxalates, which naturally occur in ➤ Evaluate test results in relation to

some vegetables; phytic acid, found the patient’s symptoms and other
in some cereals; and insoluble tests performed. Related laboratory
dietary fiber (in excessive amounts). tests include albumin, calcium,
Excessive protein intake can also kidney stone analysis, parathyroid
negatively affect calcium absorption, hormone, and vitamin D.
especially if it is combined with
foods high in phosphorus.
CALCIUM, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: total calcium, Ca.

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
DESCRIPTION: Calcium, the most calcium circulates as free ions that

abundant cation in the body, partici- participate in coagulation, neuromus-
pates in almost all of the vital cular conduction, intracellular regula-
processes. Calcium concentration is tion, glandular secretion, and control
largely regulated by the parathyroid of skeletal and cardiac muscle
glands and by the action of vitamin contractility. The remaining calcium
D. Of the body’s calcium reserves, 98 is bound to circulating proteins (40
to 99 percent is stored in the teeth percent bound mostly to albumin)
and skeleton. Calcium values are and anions (15 percent bound to
higher in children because of growth anions such as bicarbonate, citrate,
and active bone formation. About 45 phosphate, and lactate) and plays no
percent of the total amount of blood physiologic role. Calcium values can
be adjusted up or down by 0.8 mg/dL • Evaluate cardiac arrhythmias and coag-

for every 1 g/dL that albumin is ulation disorders to determine if
greater than or less than 4 g/dL. altered serum calcium level is
Calcium and phosphorus levels are contributing to the problem
inversely proportional. • Evaluate the effects of various disorders
Fluid and electrolyte imbalances on calcium metabolism, especially
are often seen in patients with serious diseases involving bone
illness or injury; in these clinical situ- • Monitor the effects of renal failure and
ations, the normal homeostatic various drugs on calcium levels
balance of the body is altered. During
• Monitor the effectiveness of therapy
surgery or in the case of a critical
being administered to correct abnor-
illness, bicarbonate, phosphate, and mal calcium levels, especially calcium
lactate concentrations can change deficiencies
dramatically. Therapeutic treatments
may also cause or contribute to elec- RESULT
trolyte imbalance. This is why total
calcium values can sometimes be Increased in:
misleading. Abnormal calcium levels • Acidosis
are used to indicate general malfunc-
tions in various body systems. Ionized • Acromegaly
calcium is used in more specific • Cancers (bone, Burkitt’s lymphoma,
conditions. (See monograph titled Hodgkin’s lymphoma, leukemia,
“Calcium, Ionized.”) myeloma, and metastases from other
Calcium values should be inter- organs)
preted in conjunction with results of • Dehydration
other tests. Normal calcium with an • Excessive intake (milk, antacids)
abnormal phosphorus value indicates
• Hyperparathyroidism
impaired calcium absorption (possi-
bly because of altered parathyroid • Idiopathic hypercalcemia of infancy
hormone level or activity). Normal • Malignant disease without bone
calcium with an elevated urea involvement (squamous cell carcinoma
nitrogen value indicates possible of the lung, kidney cancer)
hyperparathyroidism (primary or • Milk alkali syndrome (Burnett’s
secondary). Normal calcium with syndrome)
decreased albumin value is an indica- • Paget’s disease
tion of hypercalcemia. The most
• Pheochromocytoma
common cause of hypocalcemia (low
calcium levels) is hypoalbuminemia. • Polycythemia vera
The most common causes of hyper- • Renal transplant
calcemia (high calcium levels) are • Sarcoidosis
hyperparathyroidism and cancer. ■
• Thyrotoxicosis
INDICATIONS: • Vitamin D toxicity
• Detect parathyroid gland loss after Decreased in:
thyroid or other neck surgery, as indi-
cated by decreased levels • Acute pancreatitis
Calcium, Serum 261
• Alcoholism (shortened ST segment), lethargy, muscle

weakness, apathy, anorexia, headache,
• Alkalosis
and nausea and ultimately may result in
• Chronic renal failure coma. Possible interventions include the
administration of normal saline and
• Cystinosis
diuretics to speed up excretion or admin-
• Hepatic cirrhosis istration of calcitonin or steroids to force
the circulating calcium into the cells.
• Hyperphosphatemia
• Hypoalbuminemia INTERFERING FACTORS:
• Hypoparathyroidism (congenital, idio- • Drugs that may increase calcium levels
pathic, surgical) include anabolic steroids, some
• Inadequate nutrition antacids, calcitriol, calcium salts, dana-
zol, diuretics (long-term), ergocalcif-
• Leprosy erol, isotretinoin, lithium, oral
• Long-term anticonvulsant therapy contraceptives, parathyroid extract,
parathyroid hormone, prednisone,
• Magnesium deficiency progesterone, tamoxifen, vitamin A,
• Malabsorption (celiac disease, tropical and vitamin D.
sprue, pancreatic insufficiency) • Drugs that may decrease calcium levels
• Massive blood transfusion include albuterol, alprostadil, amino-
glycosides, anticonvulsants, calcitonin,
• Neonatal prematurity diuretics (initially), glucagon, gluco-
• Osteomalacia (advanced) corticoids, glucose, laxatives (excessive
use), magnesium salts, methicillin,
• Renal tubular disease phosphates, plicamycin, sodium sulfate
• Vitamin D deficiency (rickets) (given intravenously), tetracycline (in
pregnancy), trazodone, and viomycin.
CRITICAL VALUES: • Calcium exhibits diurnal variation;
Less than 7 mg/dL serial samples should be collected at
Greater than 12 mg/dL (some the same time of day for comparison.
patients can tolerate higher • Venous hemostasis caused by
concentrations) prolonged use of a tourniquet during
Observe the patient for symptoms of venipuncture can falsely elevate
critically decreased or elevated calcium calcium levels.
levels. Hypocalcemia is evidenced by
convulsions, arrhythmias, changes in • Patients on ethylenediaminetetra-
electrocardiogram (ECG) in the form of acetic acid (EDTA) therapy (chelation)
prolonged ST segment and Q-T interval, may show falsely decreased calcium
facial spasms (positive Chvostek’s sign), values.
tetany, muscle cramps, numbness in • Hemolysis and icterus cause false-
extremities, tingling, and muscle twitch- positive results because of interference
ing (positive Trousseau’s sign). Possible from biologic pigments.
interventions include seizure precautions,
increased frequency of ECG monitoring, • Specimens should never be collected
and administration of calcium or magne- above an intravenous (IV) line because
sium. of the potential for dilution when the
Severe hypercalcemia is manifested by specimen and the IV solution combine
polyuria, constipation, changes in ECG in the collection container, falsely
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
increasing the result.
Nursing Implications and Post-test:
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: ing or hematoma formation. Apply
pressure bandage.
➤ Obtain a history of the patient’s ➤ Patients with abnormal calcium
complaints, including a list of known values should be informed that daily
allergens. intake of calcium is important even
➤ Obtain a history of the patient’s though body stores in the bones can
cardiovascular, gastrointestinal, geni- be called on to supplement circulat-
tourinary, hematopoietic, hepatobil- ing levels. Dietary calcium can be
iary, and musculoskeletal systems, obtained from animal or plant
as well as results of previously sources. Milk and milk products,
performed tests and procedures. For sardines, clams, oysters, salmon,
related tests, refer to the cardiovas- rhubarb, spinach, beet greens, broc-
cular, gastrointestinal, genitourinary, coli, kale, tofu, legumes, and forti-
hematopoietic, hepatobiliary, and fied orange juice are high in calcium.
musculoskeletal system tables. Milk and milk products also contain
➤ Obtain a list of medications the vitamin D and lactose, which assist
patient is taking, including herbs, calcium absorption. Cooked vegeta-
nutritional supplements, and bles yield more absorbable calcium
nutraceuticals. The requesting health than raw vegetables. Patients
care practitioner and laboratory should be informed of the sub-
should be advised if the patient stances that can inhibit calcium
regularly uses these products so absorption by irreversibly binding to
that their effects can be taken into some of the calcium, making it
consideration when reviewing unavailable for absorption, such as
results. oxalates, which naturally occur in
some vegetables; phytic acid, found
➤ Note any recent procedures that can in some cereals; and insoluble
interfere with test results. dietary fiber (in excessive amounts).
➤ There are no food, fluid, or medica- Excessive protein intake can also
tion restrictions unless by medical negatively affect calcium absorption,
direction. especially if it is combined with
➤ Review the procedure with the foods high in phosphorus.
patient. ➤ Evaluate test results in relation to
➤ Inform the patient that specimen the patient’s symptoms and other
collection takes approximately 5 to tests performed. Related laboratory
10 minutes. tests include albumin, alkaline phos-
phatase, calcitonin, ionized calcium,
Intratest: urine calcium, electrolytes, kidney
stone analysis, magnesium, urine
➤ Direct the patient to breathe magnesium, parathyroid hormone,
normally and to avoid unnecessary phosphorus, urine phosphorus, total
movement. protein, urinalysis, and vitamin D.
Calcium, Urine 263
CALCIUM, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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.
DESCRIPTION: Regulating electrolyte • Evaluate dietary intake and absorption

balance is a major function of the • Evaluate renal loss
kidneys. In normally functioning
kidneys, urine levels increase when • Monitor patients on calcium replace-
ment
serum levels are high and decrease
when serum levels are low to maintain
homeostasis. Analyzing urinary elec-
RESULT
trolyte levels can provide important Increased in:
clues to the functioning of the
kidneys and other major organs. Tests • Acromegaly
for calcium in urine usually involve • Diabetes
timed urine collections during a 12-
or 24-hour period. Measurement of • Fanconi’s syndrome
random specimens may also be • Glucocorticoid excess
requested. Urinary calcium excretion • Hepatolenticular degeneration
may also be expressed as calcium-to-
creatinine ratio: In a healthy individ- • Hyperparathyroidism
ual with constant muscle mass, the • Hyperthyroidism
ratio is less than 0.14. ■
• Idiopathic hypercalciuria
INDICATIONS: • Immobilization
• Assist in establishing the presence of • Kidney stones
kidney stones
• Some instances of leukemia and
• Evaluate bone disease lymphoma
• Myeloma tonin, calcitriol, corticosteroids, corti-

cotropin, dexamethasone, diuretics
• Neoplasm of the breast or bladder
(initially), ergocalciferol, ethacrynic
• Osteitis deformans acid, mannitol (initially), meralluride,
mercaptomerin, mersalyl, nandrolone,
• Osteolytic bone metastases (carci-
parathyroid extract, parathyroid
noma, sarcoma)
hormone, plicamycin, sodium sulfate,
• Osteoporosis sulfates, triamterene, viomycin, and
vitamin D.
• Paget’s disease
• Drugs that can decrease urine calcium
• Renal tubular acidosis
levels include angiotensin, bicarbonate,
• Sarcoidosis calcitonin, citrates, diuretics (chronic),
lithium, neomycin, oral contraceptives,
• Schistosomiasis
and spironolactone.
• Thyrotoxicosis
• Failure to collect all the urine and store
• Vitamin D intoxication the specimen properly during the 24-
hour test period invalidates the results.
Decreased in:
• Hypocalcemia (other than renal

disease) Nursing Implications and
• Hypocalciuric hypercalcemia (familial, Procedure ● ● ● ● ● ● ● ● ● ● ●
nonfamilial)
Pretest:
• Hypoparathyroidism
• 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
• 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
• Pseudohypoparathyroidism herbs, nutritional supplements, and
• Renal osteodystrophy care practitioner and laboratory
• Rickets should be advised if the patient
• Vitamin D deficiency that their effects can be taken into
results.
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.
Calcium, Urine 265
➤ 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.
CALCULUS, KIDNEY STONE PANEL

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

SPECIMEN: Kidney stones.
REFERENCE VALUE: (Method: Infrared spectrometry) None detected.
DESCRIPTION: Renal calculi (kidney attach stones to any transportation

stones) are formed by the crystalliza- or collection container, because the
tion of calcium oxalate (most adhesive interferes with infrared
common), magnesium ammonium spectrometry.
phosphate, calcium phosphate, uric
acid, and cystine. Formation of stones
may be due to reduced urine flow and Nursing Implications and
excessive amounts of the above- Procedure ● ● ● ● ● ● ● ● ● ● ●
mentioned insoluble substances. The

presence of stones is confirmed by Pretest:
diagnostic visualization or passing of ➤ Obtain a history of the patient’s
the stones in the urine. The chemical complaints, especially hematuria,
nature of the stones is confirmed recurrent urinary tract infection, and
abdominal pain, and a list of known
qualitatively. ■ allergens.
INDICATIONS: Identify substances pres- genitourinary system and results of
ent in renal calculi previously performed tests and
RESULT to the genitourinary system tables.
Positive findings in: Presence of
renal calculi nutritional supplements, and nutra-
ceuticals. The requesting health care
Negative findings in: N/A practitioner and laboratory should be
INTERFERING FACTORS: when reviewing results.
• Drugs and substances that may Intratest:

increase the formation of urine calculi
include probenecid and vitamin D. ➤ The patient presenting with symp-
toms indicating the presence of
• Adhesive tape should not be used to kidney stones may be provided with
Carbon Dioxide 267
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: CO2 combining power, CO2, tCO2.

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

electrode)
Conventional SI Units
Carbon Dioxide Units (Conversion Factor 1)
Plasma or serum (venous)

Infant–2 y 13–29 mmol/L 13–29 mmol/L
2 y and older 23–29 mmol/L 23–29 mmol/L
Whole blood (venous)
Infant–2 y 18–28 mmol/L 18–28 mmol/L
2 y and older 22–26 mmol/L 22–26 mmol/L
DESCRIPTION: Serum or plasma • Monitor decreased venous CO2 as a

carbon dioxide (CO2) measurement result of compensated respiratory alka-
is usually done as part of an elec- losis
trolyte panel. Total CO2 (tCO2) is an • Monitor increased venous CO2 as a
important component of the body’s result of compensation for respiratory
buffering capability, and measure- acidosis secondary to significant respi-
ments are used mainly in the evalua- ratory system infection or cancer;
tion of acid-base balance. It is decreased respiratory rate
important to understand the differ-
ences between tCO2 (CO2 content) RESULT
and CO2 gas (pCO2). Total CO2
reflects the majority of CO2 in the Increased in:
body mainly in the form of bicarbon- • Acute intermittent porphyria
ate (HCO3–), is present as a base, and
• Airway obstruction
is regulated by the kidneys. CO2 gas
contributes little to the tCO2 level, is • Asthmatic shock
acidic, and is regulated by the lungs. • Brain tumor
(See monograph titled “Blood Gases”
for more information.) • Bronchitis (chronic)
CO2 provides the basis for the prin- • Cardiac disorders
cipal buffering system of the extracel- • Depression of respiratory center
lular fluid system, which is the
bicarbonate–carbonic acid buffer • Electrolyte disturbance (severe)
system. CO2 circulates in the body • Emphysema
either bound to protein or physically
• Hypothyroidism
dissolved. Constituents in the blood
that contribute to tCO2 levels are • Hypoventilation
bicarbonate, carbamino compounds, • Metabolic alkalosis
and carbonic acid (carbonic acid
• Myopathy
includes undissociated carbonic acid
and dissolved CO2). Bicarbonate is • Poliomyelitis
the second largest group of anions in • Pneumonia
the extracellular fluid (chloride being
the largest group of extracellular • Respiratory acidosis
anions). tCO2 levels closely reflect • Tuberculosis (pulmonary)
bicarbonate (HCO3–) levels in the
blood, because 90 to 95 percent of Decreased in:
CO2 circulates as HCO3–. ■
• Acute renal failure
INDICATIONS: • Anxiety
• Evaluate decreased venous CO2 in the • Dehydration
case of compensated metabolic acidosis
• Diabetic ketoacidosis
• Evaluate increased venous CO2 in
• Diarrhea (severe)
the case of compensated metabolic
alkalosis • High fever
Carbon Dioxide 269
• Metabolic acidosis
• Respiratory alkalosis Procedure ● ● ● ● ● ● ● ● ● ● ●
• Salicylate intoxication
• Starvation Pretest:
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
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.
Post-test: the patient’s symptoms and other

tests performed. Related labora-
➤ Observe venipuncture site for bleed- tory tests include arterial/alveolar
ing or hematoma formation. Apply oxygen ratio, anion gap, blood
pressure bandage. gases, electrolytes, ketones, and
➤ Evaluate test results in relation to salicylate.
CARBOXYHEMOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Carbon monoxide, CO, COHb, COH.

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

of Hemoglobin SI Units (Conversion Factor 0.01)
Newborns 10–12% 0.1–0.12
Nonsmokers Up to 2% Up to 0.02
Smokers Up to 12% Up to 0.12
DESCRIPTION: Exogenous carbon competitively and dramatically reduc-

monoxide (CO) is a colorless, odor- ing the oxygen-carrying capacity
less, tasteless byproduct of incomplete of hemoglobin. The increased
combustion derived from the exhaust percentage of bound CO reflects the
of automobiles, coal and gas burning, extent to which normal transport of
and tobacco smoke. Endogenous CO oxygen has been negatively affected.
is produced as a result of red blood Overexposure causes hypoxia, which
cell catabolism. CO levels are elevated results in headache, nausea, vomiting,
in newborns as a result of the vertigo, collapse, or convulsions.
combined effects of high hemoglobin Toxic exposure causes anoxia,
turnover and the inefficiency of the increased levels of lactic acid, and irre-
infant’s respiratory system. CO binds versible tissue damage, which can
tightly to hemoglobin with an affinity result in coma or death. Acute expo-
250 times greater than oxygen, sure may be evidenced by a cherry red
Carboxyhemoglobin 271
color to the lips, skin, and nail beds;

this observation may not be apparent
in cases of chronic exposure. A direct
Procedure ● ● ● ● ● ● ● ● ● ● ●
correlation has been implicated

Pretest:
between carboxyhemoglobin levels
and symptoms of atherosclerotic ➤ Obtain a history of the patient’s
disease, angina, and myocardial complaints, including a list of known
allergens.
infarction. ■
respiratory system and results of
INDICATIONS: previously performed tests and
• Assist in the diagnosis of suspected CO
to the respiratory system table.
poisoning
➤ Obtain a list of medications
• Evaluate exposure to fires and smoke the patient is taking, including
inhalation herbs, nutritional supplements, and
• Evaluate the effect of smoking on the care practitioner and laboratory
patient should be advised if the patient
RESULT that their effects can be taken into
results.
Increased in:
• CO poisoning interfere with test results.
• Hemolytic disease ➤ There are no food, fluid, or medica-
• Tobacco smoking direction.
Decreased in: N/A patient. Explain to the patient or
family members that the cause of
CRITICAL VALUES: the headache, vomiting, dizziness,
convulsions, or coma could be
Asymptomatic: 10 to 20 percent related to CO exposure.
Disturbance of judgment,
headache, dizziness: 10 to 30 ➤ Inform the patient that specimen
percent
10 minutes.
Toxic concentration: greater than
20 percent ➤ If carboxyhemoglobin measurement
will be performed simultaneously
Coma, respiratory arrest, and with arterial blood gases, prepare an
death: greater than 50 percent ice slurry in a cup or plastic bag and
A possible intervention in moderate have it on hand for immediate trans-
CO poisoning is the administration of port of the specimen to the labora-
supplemental oxygen given at atmos- tory.
pheric pressure. In severe CO poisoning,
hyperbaric oxygen treatments may be Intratest:
used.
INTERFERING FACTORS: Specimen movement.
should be collected before administra- ➤ Observe standard precautions and
tion of oxygen therapy. follow the general guidelines in
Appendix A. Perform a venipuncture, Post-test:

green- or lavender-top tube. ➤ Observe venipuncture site for bleed-
➤ Label the specimen, and promptly pressure bandage.
tightly capped sample should be ➤ Inform the patient of smoking cessa-
placed in an ice slurry immediately tion programs, as appropriate.
after collection. Information on the ➤ Evaluate test results in relation to
specimen label can be protected the patient’s symptoms and other
from water in the ice slurry if the tests performed. Related laboratory
specimen is first placed in a protec- tests include arterial/alveolar oxygen
tive plastic bag. ratio and blood gases.
CARCINOEMBRYONIC ANTIGEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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
D ESCRIPTION : Carcinoembryonic useful for monitoring response to

antigen (CEA) is a glycoprotein antineoplastic therapy in breast and
normally produced only during early gastrointestinal cancer. ■
fetal life and rapid multiplication of
epithelial cells, especially those of the INDICATIONS:
digestive system. CEA also appears in
the blood of chronic smokers. • Determine stage of colorectal cancer
Although the test is not diagnostic for and test for recurrence
any specific disease and is not useful • Monitor response to treatment of
as a screening test for cancer, it is breast and gastrointestinal cancers
Carcinoembryonic Antigen 273
RESULT because smokers may have false

elevations.
Increased in: ➤ There are no food, fluid, or medica-
• Benign tumors, including benign direction.
breast disease ➤ Review the procedure with the
• Colorectal, pulmonary, gastric, pancre- patient.
atic, breast, head or neck, esophageal, ➤ Inform the patient that specimen
ovarian, or prostate cancer collection takes approximately 5 to
10 minutes.
• Chronic tobacco smoking
• Radiation therapy (transient) Intratest:
movement.
INTERFERING FACTORS: N/A Appendix A. Perform a venipuncture,
red-top or lavender-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: Post-test:
➤ 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.
CATECHOLAMINES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Epinephrine, norepinephrine, dopamine.

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

Epinephrine
Supine, 30 min 0–110 pg/mL 0–600 pmol/L
Standing, 30 min 0–140 pg/mL 0–764 pmol/L
Norepinephrine
Supine, 30 min 70–750 pg/mL 414–4432 pmol/L
Standing, 30 min 200–1700 pg/mL 1182–10,047 pmol/L
Dopamine
Supine or standing 0–30 pg/mL 0–196 pmol/L
DESCRIPTION: Catecholamines are urement is not as reliable as a 24-hour

produced by the chromaffin tissue of timed urine test. Results are most reli-
the adrenal medulla. They are also able when the specimen is collected
found in sympathetic nerve endings during a hypertensive episode.
and in the brain. The major cate- Catecholamines are measured when
cholamines are epinephrine, norepi- there is high suspicion of pheochro-
nephrine, and dopamine. They mocytoma but urine results are
prepare the body for the fight-or- normal or borderline. Findings
flight stress response, help regulate should be compared with the metabo-
metabolism, and are excreted from lites of epinephrine and norepineph-
the body by the kidneys. rine, metanephrines and vanillyl-
Catecholamine levels are affected by mandelic acid, and the product of
diurnal variations, fluctuating in dopamine metabolism, homovanillic
response to stress, postural changes, acid. Use of a clonidine suppression
diet, smoking, drugs, and tempera- test with measurement of plasma
ture changes. As a result, blood meas- catecholamines may be requested.
Catecholamines 275
Failure to suppress production of • Shock (epinephrine and norepineph-

catecholamines after administration rine)
of clonidine supports the diagnosis of • Strenuous exercise (epinephrine and
pheochromocytoma. ■ norepinephrine)
INDICATIONS:
Decreased in:
• Assist in the diagnosis of neuroblas-
toma, ganglioneuroma, or dysautono- • Autonomic nervous system dysfunc-
mia tion (norepinephrine)
• Assist in the diagnosis of paragan- • Orthostatic hypotension (norepineph-
gliomas rine)
• Assist in the diagnosis of pheochromo- • Parkinson’s disease (dopamine)
cytoma
• Evaluate acute hypertensive episode CRITICAL VALUES: N/A
• Evaluate hypertension of unknown
origin INTERFERING FACTORS:
• Screen for pheochromocytoma among • Drugs that may increase catecholamine
family members with an autosomal- levels include ajmaline, chlorpro-
dominant inheritance pattern for mazine, cyclopropane, diazoxide, ether,
Lindau–von Hippel disease or multiple monoamine oxidase inhibitors, nitro-
endocrine neoplasia glycerin, pentazocine, perphenazine,
phenothiazine, promethazine, and
RESULT theophylline.
Increased in: • Drugs that may decrease cate-

cholamine levels include clonidine,
• Diabetic acidosis (epinephrine and metyrosine, and reserpine.
norepinephrine)
• Stress, hypoglycemia, smoking, and
• Ganglioblastoma (epinephrine, slight drugs can produce elevated plasma
increase; norepinephrine, large catecholamines.
increase)
• Secretion of catecholamines exhibits
• Ganglioneuroma (all are increased; diurnal variation, with the lowest levels
norepinephrine, largest increase) occurring at night.
• Hypothyroidism (epinephrine and • Secretion of catecholamines varies
norepinephrine) during the menstrual cycle, with
• Long-term manic-depressive disorders higher levels excreted during the luteal
(epinephrine and norepinephrine) phase and lowest levels during ovula-
tion.
• Myocardial infarction (epinephrine
and norepinephrine) • Diets high in amines (e.g., bananas,
avocados, beer, aged cheese, chocolate,
• Neuroblastoma (all are increased; cocoa, coffee, fava beans, grains, tea,
norepinephrine and dopamine, largest vanilla, walnuts, Chianti wine) can
increase) produce elevated plasma cate-
• Pheochromocytoma (epinephrine, cholamine levels, although this effect is
continuous or intermittent increase; more likely to be seen relative to
norepinephrine, slight increase) certain urinary metabolites.
required. Inform the patient that

Nursing Implications and specimen collection takes approxi-
Procedure ● ● ● ● ● ● ● ● ● ● ● mately 5 to 10 minutes.
➤ Inform the patient that an intermit-
Pretest: tent infusion device may be inserted
➤ Obtain a history of the patient’s before the test because the stress
complaints, including a list of known of repeated venipunctures may
allergens. increase catecholamine levels.
endocrine system and results of Intratest:
procedures. For related tests, refer ➤ Ensure that the patient complied
to the endocrine system table. with dietary preparations and other
➤ Obtain a list of the medications the pretesting restrictions.
patient is taking, including herbs, ➤ Direct the patient to breathe
nutritional supplements, and normally and to avoid unnecessary
nutraceuticals. The requesting health movement.
care practitioner and laboratory ➤ Observe standard precautions and
should be advised if the patient follow the general guidelines in
regularly uses these products so Appendix A. Perform a venipuncture,
that their effects can be taken into and collect the specimen in a chilled
consideration when reviewing 5-mL green-top tube between 6 and
results. 8 a.m.
Instruct the patient to: ➤ Ask the patient to stand for 10
➤ Follow a normal sodium diet for 3 minutes, and then obtain a second
days before testing. sample as previously described.
➤ Abstain from smoking tobacco for ➤ Label the specimen, noting the time
24 hours before testing. of collection and position of the
➤ Avoid consumption of foods high in patient, and promptly transport it to
amines for 48 hours before testing. the laboratory.
➤ Avoid self-prescribed medications
for 2 weeks before testing (espe- Post-test:
cially appetite suppressants and cold
and allergy medications, such as ➤ Observe venipuncture site for bleed-
nose drops, cough suppressants, ing or hematoma formation. Apply
and bronchodilators). pressure bandage.
➤ Withhold health care practitioner– ➤ Instruct the patient to resume usual
prescribed medication as directed diet and medication as directed by
(especially methyldopa, epinephrine, the health care practitioner.
levodopa, and methenamine mande- ➤ Assess the patient for increased
late). pulse and blood pressure, hyper-
➤ Fast from food and fluids for 10 to 12 glycemia, shakiness, and palpita-
hours before the test. tions associated with increased
values.
➤ Inform the patient that he or she ➤ Evaluate test results in relation to
may be asked to keep warm and to the patient’s symptoms and other
rest for 45 to 60 minutes before the tests performed. Related laboratory
test. tests include calcitonin, urine cate-
➤ Review the procedure with the cholamines, urine homovanillic acid,
patient. Inform the patient that urine metanephrines, and urine
multiple specimens may be vanillylmandelic acid.
Catecholamines, Urine 277
CATECHOLAMINES, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Epinephrine, norepinephrine, dopamine.

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

Epinephrine
1–4 y 0–6.0 g/24 h 0–32.8 nmol/24 h
4 – 10 y 0–10.0 g/24 h 0–54.6 nmol/24 h
10–15 y 0.5–20 g/24 h 2.7–109 nmol/24 h
Adult 0–20 g/24 h 0–109 nmol/24 h
Norepinephrine
1–4 y 0–29 g/24 h 0–171 nmol/24 h
4–10 y 8–65 g/24 h 47–384 nmol/24 h
10 y–adult 15–80 g/24 h 89–473 nmol/24 h
Dopamine
1–4 y 10–260 g/24 h 65–1698 nmol/24 h
4 y–adult 65–400 g/24 h 424–2612 nmol/24 h
DESCRIPTION: Catecholamines are ating in response to stress, postural

produced by the chromaffin tissue of changes, diet, smoking, drugs, and
the adrenal medulla. They also are temperature changes. As a result,
found in sympathetic nerve endings blood measurement is not as reliable
and in the brain. The major cate- as a 24-hour timed urine test. For test
cholamines are epinephrine, norepi- results to be valid, all of the above-
nephrine, and dopamine. They mentioned environmental variables
prepare the body for the fight-or- must be controlled when the test is
flight stress response, help regulate performed. Elevated homovanillic
metabolism, and are excreted from acid levels rule out pheochromocy-
the body by the kidneys. Levels are toma because this tumor primarily
affected by diurnal variations, fluctu- secretes epinephrine. Elevated cate-
cholamines without hypertension • Pheochromocytoma (epinephrine,

suggest neuroblastoma or ganglioneu- continuous or intermittent increase;
roma. Findings should be compared norepinephrine, slight increase)
with metanephrines and vanillylman- • Shock (epinephrine and norepineph-
delic acid, which are the metabolites rine)
of epinephrine and norepinephrine.
• Strenuous exercise (epinephrine and
Findings should also be compared norepinephrine)
with homovanillic acid, which is the
product of dopamine metabolism. ■ Decreased in:
INDICATIONS: • Autonomic nervous system dysfunc-

tion (norepinephrine)
toma, ganglioneuroma, or dysautono- • Orthostatic hypotension (norepineph-
mia rine)
• Assist in the diagnosis of pheochromo- • Parkinson’s disease (dopamine)
cytoma
• Evaluate acute hypertensive episode CRITICAL VALUES: N/A
• Evaluate hypertension of unknown INTERFERING FACTORS:
origin
• Drugs that may increase urine
• Screen for pheochromocytoma among catecholamine levels include acetamin-
family members with an autosomal- ophen, atenolol, dopamine (intra-
dominant inheritance pattern for venous), isoproterenol, methyldopa,
Lindau–von Hippel disease or multiple niacin, nitroglycerin, prochlorperazine,
endocrine neoplasia rauwolfia, reserpine, syrosingopine,
and theophylline.
RESULT
• Drugs that may decrease urine cate-
Increased in: cholamine levels include clonidine,
decaborane, guanethidine, guanfacine,
• Diabetic acidosis (epinephrine and methyldopa, ouabain, radiographic
norepinephrine) substances, reserpine, and bretylium
tosylate.
• Ganglioblastoma (epinephrine, slight
increase; norepinephrine, large • Stress, hypoglycemia, smoking, and
increase) drugs can produce elevated cate-
cholamines.
• Ganglioneuroma (all are increased;
norepinephrine, largest increase) • Secretion of catecholamines exhibits
diurnal variation, with the lowest levels
• Hypothyroidism (epinephrine and
occurring at night.
norepinephrine)
• Secretion of catecholamines varies
• Long-term manic-depressive disorders
during the menstrual cycle, with
(epinephrine and norepinephrine)
higher levels excreted during the luteal
• Myocardial infarction (epinephrine phase and lowest levels during ovula-
and norepinephrine) tion.
• Neuroblastoma (all are increased; • Diets high in amines (e.g., bananas,
norepinephrine and dopamine, largest avocados, beer, aged cheese, chocolate,
increase) cocoa, coffee, fava beans, grains, tea,
Catecholamines, Urine 279
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.
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.
Intratest:
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
24 hours before testing.
➤ 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
specimen was discarded as the less than what was recorded as

beginning of the timed collection output, some urine may have been
period. The next morning, ask the discarded, invalidating the test.
patient to void at the same time the ➤ Label the specimen and promptly
collection was started and add this transport it to the laboratory. Include
last voiding to the container. on the label the amount of urine,
➤ If an indwelling catheter is in place, test start and stop times, and inges-
replace the tubing and container tion of any foods or medications that
system at the start of the collection can affect test results.
time. Keep the container system on
ice during the collection period or Post-test:
empty the urine into a larger
container periodically during the ➤ Instruct the patient to resume usual
collection period; monitor to ensure diet and medication as directed by
continued drainage, and conclude the health care practitioner.
the test the next morning at the ➤ Evaluate test results in relation to
same hour the collection was the patient’s symptoms and other
begun. tests performed. Related laboratory
➤ At the conclusion of the test, tests include calcitonin, plasma cate-
compare the quantity of urine with cholamines, urine homovanillic acid,
the urinary output record for the urine metanephrines, and urine
collection; if the specimen contains vanillylmandelic acid.
CD4/CD8 ENUMERATION
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: T cell profile.

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

CD3 876–1900/mm3
CD4 450–1400/mm3
CD8 190–725/mm3
CD20 64–475/mm3
CD4/CD8 ratio 1.0–3.5
DESCRIPTION: Enumeration of stage of development are used to diag-

lymphocytes, identification of cell nose and classify malignant myelo-
lineage, and identification of cellular proliferative diseases and to plan
CD4/CD8 Enumeration 281
treatment. T cell enumeration is

also useful in the evaluation and
management of immunodeficiency
Procedure ● ● ● ● ● ● ● ● ● ● ●
and autoimmune disease. A severely

Pretest:
depressed CD4 count is an excellent
predictor of imminent opportunistic ➤ Obtain a history of the patient’s
infection. ■
allergens.
INDICATIONS: immune system and results of previ-
• Assist in the diagnosis of AIDS and ously performed tests and proce-
plan treatment dures. For related tests, refer to the
immune system table.
• Evaluate malignant myeloproliferative ➤ Obtain a list of medications the
diseases and plan treatment patient is taking, including herbs,
• Evaluate thymus-dependent or cellular nutritional supplements, and
immunocompetence
RESULT regularly uses these products so
Increased in: consideration when reviewing
results.
• Malignant myeloproliferative diseases
(e.g., acute and chronic lymphocytic interfere with test results.
leukemia, lymphoma)
Decreased in:
direction.
• AIDS ➤ Review the procedure with the
patient.
• Aplastic anemia
• Hodgkin’s disease collection takes approximately 5 to
10 minutes.
Intratest:
• Drugs that may increase T cell count normally and to avoid unnecessary
include interferon-. movement.
• Drugs that may decrease T cell count follow the general guidelines in
include chlorpromazine and pred- Appendix A. Perform a venipuncture,
nisone. and collect the specimen in a 5-mL
green-top tube.
• Specimens should be stored at room
temperature. ➤ Label the specimen, and promptly
can decrease T cell counts. Post-test:
• Values may be abnormal in patients ➤ Observe venipuncture site for bleed-
with severe recurrent illness or after ing or hematoma formation. Apply
recent surgery requiring general anes- pressure bandage.
thesia. ➤ Educate the patient as to the risk of
infection related to immunosup- ➤ Recognize anxiety related to test

pressed inflammatory response and results and offer support. Provide
fatigue related to decreased energy teaching and information regarding
production. the clinical implications of the test
➤ As appropriate, stress the impor- results, as appropriate. Educate the
tance of good nutrition and suggest patient regarding access to counsel-
that the patient meet with a nutri- ing services.
tional specialist. Stress the impor- ➤ Evaluate test results in relation to
tance of following care plan for the patient’s symptoms and other
medications and follow-up visits. tests performed. Related laboratory
Inform the patient that subsequent tests include 2-microglobulin, bone
requests for follow-up blood work at marrow, complete blood count, and
regular intervals should be antici- HIV-1/HIV-2 antibody.
pated.
CEREBROSPINAL FLUID ANALYSIS

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

SPECIMEN: CSF (1 to 3 mL) collected in three or four separate plastic
conical tubes. Tube 1 is used for chemistry and serology testing, tube 2 is
used for microbiology, tube 3 is used for cell count, and tube 4 is used for
miscellaneous testing.
REFERENCE VALUE: (Method: Macroscopic evaluation of appearance; spec-

trophotometry for glucose, lactic acid, and protein; radioimmunoassay for
myelin basic protein; nephelometry for IgG; electrophoresis for oligoclonal
banding; Gram stain, India ink preparation, and culture for microbiology;
microscopic examination of fluid for cell count; flocculation for Venereal
Disease Research Laboratory [VDRL])
Lumbar Puncture Conventional Units SI Units

Color and appearance Crystal clear
(Conversion Factor 10)
Protein 15–45 mg/dL 150–450 mg/L
Glucose
Infant or child 60–80 mg/dL 3.3–4.4 mmol/L
Adult 40–70 mg/dL 2.2–3.9 mmol/L

Cerebrospinal Fluid Analysis 283
Lumbar Puncture Conventional Units SI Units

Lactic acid
Neonate 10–60 mg/dL 1.1–6.7 mmol/L
3–10 d 10–40 mg/dL 1.1–4.4 mmol/L
Adult Less than Less than 2.8 mmol/L
25.2 mg/dL
Myelin basic protein Less than Less than 2.5 g/L
2.5 ng/mL
Oligoclonal bands Absent
IgG Less than Less than 34 mg/L
3.4 mg/dL
Gram stain Negative
India ink Negative
Culture No growth
RBC count 0 0
WBC count
Less than 1 y 0–30/mL 0–30 106/L
1–4 y 0–20/mL 0–20 106/L
5–12 y 0–10/mL 0–10 106/L
Adult 0–5/mL 0–5 106/L
WBC Differential Adult Children Adult Children
Lymphocytes 40–80% 5–13% 0.4–0.8 0.55–0.35
Monocytes 15–45% 50–90% 0.15–0.45 0.50–0.90
Neutrophils 0–6% 0–8% 0–0.6 0–0.8
VDRL Nonreactive
Cytology No abnormal cells seen
RBC red blood cell; VDRL Venereal Disease Research Laboratory; WBC white
blood cell.
DESCRIPTION: Cerebrospinal fluid frequently obtained by lumbar punc-

(CSF) circulates in the subarachnoid ture and sometimes by ventricular
space and has a twofold function: to or cisternal puncture. Lumbar punc-
protect the brain and spinal cord from ture can also have therapeutic uses,
injury and to transport products of including injection of drugs and anes-
cellular metabolism andeurosecretion. thesia. ■
CSF analysis helps determine the
presence and cause of bleeding and
assists in diagnosing cancer, infec- INDICATIONS:
tions, and degenerative and autoim- • Assist in the diagnosis and differentia-
mune diseases of the brain and spinal tion of subarachnoid or intracranial
cord. Specimens for analysis are most hemorrhage
• 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
Cerebrospinal Fluid Analysis 285
CRITICAL VALUES: ➤ Obtain a history of the patient’s

immune and musculoskeletal
• Positive Gram stain, India ink prepara- systems, as well as results of previ-
tion, or culture ously performed tests and proce-
dures. For related tests, refer to the
• Presence of malignant cells immune and musculoskeletal
Any of the above-listed results should system tables.
be communicated to the requesting ➤ Obtain a list of medications the
health care practitioner immediately. patient is taking, including herbs,
INTERFERING FACTORS: nutraceuticals. The requesting health
• Drugs that may decrease CSF protein should be advised if the patient
levels include cefotaxime and dexa- regularly uses these products so
methasone. that their effects can be taken into
• Interferon- may increase myelin basic results.
protein levels. ➤ Note any recent procedures that can
• Drugs that may increase CSF glucose interfere with test results.
levels include cefotaxime and dexa- ➤ There are no food, fluid, or medica-
methasone. tion restrictions unless by medical
direction.
• RBC count may be falsely elevated
with a traumatic spinal tap. ➤ Review the procedure with the
patient.
• This procedure is contraindicated if ➤ Inform the patient that the position
infection is present at the needle required may be awkward, but that
insertion site. someone will assist during the
procedure. Stress the importance of
• Recent radioactive scans or radiation remaining still and breathing
within 1 week before the test can inter- normally throughout the procedure.
➤ Inform the patient that a stinging
munoassay is the test method. sensation may be felt when the local
• Note any recent procedures that can anesthetic is injected. Tell the patient
interfere with test results. to report any pain or other sensa-
tions that may require repositioning
• It may also be contraindicated in the spinal needle.
patients with degenerative joint ➤ Assess if the patient has an allergy
disease or coagulation defects to local anesthetics, and inform the
and in patients who are uncooperative health care practitioner accordingly.
during the procedure. ➤ Obtain written and informed
• Use with extreme caution in patients consent before administering any
with increased intracranial pres- medications prior to the procedure.
sure because overly rapid removal ➤ Inform the patient that the proce-
of CSF can result in herniation. dure is performed by a health care
practitioner and takes about 20
minutes.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: normally and to avoid unnecessary
movement.
complaints, including a list of known ➤ Record baseline vital signs.
allergens. ➤ To perform a lumbar puncture, posi-
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.
Ceruloplasmin 287
CERULOPLASMIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Copper oxidase, Cp.

REFERENCE VALUE: (Method: Nephelometry)
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
DESCRIPTION: Ceruloplasmin is an RESULT

2-globulin produced by the liver
that binds copper for transport in the Increased in:
blood after it is absorbed from the • Acute infections
gastrointestinal system. Decreased
• Biliary cirrhosis
production of this globulin causes
copper to be deposited in body tissues • Cancer of the bone, lung, stomach
such as the brain, liver, corneas, and • Copper intoxication
kidneys. ■
• Hodgkin’s disease
INDICATIONS: • Leukemia
• Assist in the diagnosis of Menkes • Pregnancy (last trimester)
(kinky hair) syndrome
• Rheumatoid arthritis
• Assist in the diagnosis of Wilson’s
disease • Tissue necrosis
• Determine genetic predisposition to Decreased in:

Wilson’s disease
• Menkes syndrome
• Monitor patient response to total
• Nutritional deficiency of copper
parenteral nutrition (hyperalimenta-
tion) • Wilson’s disease

10 minutes.
Intratest:
• Drugs that may increase ceruloplasmin
levels include anticonvulsants, ➤ Direct the patient to breathe
norethindrone, oral contraceptives,
movement.
and tamoxifen.
• Drugs that may decrease ceruloplasmin follow the general guidelines in
levels include asparaginase and Appendix A. Perform a venipuncture,
levonorgestrel (Norplant). and collect the specimen in a 5-mL
• Excessive therapeutic intake of zinc
may interfere with intestinal absorp- transport it to the laboratory.
tion of copper.
Post-test:
Nursing Implications and ➤ Observe venipuncture site for bleed-

Procedure ● ● ● ● ● ● ● ● ● ● ●
pressure bandage.
Pretest: ➤ Instruct the patient with copper defi-
ciency to increase intake of foods
➤ Obtain a history of the patient’s rich in copper, as appropriate. Organ
complaints, including a list of known meats, shellfish, nuts, and legumes
allergens. are good sources of dietary copper.
➤ Obtain a history of the patient’s High intake of zinc, iron, calcium,
hepatobiliary system and results of and manganese interferes with
previously performed tests and copper absorption. Copper defi-
procedures. For related tests, refer ciency does not normally occur in
to the hepatobiliary system table. adults; however, patients receiving
long-term total parenteral nutrition
➤ Obtain a list of medications the should be evaluated if signs and
patient is taking, including herbs, symptoms of copper deficiency
nutritional supplements, and appear, such as jaundice or eye
nutraceuticals. The requesting health color changes. Kayser-Fleischer rings
care practitioner and laboratory (green-gold rings) in the cornea and
should be advised if the patient a liver biopsy specimen showing
regularly uses these products so more than 250 g of copper per
that their effects can be taken into gram confirms Wilson’s disease.
results. ➤ Inform the patient of the need for
follow-up medical care as appropri-
➤ There are no food, fluid, or medica- ate.
➤ Review the procedure with the tests performed. Related laboratory
patient. tests include copper, liver biopsy,
➤ Inform the patient that specimen and zinc.
Chest X-Ray 289
CHEST X-RAY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Chest radiography, CXR.

AREA OF APPLICATION: Lungs.
CONTRAST: None.
DESCRIPTION: Chest radiography, chest and diaphragm during breath-

commonly called chest x-ray, is one ing and coughing. In the beginning of
of the most frequently performed the disease process of tuberculosis,
radiologic diagnostic studies. This asthma, and chronic obstructive
study yields information about the pulmonary disease, the results of the
pulmonary, cardiac, and skeletal chest x-ray may not correlate with the
systems. X-rays penetrate air easily; clinical status of the patient and may
areas filled with air appear dark or even be normal. ■
black on x-ray film. Bones appear
near-white on the film because x-rays INDICATIONS:
cannot penetrate them to reach the • Evaluate known or suspected
film. Organs and tissues appear as pulmonary disorders, chest trauma,
shades of gray because they absorb cardiovascular disorders, and skeletal
more x-ray than air but less than disorders
bone. A routine chest x-ray includes a
• Aid in the diagnosis of diaphragmatic
posteroanterior and lateral view. hernia
Portable x-rays, done in more acute or
critical situations, can be done at the • Monitor resolution, progression, or
bedside and include only the antero- maintenance of disease
posterior projection. Films may be • Monitor effectiveness of the treatment
taken with the patient supine or in a regimen
lateral decubitus position, if the pres- • Evaluate placement and position of an
ence of free pleural fluid is in ques- endotracheal tube, tracheostomy tube,
tion. Other projections that can be nasogastric feeding tube, pacemaker
obtained are the obliques, lateral wires, and intra-aortic balloon pump
decubitus, and lordotic; in general,
the part being studied is placed next RESULT
to the film. Films may be taken on
full inspiration and on full expiration Normal Findings:
to detect a pneumothorax. Fluoro- • Normal lung fields, cardiac size, medi-
scopic studies of the chest can also be astinal structures, thoracic spine, ribs,
done to evaluate movement of the and diaphragm
Abnormal Findings: • Metallic objects within the examina-

tion field (e.g., jewelry, earrings),
• Atelectasis which may inhibit organ visualization
• Bronchitis and can produce unclear images
• Curvature of the spinal column (scol- • Improper adjustment of the radi-
iosis) ographic equipment to accommodate
• Enlarged heart obese or thin patients, which can cause
overexposure or underexposure and a
• Enlarged lymph nodes poor-quality study
• Flattened diaphragm • Patients who are very obese, who may
• Foreign bodies lodged in the exceed the weight limit for the equip-
pulmonary system ment
• Fractures of the sternum, ribs, and • Incorrect positioning of the patient,
spine which may produce poor visualization
• Lung pathology, including tumors
• Malposition of tubes or wires Other considerations:
• Mediastinal tumor and pathology • Consultation with a physician should
• Pericardial effusion occur before the procedure for radia-
• Pericarditis of patients who are lactating.
• Pleural effusion • Risks associated with radiographic
• Pneumonia overexposure can result from frequent
• Pneumothorax room with the patient should wear a
• Pulmonary bases, fibrosis, infiltrates protective lead apron, stand behind a
shield, or leave the area while the
• Tuberculosis examination is being done. Badges that
• Vascular abnormalities reveal the level of exposure to radiation
should be worn by persons working in
CRITICAL VALUES: N/A the area where the examination is being
done.
This procedure is contraindicated Nursing Implications and
for: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients who are pregnant or suspected Pretest:

of being pregnant, unless the potential
benefits of the procedure far outweigh ➤ Inform the patient about the
the risks to the fetus and mother purpose of the procedure, various
positions to assume, and the need
to hold his or her breath. For related
tests, refer to the cardiovascular and
imaging:
• Inability of the patient to cooperate or ➤ Inform the patient that the proce-
remain still during the procedure dure takes 5 to 10 minutes.
because of age, significant pain, or ➤ There are no food or fluid restric-
mental status tions.
Chlamydia Group Antibody 291
➤ 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.
CHLAMYDIA GROUP ANTIBODY

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REFERENCE VALUE: (Method: Indirect fluorescent antibody, polymerase
chain reaction) Negative or less than fourfold increase in titer.
DESCRIPTION: Chlamydia, one of symptoms of the first phase of

the most common sexually transmit- the disease appearing 2 to 6 weeks
ted infections, is caused by Chlamydia after infection; another causes a
trachomatis. These gram-negative genital tract infection different from
bacteria are called obligate cell para- lymphogranuloma venereum, in
sites because they require living cells which symptoms in men appear 7 to
for growth. There are three serotypes 28 days after intercourse (women are
of C. trachomatis: One group causes generally asymptomatic); and the
lymphogranuloma venereum, with third causes the ocular disease
trachoma (incubation period, 7 to 10 CRITICAL VALUES: N/A

days). Chlamydia psittaci is the cause
of psittacosis in birds and humans. It INTERFERING FACTORS: N/A
is increasing in prevalence as a
pathogen responsible for other signif-
icant diseases of the respiratory Nursing Implications and
system. The incubation period for C. Procedure ● ● ● ● ● ● ● ● ● ● ●
psittaci infections in humans is 7 to

15 days, which is followed by chills, Pretest:
fever, and a persistent nonproductive ➤ Obtain a history of the patient’s
cough. complaints, including a list of known
Chlamydia is difficult to culture allergens.
and grow, so antibody testing has ➤ Obtain a history of the patient’s
become the technology of choice. The immune and reproductive systems,
antigen used in many screening kits is as well as results of previously
not species specific and can confirm related tests, refer to the immune
only the presence of Chlamydia spp. and reproductive system tables.
Newer technology using DNA probes ➤ Obtain a list of medications the
can identify the species. Assays that patient is taking, including herbs,
can specifically identify C. trachomatis nutritional supplements, and
require special collection and trans- nutraceuticals. The requesting health
port kits. They also have specific should be advised if the patient
collection instructions, and the speci- regularly uses these products so
mens are collected on swabs. The that their effects can be taken into
laboratory performing this testing consideration when reviewing
should be consulted before specimen results.
collection. ■ ➤ There are no food, fluid, or medica-
INDICATIONS: direction.
• Establish Chlamydia as the cause of patient.
atypical pneumonia ➤ Inform the patient that several tests
• Establish the presence of chlamydial may be necessary to confirm diag-
infection nosis. Any individual positive result
should be repeated in 7 to 10 days to
monitor a change in titer.
RESULT
➤ Inform the patient that each speci-
Positive findings in: men collection takes approximately
5 to 10 minutes.
• Chlamydial infection
Intratest:
• Infantile pneumonia
• Infertility normally and to avoid unnecessary
• Lymphogranuloma venereum movement.
• Ophthalmia neonatorum follow the general guidelines in
• Pelvic inflammatory disease Appendix A. Perform a venipuncture,
• Urethritis red-top tube.
Chloride, Serum 293
➤ Label the specimen, and promptly patient regarding access to counsel-

transport it to the laboratory. ing services. Provide a nonjudgmen-
tal, nonthreatening atmosphere for a
Post-test: discussion during which you explain
the risks of sexually transmitted
➤ Observe venipuncture site for bleed- diseases. It is also important to
ing or hematoma formation. Apply discuss emotions the patient may
pressure bandage. experience (guilt, depression, anger)
➤ Counsel the patient, as appropriate, if test results indicate the presence
as to the risk of sexual transmission of Chlamydia.
and educate the patient regarding ➤ Provide emotional support if the
proper prophylaxis. Reinforce the patient is pregnant and if results are
importance of strict adherence to positive. Inform the patient that
the treatment regimen. Chlamydia infection during preg-
➤ Inform the patient with positive C. nancy places the newborn at risk
trachomatis that findings must be for pneumonia and conjunctivitis.
reported to a local health depart- Educate the patient regarding
ment official, who will question the access to counseling services.
patient regarding his or her sexual ➤ Emphasize the need to return to
partners. have a convalescent blood sample
➤ Recognize anxiety related to test taken in 7 to 14 days.
results. Provide teaching and ➤ Evaluate test results in relation to
disease information, as appropriate. the patient’s symptoms and other
➤ Offer support, as appropriate, to tests performed. Related laboratory
patients who may be the victim of tests include Chlamydia and Neisse-
rape or sexual assault. Educate the ria cultures and syphilis serology.
CHLORIDE, SERUM
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SYNONYM/ACRONYM: Cl.
SI Units
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
DESCRIPTION: Chloride is the most The patient’s clinical picture needs

abundant anion in the extracellular to be considered in the evaluation of
fluid. Its most important function is in electrolytes. Fluid and electrolyte im-
the maintenance of acid-base balance, balances are often seen in patients
in which it competes with bicarbonate with serious illness or injury because
for sodium. Chloride levels generally in these cases the clinical situation has
increase and decrease proportional to affected the normal homeostatic bal-
sodium levels and inversely propor- ance of the body. It is also possible
tional to bicarbonate levels. Chloride that therapeutic treatments being ad-
also participates with sodium in the ministered are causing or contribut-
maintenance of water balance and aids ing to the electrolyte imbalance. Chil-
in the regulation of osmotic pressure. dren and adults are at high risk for
Chloride contributes to gastric acid fluid and electrolyte imbalances when
(hydrochloric acid) for digestion and chloride levels are depleted. Children
activation of enzymes. The chloride are considered to be at high risk dur-
content of venous blood is slightly ing chloride imbalance because a pos-
higher than that of arterial blood itive serum chloride balance is impor-
because chloride ions enter red blood tant for expansion of the extracellular
cells in response to absorption of fluid compartment. Anemia, the re-
carbon dioxide into the cell. As carbon sult of decreased hemoglobin levels, is
dioxide enters the blood cell, bicar- a frequent issue for elderly patients.
bonate leaves and chloride is absorbed Since hemoglobin participates in a
in exchange to maintain electrical major buffer system in the body, de-
neutrality within the cell. pleted hemoglobin levels affect the ef-
Chloride is provided by dietary ficiency of chloride ion exchange for
intake, mostly in the form of sodium bicarbonate in red blood cells, which
chloride. It is absorbed by the in turn affects acid-base balance. El-
gastrointestinal system, filtered out by derly patients are also at high risk
the glomeruli, and reabsorbed by the because their renal response to change
renal tubules. Excess chloride is in pH is slower, resulting in a more
excreted in the urine. Serum values rapid development of electrolyte
normally remain fairly stable. A slight imbalance. ■
decrease may be detectable after meals
because chloride is used to produce INDICATIONS:
hydrochloric acid as part of the diges-
tive process. Measurement of chloride • Assist in confirming a diagnosis of
disorders associated with abnormal
levels is not as essential as measure-
chloride values, as seen in acid-base
ment of other electrolytes such as and fluid imbalances
sodium or potassium. Chloride is
usually included in standard elec- • Differentiate between types of acidosis
trolyte panels to detect the presence of (hyperchloremic versus anion gap)
unmeasured anions via calculation of • Monitor effectiveness of drug therapy
the anion gap. Chloride levels are to increase or decrease serum chloride
usually not interpreted apart from levels
sodium, potassium, carbon dioxide,
and anion gap. RESULT
Chloride, Serum 295
Increased in: of other electrolyte values and requires

clinical knowledge of the patient.
• Acute renal failure The following may be seen in
• Cushing’s disease hypochloremia: twitching or tremors,
which may indicate excitability of the
• Dehydration nervous system; slow and shallow breath-
• Diabetes insipidus ing; and decreased blood pressure as a
result of fluid loss. Possible interventions
• Excessive infusion of normal saline relate to treatment of the underlying
• Head trauma with hypothalamic stim- cause.
ulation or damage Signs and symptoms associated with
hyperchloremia are weakness, lethargy,
• Hyperparathyroidism (primary) and deep, rapid breathing. Proper inter-
• Metabolic acidosis (associated with ventions include treatments that correct
prolonged diarrhea) the underlying cause.
• Renal tubular acidosis

• Respiratory alkalosis (e.g., hyperventi-
• Drugs that may cause an increase
lation)
in chloride levels include acetazo-
• Salicylate intoxication lamide, acetylsalicylic acid, ammo-
nium chloride, bromide, chloroth-
Decreased in: iazide, cholestyramine, cyclosporine,
guanethidine, lithium, methyldopa,
• Addison’s disease oxyphenbutazone, phenylbutazone,
• Burns and triamterene.
• Congestive heart failure • Drugs that may cause a decrease in

chloride levels include bicarbonate,
• Excessive sweating corticosteroids, corticotropin, corti-
sone, diuretics, ethacrynic acid,
• Gastrointestinal loss from vomiting
furosemide, hydroflumethiazide, laxa-
(severe), diarrhea, nasogastric suction,
tives (if chronic abuse occurs), manni-
or fistula
tol, meralluride, mersalyl, methy-
• Metabolic alkalosis clothiazide, metolazone, and triam-
terene. Many of these drugs can cause
• Overhydration a diuretic action that inhibits the tubu-
• Respiratory acidosis (chronic) lar reabsorption of chloride. Note:
Triamterene has nephrotoxic and
• Salt-losing nephritis azotemic effects, and when organ
• Syndrome of inappropriate antidi- damage has occurred, increased serum
uretic hormone secretion chloride levels result.
• Water intoxication • Elevated triglyceride or protein levels
may cause a volume-displacement
CRITICAL VALUES: error in the specimen, reflecting falsely
Less than 80 mEq/L decreased chloride values when chlo-
ride measurement methods employing
Greater than 115 mEq/L
predilution specimens are used (e.g.,
Observe the patient for symptoms of
indirect ion-selective electrode, flame
critically decreased or elevated chloride
photometry).
levels. Proper interpretation of chloride
values must be made within the context • Specimens should never be collected
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,
contained in the IV solution, falsely red- or tiger-top tube.
increasing the result.

Procedure ● ● ● ● ● ● ● ● ● ● ●

pressure bandage.
➤ Obtain a history of the patient’s ➤ Observe the patient on saline IV
complaints, including a list of known fluid replacement therapy for signs
allergens. of overhydration, especially in cases
➤ Obtain a history of the patient’s in which there is a history of cardiac
cardiovascular, endocrine, gastroin- or renal disease. Signs of overhydra-
testinal, genitourinary, and respiration include constant, irritable
tory systems, as well as results of cough; chest rales; dyspnea; or
previously performed tests and engorgement of neck and hand
procedures. For related tests, refer veins.
to the cardiovascular, endocrine, ➤ Evaluate the patient for signs and
gastrointestinal, genitourinary, and symptoms of dehydration.
respiratory system tables. Dehydration is a significant and
➤ Obtain a list of medications the common finding in geriatric and
patient is taking, including herbs, other patients in whom renal func-
nutritional supplements, and tion has deteriorated.
nutraceuticals. The requesting health ➤ Monitor daily weights as well as
care practitioner and laboratory intake and output to determine
should be advised if the patient whether fluid retention is occurring
regularly uses these products so because of sodium and chloride
that their effects can be taken into excess. Patients at risk for or with a
consideration when reviewing history of fluid imbalance are also at
results. risk for electrolyte imbalance.
➤ There are no food, fluid, or medica- ➤ Careful observation of the patient on
tion restrictions unless by medical IV fluid replacement therapy is
direction. important. A patient receiving a
➤ Specimens should not be collected continuous 5% dextrose solution
during hemodialysis. (D5W) may not be taking in an
➤ Review the procedure with the adequate amount of chloride to
patient. meet the body’s needs. The patient,
if allowed, should be encouraged to
➤ Inform the patient that specimen drink fluids such as broths, tomato
collection usually takes 5 to 10 juice, or colas and to eat foods such
minutes. as meats, seafood, or eggs, which
contain sodium and chloride. The
Intratest: use of table salt may also be appro-
➤ Direct the patient to breathe priate.
normally and to avoid unnecessary ➤ Instruct patients with elevated chlo-
Chloride, Sweat 297
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
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SYNONYMS/ACRONYM: Sweat test, pilocarpine iontophoresis sweat test,

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

iontophoresis.
REFERENCE VALUE: (Method: Ion-specific electrode or titration)
SI Units
Normal 5–40 mEq/L 5–40 mmol/L
Intermediate 40–60 mEq/L 40–60 mmol/L
DESCRIPTION: Cystic fibrosis (CF) is pancreas, small intestine, bile ducts,

a genetic disease that affects normal and skin. Clinical presentation may
functioning of the exocrine glands, include chronic problems of the
causing them to excrete large gastrointestinal and/or respiratory
amounts of electrolytes. Patients with system. Testing of stool samples for
CF have sweat electrolyte levels two decreased trypsin activity has been
to five times normal. Sweat test used as a screen for CF in infants and
values, with family history and signs children, but this is a much less reli-
and symptoms, are required to estab- able method than the sweat test.
lish a diagnosis of CF. CF is transmit- The sweat test is a noninvasive
ted as an autosomal-recessive trait study done to assist in the diagnosis
and is characterized by abnormal of CF when considered with other
exocrine secretions within the lungs, test results and physical assessments.
This test is usually performed on chil- • Hypothyroidism

dren, although adults may also be • Mucopolysaccharidosis
tested; it is not usually ordered on
adults because results can be highly • Nephrogenic diabetes insipidus
variable and should be interpreted
Decreased in:
with caution. Sweat for specimen
collection is induced by a small elec- • Edema
trical current carrying the drug pilo-
• Hypoaldosteronism
carpine. The test measures the
concentration of chloride produced • Hypoproteinemia
by the sweat glands of the skin. A • Sodium depletion
high concentration of chloride in the
specimen indicates the presence of CRITICAL VALUES:
CF. The sweat test is used less 20 years or younger: Greater than
commonly to measure the concentra- 60 mmol/L considered diagnostic
tion of sodium ions for the same of CF
purpose. ■ Older than 20 years: Greater than
70 mmol/L considered diagnostic
INDICATIONS: of CF
The validity of the test result is
• Assist in the diagnosis of CF
affected tremendously by proper speci-
• Screen for CF in individuals with a men collection and handling. Before
family history of the disease proceeding with appropriate patient
• Screen for suspected CF in children education and counseling, it is important
with recurring respiratory infections to perform duplicate testing on patients
whose results are in the diagnostic or
• Screen for suspected CF in infants with intermediate ranges. A negative test
failure to thrive and infants who pass should be repeated if test results do not
meconium late support the clinical picture.
• Screen for suspected CF in individuals
with malabsorption syndrome INTERFERING FACTORS:
RESULT • An inadequate amount of sweat may
produce inaccurate results. Sweat test-
Increased in: ing in infants less than 1 month old is
not recommended because they are
• Addison’s disease often incapable of producing an
• Alcoholic pancreatitis adequate amount of sweat sample.
• Chronic pulmonary infections • This test should not be performed on
patients with skin disorders (e.g.,
• Congenital adrenal hyperplasia rash, erythema, eczema).
• CF • Improper cleaning of the skin or
• Familial cholestasis improper application of gauze pad or
filter paper for collection affects test
• Familial hypoparathyroidism results.
• Fucosidosis • Hot environmental temperatures may
• Glucose-6-phosphate dehydrogenase reduce the sodium chloride concentra-
deficiency tion in sweat; cool environmental
Chloride, Sweat 299
temperatures may reduce the amount tion usually takes approximately 75

of sweat collected. to 90 minutes.
➤ Explain that a positive sweat test
• If the specimen container that stores alone is not diagnostic of CF; repeti-
the gauze or filter paper is handled tion of borderline and positive tests
without gloves, the test results may is generally recommended.
show a false increase in the final weight
of the collection container. Intratest:
• Screening for CF can be performed ➤ The patient is placed in a position
using a silver nitrate test paper, and a that will allow exposure of the
positive test can be validated by pilo- site on the forearm or thigh. To
carpine iontophoresis. ensure collection of an adequate
amount of sweat in a small infant,
two sites (right forearm and right
thigh) can be used. The patient
Nursing Implications and should be covered to prevent cool
Procedure ● ● ● ● ● ● ● ● ● ● ● environmental temperatures from
affecting sweat production. The site
Pretest: selected for iontophoresis should
never be the chest or left side
➤ Obtain a history of the patient’s because of the risk of cardiac arrest
complaints, including a list of known from the electrical current.
allergens.
➤ The site is washed with distilled
➤ Obtain a history of the patient’s water and dried. A positive electrode
endocrine and respiratory systems, is attached to the site on the right
especially failure to thrive or CF in forearm or right thigh and covered
other family members, as well as with a pad that is saturated with
results of previously performed pilocarpine, a drug that stimulates
tests and procedures. For related sweating. A negative electrode is
tests, refer to the endocrine and covered with a pad that is saturated
respiratory system tables. with bicarbonate solution. Ionto-
➤ Obtain a list of medications the phoresis is achieved by supplying a
patient is taking, including herbs, low (4 to 5 mA) electrical current via
nutritional supplements, and the electrode for 12 to 15 minutes.
nutraceuticals. The requesting health Battery-powered equipment is
care practitioner and laboratory preferred over an electrical outlet to
should be advised if the patient supply the current.
regularly uses these products so ➤ The electrodes are removed, reveal-
that their effects can be taken into ing a red area at the site, and the site
consideration when reviewing is washed with distilled water and
results. dried to remove any possible
➤ There are no food, fluid, or medica- contaminants on the skin.
tion restrictions unless by medical ➤ Preweighed disks made of filter
direction. paper are placed on the site with a
➤ Inform the patient and caregiver forceps; to prevent evaporation of
there is no pain associated with the sweat collected at the site, the disks
test, but a stinging sensation may be are covered with paraffin or plastic
experienced when the low electrical and sealed at the edges. The disks
current is applied at the site. are left in place for about 1 hour.
➤ Review the procedure with the Distract the child with books or
patient and caregiver. Encourage the games to allay fears.
caregiver to stay with and support ➤ After 1 hour, the paraffin covering is
the child during the test. The removed, and disks are placed in a
iontophoresis and specimen collec- preweighed container with forceps.
The container is sealed and sent vitamin (A, D, E, and K) supplemen-

immediately to the laboratory for tation. Malnutrition also is seen
weighing and analysis of chloride commonly in patients with chronic,
content. At least 100 mg of sweat is severe respiratory disease for many
required for accurate results. reasons, including fatigue, lack of
➤ Terminate the test if the patient appetite, and gastrointestinal
complains of burning at the elec- distress. Research has estimated
trode site. Reposition the electrode that the daily caloric intake for respi-
before the test is resumed. ration in patients with chronic
obstructive pulmonary disease
➤ Label the specimen, and promptly (COPD) is 10 times higher than
transport it to the laboratory. Do not normal individuals. Inadequate nutri-
directly handle the preweighed tion can result in hypophosphatemia,
specimen container or filter paper. especially in a respirator-dependent
patient. During periods of starvation,
Post-test: phosphorus leaves the intracellular
➤ Observe the site for unusual color, space and moves outside the tissue,
sensation, or discomfort. resulting in dangerously decreased
phosphorus levels. To prevent
➤ Inform the patient and caregiver that pulmonary infection and decrease
redness at the site fades in 2 to 3 the extent of lung tissue damage,
hours. adequate intake of vitamins A and C
➤ Reinforce information regarding is also important. Excessive loss of
diagnosis and recommended treat- sodium chloride through the sweat
ment regimen. Provide information glands of a patient with CF may
regarding genetic counseling and necessitate increased salt intake,
possible screening of other family especially in environments where
members if appropriate. increased sweating is induced. The
➤ Help the patient and caregiver to importance of following the
cope with long-term implications. prescribed diet should be stressed
Recognize that anticipatory anxiety to the patient and caregiver.
and grief related to potential lifestyle ➤ Water balance needs to be moni-
changes may be expressed when tored closely in patients with COPD.
someone is faced with a chronic Fluid retention can lead to
disorder. Provide teaching and infor- pulmonary edema.
mation regarding the clinical implica-
tions of the test results, as ➤ If appropriate, instruct the patient
appropriate. and caregiver that ineffective airway
clearance related to excessive
➤ If appropriate, instruct the patient production of mucus and decreased
and caregiver that nutrition may be ciliary action may result.
altered because of impaired diges-
tive processes associated with CF. ➤ Evaluate test results in relation to
Increased viscosity of exocrine gland the patient’s symptoms and other
secretion may lead to poor absorp- tests performed. Related laboratory
tion of digestive enzymes and fat- tests include 1-antitrypsin/pheno-
soluble vitamins, necessitating type, amylase, anion gap, elec-
supplementary oral intake of diges- trolytes, fecal analysis, fecal fat,
tive enzymes with each meal and osmolality, and phosphorus.
Cholangiography, Percutaneous Transhepatic 301
CHOLANGIOGRAPHY,
PERCUTANEOUS TRANSHEPATIC
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SYNONYMS/ACRONYMS: Percutaneous cholecystogram, PTC, PTHC.

AREA OF APPLICATION: Biliary system.
CONTRAST: Radiopaque iodine-based contrast medium.
DESCRIPTION: Percutaneous trans- INDICATIONS:

hepatic cholangiography (PTC) is a • Aid in the diagnosis of obstruction
test used to the visualize the biliary caused by gallstones, benign strictures,
system in order to evaluate persistent malignant tumors, congenital cysts,
upper abdominal pain after cholecys- and anatomic variations
tectomy and to determine the pres-
• Distinguish between obstructive and
ence and cause of obstructive nonobstructive jaundice
jaundice. The liver is punctured with
a thin needle under fluoroscopic • Determine the cause of upper abdomi-
guidance, and contrast medium is nal pain after cholecystectomy
injected as the needle is slowly with- • Determine the cause, extent, and loca-
drawn. This test visualizes the biliary tion of mechanical obstruction
ducts without depending on the gall-
bladder’s concentrating ability. The RESULT
intrahepatic and extrahepatic biliary Normal Findings:
ducts, and occasionally the gallblad-
der, can be visualized to determine • Gallbladder appears normal in size and
possible obstruction. In obstruction shape.
of the extrahepatic ducts, a catheter • Biliary ducts are normal in diameter,
can be placed in the duct to allow with no evidence of dilation, filling
external drainage of bile. Endoscopic defects, duct narrowing, or extravasa-
retrograde cholangiopancreatography tion.
(ERCP) and PTC are the only meth- • Contrast medium fills the ducts and
ods available to view the biliary tree in flows freely.
the presence of jaundice. ERCP poses
less risk and is probably done more Abnormal Findings:
often. PTC is an invasive procedure • Anatomic biliary or pancreatic duct
and has potential risks, including variations
bleeding, septicemia, bile peritonitis,
• Biliary sclerosis
and extravasation of the contrast
medium. ■ • Cholangiocarcinoma
• Cirrhosis because of age, significant pain, or

mental status
• Common bile duct cysts
• Insufficient injection of contrast
• Gallbladder carcinoma medium, which may produce poor-
• Gallstones quality films
• Hepatitis • Metallic objects within the examina-
tion field (e.g., jewelry or body rings),
• Nonobstructive jaundice which may inhibit organ visualization
• Pancreatitis and can produce unclear images
• Sclerosing cholangitis • Improper adjustment of the radio-
graphic equipment to accommodate
• Tumors, strictures, inflammation, or obese or thin patients, which can cause
gallstones of the common bile duct overexposure or underexposure and
poor-quality study
INTERFERING FACTORS: exceed the weight limit for the equip-
ment
This procedure is contraindicated • Incorrect positioning of the patient,
for: which may produce poor visualization
iodinated dye. The contrast • Gas or feces in the gastrointestinal tract
medium used may cause a life- resulting from inadequate cleansing or
threatening allergic reaction. Patients failure to restrict food intake before the
with a known hypersensitivity to the study
medium may benefit from premedica- • Retained barium from a previous radi-
tion with corticosteroids or the use of ologic procedure
nonionic contrast medium.
• Gas that overfills the biliary ducts
of being pregnant, unless the potential Other considerations:
the risks to the fetus and mother. • Peritonitis may occur as a result of bile
extravasation.
• Patients with cholangitis. The injection
of the contrast medium can • Failure to follow dietary restrictions
increase biliary pressure leading before the procedure may cause the
to bacteremia, septicemia, and shock. procedure to be canceled or repeated.
• Patients with postoperative wound
sepsis, hypersensitivity to iodine, or
acute renal failure.
• Patients with bleeding disorders, • Risks associated with radiographic
massive ascites, or acute renal overexposure can result from frequent
failure. x-ray procedures. Personnel in the
imaging: protective lead apron, stand behind a
• Inability of the patient to cooperate or examination is being done. Badges that
remain still during the procedure reveal the level of exposure to radiation
Cholangiography, Percutaneous Transhepatic 303
should be worn by persons working in ➤ Schedule gastrointestinal or any

the area where the examination is being barium studies after this study.
done. ➤ Obtain baseline vital signs.
➤ Instruct the patient to refrain from
food and fluids for 6 to 8 hours
before the test.
Procedure ● ● ● ● ● ● ● ● ● ● ●
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.
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.
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.
➤ 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 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
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SYNONYM/ACRONYM: T-tube cholangiography.

AREA OF APPLICATION: Gallbladder, bile ducts.
CONTRAST: Iodinated contrast medium.
DESCRIPTION: After cholecystec- tion of a contrast medium through

tomy, a self-retaining, T-shaped tube the T-tube inserted during surgery.
may be inserted into the common This test may be performed at the
bile duct. Postoperative (T-tube) time of surgery and 7 to 10 days after
cholangiography is a fluoroscopic and cholecystectomy to assess the patency
radiographic examination of the of the common bile duct and to
biliary tract that involves the injec- detect any remaining calculi. T-tube
Cholangiography, Postoperative 305
placement can also be done after a • Patients with allergies to shellfish

liver transplant because biliary duct or iodinated dye. The contrast
obstruction or anastomotic leakage medium used may cause a life-
is possible. This test should be threatening allergic reaction. Patients
performed before any gastrointestinal with a known hypersensitivity to the
medium may benefit from premedica-
studies using barium and after any
tion with corticosteroids or the use of
studies involving the measurement of nonionic contrast medium.
iodinated compounds. ■
INDICATIONS: imaging:
• Identify the cause, extent, and location
of obstruction after surgery • Inability of the patient to cooperate or
• Determine biliary duct patency before because of age, significant pain, or
T-tube removal mental status
RESULT • Metallic objects within the examina-

Normal Findings: which may inhibit organ visualization
and can produce unclear images
• Biliary ducts are normal in size.
• Contrast medium fills the ductal media, which may produce poor-
system and flows freely. quality films
Abnormal Findings: • Improper adjustment of the radio-
• Filling defects, dilation, or shadows obese or thin patients, which can cause
within the biliary ducts, indicating overexposure or underexposure and
calculi or neoplasm poor-quality study
• Appearance of channels of contrast • Patients who are very obese, who may
medium outside of the biliary ducts, exceed the weight limit for the equip-
indicating a fistula ment
CRITICAL VALUES: N/A • Incorrect positioning of the patient,
INTERFERING FACTORS: of the area to be examined
• Presence of ascites, which may interfere
This procedure is contraindicated with the quality of the procedure
for:
• Patients who are pregnant or suspected resulting from inadequate cleansing or
of being pregnant, unless the potential failure to restrict food intake before the
benefits of the procedure far outweigh study
• Retained barium from a previous
• Patients with cholangitis. The injection radiologic procedure
of the contrast medium can
increase biliary pressure, leading
to bacteremia, septicemia, and shock. Other considerations:
• Patients with postoperative wound • Air bubbles resembling calculi may be

sepsis, hypersensitivity to iodine, seen if there is inadvertent injection
or acute renal failure. of air.
• Peritonitis may occur as a result of bile ➤ Restrict food and fluids 8 to 12 hours
extravasation. before the procedure.
➤ Note recent administration of
barium because residual barium can
before the procedure may cause the obscure the organ to be examined.
➤ 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.
Intratest:
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.
➤ 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
Cholangiopancreatography, Endoscopic Retrograde 307
is healed to perform a percutaneous ➤ A physician specializing in this

removal. branch of medicine sends a written
report to the ordering provider, who
Post-test: discusses the results with the
patient.
➤ Instruct the patient to be alert for
symptoms of delayed reaction to the ➤ Note test results in relation to
contrast medium, such as urticaria, other tests performed and the
headache, nausea, or vomiting. patient’s symptoms. Inform the
patient that an abnormal examina-
➤ Emphasize that any severe pain, tion may indicate the need for
fever, difficulty breathing, increased additional studies. Related diagnos-
pulse rate, bile extravasation, or tic tests include hepatobiliary scan;
bleeding must be reported to the hepatobiliary ultrasound; kidney,
physician immediately. ureter, and bladder film; and
➤ Instruct the patient to resume activ- computed tomography scan of the
ity, medication, and diet as directed abdomen.
after the examination.
CHOLANGIOPANCREATOGRAPHY,
ENDOSCOPIC RETROGRADE
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SYNONYM/ACRONYM: ERCP.
AREA OF APPLICATION: Gallbladder, bile ducts, pancreatic ducts.
DESCRIPTION: Endoscopic retro- jaundice, because the ducts can be

grade cholangiopancreatography visualized even when the patient’s
(ERCP) allows direct visualization of bilirubin level is high. (In contrast,
the pancreatic and biliary ducts with oral cholecystography and intra-
a flexible endoscope and, after injec- venous cholangiography are not able
tion of contrast material, with x-rays. to visualize the biliary system when
It allows the physician to view the the patient has high bilirubin levels.)
pancreatic, hepatic, and common bile By endoscopy, the distal end of the
ducts and the ampulla of Vater. common bile duct can be widened,
ERCP and percutaneous transhepatic and gallstones can be removed and
cholangiography (PTC) are the only stents placed in narrowed bile ducts
procedures that allow direct visualiza- to allow bile to be drained in jaun-
tion of the biliary and pancreatic diced patients. During endoscopy,
ducts. ERCP is less invasive and has specimens of suspicious tissue can
less morbidity than PTC. It is useful be taken for pathologic review, and
in the evaluation of patients with manometry pressure readings can
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
INDICATIONS: • A patient with Zenker’s diverticulum

involving the esophagus, who may be
• Assess jaundice of unknown cause to unable to undergo ERCP
differentiate biliary tract obstruction
• A patient with unstable cardiopul-
from liver disease
monary status, blood coagulation
• Identify obstruction caused by calculi, defects, or cholangitis (test may have to
cysts, ducts, strictures, stenosis, and be rescheduled unless patient received
anatomic abnormalities antibiotic therapy before the test)
• Retrieve calculi from the distal • A patient with known acute pancre-
common bile duct and release stric- atitis
tures
• Perform therapeutic procedures, such
as sphincterotomy and placement of Nursing Implications and
biliary drains Procedure ● ● ● ● ● ● ● ● ● ● ●
• Collect specimens for cytology Pretest:
RESULT ➤ Explain to the patient the purpose of

the study and how the procedure is
Normal Findings: performed.
• Normal appearance of the duodenal for the procedure from the patient.
papilla ➤ Obtain a history of suspected or
• Patency of the pancreatic and common existing disease of the pancreas,
bile ducts gallbladder, duct system, or other
intestinal disorders. For related
Abnormal Findings: tests, refer to the hepatobiliary and
gastrointestinal system tables.
• Duodenal papilla tumors ➤ Determine if the patient has aller-
gies or sensitivities to anesthetics,
• Pancreatic cancer analgesics, antibiotics, or iodine.
• Pancreatic fibrosis ➤ Obtain results of other tests and
procedures done to diagnose disor-
• Pancreatitis ders of or to provide treatment for
• Sclerosing cholangitis the pancreas, gallbladder, biliary
ducts, or intestinal system.
CRITICAL VALUES: N/A ➤ Explain that the procedure usually
takes 30 to 60 minutes to complete
INTERFERING FACTORS: and generally is performed in an
endoscopy suite by a physician and
• Inability of the patient to cooperate support staff. The physician inter-
with the procedure because of age, prets the results and sends the
significant pain, or mental status patient’s physician a written report,
to be discussed with the patient.
before the procedure ➤ Inform the patient that a flushed
feeling may be experienced when
• Previous surgery involving the stomach the contrast medium is injected.
Cholangiopancreatography, Endoscopic Retrograde 309
➤ 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
examination may indicate the need nostic tests include ultrasound of

for further studies. the bile ducts, hepatobiliary scan,
➤ Evaluate test results in relation and computed tomography and
to the patient’s symptoms and magnetic resonance imaging of the
other tests performed. Related diag- abdomen.
CHOLESTEROL, HDL, LDL

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

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

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
30–44 y
Male 80–185 mg/dL 2.07–4.79 mmol/L
Greater than 45 y
Male 90–185 mg/dL 2.33–4.79 mmol/L
After age 10 years, values for African Americans are approximately 10 mg/dL higher
than in whites in the same age group.
Cholesterol, HDL, LDL 311
DESCRIPTION: High-density lipo- using the following Friedewald

protein cholesterol (HDLC) and formula:
low-density lipoprotein cholesterol LDLC (Total Cholesterol)
(LDLC) are the major transport (HDLC) (VLDLC)
proteins for cholesterol in the body. It Very-low-density lipoprotein choles-
is believed that HDLC may have terol (VLDLC) is estimated by divid-
protective properties in that its role ing the triglycerides (conventional
includes transporting cholesterol units) by 5. Triglycerides in SI units
from the arteries to the liver. LDLC is would be divided by 2.18 to estimate
the major transport protein for VLDLC. It is important to note that
cholesterol to the arteries from the the formula is valid only if the triglyc-
liver. LDLC can be calculated using erides are less than 400 mg/dL or
total cholesterol, total triglycerides, 4.52 mmol/L. ■
and HDLC levels.
HDLC levels less than 40 mg/dL INDICATIONS:
in men and women represent a coro- • Determine the risk of cardiovascular
nary risk factor. There is an inverse disease
relationship between HDLC and risk
of coronary artery disease (CAD) • Evaluate the response to dietary
(i.e., lower HDLC levels represent a and drug therapy for hypercholes-
higher risk of CAD). Levels of LDLC terolemia
in terms of risk for CAD are directly • Investigate hypercholesterolemia in
proportional to risk and vary by age light of family history of cardiovascular
group. The LDLC can be estimated disease
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
HDLC increased in: HDLC decreased in:
• Exercise • A--lipoproteinemia
• Familial hyper--lipoproteinemia • Fish eye disease
• Alcoholism • Genetic predisposition or enzyme/
• Biliary cirrhosis cofactor deficiency
• Chronic hepatitis • Hypertriglyceridemia
• Obesity • Chronic anemias

• Sedentary lifestyle • Chronic pulmonary disease
• Smoking • Severe hepatocellular destruction or
• Tangier disease disease
• Chronic renal failure • Hyperthyroidism
• Cholestasis • Inflammatory joint disease
• Uncontrolled diabetes • Myeloma
• Hepatocellular disorders • Reye’s syndrome
• Premature CAD
LDLC increased in:
• Drugs that may increase HDLC levels
• Corneal arcus include albuterol, anticonvulsants,
cholestyramine, cimetidine, clofibrate
• Hyperlipoproteinemia types IIa and
and other fibric acid derivatives, estro-
IIb
gens, ethanol (moderate use), lovas-
• Premature CAD tatin, niacin, oral contraceptives,
• Tendon and tuberous xanthomas pravastatin, pindolol, prazosin, and
simvastatin.
• Anorexia nervosa
• Drugs that may decrease HDLC levels
• Chronic renal failure include acebutolol, atenolol, nonselec-
• Cushing’s syndrome tive -adrenergic blocking agents,
danazol, diuretics, etretinate, inter-
• Diabetes
feron, isotretinoin, linseed oil, meto-
• Diet high in cholesterol and saturated prolol, neomycin, probucol, pro-
fat gesterone, thiazides, and steroids.
• Dysglobulinemias • Drugs that may increase LDLC levels
• Hepatic disease include androgens, catecholamines,
chenodiol, cyclosporine, danazol,
• Hepatic obstruction diuretics, glucogenic corticosteroids,
• Hypothyroidism etretinate, and progestins.
• Nephrotic syndrome • Drugs that may decrease LDLC levels
• Porphyria include aminosalicylic acid, cholestyra-
mine, colestipol, estrogens, fibric acid
• Pregnancy derivatives, interferon, lovastatin,
neomycin, niacin, paravastatin,
LDLC decreased in: prazosin, probucol, simvastatin, tera-
zosin, and thyroxine.
• Genetic predisposition or enzyme/
cofactor deficiency • Some of the drugs used to lower total
cholesterol and LDLC or increase
• Hypolipoproteinemia and a--lipopro- HDLC may cause liver damage.
teinemia
• Grossly elevated triglyceride levels
• Tangier disease invalidate the Friedewald formula for
• Acute stress (severe burns, illness) mathematical estimation of LDLC,
and if the triglyceride is greater than collection takes approximately 5 to

400 mg/dL, the formula should not be 10 minutes.
used.
Intratest:
• Fasting before specimen collection is
highly recommended. Ideally the ➤ Ensure that the patient has complied
patient should be on a stable diet for 3 with dietary preparations and other
weeks and fast 12 hours before speci-
men collection. ➤ Direct the patient to breathe
movement.
Pretest: red- or tiger-top tube.
allergens.
Post-test:
cardiovascular system and results of ➤ Observe venipuncture site for bleed-
previously performed tests and ing or hematoma formation. Apply
procedures. The presence of other pressure bandage.
risk factors, such as family history of ➤ Instruct the patient to resume usual
heart disease, smoking, obesity, diet and medication as directed by
diet, lack of physical activity, hyper- the health care practitioner.
tension, diabetes, previous myocar-
dial infarction, and previous vascular ➤ Decreased HDLC level and in-
disease, should be investigated. For creased LDLC level may be associ-
related tests, refer to the cardiovas- ated with CAD. Nutritional therapy is
cular system table. recommended for the patient identi-
fied to be at high risk for developing
➤ Obtain a list of medications the CAD. If overweight, the patient
patient is taking, including herbs, should be encouraged to achieve a
nutritional supplements, and normal weight. The American Heart
nutraceuticals. The requesting health Association Step 1 and Step 2 diets
care practitioner and laboratory may be helpful in achieving a goal
should be advised if the patient of lowering total cholesterol and
regularly uses these products so triglyceride levels. The Step 1 diet
that their effects can be taken into emphasizes a reduction in foods
consideration when reviewing high in saturated fats and choles-
results. terol. Red meats, eggs, and dairy
➤ Instruct the patient to fast 12 hours products are the major sources of
before specimen collection. saturated fats and cholesterol. If
➤ Confirm with the requesting health triglycerides also are elevated, the
care practitioner that the patient patient should be advised to elimi-
should withhold medications known nate or reduce alcohol and simple
to influence test results, and instruct carbohydrates from the diet. The
the patient accordingly. Step 2 diet recommends stricter
reductions.
➤ There are no fluid restrictions unless
by medical direction. ➤ Numerous studies point to the
prevalence of excess body weight in
➤ Review the procedure with the American children and adolescents.
patient. Experts estimate that obesity is
➤ Inform the patient that specimen present in 25 percent of the popula-
tion aged 6 to 11 years. The medical, ➤ Evaluate test results in relation to

social, and emotional consequences the patient’s symptoms and other
of excess body weight are signifi- tests performed. Related laboratory
cant. Special attention should be tests include apolipoprotein A and B,
given to instructing the child and C-reactive protein, total cholesterol,
caregiver regarding health risks and homocysteine, lipoprotein elec-
weight-control education. trophoresis, and triglycerides.
CHOLESTEROL, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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.
DESCRIPTION: Cholesterol is a lipid intestinal mucosa. Cholesterol is an

needed to form cell membranes and a integral component in cell membrane
component of the materials that maintenance and hormone produc-
render the skin waterproof. It also tion. Very low cholesterol values, as is
helps form bile salts, adrenal cortico- sometimes seen in critically ill
steroids, estrogen, and androgens. patients, can be as life-threatening as
Cholesterol is obtained from the diet very high levels.
(exogenous cholesterol) and also According to the National
synthesized in the body (endogenous Cholesterol Education Program,
cholesterol). Although most body maintaining cholesterol levels less
cells can form some cholesterol, it is than 200 mg/dL significantly reduces
produced mainly by the liver and the risk of coronary heart disease; no
Cholesterol, Total 315
age and gender stratification is • Diets high in cholesterol and fats

presented as part of its recommenda- • Familial hyperlipoproteinemia
tion. Numerous studies have been
done, and there are inconsistencies • Glomerulonephritis
among the studies as to target • Glycogen storage disease (von Gierke
“normals” segregated by age and disease)
gender. Beyond the total cholesterol • Gout
and high-density lipoprotein choles-
terol (HDLC) values, other impor- • Hypothyroidism (primary)
tant risk factors must be considered. • Ischemic heart disease
Many myocardial infarctions occur
even in patients whose cholesterol
levels are considered to be within • Obesity
acceptable limits or who are in a • Pancreatic and prostatic malignancy
moderate-risk category. The combi-
• Pregnancy
nation of risk factors and lipid values
helps identify individuals at risk so • Werner’s syndrome
that appropriate interventions can
be taken. If the cholesterol level is Decreased in:
greater than 200 mg/dL, repeat test- • Burns
ing after a 12- to 24-hour fast is
• Chronic myelocytic leukemia
recommended. ■
• Chronic obstructive pulmonary disease
INDICATIONS: • Hyperthyroidism
• Assist in determining risk of cardiovas-
• Liver disease (severe)
cular disease
• Malabsorption and malnutrition
• Assist in the diagnosis of nephrotic
syndromes
syndrome, hepatic disease, pancreatitis,
and thyroid disorders • Myeloma
• Evaluate the response to dietary and • Pernicious anemia
drug therapy for hypercholesterolemia
• Investigate hypercholesterolemia in
• Severe illness
light of family history of cardiovascular
disease • Sideroblastic anemias
• Tangier disease
RESULT
• Thalassemia
Increased in:
• Waldenström’s macroglobulinemia
• Acute intermittent porphyria
• Alcoholism
• Anorexia nervosa INTERFERING FACTORS:
• Cholestasis • Drugs that may increase cholesterol
levels include amiodarone, androgens,
• Chronic renal failure
catecholamines, cyclosporine, danazol,
• Diabetes (with poor control) diclofenac, disulfiram, glucogenic
corticosteroids, ibuprofen, iso- dures. The presence of other risk

tretinoin, levodopa, methyclothiazide, factors, such as family history of
miconazole (owing to castor oil heart disease, smoking, obesity,
vehicle, not the drug), nafarelin, diet, lack of physical activity, hyper-
tension, diabetes, previous myocar-
nandrolone, some oral contracep- dial infarction, and previous vascular
tives, oxymetholone, phenobarbital, disease, should be investigated. For
phenothiazine, prochlorperazine, and related tests, refer to the cardiovas-
sotalol. cular, gastrointestinal, hematopoi-
etic, and hepatobiliary system
• Drugs that may decrease cholesterol tables.
levels include acebutolol, amiloride,
aminosalicylic acid, ascorbic acid, ➤ Obtain a list of medications the
asparaginase, atenolol, atorvastatin, nutritional supplements, and nutra-
beclobrate, bezafibrate, carbutamide, ceuticals. The requesting health care
cerivastatin, cholestyramine, ciprofi- practitioner and laboratory should be
brate, clofibrate, clonidine, colestipol, advised if the patient regularly uses
dextrothyroxine, doxazosin, enalapril, these products so that their effects
estrogens, fenofibrate, fenfluramine, can be taken into consideration
fluvastatin, gemfibrozil, haloperidol, when reviewing results.
hydralazine, interferon, lovastatin, ➤ Instruct the patient to withhold alco-
neomycin, niacin, pravastatin, probu- hol and drugs known to alter choles-
col, simvastatin, tamoxifen, terazosin, terol levels for 12 to 24 hours before
thyroxine, ursodiol, and verapamil. specimen collection, at the direction
of the health care practitioner.
• Ingestion of alcohol 12 to 24 hours ➤ There are no fluid or medication
before the test can falsely elevate restrictions unless by medical direc-
results. tion.
• Ingestion of drugs that alter cholesterol ➤ Fasting 6 to 12 hours before speci-
levels within 12 hours of the test may men collection is required if triglyc-
give a false impression of cholesterol eride measurements are included; it
is recommended if cholesterol levels
levels, unless the test is done to evalu- alone are measured for screening.
ate such effects.
• Positioning can affect results; lower patient.
levels are obtained if the specimen is ➤ Inform the patient that specimen
from a patient who has been supine for collection takes approximately 5 to
20 minutes. 10 minutes.
Intratest:
Nursing Implications and with dietary preparations and other
Procedure ● ● ● ● ● ● ● ● ● ● ● pretesting restrictions.
➤ 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.
Chromosome Analysis, Blood 317
Post-test: terol. If triglycerides are also

elevated, the patient should be
➤ Observe venipuncture site for bleed- advised to eliminate or reduce alco-
ing or hematoma formation. Apply hol and simple carbohydrates from
pressure bandage. the diet. The Step 2 diet recom-
➤ Instruct the patient to resume usual mends stricter reductions.
diet and medication as directed by ➤ Numerous studies point to the
the health care practitioner. prevalence of excess body weight in
➤ Secondary causes for increased American children and adolescents.
cholesterol levels should be ruled Experts estimate that obesity is
out before therapy to decrease present in 25 percent of the popula-
levels is initiated by use of drugs. tion aged 6 to 11 years. The medical,
➤ Increases in total cholesterol levels social, and emotional consequences
may be associated with coronary of excess body weight are signifi-
artery disease (CAD). Nutritional cant. Special attention should be
therapy is recommended for given to instructing the child and
patients identified to be at high risk caregiver regarding health risks and
for developing CAD. If overweight, weight control education.
the patient should be encouraged to ➤ Evaluate test results in relation to
achieve a normal weight. The the patient’s symptoms and other
American Heart Association Step 1 tests performed. Related laboratory
and Step 2 diets may be helpful in tests include apolipoprotein A and B,
achieving a goal of lowering total C-reactive protein, HDLC, low-
cholesterol and triglyceride levels. density lipoprotein cholesterol, very-
The Step 1 diet emphasizes a reduc- low-density lipoprotein cholesterol,
tion in foods high in saturated fats chylomicrons, creatine kinase and
and cholesterol. Red meats, eggs, isoenzymes, homocysteine, lipopro-
and dairy products are the major tein electrophoresis, myoglobin,
sources of saturated fats and choles- triglycerides, and troponin.
CHROMOSOME ANALYSIS, BLOOD

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

chromosomal abnormalities identified.
DESCRIPTION: Testing for birth de- tardation can be accomplished

fects as well as mental and physical re- through the use of several technolo-
gies. Chromosome analysis by INDICATIONS:

phytohemagglutination assay is
• Evaluate conditions related to crypt-
used to detect Down’s syndrome orchidism, hypogonadism, primary
and abnormal sexual development. amenorrhea, and infertility
Fluorescence in situ hybridization
(FISH) testing is useful in the • Evaluate congenital anomaly, delayed
detection of specific microdele- development (physical or mental),
tion syndromes (e.g., Prader-Willi, mental retardation, and ambiguous
Angelman, Beckwith-Wiedemann, sexual organs
Smith-Magenis, DiGeorge, Williams, • Investigate the carrier status of patients
Miller-Dieker) and other acquired or relatives with known genetic abnor-
chromosomal changes associated malities
with hematologic disorders. Amniotic
• Investigate the cause of multiple
fluid, chorionic villus sampling, and
miscarriages
cells from fetal tissue or products of
conception can also be evaluated for • Provide prenatal care or genetic coun-
chromosomal abnormalities. ■ seling
RESULT: The following tables list some common genetic defects:
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

Chromosome Analysis, Blood 319
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
Syndrome Sex-Chromosome Defect Features

XYY 47,XYY Tall, increased risk of
behavioral problems
Klinefelter’s 47,XXY Hypogonadism, infertility,
underdeveloped
secondary sex
characteristics, learning
disabilities
Triple X 47,XXX Increased risk of infertility
and learning disabilities
Ullrich-Turner 45,X Short, gonadal
dysgenesis, webbed
neck, low posterior
hairline, renal and
cardiovascular
abnormalities
CRITICAL VALUES: N/A disorders, and results of previously

related tests, refer to the reproduc-
INTERFERING FACTORS: N/A tive system table.
Nursing Implications and herbs, nutritional supplements, and
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: should be advised if the patient
➤ Obtain a history of the patient’s that their effects can be taken into
complaints, including a list of known consideration when reviewing
allergens. results.
➤ Obtain a history of the patient’s ➤ There are no food, fluid, or medica-
reproductive system, family history tion restrictions unless by medical
of known or suspected genetic direction.
➤ Review the procedure with the clinical implications of the test

patient. results, as appropriate. Encourage
➤ Inform the patient that specimen the family to seek counseling if they
collection takes approximately 5 to are contemplating pregnancy termi-
10 minutes. nation or to seek genetic counseling
if a chromosomal abnormality is
Intratest: determined. Decisions regarding
elective abortion should occur in
➤ Direct the patient to breathe the presence of both parents.
normally and to avoid unnecessary Provide a nonjudgmental, nonthreat-
movement. ening atmosphere for discussing the
➤ Observe standard precautions and risks and difficulties of delivering and
follow the general guidelines in raising an abnormal infant, as well as
Appendix A. Perform a venipuncture, exploring other options (termination
and collect the specimen in a 5-mL of pregnancy or adoption). It is also
green-top tube. important to discuss feelings the
mother and father may experience
(e.g., guilt, depression, anger) if fetal
abnormalities are detected. Educate
Post-test: the patient and family regarding
access to counseling services, as
➤ Observe venipuncture site for bleed- appropriate.
ing or hematoma formation. Apply ➤ Evaluate test results in relation to
pressure bandage. the patient’s symptoms and other
➤ Respond to anxiety the patient may tests performed. Related laboratory
experience because of the sensitive tests include amniotic fluid analysis,
nature of the testing. Provide teach- 1-fetoprotein, and chorionic villus
ing and information regarding the biopsy.
CLOT RETRACTION
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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.
DESCRIPTION: The clot retraction extent of clot retraction. Normally,

test measures the adequacy of platelet when blood clots in a test tube, it
function by measuring the speed and retracts away from the sidewalls of the
Clot Retraction 321
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,
adenosine triphosphate (ATP), and
Procedure ● ● ● ● ● ● ● ● ● ● ●
pyruvate kinase. Clot retraction is also
influenced by hematocrit and by Pretest:
fibrinogen structure and concentra-
tion. ■ complaints, including a list of known
allergens.
• Evaluate the adequacy of platelet func- hematopoietic system and results of
tion previously performed tests and
• Evaluate thrombocytopenia of to the hematopoietic system table.
unknown origin ➤ Obtain a list of medications the
• 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
RESULT consideration when reviewing
results.
Increased in: N/A ➤ Note any recent procedures that can
Decreased in: Glanzmann’s throm- ➤ There are no food, fluid, or medica-
basthenia tion restrictions unless by medical
direction.
patient.
• 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
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.
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: See table.

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

50 to 150 percent.
Preferred Name Synonym

Factor I Fibrinogen —
Factor II Prothrombin Prethrombin
Factor III Tissue factor Tissue thromboplastin
Factor IV Calcium Ca2
Factor V Proaccelerin Labile factor, accelerator
globulin (AcG)
Factor VII Proconvertin Stabile factor, serum
prothrombin conversion
accelerator,
autoprothrombin I
Factor VIII:C Antihemophilic factor Antihemophilic globulin
(AHF) (AHG), antihemophilic
factor A, platelet cofactor 1
Factor IX Plasma thromboplastin Christmas factor,
component (PTC) antihemophilic factor B,
platelet cofactor 2
Factor X Stuart-Prower factor Autoprothrombin III,
thrombokinase

Coagulation Factors 323
Preferred Name Synonym

Factor XI Plasma thromboplastin Antihemophilic factor C
antecedent (PTA)
Factor XII Hageman factor Glass factor, contact factor
Factor XIII Fibrin-stabilizing factor Laki-Lorand factor (LLF),
(FSF) fibrinase, plasma
transglutinase
Prekallikrein Fletcher factor
High-molecular-weight Fitzgerald factor, contact
kininogen (HMWK) activation cofactor,
Williams factor, Falujenc
factor
DESCRIPTION: The coagulation pro- factors I, V, VIII, and XIII. They

teins respond to blood vessel injury in are the most labile of the
factors and are consumed
a chain of events. The intrinsic and
during the coagulation process.
extrinsic pathways of secondary he- The factors listed in the table
mostasis are a series of reactions in- are the ones most commonly
volving the substrate protein fibrino- measured. ■
gen, the coagulation factors (also
known as enzyme precursors or zymo- INDICATIONS:
gens), nonenzymatic cofactors (Ca2 ), • Identify the presence of inherited
and phospholipid. The factors were bleeding disorders
assigned Roman numerals in the
• Identify the presence of qualitative or
order of their discovery, not their quantitative factor deficiency
place in the coagulation sequence.
Factor VI was originally thought to be RESULT
a separate clotting factor. It was sub-
sequently proved to be the same as a Increased in: N/A
modified form of Factor V, and there-
fore the number is no longer used. Decreased in:
The coagulation factors are formed • Congenital deficiency
in the liver. They can be divided into
three groups based on their common • Disseminated intravascular coagula-
tion
properties:
• Liver disease
1. The contact group is activated
in vitro by a surface such as CRITICAL VALUES: N/A
glass and is activated in vivo by
collagen. The contact group INTERFERING FACTORS:
includes factor XI, factor XII,
prekallikrein, and high- • Drugs that may increase factor II
molecular-weight kininogen. levels include fluoxymesterone,
methandrostenolone, nandrolone, and
2. The prothrombin or vitamin
K–dependent group includes
oxymetholone.
factors II, VII, IX, and X. • Drugs that may decrease factor II levels
3. The fibrinogen group includes include warfarin.
• 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 ● ● ● ● ● ● ● ● ● ● ●
levels include chlormadinone and oral

contraceptives. Pretest:
• Drugs that may decrease factor IX ➤ Obtain a history of the patient’s
levels include asparaginase and complaints, including a list of known
warfarin. allergens.
• Drugs that may decrease factor X levels hematopoietic and hepatobiliary
include chlormadinone, dicumarol, systems, any bleeding disorders,
oral contraceptives, and warfarin. and results of previously performed
• Drugs that may decrease factor XI bleeding time, clotting time,
levels include asparaginase and capto- complete blood count, partial throm-
pril. boplastin time, platelets, and
prothrombin time. For related tests,
• Drugs that may decrease factor XII refer to the hematopoietic and hepa-
levels include captopril. tobiliary system tables.
• Test results of patients on anticoagu- ➤ Obtain a list of medications the
lant therapy are unreliable. patient is taking, including anticoag-
ulant therapy, acetylsalicylic acid,
• Placement of tourniquet for longer herbals, and nutraceuticals known
than 1 minute can result in venous to affect coagulation. It is recom-
stasis and changes in the concentration mended that use of these
of plasma proteins to be measured. substances be discontinued 14 days
Platelet activation may also occur before dental or surgical procedures.
under these conditions, causing erro-
neous results. advised if the patient regularly uses
• Vascular injury during phlebotomy can these products so that their effects
activate platelets and coagulation can be taken into consideration
factors, causing erroneous results.
• Hemolyzed specimens must be rejected tion restrictions unless by medical
because hemolysis is an indication of direction.
Cold Agglutinin Titer 325
➤ 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:
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.
COLD AGGLUTININ TITER

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

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

against type O RBCs at 2C to 8C. Type O cells are used because they have
no antigens on the cell membrane surface. Agglutination with patient sera
would not occur because of reaction between RBC blood type antigens and
patient blood type antibodies.) Negative: Single titer less than 1:32 or less
than a fourfold increase in titer over serial samples.
DESCRIPTION: Cold agglutinins are 25 days and begin to diminish 30

antibodies that cause clumping or days after onset. ■
agglutination of RBCs at cold
temperatures in individuals with INDICATIONS:
certain conditions or who are infected • Assist in the confirmation of primary
by particular organisms. Cold agglu- atypical pneumonia, influenza, or
tinins are associated with Mycoplasma pulmonary embolus
pneumoniae infection. M. pneumoniae
• Provide additional diagnostic support
has I antigen specificity to human
for cold agglutinin disease associated
RBC membranes. Fetal cells largely with viral infections or lymphoreticular
contain i antigens, but by 18 months cancers
most cells carry the I antigen. The
agglutinins are usually immunoglobu- RESULT
lin M (IgM) antibodies and cause
agglutination of cells at temperatures Increased in:
in the range of 0C to 10C. The
temperature of circulating blood in
the extremities may be lower than • Malaria
core temperatures. RBCs of affected • Multiple myeloma
individuals may agglutinate and
obstruct blood vessels in fingers, toes, • M. pneumoniae (primary atypical
pneumonia)
and ears, or they may initiate the
complement cascade. Affected cells • Raynaud’s syndrome (severe)
may be lysed immediately within the • Systemic lupus erythematosus
capillaries and blood vessels as a result
of the action of complement on the • Trypanosomiasis
cell wall, or they may return to the
Decreased in: N/A
circulatory system and be lysed in the
spleen by macrophages.
The titer end point is the highest
dilution of serum that shows a INTERFERING FACTORS:
specific antigen-antibody reaction.
Single titers greater than 1:64, or a • Antibiotic use may interfere with or
fourfold increase in titer between decrease antibody production.
specimens collected 5 or more days • A high antibody titer may interfere
apart, are clinically significant. with blood typing and crossmatching
Patients affected with primary atypi- procedures.
cal viral pneumonia exhibit a rise in • High titers may appear spontaneously
titer 8 to 10 days after the onset of in elderly patients and persist for many
illness. IgM antibodies peak in 12 to years.
Collagen Crosslinked N-Telopeptide 327
• 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.
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.
immune and respiratory systems,
as well as results of previously Post-test:
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.
when reviewing results. ➤ Evaluate test results in relation to
➤ 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.
SPECIMEN: Urine (2 mL) from a random specimen collected in a clean

plastic container.
Male 0–85 nmol bone collagen

equivalents/mmol
creatinine
Female (premenopausal) 14–76 nmol bone collagen
equivalents/mmol
creatinine
DESCRIPTION: Osteoporosis is the mechanism is unknown. Results of

most common bone disease in the some recently published studies indi-
West. It is often called the “silent dis- cate that there may be significant ad-
ease” because bone loss occurs with- verse side effects to estrogen replace-
out symptoms. The formation and ment therapy; more research is
maintenance of bone mass is depend- needed to understand the long-term
ent on a combination of factors that effects (positive and negative) of this
include genetics, nutrition, exercise, therapy. Other treatments include
and hormone function. Normally the raloxifene (selectively modulates es-
rate of bone formation is equal to the trogen receptors), calcitonin (interacts
rate of bone resorption. After midlife, directly with osteoclasts), and bispho-
the rate of bone loss begins to in- sphates (inhibit osteoclast-mediated
crease. Osteoporosis is more com- bone resorption).
monly identified in women than in A noninvasive test to detect the
men. Other risk factors include thin, presence of collagen crosslinked
small-framed body structure; family N-telopeptide (NTx) is used to follow
history of osteoporosis; diet low in the progress of patients who have
calcium; Caucasian or Asian race; ex- begun treatment for osteoporosis.
cessive use of alcohol; cigarette smok- NTx is formed when collagenase acts
ing; sedentary lifestyle; long-term use on bone. Small NTx fragments are
of corticosteroids, thyroid replace- excreted in the urine after bone
ment medications, or antiepileptics; resorption. A desirable response, 2 to
history of bulimia, anorexia nervosa, 3 months after therapy is initiated, is
chronic liver disease, or malabsorp- a 30 percent reduction in NTx and a
tion disorders; and postmenopausal reduction of 50 percent below base-
state. Osteoporosis is a major conse- line by 12 months. ■
quence of menopause in women
owing to the decline of estrogen pro- INDICATIONS:
duction. Osteoporosis is rare in pre-
• Assist in the evaluation of osteoporosis
menopausal women. Estrogen re-
placement therapy (after menopause) • Assist in the management and treat-
is one strategy that has been com- ment of osteoporosis
monly employed to prevent osteo- • Monitor effects of estrogen replace-
porosis, although its exact protective ment therapy
Collagen Crosslinked N-Telopeptide 329
RESULT ➤ Inform the patient that specimen

10 minutes.
Increased in:
• Hyperparathyroidism Intratest:
• Osteomalacia ➤ Observe standard precautions and
• 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.
CRITICAL VALUES: N/A transport it to the laboratory.
INTERFERING FACTORS: Post-test:

• NTx levels are affected by urinary ➤ Increased NTx levels may be associ-
excretion, and values may be influ- ated with osteoporosis. Nutritional
enced by the presence of renal impair- therapy may be indicated for
ment or disease. patients identified as being at high
risk for developing osteoporosis.
Educate the patient about the
National Osteoporosis Foundation’s
Nursing Implications and guidelines regarding a regular regi-
Procedure ● ● ● ● ● ● ● ● ● ● ● men of weight-bearing exercises,
limited alcohol intake, avoidance of
Pretest: tobacco products, and adequate
dietary intake of vitamin D (400 to
➤ Obtain a history of the patient’s 800 IU/d) and calcium (120 mg/d).
complaints, including a list of known Dietary calcium can be obtained in
allergens. animal or plant sources. Milk and
➤ Obtain a history of the patient’s milk products, sardines, clams,
musculoskeletal and reproductive oysters, salmon, rhubarb, spinach,
systems, as well as results of previ- beet greens, broccoli, kale, tofu,
ously performed tests and proce- legumes, and fortified orange juice
dures. For related tests, refer to the are high in calcium. Milk and milk
musculoskeletal and reproductive products also contain vitamin D and
system tables. lactose to assist in absorption.
➤ Obtain a list of medications the Cooked vegetables yield more
patient is taking, including herbs, absorbable calcium than raw vegeta-
nutritional supplements, and nutra- bles. Patients should also be
ceuticals. The requesting health care informed of the substances that can
practitioner and laboratory should be inhibit calcium absorption by irre-
advised if the patient is regularly versibly binding to some of the
using these products so that their calcium and making it unavailable
effects can be taken into considera- for absorption, such as oxalates,
tion when reviewing results. which naturally occur in some
vegetables; phytic acid, found in
➤ There are no food, fluid, or medica- some cereals; and excessive intake
tion restrictions unless by medical of insoluble dietary fiber. Excessive
direction. protein intake also can affect calcium
➤ Review the procedure with the absorption negatively, especially if it
patient. is combined with foods high in phos-
phorus. Vitamin D is synthesized by tests performed. Related laboratory

the skin and is available in fortified tests include alkaline phosphatase,
dairy foods and cod liver oil. serum and urine calcium, phospho-
➤ Evaluate test results in relation to rus, calcitonin, parathyroid hormone,
the patient’s symptoms and other phosphorus, and vitamin D.
COLONOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Full colonoscopy, lower endoscopy, lower panen-

doscopy.

CONTRAST: Air.
DESCRIPTION: Colonoscopy allows INDICATIONS:

inspection of the mucosa of the entire • Determine cause of lower GI disorders,
colon, ileocecal valve, and terminal especially when barium enema and
ileum using a flexible fiberoptic proctosigmoidoscopy are inconclusive
colonoscope inserted through the
• Determine source of rectal bleeding
anus and advanced to the terminal and perform hemostasis by coagulation
ileum. The colonoscope is a multi-
channel instrument that allows view- • Remove foreign bodies and sclerosing
strictures by laser
ing of the gastrointestinal (GI) tract
lining, insufflation of air, aspiration of • Confirm diagnosis of colon cancer and
fluid, obtaining of tissue biopsy inflammatory bowel disease
samples, and passage of a laser beam • Follow up on previously diagnosed and
for obliteration of tissue and control treated colon cancer
of bleeding. Mucosal surfaces of the • Detect Hirschsprung’s disease and
lower GI tract are examined for ulcer- determine the areas affected by the
ations, polyps, chronic diarrhea, disease
hemorrhagic sites, neoplasms, and • Reduce volvulus and intussusception
strictures. During the procedure, in children
tissue samples may be obtained for
• Remove colon polyps
cytology, and some therapeutic proce-
dures may be performed, such as exci- • Investigate iron-deficiency anemia of
sion of small tumors or polyps, unknown origin
coagulation of bleeding sites, and • Evaluate postsurgical status of colon
removal of foreign bodies. ■ resection
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
Abnormal Findings: remain still during the procedure
• Bleeding sites
mental status
• Benign lesions
• Bowel distention exceed the weight limit for the equip-
ment
• Bowel infection or inflammation
• Colon cancer
• 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
CRITICAL VALUES: N/A • Failure to follow dietary restric-
tions before the procedure may cause
INTERFERING FACTORS: the procedure to be canceled or
repeated.
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.
barium because it can obscure the

Nursing Implications and area to be examined.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Resuscitation equipment should be
readily available.
Pretest:
➤ Explain to the patient the purpose of Intratest:
performed. ➤ Two hours before the procedure,
administer a warm tap water or
➤ Obtain a written, informed consent saline enema until the returns are
for the procedure from the patient. clear or as ordered.
➤ Obtain a history of GI disorders, ➤ Have the patient put on a hospital
noting any information relating to gown and void.
lower bowel, anal, rectal, or coagula-
tion disorders. ➤ An intravenous (IV) line may be
started to allow infusion of a seda-
➤ Note use of drugs that affect bleed- tive or IV fluids.
ing, such as aspirin and other salicy-
lates. ➤ Obtain baseline vital signs.
➤ Note intake of oral iron preparations ➤ Administer ordered sedation.
1 week before the procedure ➤ The patient is placed on an examina-
because these cause black, sticky tion table in the left lateral decubitus
feces that are difficult to remove position and draped with the
with bowel preparation. buttocks exposed.
➤ Obtain the results of other tests ➤ The physician performs a visual
(particularly hematologic or coagula- inspection of the perianal area and a
tion tests), treatments, surgeries, digital rectal examination.
medication usage, and procedures ➤ The patient is requested to bear
done to diagnose or treat disorders down as if having a bowel move-
of the intestinal system. For related ment as the fiberoptic tube is
tests, refer to the gastrointestinal inserted through the rectum.
system table.
➤ The scope is advanced through the
➤ Determine date of last menstrual sigmoid. The patient’s position is
period and possibility of pregnancy changed to supine to facilitate
in perimenopausal women. passage into the transverse colon.
➤ Explain that the procedure usually Air is insufflated through the tube
takes 30 to 60 minutes to complete during passage to aid in visualiza-
and is generally performed in an tion.
endoscopy suite by a physician and ➤ The patient is instructed to take
support staff. deep breaths to aid in movement of
➤ Restrict the diet to clear liquids for the scope downward through the
48 hours before beginning oral ascending colon to the cecum and
bowel preparation. into the terminal portion of the
➤ Ensure that ordered laxatives have ileum.
been administered late in the after- ➤ Air is insufflated to distend the GI
noon of the day before the proce- tract, as needed. Biopsies, cultures,
dure. or any endoscopic surgery is
➤ Inform the patient that it is important performed.
that the bowel be cleaned thor- ➤ Foreign bodies or polyps are
oughly so that the physician can removed and placed in appropriate
visualize the colon and that the specimen containers, labeled prop-
patient will have to receive enemas erly, and sent to the laboratory.
before the test. ➤ Photographs are obtained for future
➤ Note recent administration of reference.
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Endometrial biopsy, cervical biopsy.

AREA OF APPLICATION: Vagina and cervix.
CONTRAST: None.
DESCRIPTION: In this procedure, the magnifies the mucosal surfaces.

vagina and cervix are viewed using a Colposcopy is usually performed
colposcope, a special binocular after suspicious Papanicolaou (Pap)
microscope and light system that test results or when suspected lesions
cannot be visualized fully by the • Invasive carcinoma

naked eye. The procedure is useful for • Infection
identifying areas of cellular dysplasia
and diagnosing cervical cancer • Inflammation
because it provides the best view of • Leukoplakia
the suspicious lesion, ensuring that
the most representative area of the CRITICAL VALUES: N/A
lesion is obtained for cytologic analy-
sis to confirm malignant changes. INTERFERING FACTORS:
Colposcopy is also valuable for assess-
ing women with a history of exposure This procedure is contraindicated
to diethylstilbestrol (DES) in utero. for:
The goal is to identify precursor • Patients who are pregnant or suspected
changes in cervical tissue before the of being pregnant, unless the potential
changes advance from benign or atyp- benefits of the procedure far outweigh
ical cells to cervical cancer. the risks to the fetus and mother
Photographs (cervicography) can also • Patients with cardiac conditions
be taken of the cervix. ■
• Patients with bleeding disorders, espe-
INDICATIONS: cially if cervical biopsy specimens are
to be obtained
• Evaluate the cervix after abnormal Pap
smear • Women who are currently menstruat-
ing
• Evaluate vaginal lesions
• Monitor women whose mothers took Factors that may impair clear
DES during pregnancy imaging:
• Localize the area from which cervical • Inability of the patient to cooperate or
biopsy samples should be obtained remain still during the procedure
because such areas may not be visible because of age, significant pain, or
to the naked eye mental status
• Monitor conservatively treated cervical • Inadequate cleansing of the cervix of
intraepithelial neoplasia secretions and medications
RESULT • Scarring of the cervix
Normal Findings:
• Normal appearance of the vagina and
cervix Procedure ● ● ● ● ● ● ● ● ● ● ●
• No abnormal cells or tissues Pretest:

➤ Inform the patient that the purpose
Abnormal Findings:
of the procedure is to assess the
• Atrophic changes vagina and cervix, and that it is
generally performed in a physician’s
• Cervical erosion office by a physician or nurse practi-
tioner.
• Cervical intraepithelial neoplasia
➤ Assess whether the patient is aller-
• Papilloma, including condyloma gic to latex.
Colposcopy 335
➤ Assess date of last menstrual period ➤ The cervix is swabbed with 3%

to ascertain possible pregnancy in acetic acid to remove mucus or any
perimenopausal women. The proce- cream medication and to improve
dure is contraindicated during the contrast between tissue types.
menstruation; it is best performed 1 The scope is positioned at the
week after menses ends. speculum and is focused on the
➤ Obtain a history of the patient’s cervix. The area is examined care-
reproductive system and previously fully, using light and magnification.
performed laboratory tests (espe- Photographs can be taken for future
cially Pap test and blood clotting reference.
times), surgeries, therapies, and ➤ Tissues that appear abnormal or
procedures. For related tests, refer atypical undergo biopsy using a
to the reproductive system table. forceps inserted through the specu-
➤ Obtain a history of the patient’s lum. Bleeding, which is common
complaints, including a list of known after cervical biopsy, may be
allergens. controlled by cautery, suturing, or
application of silver nitrate or ferric
➤ Obtain a list of the medications the subsulfate (Monsel’s solution) to the
patient is taking, including herbs, site.
nutritional supplements, and nutra-
ceuticals. The requesting health care ➤ The vagina is rinsed with sterile
practitioner and laboratory should be saline or water to remove the acetic
advised if the patient regularly uses acid and prevent burning after the
these products so that their effects procedure. If bleeding persists, a
can be taken into consideration tampon may be inserted after
when reviewing results. removal of the speculum.
➤ Do not restrict food or fluids before ➤ Biopsy samples are placed in appro-
the test. priate containers with special pre-
servative solution, labeled properly,
➤ Explain to the patient that if a and promptly taken to the laboratory.
biopsy is performed, she may feel
menstrual-like cramping during the
procedure and experience a minimal Post-test:
amount of bleeding.
➤ Inform the patient to remove the
➤ Gloves are worn throughout the vaginal tampon, if inserted, within 8
procedure. to 24 hours; after that time, the
➤ Obtain a written, informed consent patient should wear pads if there is
for the procedure from the patient. bleeding or drainage.
➤ Inform the patient that the proce- ➤ Inform the patient that if a biopsy
dure lasts approximately 10 to 15 was performed, a discharge may
minutes. persist for a few days to a few
weeks.
Intratest: ➤ Advise the patient to avoid strenu-
ous exercise 8 to 24 hours after the
➤ Ask the patient to remove clothing procedure, and to avoid douching
from the waist down. and intercourse for about 2 weeks or
➤ Give the patient a gown and robe to as directed by the practitioner.
wear; have the patient void. ➤ Emphasize that persistent vaginal
➤ Place the patient in the lithotomy bleeding or abnormal vaginal
position on the examining table and discharge, abdominal pain, and fever
drape. Cleanse the external genitalia must be reported to the physician
with an antiseptic solution. immediately.
➤ If a Pap smear is performed, the ➤ Inform the patient that further test-
vaginal speculum is inserted, using ing may be necessary to evaluate
water as a lubricant. the success of the therapy or to
determine the need for a change in ➤ A physician specializing in this

therapy. branch of medicine sends a written
➤ Evaluate for signs of infection, such report to the ordering provider, who
as pain, fever, increased pulse rate, discusses the results with the
chills, flushing, abdominal pain, patient.
tachycardia, or muscle aches. ➤ Evaluate test results in relation to
➤ Determine if the patient or family the patient’s symptoms and any
members have any further ques- related tests performed.
tions or concerns.
COMPLEMENT C3 AND
COMPLEMENT C4
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: C3 and C4.

C3
SI Units
Newborn 57–116 mg/dL 570–1160 mg/L
6 mo–adult 74–166 mg/dL 740–1660 mg/L
Adult 83–177 mg/dL 830–1770 mg/L
C4
SI Units
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
Complement C3 and Complement C4 337
DESCRIPTION: Complement is an essential activating protein in the

proteins act as enzymes that aid in the classic and alternate complement
immunologic and inflammatory cascades. It is decreased in patients
response. The complement system is with immunologic diseases, in whom
an important mechanism for the it is consumed at an increased rate.
destruction and removal of foreign C4 is produced primarily in the liver
materials. Serum complement levels but can also be produced by mono-
are used to detect autoimmune cytes, fibroblasts, and macrophages.
diseases. C3 and C4 are the most C4 participates in the classic comple-
frequently assayed complement ment pathway. ■
proteins, along with total comple-
ment.
Circulating C3 is synthesized in INDICATIONS:
the liver and comprises 70 percent of • Detect genetic deficiencies
the complement system, but cells in
other tissues can also produce C3. C3 • Evaluate immunologic diseases
RESULT
Normal C4 and Acute glomerulonephritis, membranous

decreased C3 glomerulonephritis, immune complex
diseases, SLE, C3 deficiency
Decreased C4 and Immune complex diseases,
normal C3 cryoglobulinemia, C4 deficiency,
hereditary angioedema
Decreased C4 and Immune complex diseases

decreased C3
Increased in: Decreased in:
• 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)
Autoimmune hemolytic anemia ➤ Obtain a list of medications the

Autoimmune thyroiditis patient is taking, including herbs,
Cryoglobulinemia ceuticals. The requesting health care
Glomerulonephritis practitioner and laboratory should be
Juvenile dermatomyositis advised if the patient regularly uses
Meningitis (bacterial, viral) these products so that their effects
Pneumonia when reviewing results.
Streptococcal or staphylococcal ➤ There are no food, fluid, or medica-
sepsis tion restrictions unless by medical
direction.
patient.
• Drugs that may increase C3 levels collection takes approximately 5 to
include cimetidine and cyclophos- 10 minutes.
phamide.
Intratest:
• Drugs that may decrease C3 levels
include danazol and phenytoin. ➤ Direct the patient to breathe
• Drugs that may increase C4 levels movement.
include cimetidine, cyclophospha- ➤ Observe standard precautions and
mide, and danazol. follow the general guidelines in
• Drugs that may decrease C4 levels and collect the specimen in a 5-mL
include dextran and penicillamine. red-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ● Post-test:
Pretest: ➤ Observe venipuncture site for bleed-
➤ Obtain a history of the patient’s pressure bandage.
complaints, including a list of known ➤ Evaluate test results in relation to
allergens. the patient’s symptoms and other
immune system and results of previ- tests include anticardiolipin antibody,
ously performed tests and proce- antinuclear antibodies, total comple-
dures. For related tests, refer to the ment, and erythrocyte sedimenta-
immune system table. tion rate.
COMPLEMENT, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Total hemolytic complement, CH50, CH100.

Complement, Total 339

REFERENCE VALUE: (Method: Quantitative hemolysis)
Conventional Units SI Units (Conversion Factor (1000)

40–100 CH50 U/mL 40–100 CH50 kU/L
DESCRIPTION: The complement Increased in:

system comprises proteins that • Acute-phase immune response
become activated and interact in a
sequential cascade. The complement Decreased in:
system is an important part of the
• Autoimmune diseases
body’s natural defense against allergic
and immune reactions. It is activated • Autoimmune hemolytic anemia
by plasmin and is interrelated with • Burns
the coagulation and fibrinolytic • Cryoglobulinemia
systems. Activation of the comple-
• Hereditary deficiency
ment system results in cell lysis,
release of histamine, chemotaxis of • Infections (bacterial, parasitic, viral)
white blood cells, increased vascular • Liver disease
permeability, and contraction of • Malignancy
smooth muscle. The activation of this
system can sometimes occur with • Membranous glomerulonephritis
uncontrolled self-destructive effects • Rheumatoid arthritis
on the body. In the serum comple- • Systemic lupus erythematosus
ment assay, a patient’s serum is
• Trauma
mixed with sheep red blood cells
coated with antibodies. If comple- • Vasculitis
ment is present in sufficient quanti-
ties, 50 percent of the red blood cells CRITICAL VALUES: N/A
are lysed. Lower amounts of lysed
cells are associated with decreased
complement levels. ■ • Drugs that may increase total comple-
ment levels include cyclophosphamide
INDICATIONS: and danazol.
• Evaluate complement activity in • Specimen should not remain at room

autoimmune disorders temperature longer than 1 hour.
• Assist in the diagnosis of hereditary

angioedema Nursing Implications and
• Evaluate and monitor therapy for Procedure ● ● ● ● ● ● ● ● ● ● ●
systemic lupus erythematosus

Pretest:
• Screen for complement deficiency ➤ Obtain a history of the patient’s
RESULT allergens.

immune system and results of previ-
ously performed tests and proce- ➤ Direct the patient to breathe
dures. For related tests, refer to the normally and to avoid unnecessary
immune system table. movement.
➤ Obtain a list of medications the ➤ Observe standard precautions and
patient is taking, including herbs, follow the general guidelines in
nutritional supplements, and Appendix A. Perform a venipuncture,
nutraceuticals. The requesting health and collect the specimen in a 5-mL
care practitioner and laboratory red-top tube.
should be advised if the patient ➤ Label the specimen, and promptly
regularly uses these products so transport it to the laboratory.
consideration when reviewing Post-test:
results.
pressure bandage.
direction.
patient.
➤ Inform the patient that specimen tests include antinuclear antibodies,
collection takes approximately 5 to C3, C4, and erythrocyte sedimenta-
10 minutes. tion rate.
COMPLETE BLOOD COUNT

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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.
Complete Blood Count 341
REFERENCE VALUE: (Method: Automated, computerized multichannel

analyzers that sort and size cells on the basis of changes in either electrical
impedance or light pulses as the cells pass in front of a laser. Many of these
analyzers are capable of determining a five-part WBC differential.) This
battery of tests includes hemoglobin, hematocrit, red blood cell (RBC)
count, RBC morphology, RBC indices, RBC distribution width index
(RDW), platelet count, platelet size, WBC count, and WBC differential.
The five-part automated WBC differential identifies and enumerates
neutrophils, lymphocytes, monocytes, eosinophils, and basophils.
Hemoglobin
SI Units
Cord blood 13.5–20.5 g/dL 135–205 mmol/L
2 wk 13.4–19.8 g/dL 134–198 mmol/L
1 mo 10.7–17.1 g/dL 107–171 mmol/L
6 mo 11.1–14.4 g/dL 111–144 mmol/L
1y 11.3–14.1 g/dL 113–141 mmol/L
9–14 y 12.0–14.4 g/dL 120–144 mmol/L
Adult
Male 13.2–17.3 g/dL 132–173 mmol/L
Female 11.7–15.5 g/dL 117–155 mmol/L
Older adult
(65–74 y)
Male 12.6–17.4 g/dL 126–174 mmol/L
Female 11.7–16.1 g/dL 117–161 mmol/L
Hematocrit
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.
342
White Blood Cell Count and Differential
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%
Red Blood Cell Count

Age Conventional Units SI Units
Cord blood 4.14–4.69 106
cells/mm 3
4.14–4.69 1012 cells /L
1d 5.33–5.47 106 cells/mm3 5.33–5.47 1012 cells /L
2 wk 4.32–4.98 106 cells/mm3 4.32–4.98 1012 cells /L
1 mo 3.75–4.95 106 cells/mm3 3.75–4.95 1012 cells /L
6 mo 3.71–4.25 106 cells/mm3 3.71–4.25 1012 cells /L
1y 4.40–4.48 106 cells/mm3 4.40–4.48 1012 cells /L
10 y 4.75–4.85 106 cells/mm3 4.75–4.85 1012 cells /L
Adult
Male 4.71–5.14 106 cells/mm3 4.71–5.14 1012 cells /L
Female 4.20–4.87 106 cells/mm3 4.20–4.87 1012 cells /L
Red Blood Cell Indices

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
Female 85–95 28–32 33–35 11.6–14.8
MCV mean corpuscular volume; MCH mean corpuscular hemoglobin; MCHC
mean corpuscular hemoglobin concentration; RDW RBC distribution width index.
Red Blood Cell Morphology
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
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
Red Blood Cell Inclusions

Within
Inclusions Normal Limits 1 2 3 4
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
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
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
DESCRIPTION: A complete blood • Monitor fluid imbalances or treatment

count (CBC) is a group of tests used for fluid imbalances
for basic screening purposes. It is • Monitor hematologic status during
probably the most widely ordered pregnancy
laboratory test. Results provide the
enumeration of the cellular elements • Monitor progression of nonhemato-
logic disorders, such as chronic
of the blood, measurement of RBC
obstructive pulmonary disease, malab-
indices, and determination of cell sorption syndromes, cancer, and renal
morphology by automation and eval- disease
uation of stained smears. The results
can provide valuable diagnostic infor- • Monitor response to chemotherapy
mation regarding the overall health of and evaluate undesired reactions
to drugs that may cause blood
the patient and the patient’s response
dyscrasias
to disease and treatment. ■
• Provide screening as part of a general
INDICATIONS: physical examination, especially on
admission to a health care facility or
• Detect hematologic disorder,
before surgery
neoplasm, leukemia, or immunologic
abnormality
RESULT: See monographs titled
• Determine the presence of hereditary “Hemoglobin,” “Hematocrit,” “Red
hematologic abnormality Blood Cell Indices,” “Red Blood Cell
• Evaluate known or suspected anemia Morphology and Inclusions,” “Red
and related treatment Blood Cell Count,” “Platelet Count,”
and “White Blood Cell Count and
• Monitor the effects of physical or Differential.”
emotional stress
• Monitor blood loss and response to Increased in: See above-listed
blood replacement monographs.
Decreased in: See above-listed • Elevated serum glucose or sodium

monographs. levels may produce elevated mean
corpuscular volume values because of
CRITICAL VALUES swelling of erythrocytes.
• Recent transfusion history should be
Hemoglobin:
considered when evaluating the CBC.
• Less than 6 g/dL
• Greater than 18 g/dL
Hematocrit: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Less than 18 percent Pretest:

• Greater than 54 percent ➤ Obtain a history of the patient’s
WBC count (on admission): allergens.
• Less than 2500/mm3 gastrointestinal, hematopoietic,
• Greater than 30,000/mm3 immune, and respiratory systems,
as well as results of previously
Platelet: performed tests and procedures. For
related tests, refer to the gastroin-
• Less than 20,000/mm3 testinal, hematopoietic, immune,
• Greater than 1,000,000/mm3 ➤ Obtain a list of medications the
The presence of abnormal cells, other patient is taking, including herbs,
morphologic characteristics, or cellular
inclusions may signify a potentially life- practitioner and laboratory should be
threatening or serious health condition advised if the patient regularly uses
and should be investigated. Examples are these products so that their effects
the presence of sickle cells, moderate can be taken into consideration
numbers of spherocytes, marked schisto- when reviewing results.
cytosis, oval macrocytes, basophilic ➤ There are no food, fluid, or medica-
stippling, eosinophil count greater than tion restrictions unless by medical
10 percent, monocytosis greater than direction.
15 percent, nucleated RBCs (if patient is ➤ Review the procedure with the
not an infant), malarial organisms, patient.
hypersegmented neutrophils, agranular ➤ Inform the patient that specimen
neutrophils, blasts or other immature collection takes approximately 5 to
cells, Auer rods, Döhle bodies, marked 10 minutes.
toxic granulation, or plasma cells.
Intratest:
• Failure to fill the tube sufficiently (less normally and to avoid unnecessary
than three-fourths full) may yield inad- movement.
equate sample volume for automated ➤ Observe standard precautions and
analyzers and may be a reason for spec- follow the general guidelines in
imen rejection. Appendix A. Perform a venipuncture,
• Hemolyzed or clotted specimens lavender-top (EDTA) tube. An EDTA
should be rejected for analysis. Microtainer sample may be obtained
Computed Tomography, Abdomen 347
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Computed axial tomography (CAT), computed

transaxial tomography (CTT), abdominal CT.

CONTRAST: Can be done with or without iodinated contrast medium.
DESCRIPTION: Abdominal multiple x-ray beams and a series of

computed tomography (CT) is a detectors that rotate around the
noninvasive procedure used to patient to produce cross-sectional
enhance certain anatomic views of views in a three-dimensional fashion
the abdominal structures, but it by detecting and recording differ-
becomes invasive when a contrast ences in tissue density after having an
medium is used. The patient lies on a x-ray beam passed through bone and
table and is moved in and out of a tissue. These density measurements
doughnut-like device called a gantry, are sent to a computer that produces
which houses the x-ray tube and asso- a digital image of the anatomy,
ciated electronics. The scanner uses enabling a physician to look at slices
or thin sections of certain anatomic RESULT

views of the liver, biliary tract,
pancreas, kidneys, spleen, intestines, Normal Findings:
and vascular system. Differentiations
• Normal size, position, and shape of
can be made among solid, cystic, abdominal organs and vascular system
inflammatory, or vascular lesions, and
suspected hematomas and aneurysms Abnormal Findings:
can be identified. Iodinated contrast
medium is given intravenously for • Adrenal tumor or hyperplasia
blood vessel and vascular evaluation • Abdominal aortic aneurysm
or orally for bowel and adjacent struc- • Abdominal abscess
ture evaluation. Images can be
recorded on photographic or x-ray • Dilation of the common hepatic duct,
film or stored in digital format as digi- common bile duct, or gallbladder
tized computer data. Cine scanning is • Hematomas, diverticulitis, gallstones
used to produce a series of moving • Hemoperitoneum
images of the area scanned. The CT
scan can be used to guide biopsy • Hepatic cysts or abscesses
needles into areas of abdominal • Pancreatic pseudocyst
tumors to obtain tissue for laboratory
• Primary and metastatic neoplasms
analysis and placement of catheters
for drainage of intra-abdominal • Renal calculi, bowel perforation, and
abscesses. Tumors, before and after GI bleeding and obstruction
therapy, may be monitored with CT • Splenic laceration, tumor, infiltration,
scanning. ■ and trauma
INDICATIONS: CRITICAL VALUES: N/A

• Assist in differentiating between INTERFERING FACTORS:
benign and malignant tumors
• Evaluation of retroperitoneal lymph This procedure is contraindicated
nodes for:
• Detect tumor extension of masses and • Patients with allergies to shellfish or

metastasis into the abdominal area iodinated dye. The contrast
• Detect aortic aneurysms
• Differentiate aortic aneurysms from with a known hypersensitivity to the
tumors near the aorta medium may benefit from premedica-
tion with corticosteroids or the use of
• Differentiate between infectious and
inflammatory processes
• Patients who are claustrophobic.
• Evaluate cysts, masses, abscesses, renal
calculi, gastrointestinal (GI) bleeding • Patients who are pregnant or suspected
and obstruction, and trauma of being pregnant, unless the potential
• Monitor and evaluate the effectiveness
of medical, radiation, or surgical thera-
pies • Elderly and other patients who are
Computed Tomography, Abdomen 349
chronically dehydrated before the tion safety concerns regarding infants

test, because of their risk of of patients who are lactating.
• Patients who are in renal failure. overexposure can result from frequent
• Young patients (17 years old and
younger), unless the benefits of the x-
ray diagnosis outweigh the risks of
exposure to high levels of radiation.
imaging: nation is being done should wear
• Inability of the patient to cooperate or sure to radiation.
mental status
• Patients with extreme claustrophobia Procedure ● ● ● ● ● ● ● ● ● ● ●
unless sedation is given before the

study Pretest:
• Improper adjustment of the radio- ➤ Inform the patient that the
graphic equipment to accommodate procedure assesses the abdomen.
obese or thin patients, which can cause ➤ Inform the patient that the proce-
overexposure or underexposure and a dure is performed in a radiology
poor-quality study department by a technologist and a
physician and takes approximately
• Patients who are very obese, who may 30 to 60 minutes.
ment
tivities to x-ray contrast medium or
• Incorrect positioning of the patient, shellfish.
which may produce poor visualization ➤ Obtain a list of medications the
of the area to be examined patient is taking.
• Gas or feces in the GI tract resulting ➤ Obtain a history of the patient’s
abdominal system and organs, as
from inadequate cleansing or failure to
well as results of previously
restrict food intake before the study performed tests and procedures. For
• Retained barium from a previous radi- related tests, refer to the GI, hepato-
ologic procedure biliary, or genitourinary and renal
system tables.
• Metallic objects within the examina- ➤ Determine previous laboratory
tion field (e.g., jewelry or body rings), abnormalities, especially blood urea
which may inhibit organ visualization nitrogen (BUN) and creatinine, if
and can produce unclear images contrast medium is to be used.
➤ Determine date of last menstrual
Other considerations: period and the possibility of
pregnancy in perimenopausal
• Failure to follow dietary restrictions women.
➤ 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- ➤ Inform the patient that iodinated
contrast medium may be injected unclear images. Make sure jewelry,

after the first series of x-rays, which watches, chains, belts, and any
will be followed by a second series other metallic objects have been
of scans. removed.
➤ Patients receiving metformin ➤ Move table into the scanner, and
(Glucophage) for non–insulin- instruct the patient to remain still.
dependent (type 2) diabetes should The scanner makes noises as it
discontinue the drug on the day of rotates around the body. The patient
the test and continue to withhold it may be asked to take deep breaths
for 48 hours after the test. Failure to to facilitate visualization. A number
do so may result in lactic acidosis. of images are taken. A computer
➤ Inform the patient that he or she reconstructs these images so they
may experience nausea, a feeling of can be reviewed.
warmth, a salty or metallic taste, or ➤ Administer contrast medium, if
a transient headache after injection ordered. A second series of images
of contrast medium, if given. is obtained.
Instruct the patient to take slow,
deep breaths if this occurs. Post-test:
➤ Ensure barium studies have been ➤ Instruct the patient to resume
performed more than 4 days before normal activity, diet, and previous
the scan. medication use, unless otherwise
➤ The patient may be requested to indicated. Renal function should be
drink approximately 450 mL of a assessed before metformin is
dilute barium solution (approxi- restarted.
mately 1% barium) beginning 1 hour ➤ Instruct the patient to increase fluid
before the examination. This is intake to help eliminate the contrast
administered to distinguish GI medium, if used.
organs from the other abdominal
organs. ➤ Inform the patient that diarrhea may
occur after ingestion of oral contrast
➤ Restrict food and fluids for 6 to 8 medium.
hours, if contrast medium is to be
given. ➤ Instruct the patient or caregiver to
note change in urinary output after
Intratest: iodinated contrast medium adminis-
tration in patients with impaired
➤ Administer sedative to a child or to renal function.
an uncooperative adult, as ordered. ➤ Observe for delayed allergic reac-
➤ Administer antianxiety agent, as tions, such as urticaria (hives),
ordered, if the patient is experienc- headache, nausea, or vomiting, if
ing claustrophobia. Administer an contrast medium was administered.
antihistamine or steroid, as ordered ➤ A physician specializing in this
by a physician, for patients with a branch of medicine sends a written
known significant allergic reaction to report to the ordering provider, who
the IV contrast medium. discusses the results with the
➤ Administer an enema to remove patient.
barium from the GI tract, as ordered. ➤ Evaluate test results in relation to
➤ Place the patient in a supine posi- the patient’s symptoms and other
tion on a flat table with foam tests performed. Related diagnostic
wedges that help maintain position tests include angiogram and
and immobilization. Ask the patient magnetic resonance imaging of
to lie still during the proce- the abdomen; and kidney, ureter,
dure because movement produces and bladder (KUB) film.
Computed Tomography, Angiography 351
ANGIOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Computed axial tomography (CAT) angiography,

CTA.
AREA OF APPLICATION: Vessels.

DESCRIPTION: Computed tomogra- images are helpful when there are

phy angiography (CTA) is a noninva- heavily calcified vessels. The axial
sive procedure that enhances certain images give the most precise informa-
anatomic views of vascular structures. tion regarding the true percentage of
This procedure complements tradi- stenosis, and they can also evaluate
tional angiography and allows recon- intracerebral aneurysms. Small ulcera-
struction of the images in different tions and plaque irregularity are read-
planes and removal of surrounding ily seen with CTA; the degree of
structures, leaving only the vessels to stenosis can be estimated better with
be studied. While lying on a table, the CTA because of the increased number
patient moves in and out of a of imaging planes. Density measure-
doughnut-like device called a gantry, ments are sent to a computer that
which houses the x-ray tube and asso- produces a digital image of the
ciated electronics. The scanner uses anatomy, enabling a physician to look
multiple x-ray beams and a series of at slices or thin sections of certain
detectors that rotate around the anatomic views of the vessels.
patient to produce cross-sectional Iodinated contrast medium is given
views in a three-dimensional fashion intravenously for vascular evaluation.
by detecting and recording differences Images can be recorded on photo-
in tissue density after having an x-ray graphic or x-ray film or stored in
beam passed through the tissues. CTA digital format as digitized computer
uses spiral CT technology and collects data. ■
large amounts of data with each scan.
Retrospectively, the data can be
INDICATIONS:
manipulated to produce the desired
image without exposure to additional • Detect vascular disease
radiation or contrast medium.
• Differentiate between vascular and
Multiplanar reconstruction images
nonvascular tumors
are reviewed by the physician at a
computerized workstation. These • Detect stenosis
• Detect aneurysms benefits of the procedure far outweigh

tumors near the aorta • Elderly and other patients who are
• Evaluate atherosclerosis
• Detect embolism or other occlusions contrast-induced renal failure.
• Detect fistula • Patients who are in renal failure.
• Evaluate hemorrhage or trauma • Young patients (17 years old and
younger), unless the benefits of the
• Monitor and evaluate the effectiveness
x-ray diagnosis outweigh the risks of
of medical or surgical therapies
RESULT Factors that may impair clear
imaging:
Normal Findings:
vascular structures
Abnormal Findings: mental status
• Patients with extreme claustrophobia
• Aortic aneurysm unless sedation is given before the
• Cysts or abscesses study
• Emboli • Improper adjustment of the radio-
• Hemorrhage obese or thin patients, which can cause
• Neoplasm overexposure or underexposure and a
poor-quality study
• Occlusion
• Shunting exceed the weight limit for the equip-
• Stenosis ment
CRITICAL VALUES: N/A which may produce poor visualization
• Gas or feces in the gastrointestinal
tract, resulting from inadequate cleans-
for: ing or failure to restrict food intake
before the study
• Patients with allergies to shellfish or • Metallic objects within the examina-
iodinated dye. The contrast tion field (e.g., jewelry or body
medium used may cause a life- rings), which may inhibit organ
threatening allergic reaction. Patients visualization and can produce unclear
with a known hypersensitivity to the images
tion with corticosteroids or the use of Other considerations:
• Patients who are pregnant or suspected tion safety concerns regarding infants
of being pregnant, unless the potential of patients who are lactating.
Computed Tomography, Angiography 353
• Risks associated with radiographic ➤ Inform the patient that he or

overexposure can result from frequent she may experience nausea, a feel-
x-ray procedures. Personnel in the ing of warmth, a salty or metallic
room with the patient should wear a taste, or a transient headache after
injection of contrast medium, if
protective lead apron, stand behind a given. Instruct the patient to take
shield, or leave the area while the slow, deep breaths if this occurs.
➤ Restrict food and fluids for 6 to 8
working in the area where the exami- hours.
nation is being done should wear
Intratest:
sure to radiation.
➤ Administer sedative to a child or to
an uncooperative adult, as ordered.
Nursing Implications and ➤ Administer antianxiety agent, as
ordered, if the patient is experienc-
Procedure ● ● ● ● ● ● ● ● ● ● ●
ing claustrophobia.
Pretest: ➤ Administer an antihistamine or
steroid, as ordered by a physician,
➤ Inform the patient that the proce- for patients with a known significant
dure assesses the vessels. allergic reaction to the IV contrast
➤ Inform the patient that the proce- medium.
dure is performed in a radiology ➤ Place the patient in a supine position
department by a technologist and a on a flat table with 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 or shell- ment produces unclear images.
fish. Make sure jewelry, watches, chains,
belts, and any other metallic objects
➤ Obtain a list of medications the have been removed.
patient is taking.
➤ Instruct the patient to remain still
➤ Determine previous laboratory while the table moves into the scan-
abnormalities, especially blood urea ner. The scanner will make noises
nitrogen and creatinine, if contrast as it rotates around the body. The
medium is to be used. patient may be asked to take
➤ Ensure that results of blood tests deep breaths to facilitate visualiza-
are obtained and recorded before tion. A number of images are
the procedure. taken. A computer reconstructs
➤ Obtain a history of patient’s cardio- these images so they can be
vascular system and results from reviewed.
previously performed tests and ➤ Contrast medium is administered.
procedures. For related tests,
refer to the cardiovascular system Post-test:
table.
➤ Inform the patient that intravenous ➤ Instruct the patient to resume
iodinated contrast medium will be normal activity and diet, unless
used. otherwise indicated. Renal function
should be assessed before
➤ Patients receiving metformin metformin is restarted.
dependent (type 2) diabetes should ➤ Instruct the patient to increase fluid
discontinue the drug on the day of intake to help eliminate the contrast
the test and continue to withhold it medium.
for 48 hours after the test. Failure to ➤ Instruct the patient or caregiver to
do so may result in lactic acidosis. note change in urinary output after
iodinated contrast medium adminis- discusses the results with the

tration in patients with impaired patient.
renal function.
➤ Observe for delayed allergic reac- the patient’s symptoms and other
tions, such as urticaria (hives), tests performed. Related diagnostic
headache, nausea, or vomiting. tests include Doppler ultrasound,
➤ A physician specializing in this angiography, and magnetic reso-
branch of medicine sends a written nance angiography.
BILIARY TRACT AND LIVER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

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

DESCRIPTION: Computed tomogra- produces a digital image of the

phy (CT) of the liver and biliary tract anatomy, enabling a physician to
is a noninvasive procedure that look at slices or thin sections of
enhances certain anatomic views of certain anatomic views of the
these structures, but it becomes inva- liver, biliary tract, and vascular
sive with the use of contrast medium. system. Differentiations can be made
The patient lies on a table that moves among solid, cystic, inflammatory,
in and out of a doughnut-like device or vascular lesions, and suspected
called a gantry, which houses the x-ray hematomas and aneurysms can
tube and associated electronics. The be identified. Iodinated contrast
scanner uses multiple x-ray beams medium is given intravenously for
and a series of detectors that rotate blood vessel and vascular evaluation.
around the patient to produce cross- Images can be recorded on photo-
sectional views in a three-dimensional graphic or x-ray film or stored in digi-
fashion by detecting and recording tal format as digitized computer data.
differences in tissue density after Cine scanning produces a series of
having an x-ray beam passed through moving images of the area scanned.
the tissues. These density measure- The CT scan can be used to guide
ments are sent to a computer that biopsy needles into areas of suspected
Computed Tomography, Biliary Tract and Liver 355
tumors to obtain tissue for laboratory CRITICAL VALUES: N/A

analysis and placement of catheters
for drainage of abscesses. Tumors, INTERFERING FACTORS:
before and after therapy, may be
monitored with CT scanning. ■ This procedure is contraindicated
for:
INDICATIONS: • Patients with allergies to shellfish or
• Assist in differentiating between iodinated dye. The contrast
benign and malignant tumors medium used may cause a life-
• Detect dilation or obstruction of the with a known hypersensitivity to the
biliary ducts with or without calcifica- medium may benefit from premedica-
tion or gallstone tion with corticosteroids or the use of
• Detect tumor extension of masses and nonionic contrast medium.
metastasis into the hepatic area • Patients who are claustrophobic.
• Distinguish between obstructive and • Patients who are pregnant or suspected
nonobstructive jaundice of being pregnant, unless the potential
• Differentiate aortic aneurysms from benefits of the procedure far outweigh
tumors near the aorta the risks to the fetus and mother.
• Differentiate infectious from inflam- • Elderly and other patients who are
matory processes chronically dehydrated before
• Evaluate hepatic cysts, masses, contrast-induced renal failure.
abscesses, hematomas, or hepatic
trauma • Patients who are in renal failure.
• Detect liver abnormalities, such as • Young patients (17 years old and
cirrhosis with ascites and fatty liver younger), unless the benefits of the x-
• Monitor and evaluate effectiveness of exposure to high levels of radiation.
medical, radiation, or surgical therapies
RESULT imaging:

• Normal size, position, and contour of because of age, significant pain, or
the liver and biliary ducts mental status
Abnormal Findings: • Patients with extreme cases of claustro-
phobia unless sedation is given before
• Dilation of the common hepatic duct, the study
common bile duct, or gallbladder
• Improper adjustment of the radio-
• Hepatic cysts or abscesses graphic equipment to accommodate
• Hematomas obese or thin patients, which can cause
• Gallstones
poor-quality study
• Jaundice (obstructive or nonobstruc-
tive)
• Primary and metastatic neoplasms ment
• Incorrect positioning of the patient, hepatobiliary and gastrointestinal

which may produce poor visualization systems, as well as results of previ-
of the area to be examined ously performed tests and proce-
• Gas or feces in the gastrointestinal tract hepatobiliary and gastrointestinal
resulting from inadequate cleansing or system tables.
failure to restrict food intake before the ➤ Determine previous laboratory
study abnormalities, especially blood urea
nitrogen (BUN) and creatinine, if
• Retained barium from a previous radi- contrast medium is to be used.
ologic procedure
➤ Ensure that the results of blood
• Metallic objects within the examina- tests are obtained and recorded
tion field (e.g., jewelry or body rings), before the procedure.
which may inhibit organ visualization ➤ Determine date of last menstrual
and can produce unclear images period and the possibility of preg-
nancy in perimenopausal women.
Other considerations: ➤ Inform the patient that iodinated
contrast medium may be injected
• Consultation with a physician should after the first series of x-rays, which
occur before the procedure for radia- will be followed by a second series
tion safety concerns regarding infants of scans.
of patients who are lactating. ➤ Patients receiving metformin
• Risks associated with radiographic (Glucophage) for non–insulin-
discontinue the drug on the day of
x-ray procedures. Personnel in the the test and continue to withhold it
room with the patient should wear a for 48 hours after the test. Failure to
protective lead apron, stand behind a do so may result in lactic acidosis.
shield, or leave the area while the ➤ Inform the patient that he or she
examination is being done. Personnel may experience nausea, a feeling of
working in the area where the exami- warmth, a salty or metallic taste, or
nation is being done should wear a transient headache after injection
badges that reveal their level of expo- of contrast medium, if given.
sure to radiation. Instruct the patient to take slow,
deep breaths if this occurs.
➤ Question the patient to ensure that
Nursing Implications and barium studies were performed
more than 4 days before the scan.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Restrict food and fluids for 6 to

Pretest: 8 hours, if contrast medium is to be
given.
➤ Inform the patient that the procedure
assesses the liver and bile ducts. Intratest:
➤ Inform the patient that the proce- ➤ Administer sedative to a child or
dure is performed in a radiology to an uncooperative adult, as
department by a technologist and a ordered.
30 minutes. ➤ Administer antianxiety agent, as
➤ Obtain a history of allergies or sensi- ing claustrophobia.
tivities to contrast medium or shell-
fish. ➤ Administer an antihistamine or
➤ Obtain a list of medications the for patients with a known significant
patient is taking. allergic reaction to the IV contrast
➤ Obtain a history of the patient’s medium.
Computed Tomography, Brain 357
➤ Administer an enema to remove indicated. Renal function should be

barium from the gastrointestinal assessed before metformin is
tract, as ordered. restarted.
➤ Place the patient in a supine position ➤ Instruct the patient to increase fluid
on a flat table with foam wedges to intake to help eliminate the contrast
help maintain position and immobi- medium, if used.
lization. Ask the patient to lie still
during the procedure because move- ➤ Instruct the patient or caregiver to
ment produces unclear images. note changes in urinary output after
Make sure jewelry, watches, chains, iodinated contrast medium adminis-
belts, and any other metallic objects tration in patients with impaired
have been removed. renal function.
➤ As the table moves into the scanner, ➤ Observe for delayed allergic reac-
instruct the patient to remain still. tions, such as urticaria (hives),
The scanner makes noises as it headache, nausea, or vomiting, if
rotates around the body. The patient contrast medium was used.
may be asked to take deep breaths ➤ A physician specializing in this
to facilitate visualization. A number branch of medicine sends a written
of images are taken. A computer report to the ordering provider, who
reconstructs these images so they discusses the results with the
can be reviewed. patient.
➤ Administer contrast medium, if
ordered. A second series of images ➤ Evaluate test results in relation to
is obtained. the patient’s symptoms and other
tests performed. Related diagnostic
Post-test: tests include hepatobiliary scan;
ultrasound of the liver; kidney,
➤ Instruct the patient to resume ureter, and bladder (KUB) film; and
normal activity, diet, and previous magnetic resonance imaging of the
medication use, unless otherwise abdomen.
COMPUTED TOMOGRAPHY, BRAIN

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

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

DESCRIPTION: Computed tomogra- brain tissue, cerebrospinal fluid, and

phy (CT) of the brain is a noninva- blood circulation. Brain CT becomes
sive procedure used to assist in invasive if contrast medium is used
diagnosing abnormalities of the head, for image enhancement when pathol-
ogy causing destruction of the blood- INDICATIONS:

brain barrier is suspected. CT is
• Determine the presence of multiple
useful for evaluating suspected brain sclerosis, as evidenced by sclerotic
tumors, infarction, intracranial plaques 3 to 4 mm in diameter
hemorrhage, hematomas, arteriove-
• Determine cause of increased intracra-
nous malformations, ventricular
nial pressure
abnormalities, aneurysms, and other
vascular abnormalities. The patient • Determine benign and cancerous
lies on a table and is moved in and out intracranial tumors and cyst forma-
tion, as evidenced by changes in tissue
of a doughnut-like device called a
densities (white indicating increased
gantry, which houses the x-ray tube density, darker areas indicating
and associated electronics. The scan- decreased density)
ner uses multiple x-ray beams and a
• Determine size and location of a lesion
series of detectors that rotate around
causing a stroke, such as an infarct or
the patient to produce cross-sectional hemorrhage
views in a three-dimensional fashion
by detecting and recording differences • Detect ventricular enlargement or
displacement by increased cere-
in tissue density after having an x-ray
brospinal fluid
beam passed through the tissues.
Low-density tissue appears black on • Determine the presence and type of
the images, medium-density tissue hemorrhage in infants and children
experiencing signs and symptoms of
appears in shades of gray, and high-
intracranial trauma, or of congenital
density tissue appears nearly white. conditions such as hydrocephalus and
These density measurements are sent arteriovenous malformations
to a computer that produces a digital
• Differentiate between cerebral infarc-
image of the anatomy, enabling a
tion and hemorrhage
physician to look at slices or thin
sections of certain anatomic views of • Detect the presence of a brain infection
the pituitary and associated vascular or inflammatory condition, such as
abscess or necrosis, as evidenced by
system. Differentiations can be made
decreased density on the image
among solid, cystic, inflammatory, or
vascular lesions, and suspected • Differentiate among hematoma loca-
hematomas or aneurysms can be tions after trauma (e.g., subdural,
epidural, cerebral), and determine the
identified. The procedure may be
extent of edema resulting from injury,
repeated after iodinated contrast as evidenced by higher blood densities
medium is given intravenously for compared with normal tissue
blood vessel and vascular evaluation.
• Evaluate abnormalities of the middle
Images can be recorded on photo-
ear ossicles, auditory nerve, and optic
graphic or x-ray film or stored in digi- nerve
tal format as digitized computer data.
Cine scanning is used to produce a • Monitor and evaluate the effectiveness
of medical, radiation, or surgical thera-
series of moving images of the area
pies
scanned. Tumor progression, before
and after therapy, and effectiveness of RESULT
medical interventions may be moni-
tored by CT scanning. ■ Normal Findings:
Computed Tomography, Brain 359
• Normal size, position, and shape of • Patients who are claustrophobic.

intracranial contents and vascular • Patients who are pregnant or suspected
system of being pregnant, unless the potential
Abnormal Findings:
• Abscess • Elderly and other patients who are
• Aneurysm chronically dehydrated before
• Arteriovenous malformations contrast-induced renal failure.
• Cerebral atrophy • Patients who are in renal failure.
• Cerebral edema • Young patients (17 years old and
• Cerebral infarction younger), unless the benefits of the x-
• Congenital abnormalities exposure to high levels of radiation.
• Craniopharyngioma Factors that may impair clear
• Cysts imaging:
• Hematomas (e.g., epidural, subdural, • Inability of the patient to cooperate or

intracerebral) remain still during the procedure
• Hemorrhage
mental status
• Hydrocephaly
• Patients with extreme claustrophobia
• Increased intracranial pressure or unless sedation is given before the
trauma study
• Infection • Improper adjustment of the radio-
• Sclerotic plaques suggesting multiple
sclerosis
• Tumor poor-quality study
• Ventricular or tissue displacement or • Patients who are very obese, who may
enlargement exceed the weight limit for the equip-
ment
This procedure is contraindicated • Retained barium from a previous radi-

for: ologic procedure
• Patients with allergies to shellfish or • Metallic objects within the examina-

iodinated dye. The contrast tion field (e.g., jewelry, body rings),
medium used may cause a life- which may inhibit organ visualization
threatening allergic reaction. Patients and can produce unclear images
with a known hypersensitivity to the Other considerations:
tion with corticosteroids or the use of • Consultation with a physician should
nonionic contrast medium. occur before the procedure for radia-
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 of
• Risks associated with radiographic the test and continue to withhold it
overexposure can result from frequent for 48 hours after the test. Failure to
x-ray procedures. Personnel in the do so may result in lactic acidosis.
room with the patient should wear a ➤ Inform the patient that he or she
protective lead apron, stand behind a may experience nausea, a feeling of
shield, or leave the area while the warmth, a salty or metallic taste, or
examination is being done. Personnel a transient headache after injection
working in the area where the exami- of contrast medium, if given.
nation is being done should wear Instruct the patient to take slow,
sure to radiation. ➤ Do not restrict food and fluids before
this procedure.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Administer sedative to a child or to
Pretest: ➤ Administer antianxiety agent, as
ing claustrophobia.
dure assesses the brain.
➤ Administer an antihistamine or
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,
which help maintain position
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.
Computed Tomography, Cardiac Scoring 361
➤ Instruct the patient or caregiver to ➤ A physician specializing in this

note change in urinary output after branch of medicine sends a written
iodinated contrast medium adminis- report to the ordering provider, who
tration in patients with impaired discusses the results with the
renal function. Renal function should patient.
be assessed before metformin is
restarted. ➤ Evaluate test results in relation to
➤ Observe for delayed allergic reac- tests performed. A related test is
tions, such as urticaria (hives), magnetic resonance imaging of the
headache, nausea, or vomiting, if brain.
contrast medium was used.
CARDIAC SCORING
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transaxial tomography (CTT), heart vessel calcium CT, cardiac plaque CT.

CONTRAST: Done without iodinated contrast medium.
DESCRIPTION: Cardiac scoring is a cross-sectional views in a three-

noninvasive test for quantifying dimensional fashion by detecting
coronary artery calcium content. and recording differences in plaque
Coronary artery disease (CAD) density after having an x-ray beam
occurs when the arteries that carry passed through the tissues. The
blood and oxygen to the heart muscle scanner takes an image of the beating
become clogged or built up with heart while the patient holds his
plaque. Plaque buildup slows the or her breath for approximately
flow of blood to the heart muscle, 20 seconds. The procedure requires
causing ischemia and increasing the no contrast medium injections.
risk of heart failure. The procedure These density measurements are
begins with a computed tomography sent to a computer that produces a
(CT) scan of the heart. The patient digital analysis of the anatomy,
lies on a table and is moved in and enabling a physician to look at the
out of a doughnut-like device called quantified amount of calcium
a gantry, which houses the x-ray (cardiac plaque score) in the coronary
tube and associated electronics. arteries. The data can be recorded on
The scanner uses multiple x-ray photographic or x-ray film or stored
beams and a series of detectors that in digital format as digitized
rotate around the patient to produce computer data. ■
INDICATIONS: MI, and a medical assessment of

cardiac risk factors needs to be done.
• Detect and quantify coronary artery Additional testing may be needed.
calcium content
CAD is the leading cause of death • If the score is greater than 400, the
in most industrialized nations procedure has detected extensive calci-
Cardiac scoring is a more powerful fied plaque in the coronary arteries,
predictor of CAD than which may have caused a critical
cholesterol screening narrowing of the vessels. A full medical
Of all myocardial infarctions (MIs),
assessment is needed as soon as possi-
45 percent occur in people ble. Further testing may be needed,
younger than age 65 and treatment may be needed to
reduce the risk of MI.
Of women who have had MIs, 44
percent will die within 1 year
after the attack CRITICAL VALUES: N/A
Women are more likely to die of
heart disease than of breast
cancer This procedure is contraindicated
• Screening for coronary artery calcium for:
in patients with: • Patients who are claustrophobic
High blood pressure
Diabetes
High cholesterol benefits of the procedure far outweigh
Family history of heart disease the risks to the fetus and mother
Personal history of smoking
• Young patients, unless the benefits of
Sedentary lifestyle the x-ray diagnosis outweigh the risks
Overweight by 20 percent or more of exposure to high levels of radiation
High-stress lifestyle
• Screening for coronary artery plaque in imaging:
patients with chest pain of unknown
cause • Inability of the patient to cooperate or
RESULT mental status
Normal Findings: • Patients with extreme claustrophobia
• If the score is 100 or less, the probabil- study
ity of having significant CAD is mini-
mal or is unlikely to be causing a • Improper adjustment of the radio-
narrowing at the time of the examina- graphic equipment to accommodate
tion. obese or thin patients, which can cause
Abnormal Findings: poor-quality study
• 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,
Computed Tomography, Cardiac Scoring 363
which may produce poor visualization ratory and cardiovascular system

of the area to be examined tables.
➤ Do not restrict food and fluids.
• Patients with metal stents in their coro-
nary arteries or metal overlying the
Intratest:
chest area
• Metallic objects within the examina- an uncooperative adult, as ordered.
which can produce unclear images ➤ Administer antianxiety agent, as
ing claustrophobia.
➤ Place the patient in a supine position
• Risks associated with radiographic on a flat table with foam wedges,
overexposure can result from frequent which help maintain position and
x-ray procedures. Personnel in the immobilization. Ask the patient
to lie still during the procedure
because movement produces
protective lead apron, stand behind a unclear images. Make sure jewelry,
shield, or leave the area while the watches, chains, belts, and any other
examination is being done. Personnel metallic objects have been removed.
working in the area where the exami- ➤ The table is moved into the scanner,
nation is being done should wear and the patient is instructed to
badges that reveal their level of expo- remain still. The scanner makes
sure to radiation. noises as it rotates around the body.
The patient may be asked to take
deep breaths to facilitate visualiza-
tion. A number of images are taken.
Nursing Implications and A computer reconstructs these
Procedure ● ● ● ● ● ● ● ● ● ● ●
images so they can be reviewed.
Pretest:
Post-test:
dure assesses the coronary arteries. ➤ A physician specializing in this
➤ 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.
➤ 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.
COLONOSCOPY
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transaxial tomography (CTT), CT virtual colonoscopy, CT colonography.

CONTRAST: Screening examinations are done without intravenous (IV)
iodinated contrast medium. Examinations done to clarify questionable or
abnormal areas may require IV iodinated contrast medium.
DESCRIPTION: Computed tomogra- conventional colonoscopy with little

phy (CT) colonoscopy is a noninva- risk of complications and no recovery
sive technique that involves time. CT colonoscopy can be done as
examining the colon by taking multi- an outpatient procedure, and the
ple CT scans of the patient’s colon patient may return to work or usual
and rectum and using computer soft- activities the same day.
ware to create three-dimensional CT colonoscopy and conventional
images. The procedure is used to colonoscopy require the bowel to be
detect polyps, which are growths of cleansed before the examination. The
tissue in the colon or rectum. Some patient lies on a table and is moved in
types of polyps increase the risk of and out of a doughnut-like device
colon cancer, especially if they are called a gantry, which houses the x-ray
large or if a patient has several tube and associated electronics. The
polyps. Compared to conventional scanner uses multiple x-ray beams
colonoscopy, CT colonoscopy is less and a series of detectors that rotate
effective in detecting polyps smaller around the patient to produce cross-
than 5 mm, more effective when the sectional views in a three-dimensional
polyps are between 5 and 9.9 mm, fashion by detecting and recording
and most effective when the polyps differences in densities in the colon
are 10 mm or larger. This test may be after having an x-ray beam passed
valuable for patients who have through it. The scanner takes an
diseases rendering them unable to image of the colon while the patient
undergo conventional colonoscopy holds his or her breath for approxi-
(e.g., bleeding disorders, lung or mately 10 to 30 seconds. The screen-
heart disease) and for patients who ing procedure requires no contrast
are unable to undergo the sedation medium injections, but if a suspi-
required for traditional colonoscopy. cious area or abnormality is detected,
The procedure is less invasive than a repeat series of images may be
Computed Tomography, Colonoscopy 365
completed after IV contrast medium Abnormal Findings:

is given. These density measurements
• Polyps or growths in colon or rectum
are sent to a computer that produces a
digital analysis of the anatomy. The • Abnormal endoluminal wall of the
data can be recorded on photographic colon
or x-ray film or stored in digital • Extraluminal extension of primary
format as digitized computer data. A cancer
drawback of CT colonoscopy is that • Mesenteric and retroperitoneal
polyp removal and biopsies of tissue lymphadenopathy
in the colon must be done using
conventional colonoscopy. Therefore, • Metachronous lesions
if polyps are discovered during CT • Metastases of cancer
colonoscopy and biopsy becomes • Tumor recurrence after surgery
necessary, the patient must undergo
bowel preparation a second time. ■ CRITICAL VALUES: N/A
INDICATIONS: INTERFERING FACTORS:
• Detect polyps in the colon
• Investigate cause of positive occult
for:
blood test
• Investigate further when flexible • Patients who are claustrophobic
sigmoidoscopy is positive for polyps • Patients who are pregnant or suspected
• Investigate further after an abnormal of being pregnant, unless the potential
barium enema benefits of the procedure far outweigh
the risks to the fetus and mother
• Examine the colon in patients with
heart or lung disease, patients unable • Young patients (17 years old and
to be sedated, and patients unable to younger), unless the benefits of the x-
undergo colonoscopy ray diagnosis outweigh the risks of
exposure to high levels of radiation
• Failure to visualize the entire colon
during conventional colonoscopy Factors that may impair clear
• Evaluate the site of resection for local imaging:
recurrence of lesions • Inability of the patient to cooperate
• Evaluate the colon for metachronous or remain still during the procedure
lesions because of age, significant pain, or
mental status
• Identify metastases
• Evaluate polyposis syndromes • Patients with extreme claustrophobia
• Evaluate the colon in patients with study
obstructing rectosigmoid disease
• Poor patient preparation or inability to
RESULT retain air in the colon
• Inability of the patient to hold his or
Normal Findings: her breath, which may cause artifacts
on the scan
• Normal colon and rectum, with no
evidence of polyps or growths • Improper adjustment of the radio-
graphic equipment to accommodate ➤ Obtain a list of medications the

obese or thin patients, which can cause patient is taking.
overexposure or underexposure and a ➤ Obtain a history of the patient’s
poor-quality study gastrointestinal system and results
• Patients who are very obese, who may procedures. For related tests, refer
exceed the weight limit for the equip- to the gastrointestinal system
ment tables.
• Incorrect positioning of the patient, ➤ Restrict diet to clear liquids for 48
which may produce poor visualization hours before beginning oral bowel
preparation.
➤ Ensure that ordered laxative has
• Gas or feces in the gastrointestinal tract been administered late in the after-
resulting from inadequate cleansing or noon the day before the procedure.
study Intratest:
• Retained barium from a previous radi- ➤ Administer sedative to a child or to
ologic procedure an uncooperative adult, as ordered.
• Metallic objects within the examina- ➤ Administer antianxiety agent, as
tion field (e.g., jewelry or body rings), ordered, if the patient is experienc-
ing claustrophobia.
which can produce unclear images
➤ The colon is distended with room air
Other considerations: or carbon dioxide by means of a
rectal tube and balloon retention
• Failure to follow dietary restrictions device. Maximal colonic distention is
before the procedure may cause the guided by patient tolerance.
procedure to be canceled or repeated. ➤ Place the patient in a supine position
on a flat table with foam wedges,
• Risks associated with radiographic which help maintain position and
overexposure can result from frequent immobilization. Ask the patient
x-ray procedures. Personnel in the to lie still during the procedure
room with the patient should wear a because movement produces
protective lead apron, stand behind a unclear images. Make sure jewelry,
shield, or leave the area while the watches, chains, belts, and any other
examination is being done. Personnel metallic objects have been removed.
working in the area where the exami- ➤ The table is moved into the scanner,
nation is being done should wear and the patient is instructed to
badges that reveal their level of expo- remain still. The scanner makes
noises as it rotates around the body.
sure to radiation.
The patient may be asked to take a
deep breath and hold it to facilitate
visualization. A number of images
Nursing Implications and are taken. A computer reconstructs
Procedure ● ● ● ● ● ● ● ● ● ● ● these images so they can be
reviewed.
Pretest: ➤ The sequence of images is repeated
in the prone position.
➤ Inform the patient that the procedure
assesses the rectum and colon.
Post-test:
dure is performed in a CT scanner by ➤ Instruct the patient to resume
a technologist and takes approxi- normal activity and diet, unless
mately 5 to 10 minutes. otherwise indicated.
Computed Tomography, Pancreas 367
➤ A physician specializing in this tests performed. Related diagnostic

branch of medicine sends a written tests include colonoscopy; CT and
report to the ordering provider, who magnetic resonance imaging of the
discusses the results with the abdomen; kidney, ureter, and blad-
patient. der (KUB) film; barium enema; and
➤ Evaluate test results in relation to proctosigmoidoscopy.
PANCREAS
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transaxial tomography (CTT).
AREA OF APPLICATION: Pancreas.

CONTRAST: Can be done with or without oral or intravenous iodinated
contrast medium.
DESCRIPTION: Computed tomogra- the patient to produce cross-sectional

phy (CT) is a noninvasive procedure views in a three-dimensional fashion
used to enhance certain anatomic by detecting and recording differ-
views of the abdominal structures, ences in tissue density, surrounding
but it becomes an invasive procedure organs, and vessels after having an x-
when contrast medium is used. CT of ray beam passed through them. These
the pancreas aids in the diagnosis density measurements are sent to a
or evaluation of pancreatic cysts, computer that produces a digital
pseudocysts, inflammation, tumors, image of the anatomy, enabling the
masses, metastases, abscesses, and radiologist to look at slices or thin
trauma. In all but the thinnest or sections of certain anatomic views of
most emaciated patients, the pancreas the pancreas and associated vascular
is surrounded by fat that clearly system. Differentiations can be made
defines its margins. While lying on a among solid, cystic, inflammatory, or
table, the patient is moved in and out vascular lesions. CT scanning can
of a doughnut-like device called a detect the swelling that accompanies
gantry, which houses the x-ray tube acute inflammation of the gland
and associated electronics. The scan- and, in chronic cases, the calcium
ner uses multiple x-ray beams and a deposits missed on other examina-
series of detectors that rotate around tions. Intravenous iodinated contrast
medium is given for blood vessel and • Pancreatic pseudocyst

vascular evaluation, and oral contrast • Pancreatic tumor
medium is given for bowel and adja-
cent structure evaluation. Images can
be recorded on photographic or x-ray
film or stored in digital format as digi-
tized computer data. Cine scanning INTERFERING FACTORS:
produces a series of moving images of
the scanned area. The CT scan can be for:
used to guide biopsy needles into
areas of pancreatic masses to obtain • Patients with allergies to shellfish or
tissue for laboratory analysis and for iodinated dye. The contrast
placement of needles to aspirate cysts medium used may cause a life-
or abscesses. CT scanning can moni- threatening allergic reaction. Patients
tor mass, cyst, or tumor growth and
post-therapy response. ■ tion with corticosteroids or the use of
INDICATIONS:
• Evaluate benign or cancerous tumors
or metastasis to the pancreas • Patients who are pregnant or suspected
• Evaluate pancreatic abnormalities (e.g., benefits of the procedure far outweigh
bleeding, pancreatitis, pseudocyst, the risks to the fetus and mother.
abscesses)
• Detect dilation or obstruction of the chronically dehydrated before
pancreatic ducts the test, because of their risk of
• Monitor and evaluate effectiveness of contrast-induced renal failure.
medical or surgical therapies • Patients who are in renal failure.
• Differentiate between pancreatic disor- • Young patients (17 years old and
ders and disorders of the retroperi- younger), unless the benefits of the x-
toneum ray diagnosis outweigh the risks of
• Evaluate unexplained weight loss, exposure to high levels of radiation.
jaundice, and epigastric pain
RESULT imaging:

Normal Findings: remain still during the procedure
• Normal size, position, and contour of because of age, significant pain, or
the pancreas, which lies obliquely in mental status
the upper abdomen • Patients with extreme claustrophobia
Abnormal Findings: study
• Acute or chronic pancreatitis • Improper adjustment of the radio-
• Obstruction of the pancreatic ducts graphic equipment to accommodate
• Pancreatic abscesses overexposure or underexposure and a
• Pancreatic carcinoma poor-quality study
Computed Tomography, Pancreas 369
• 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.
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
• 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
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.
➤ Ensure that results of blood tests
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.
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
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.
➤ 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.
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.
➤ Instruct the patient to increase fluid
intake to help eliminate the contrast
medium if used.
medium. ➤ Inform the patient that diarrhea may
occur after ingesting oral contrast
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, PELVIS

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transaxial tomography (CTT), pelvic CT.
AREA OF APPLICATION: Pelvis.

Computed Tomography, Pelvis 371
DESCRIPTION: Computed tomogra- tissue for laboratory analysis and to

phy (CT) of the pelvis is a noninva- place catheters for drainage of
sive procedure used to enhance abscesses. Tumor size, progression,
certain anatomic views of the pelvic and changes before and after therapy
structures, but it becomes an invasive may be monitored with CT scanning.
procedure when intravenous contrast In rare cases, CT pelvimetry may be
medium is used. The patient lies on a performed on a pregnant woman
table and moves in and out of a whose fetus is in a breech position.
doughnut-like device called a gantry, CT measurements are accurate, and
which houses the x-ray tube and asso- less radiation exposure occurs to the
ciated electronics. The scanner uses mother and the fetus than with radi-
multiple x-ray beams and a series of ographic pelvimetry. ■
detectors that rotate around the
patient to produce cross-sectional INDICATIONS:
views in a three-dimensional fashion • Assist in differentiating between
by detecting and recording differences benign and malignant tumors
beam pass through them. These • Evaluate pelvic lymph nodes
density measurements are sent to a • Detect tumor extension of masses and
computer that produces a digital metastasis into the pelvic area
image of the anatomy, enabling a • Differentiate infectious from inflam-
physician to look at slices or thin matory processes
sections of certain anatomic views, as
• Evaluate cysts, masses, abscesses,
appropriate depending on gender, of
ureteral and bladder calculi, gastroin-
the ovaries, uterus, fallopian tubes, testinal bleeding and obstruction, and
bladder, rectum, sigmoid colon, trauma
prostate, seminal vesicles, cervix, and
associated vascular system and to • Monitor and evaluate effectiveness of
medical, radiation, or surgical therapies
determine the presence and extent
of malignancy. Differentiations can
be made among solid, cystic, inflam- RESULT
matory, or vascular lesions, and
Normal Findings:
suspected hematomas or aneurysms
can be identified. Iodinated contrast • Normal size, position, and shape of
medium is given intravenously for pelvic organs and vascular system
blood vessel and vascular evaluation
or orally for bowel and adjacent struc- Abnormal Findings:
ture evaluation. Images can be • Bladder calculi
recorded on photographic or x-ray
• Ectopic pregnancy
film or stored in digital format as digi-
tized computer data. Cine scanning • Fibroid tumors
produces a series of moving images of • Hydrosalpinx
the scanned area. The CT scan can be
used to guide biopsy needles into • Ovarian cyst or abscess
areas of suspected tumor to obtain • Primary and metastatic neoplasms

for: resulting from inadequate cleansing or
• Patients with allergies to shellfish or study
ologic procedure
with a known hypersensitivity to the • Metallic objects within the examina-
medium may benefit from premedication field (e.g., jewelry or body rings),
tion with corticosteroids or the use of a which may inhibit organ visualization
nonionic contrast medium. and can produce unclear images
• Patients who are claustrophobic. Other considerations:
• Patients who are in renal failure. protective lead apron, stand behind a
Factors that may impair clear sure to radiation.
imaging:
• Inability of the patient to cooperate or Nursing Implications and

remain still during the procedure Procedure ● ● ● ● ● ● ● ● ● ● ●

mental status Pretest:
• Patients with extreme claustrophobia ➤ Inform the patient that the proce-
unless sedation is given before the dure assesses the pelvis.
study ➤ Inform the patient that the proce-
• Improper adjustment of the radio- dure is done in a radiology depart-
ment by a technologist and a
obese or thin patients, which can cause 30 to 60 minutes.
poor-quality study
• Patients who are very obese, who may fish.
exceed the weight limit for the equip- ➤ Obtain a list of medications the
ment patient is taking.
Computed Tomography, Pelvis 373
➤ Obtain a history of the patient’s steroid, as ordered by a physician,

pelvic system and organs, as well as for patients with a known significant
results of previously performed allergic reaction to the IV contrast
tests, procedures, surgeries, and medium.
therapies. For related tests, refer to ➤ If the patient has had a previous
the reproductive, genitourinary/renal barium procedure and some barium
and gastrointestinal system tables. is still retained, administer an enema
➤ Determine previous laboratory to remove barium from the gastroin-
abnormalities, especially blood urea testinal tract.
nitrogen (BUN) and creatinine, if ➤ Place the patient in a supine position
contrast medium is to be used. on a flat table with foam wedges to
➤ Determine date of last menstrual help maintain position and immobi-
period and the possibility of preg- lization. Ask the patient to lie still
nancy in perimenopausal women. during the procedure because move-
➤ Ensure that results of blood tests ment produces unclear images.
are obtained and recorded before Make sure jewelry, watches, chains,
the procedure. belts, and any other metallic objects
have been removed.
➤ Patients receiving metformin
(Glucophage) for non–insulin- ➤ Instruct the patient to remain still
dependent (type 2) diabetes should when the table moves into the scan-
discontinue the drug on the day of ner. The scanner makes noises as it
the test and continue to withhold it rotates around the body. The patient
for 48 hours after the test. Failure to may be asked to take deep breaths
do so may result in lactic acidosis. to facilitate visualization. A number
of images are taken. A computer
➤ Inform the patient that he or she reconstructs these images so they
may experience nausea, a feeling of can be reviewed.
a transient headache after injection ➤ Administer contrast medium, if
of contrast medium, if used. Instruct ordered. A second series of images
the patient to take slow, deep is obtained.
breaths if this occurs.
➤ Ensure that any barium studies have Post-test:
been performed more than 4 days ➤ Instruct the patient to resume
before the scan. normal activity, diet, and previous
➤ The patient may be requested to medication use, unless otherwise
drink approximately 450 mL of a indicated. Renal function should be
dilute barium solution (approxi- assessed before metformin is
mately 1% barium) beginning 1 hour restarted.
before the examination. This is done ➤ Instruct the patient to increase fluid
to distinguish gastrointestinal organs intake to help eliminate the contrast
from the other abdominal organs. medium, if used.
➤ Restrict food and fluids for 6 to 8 ➤ Inform the patient that diarrhea may
hours, if contrast medium is to be occur after ingesting oral contrast
given. medium.
➤ Instruct the patient or caregiver to
Intratest: note change in urinary output after
iodinated contrast medium adminis-
➤ Administer sedative to a child or to tration in patients with impaired
an uncooperative adult, as ordered. renal function.
➤ Administer antianxiety agent, as ➤ If contrast enhancement was used,
ordered, if patient is experiencing observe for delayed allergic reac-
claustrophobia. tions, such as urticaria (hives), itch-
➤ Administer an antihistamine or ing, headache, nausea, or vomiting.
➤ A physician specializing in this the patient’s symptoms and other

branch of medicine sends a written tests performed. Related diagnostic
report to the ordering provider, who tests include angiogram; ultrasound;
discusses the results with the kidney, ureter, and bladder (KUB)
patient. film; and magnetic resonance imag-
➤ Evaluate test results in relation to ing of the abdomen.
PITUITARY
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transaxial tomography (CTT), pituitary CT.
AREA OF APPLICATION: Pituitary/brain.

DESCRIPTION: Computed tomogra- doughnut-like device called a gantry,

phy (CT) of the pituitary is a nonin- which houses the x-ray tube and asso-
vasive procedure that enhances ciated electronics. The scanner uses
certain anatomic views of the pitu- multiple x-ray beams and a series of
itary gland and perisellar region, but detectors that rotate around the
it becomes an invasive procedure patient to produce cross-sectional
when a contrast medium is used. CT views in a three-dimensional fashion
scanning is a safe and rapid method by detecting and recording differ-
for pituitary gland evaluation. This ences in tissue density after having an
procedure aids in the evaluation of x-ray beam passed through tissue and
pituitary adenoma, craniopharyn- bone. These density measurements
gioma, meningioma, aneurysm, are sent to a computer that produces
metastatic disease, exophthalmos, a digital image of the anatomy,
and cysts. It provides unique cross- enabling a physician to look at slices
sectional anatomic information; it is or thin sections of certain anatomic
also unsurpassed in evaluating lesions views of the pituitary and associated
containing calcium. Visualization of vascular system. Differentiations can
bony septa in the sphenoid sinus and be made among solid, cystic, inflam-
evaluation for nonpneumatization of matory, or vascular lesions, and
the sphenoid sinus are best performed suspected hematomas and aneurysms
with this procedure. The patient lies can be identified. The procedure may
on a table and moves in and out of a be repeated after iodinated contrast
Computed Tomography, Pituitary 375
medium is given intravenously for CRITICAL VALUES: N/A

blood vessel and vascular evaluation.
Images can be recorded on photo- INTERFERING FACTORS:
graphic or x-ray film or stored in digi-
tal format as digitized computer data. This procedure is contraindicated
for:
Cine scanning produces a series of
moving images of the scanned area. • Patients with allergies to shellfish or
Tumors, before and after therapy, may iodinated dye. The contrast
be monitored by CT scanning. ■ medium used may cause a life-
INDICATIONS: with a known hypersensitivity to the
• Assist in differentiating between premedication with corticosteroids or
benign and malignant tumors the use of nonionic contrast medium.
• Detect congenital anomalies, such as • Patients who are claustrophobic.
partially empty sella
• Detect tumor extension of masses and
metastasis
• Detect aneurysms and vascular abnor- the risks to the fetus and mother.
malities
• Determine pituitary size and location chronically dehydrated before
in relation to surrounding structures the test, because of their risk of
• Evaluate cysts, masses, abscesses, and contrast-induced renal failure.
trauma • Patients who are in renal failure.
• Monitor and evaluate effectiveness of • Young patients (17 years old and
medical, radiation, or surgical therapies younger), unless the benefits of the x-
RESULT exposure to high levels of radiation.
Normal Findings: Factors that may impair clear
• Normal size, position, and shape of the imaging:
pituitary fossa, cavernous sinuses, and • Inability of the patient to cooperate or
vascular system remain still during the procedure
• Abscess • Patients with extreme cases of claustro-
• Adenoma phobia, unless sedation is given before
the study
• Aneurysm
• Chordoma
• Craniopharyngioma obese or thin patients, which can cause
• Cyst overexposure or underexposure and a
poor-quality study
• Meningioma
• Metastasis exceed the weight limit for the equip-
• Pituitary hemorrhage ment
• Incorrect positioning of the patient, musculoskeletal, endocrine, and

which may produce poor visualization cardiovascular system tables.
of the area to be examined ➤ Determine previous laboratory
abnormalities, especially blood urea
• Inability of the patient to hyperextend nitrogen (BUN) and creatinine, if
the neck to obtain proper images contrast medium is to be used.
• Metallic objects within the examina- ➤ Determine date of last menstrual
tion field (e.g., jewelry or body rings), period and the possibility of preg-
which may inhibit organ visualization nancy in perimenopausal women.
and can produce unclear images ➤ Ensure that the results of blood
tests are obtained and recorded
Other considerations: before the procedure.
occur before the procedure for radia- dependent (type 2) diabetes should
tion safety concerns regarding infants discontinue the drug on the day of
of patients who are lactating. the test and continue to withhold it
do so may result in lactic acidosis.
x-ray procedures. Personnel in the ➤ Inform the patient that he or she
room with the patient should wear a may experience nausea, a feeling of
protective lead apron, stand behind a a transient headache after injection
shield, or leave the area while the of contrast medium, if given.
examination is being done. Personnel Instruct the patient to take slow,
working in the area where the exami- deep breaths if this occurs.
nation is being done should wear ➤ Do not restrict food and fluids for
badges that reveal their level of expo- this procedure; however, if contrast
sure to radiation. medium is given, restrict food and
fluids for 6 to 8 hours.

Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: an uncooperative adult, as ordered.
➤ Administer antianxiety agent, as
➤ Inform the patient that the proce- ordered, if the patient is experienc-
dure assesses the pituitary gland. ing claustrophobia.
➤ Inform the patient that the proce- ➤ Administer an antihistamine or
dure is performed in a radiology steroid, as ordered by a physician,
department by a technologist and a for patients with a known significant
physician and takes approximately allergic reaction to the IV contrast
30 to 60 minutes. medium.
➤ Obtain a history of allergies or sensi- ➤ Place the patient in a supine posi-
tivities to contrast medium or shell- tion on a flat table with foam
fish. wedges to help maintain position
➤ Obtain a list of medications the and immobilization. Ask the patient
patient is taking. to lie still during the procedure be-
➤ Obtain a history of the patient’s cause movement produces unclear
endocrine system as well as results images. Make sure jewelry and any
of previously performed tests, other metallic objects have been
procedures, treatments, and surger- removed.
ies. For related tests, refer to the ➤ As the table moves into the scanner,
Computed Tomography, Renal 377
instruct the patient to remain still. ➤ Instruct the patient or caregiver to

The scanner makes noises as it note any changes in urinary output
rotates around the body. The patient after iodinated contrast medium
may be asked to take deep breaths administration in patients with
to facilitate visualization. A number impaired renal function.
reconstructs these images so they ➤ Observe for delayed allergic reac-
can be reviewed. tions, such as urticaria (hives),
headache, nausea, or vomiting, if
➤ Administer contrast medium, if using contrast medium.
is obtained. ➤ A physician specializing in this
➤ Instruct the patient to resume patient.
normal activity, diet, and previous ➤ Evaluate test results in relation to
medication use, unless otherwise the patient’s symptoms and other
indicated. Renal function should be tests performed. Related diagnostic
assessed before metformin is tests include CT, positron emission
restarted. tomography, and magnetic reso-
➤ Instruct the patient to increase fluid nance imaging of the brain; and CT
intake to help eliminate the contrast angiography and magnetic reso-
medium, if used. nance angiography.
COMPUTED TOMOGRAPHY, RENAL

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

transaxial tomography (CTT), kidney CT.

DESCRIPTION: Renal computed passed in evaluating lesions contain-

tomography (CT) is a noninvasive ing fat or calcium. The patient lies on
procedure used to enhance certain a table and is moved in and out of a
anatomic views of the renal struc- doughnut-like device called a gantry,
tures, but it becomes an invasive which houses the x-ray tube and asso-
procedure when a contrast medium is ciated electronics. The scanner uses
used. CT scanning is a safe and rapid multiple x-ray beams and a series of
method for renal evaluation that is detectors that rotate around the
independent of renal function. It patient to produce cross-sectional
provides unique cross-sectional views in a three-dimensional fashion
anatomic information and is unsur- by detecting and recording differ-
ences in tissue density after having an relation to the bladder in post-

x-ray beam passed through the tissues. transplant patients
These density measurements are sent • Detect bleeding or hyperplasia of the
to a computer that produces a digital adrenal glands
• Determine presence and type of adre-
physician to look at slices or thin
nal tumor, such as benign adenoma,
sections of certain anatomic views of cancer, or pheochromocytoma
the kidneys and associated vascular
system. Differentiations can be made • Evaluate spread of a tumor or invasion
among solid, cystic, inflammatory, or of nearby retroperitoneal organs
vascular lesions, and suspected • Aid in the diagnosis of perirenal
hematomas and aneurysms can be hematomas and abscesses and assist in
identified. The procedure is repeated localizing for drainage
after iodinated contrast medium is • Assist in differentiating between an
given intravenously for blood vessel infectious and an inflammatory process
and vascular evaluation or orally for
• Evaluate cysts, masses, abscesses, renal
bowel and adjacent structure evalua- calculi, obstruction, and trauma
tion. Images can be recorded on
photographic or x-ray film or stored • Monitor and evaluate effectiveness
in digital format as digitized of medical, radiation, or surgical thera-
pies
computer data. Cine scanning
produces a series of moving images of RESULT
the area scanned. The CT scan can be
used to guide biopsy needles into Normal Findings:
areas of suspected tumors to obtain
tissue for laboratory analysis and to
kidneys and vascular system
guide placement of catheters for
drainage of renal abscesses. Tumors, Abnormal Findings:
before and after therapy, may be
monitored with CT scanning. ■ • Adrenal tumor or hyperplasia
• Congenital anomalies, such as polycys-
INDICATIONS: tic kidney disease, horseshoe kidney,
absence of one kidney, or kidney
• Assist in differentiating between
displacement
benign and malignant tumors
• Dilation of the common hepatic duct,
• Evaluate abnormal fluid accumulation
common bile duct, or gallbladder
around the kidney
• Renal artery aneurysm
• Aid in the diagnosis of congenital
anomalies, such as polycystic kidney • Primary and metastatic neoplasms
disease, horseshoe kidney, absence of
• Renal cysts or abscesses
one kidney, or kidney displacement
• Renal cell carcinoma
metastasis into the renal area • Renal laceration, fracture, tumor, and
trauma
• Detect aneurysms and vascular abnor-
malities • Renal calculi, ureteral obstruction
• Determine kidney size and location in • Perirenal abscesses and hematomas
Computed Tomography, Renal 379
CRITICAL VALUES: N/A • Gas or feces in the gastrointestinal tract

INTERFERING FACTORS: failure to restrict food intake before the
study
This procedure is contraindicated • Retained barium from a previous radi-
for: ologic procedure
• Patients with allergies to shellfish • Metallic objects within the examina-
or iodinated dye. The contrast tion field (e.g., jewelry or body rings),
medium used may cause a life- which may inhibit organ visualization
threatening allergic reaction. Patients and can produce unclear images
contrast medium may benefit from Other considerations:
the use of nonionic contrast medium. • Failure to follow dietary restrictions
• Patients who are claustrophobic. procedure to be canceled or repeated.
• Elderly and other patients who are • Consultation with a physician should
chronically dehydrated before occur before the procedure for radia-
the test, because of their risk of tion safety concerns regarding infants
contrast-induced renal failure. of patients who are lactating.
• Patients who are in renal failure. • Risks associated with radiographic
• Young patients (17 years old and x-ray procedures. Personnel in the
younger), unless the benefits of the x- room with the patient should wear a
ray diagnosis outweigh the risks of protective lead apron, stand behind a
exposure to high levels of radiation. shield, or leave the area while the
Factors that may impair clear working in the area where the exami-
imaging: nation is being done should wear
• Inability of the patient to cooperate or badges that reveal their level of expo-
remain still during the procedure sure to radiation.
mental status
• Patients with extreme cases of claustro- Procedure ● ● ● ● ● ● ● ● ● ● ●
phobia, unless sedation is given before
the study Pretest:
• Improper adjustment of the radio- ➤ Inform the patient that the proce-
graphic equipment to accommodate dure assesses the kidneys.
overexposure or underexposure and a dure is performed in a radiology
poor-quality study department by a technologist and a
30 to 60 minutes.
ment ➤ Obtain a history of allergies or sensi-
• Incorrect positioning of the patient, fish.
which may produce poor visualization ➤ Obtain a list of medications the
of the area to be examined patient is taking.
➤ Obtain a history of the patient’s ➤ Administer an enema to remove

renal system as well as results of barium from the gastrointestinal
previously performed tests, treat- tract, as ordered.
ments, surgeries, and procedures. ➤ Place the patient in a supine position
For related tests, refer to the geni- on a flat table with foam wedges
tourinary/renal system table. that help maintain position and
➤ Determine previous laboratory immobilization. Ask the patient
abnormalities, especially blood urea to lie still during the procedure
nitrogen (BUN) and creatinine, if because movement produces
contrast medium is to be used. unclear images. Make sure jewelry,
➤ Determine date of last menstrual watches, chains, belts, and any
period and the possibility of preg- other metallic objects have been
nancy in perimenopausal women. removed.
➤ Ensure that the results of blood ➤ As the table is moved into the scan-
tests are obtained and recorded ner, instruct the patient to remain
before the procedure. still. The scanner makes noises as it
rotates around the body. The patient
➤ Patients receiving metformin may be asked to take deep breaths
(Glucophage) for non–insulin- to facilitate visualization. A number
dependent (type 2) diabetes should of images are taken. A computer
discontinue the drug on the day of reconstructs these images so they
the test and continue to withhold it can be reviewed.
do so may result in lactic acidosis. ➤ Administer a contrast medium, if
➤ Inform the patient that he or she is obtained.
may experience nausea, a feeling
of warmth, a salty or metallic taste,
or a transient headache after injec- Post-test:
tion of contrast medium, if given. ➤ Instruct the patient to resume
Instruct the patient to take slow, normal activity, diet, and previous
deep breaths if this occurs. medication use, unless otherwise
➤ Question the patient to ensure that indicated. Renal function should be
barium studies were performed assessed before metformin is
more than 4 days before the scan. restarted.
➤ The patient may be requested to ➤ Instruct the patient to increase fluid
drink approximately 450 mL of a intake to help eliminate the contrast
dilute barium solution (approxi- medium, if used.
mately 1% barium) beginning 1 hour ➤ Inform the patient that diarrhea may
before the examination. A barium occur after ingesting oral contrast
study is done to distinguish gastroin- medium.
testinal organs from the kidneys.
➤ Instruct the patient or caregiver to
➤ Restrict food and fluids for 6 to 8 ho- note change in urinary output after
urs if contrast medium is to be given. iodinated contrast medium adminis-
tration in patients with impaired
Intratest: renal function.
➤ Administer sedative to a child or to ➤ Observe for delayed allergic reac-
an uncooperative adult, as ordered. tions, such as urticaria (hives),
➤ Administer antianxiety agent, as headache, nausea, or vomiting, if
ordered, if the patient is experienc- contrast enhancement was used.
ing claustrophobia. ➤ A physician specializing in this
➤ Administer an antihistamine or branch of medicine sends a written
steroid, as ordered by a physician, report to the ordering provider, who
for patients with a known significant discusses the results with the
allergic reaction to the IV contrast patient.
medium. ➤ Evaluate test results in relation to
Computed Tomography, Spine 381
the patient’s symptoms and other phy; magnetic resonance imaging

tests performed. Related diagnostic and CT of the abdomen; and kidney,
tests include intravenous pyelogra- ureter, and bladder (KUB) film.
COMPUTED TOMOGRAPHY, SPINE

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transaxial tomography (CTT), spine CT, CT myelogram.
AREA OF APPLICATION: Spine.
DESCRIPTION: Computed tomogra- or thin sections of certain anatomic

phy (CT) of the spine is a noninva- views of the spine and associated
sive procedure that enhances certain vascular system and to determine the
anatomic views of the spinal struc- extent of malignancy. Differen-
tures, but it becomes an invasive tiations can be made among solid,
procedure when intravenous contrast cystic, inflammatory, or vascular
medium is used. CT scanning is more lesions, and suspected hematomas
versatile than conventional radiogra- and aneurysms can be identified.
phy and can easily detect and identify Iodinated contrast medium is given
tumors and their types. The patient intravenously for blood vessel and
lies on a table and is moved in and vascular evaluation or orally for bowel
out of a doughnut-like device called a and adjacent structure evaluation.
gantry, which houses the x-ray tube Images can be recorded on photo-
and associated electronics. The scan- graphic or x-ray film or stored in digi-
ner uses multiple x-ray beams and a tal format as digitized computer data.
series of detectors that rotate around Cine scanning produces a series of
the patient to produce cross-sectional moving images of the scanned area.
views in a three-dimensional fashion CT scanning can be used to guide
by detecting and recording differ- biopsy needles into areas of suspected
ences in tissue density after having tumor to obtain tissue for laboratory
an x-ray beam passed through the analysis and to guide placement of
tissues. These density measurements catheters for drainage of abscesses.
are sent to a computer that produces Tumor size, progression, and prether-
a digital image of the anatomy, apy and post-therapy changes may be
enabling a physician to look at slices monitored with CT scanning. ■
INDICATIONS: • Patients who are pregnant or suspected

• Assist in differentiating between benefits of the procedure far outweigh
benign and malignant tumors the risks to the fetus and mother.
• Detect paraspinal cysts • Elderly and other patients who are
• Detect vascular malformations chronically dehydrated before
• Detect congenital spinal anomalies, contrast-induced renal failure.
such as spina bifida, meningocele, and
myelocele • Patients who are in renal failure.
• Detect herniated intervertebral disks • Young patients (17 years old and
• Monitor and evaluate effectiveness of ray diagnosis outweigh the risks of
medical, radiation, or surgical therapies exposure to high levels of radiation.
RESULT
Normal Findings: imaging:
• Normal density, size, position, and • Inability of the patient to cooperate or

shape of spinal structures remain still during the procedure
• Congenital spinal malformations, such • Patients with extreme cases of claustro-

as meningocele, myelocele, or spina phobia, unless sedation is given before
bifida the study
• Herniated intervertebral disks • Improper adjustment of the radio-

• Paraspinal cysts obese or thin patients, which can cause
• Spinal tumors overexposure or underexposure and a
poor-quality study
• Spondylosis (cervical or lumbar)
• Vascular malformations exceed the weight limit for the equip-
ment
INTERFERING FACTORS: which may produce poor visualization
This procedure is contraindicated • Gas or feces in the gastrointestinal tract
for: resulting from inadequate cleansing or
study
medium used may cause a life- • Retained barium from a previous
threatening allergic reaction. Patients radiologic procedure
tion field (e.g., jewelry or body
rings), which may inhibit organ
• Patients who are claustrophobic. images
Computed Tomography, Spine 383
Other considerations: ➤ Patients receiving metformin

• Consultation with a physician should dependent (type 2) diabetes should
occur before the procedure for radia- discontinue the drug on the day of
tion safety concerns regarding infants the test and continue to withhold it
of patients who are lactating. for 48 hours after the test. Failure to
➤ Inform the patient that he or she
overexposure can result from frequent may experience nausea, a feeling of
x-ray procedures. Personnel in the warmth, a salty or metallic taste, or
room with the patient should wear a a transient headache after injection
protective lead apron, stand behind a of contrast medium, if given.
shield, or leave the area while the Instruct the patient to take slow,
examination is being done. Personnel deep breaths if this occurs.
working in the area where the exami- ➤ Question the patient to ensure that
nation is being done should wear barium studies were performed
badges that reveal their level of expo- more than 4 days before the scan.
sure to radiation. ➤ Restrict food and fluids for 6 to 8
hours, if contrast medium is to be
given.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest: an uncooperative adult, as ordered.
➤ Inform the patient that the proce- ➤ Administer antianxiety agent, as
dure assesses the spine. ordered, if the patient is experienc-
➤ Inform the patient that the proce- ing claustrophobia.
dure is performed in a radiology ➤ Administer an antihistamine or
department by a technologist and a steroid, as ordered by a physician,
physician and takes approximately for patients with a known significant
30 to 60 minutes. allergic reaction to the IV contrast
➤ Obtain a history of allergies or sensi- medium.
tivities to contrast medium or shell- ➤ Place the patient in a supine position
fish. on a flat table with foam wedges to
➤ Obtain a list of medications the help maintain position and immobi-
patient is taking. lization. Ask the patient to lie still
during the procedure because move-
➤ Obtain a history of the patient’s ment produces unclear images.
spine as well as results of previously Make sure jewelry, watches, chains,
performed tests, procedures, belts, and any other metallic objects
trauma, surgeries, and therapies. For have been removed.
related tests, refer to the muscu-
loskeletal system table. ➤ As the table moves into the scanner,
instruct the patient to remain still.
➤ Determine previous laboratory The scanner makes noises as it
abnormalities, especially blood urea rotates around the body. The patient
nitrogen (BUN) and creatinine, if may be asked to take deep breaths
contrast medium is to be used. to facilitate visualization. A number
➤ Determine date of last menstrual of images are taken. A computer
period and the possibility of preg- reconstructs these images so they
nancy in perimenopausal women. can be reviewed.
➤ Ensure that the results of blood ➤ Administer contrast medium, if
tests are obtained and recorded ordered. A second series of images
before the procedure. is obtained.
➤ If a CT myelogram is requested, the ➤ Instruct the patient or caregiver to

patient is removed from the scanner, note any change in urinary output
and a lumbar puncture is performed. after iodinated contrast medium
A small amount of cerebrospinal administration in patients with
fluid is removed and replaced with impaired renal function.
contrast medium. The patient is ➤ Observe for delayed allergic reac-
placed back into the scanner, and tions, such as urticaria (hives),
another series of images is headache, nausea, or vomiting, if
obtained. contrast enhancement was used.
➤ If a CT myelogram was performed,
Post-test:
instruct the patient to remain prone
➤ Instruct the patient to resume for 8 hours.
normal activity, diet, and previous ➤ A physician specializing in this
medication use, unless otherwise branch of medicine sends a written
indicated. Renal function should be report to the ordering provider, who
assessed before metformin is discusses the results with the
restarted. patient.
➤ Instruct the patient to increase fluid ➤ Evaluate test results in relation to
intake to help eliminate the contrast the patient’s symptoms and other
medium, if used. tests performed. Related diagnostic
➤ Inform the patient that diarrhea may tests include musculoskeletal
occur after ingesting oral contrast magnetic resonance imaging and
medium. bone x-rays.
COMPUTED TOMOGRAPHY, SPLEEN

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

DESCRIPTION: Computed tomogra- and abnormalities may be detected

phy (CT) of the spleen is a noninva- on abdominal scans designed to
sive procedure that enhances certain evaluate the liver, pancreas, or re-
anatomic views of the splenic struc- troperitoneum. The patient lies on a
tures, but it becomes an invasive table and is moved in and out of a
procedure with the use of contrast doughnut-like device called a gantry,
medium. The spleen is not often the which houses the x-ray tube and asso-
organ of interest when abdominal ciated electronics. The scanner uses
CT scans are obtained. However, a multiple x-ray beams and a series of
wide variety of splenic variations detectors that rotate around the
Computed Tomography, Spleen 385
patient to produce cross-sectional • Monitor and evaluate effectiveness of

views in a three-dimensional fashion medical, radiation, or surgical therapies
by detecting and recording differences • Evaluate splenic vein thrombosis
beam passed through the tissues. • Evaluate the presence of an accessory
spleen, polysplenia, or asplenia
These density measurements are sent
to a computer that produces a digital
RESULT
physician to look at slices or thin Normal Findings:
sections of certain anatomic views of
the spleen and vascular system. • Normal size, position, and shape of the
Differentiations can be made among spleen and associated vascular system
solid, cystic, inflammatory, or vascu-
Abnormal Findings:
lar lesions, and suspected hematomas
and aneurysms can be identified. CT • Abdominal aortic aneurysm
is the first choice in the evaluation of
• Hematomas
abdominal trauma because of its diag-
nostic accuracy. Iodinated contrast • Hemoperitoneum
medium is given intravenously for • Primary and metastatic neoplasms
blood vessel and vascular evaluation
• Splenic cysts or abscesses
or orally for bowel and adjacent
structure evaluation. Images can be • Splenic laceration, tumor, infiltration,
recorded on photographic or x-ray and trauma
film or stored in digital format as
digitized computer data. Cine scan- CRITICAL VALUES: N/A
ning produces a series of moving
images of the scanned area. CT
scanning can be used to guide This procedure is contraindicated
biopsy needles into areas of tumor to for:
obtain tissue for laboratory analysis
and to guide placement of catheters • Patients with allergies to shellfish or
for drainage of abscesses. Tumors,
before and after medical or surgical threatening allergic reaction. Patients
therapy, may be monitored with CT with a known hypersensitivity to the
scanning. ■ contrast medium may benefit from
INDICATIONS:
benign and malignant tumors • Patients who are pregnant or suspected
metastasis
• Differentiate infectious from inflam-
matory processes
• Evaluate cysts, masses, abscesses, and the test, because of their risk of
trauma contrast-induced renal failure.
• Patients who are in renal failure. x-ray procedures. Personnel in the

Factors that may impair clear badges that reveal their level of expo-
imaging include: sure to radiation.
because of age, significant pain, or Nursing Implications and
mental status Procedure ● ● ● ● ● ● ● ● ● ● ●
• Patients with extreme cases of claustro-

Pretest:
the study ➤ Inform the patient that the proce-
dure assesses the spleen.
dure is performed in a radiology
obese or thin patients, which can cause department by a technologist and a
overexposure or underexposure and a physician and takes approximately
poor-quality study 30 to 60 minutes.
• Patients who are very obese, who may ➤ Obtain a history of allergies or sensi-
exceed the weight limit for the equip- tivities to contrast medium or shell-
ment fish.
• Incorrect positioning of the patient, patient is taking.
of the area to be examined abdominal systems and organs,
• Gas or feces in the gastrointestinal as well as results of previously
tract, resulting from inadequate cleans- performed tests and procedures. For
related tests, refer to the gastroin-
ing or failure to restrict food intake
testinal system table.
before the study
➤ Determine previous laboratory
• Metallic objects within the examina- abnormalities, especially blood urea
tion field (e.g., jewelry or body rings), nitrogen (BUN) and creatinine, if
which may inhibit organ visualization contrast medium is to be used.
and can produce unclear images ➤ Determine date of last menstrual
period and the possibility of preg-
Other considerations: nancy in perimenopausal women.
• Failure to follow dietary restrictions tests are obtained and recorded
before the procedure may cause the before the procedure.
procedure to be canceled or repeated. ➤ Patients receiving metformin
• Consultation with a physician should (Glucophage) for non–insulin-
occur before the procedure for radia- dependent (type 2) diabetes should
tion safety concerns regarding infants discontinue the drug on the day of
of patients who are lactating. for 48 hours after the test. Failure to
• Risks associated with radiographic do so may result in lactic acidosis.
overexposure can result from frequent ➤ Inform the patient that he or she
Computed Tomography, Spleen 387
may experience nausea, a feeling of The scanner makes noises as it

warmth, a salty or metallic taste, or rotates around the body. The patient
a transient headache after injection may be asked to take deep breaths
of contrast medium, if given. to facilitate visualization. A number
Instruct the patient to take slow, of images are taken. A computer
deep breaths if this occurs. reconstructs these images so they
➤ Question the patient to ensure that can be reviewed.
barium studies were performed ➤ Administer contrast medium, if
more than 4 days before the scan. ordered. A second series of images
➤ The patient may be requested to is obtained.
drink approximately 900 mL of a
dilute barium solution (approxi- Post-test:
mately 1% barium) beginning 1 hour
before the examination. This barium ➤ Instruct the patient to resume
study helps to distinguish the spleen normal activity, diet, and previous
from the other abdominal organs. medication use, unless otherwise
➤ Restrict food and fluids for 6 to 8 indicated. Renal function should be
hours, if contrast medium is to be assessed before metformin is
given. restarted.
intake to help eliminate contrast
Intratest: medium, if used.
➤ Administer sedative to a child or to ➤ Inform the patient that diarrhea may
an uncooperative adult, as ordered. occur after ingesting oral contrast
➤ Administer antianxiety agent, as medium.
ordered, if the patient is experienc- ➤ Instruct the patient or caregiver to
ing claustrophobia. note any change in urinary output
➤ Administer an antihistamine or after iodinated contrast medium
steroid, as ordered by a physician, administration in patients with
for patients with a known significant impaired renal function.
allergic reaction to the IV contrast ➤ Observe for delayed allergic reac-
medium. tions, such as urticaria (hives),
➤ Administer an enema to remove headache, nausea, or vomiting, if
barium from the gastrointestinal contrast medium was used.
tract, as ordered. ➤ A physician specializing in this
➤ Place the patient in a supine position branch of medicine sends a written
on a flat table with foam wedges to report to the ordering provider, who
help maintain position and immobi- discusses the results with the
lization. Ask the patient to lie still patient.
during the procedure because move- ➤ Evaluate test results in relation
ment produces unclear images. to the patient’s symptoms and
Make sure jewelry, watches, chains, other tests performed. Related
belts, and any other metallic objects diagnostic tests include ultrasound
have been removed. of the spleen and CT and magne-
➤ As the table moves into the scanner, tic resonance imaging of the
instruct the patient to remain still. abdomen.
THORACIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

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

DESCRIPTION: Computed tomogra- tized computer data. Cine scanning is

phy (CT) of the thorax is more used to produce moving images of the
detailed than a chest x-ray. It is a heart. ■
noninvasive procedure used to
enhance certain anatomic views of the INDICATIONS:
lungs, heart, and mediastinal struc-
tures. The patient lies on a table and • Detect primary and metastatic
pulmonary, esophageal, or mediastinal
is moved in and out of a doughnut-
tumors
like device called a gantry, which
houses the x-ray tube and associated • Differentiate between benign tumors
electronics. The scanner uses multiple (granulomas) and malignancies
x-ray beams and a series of detectors • Detect mediastinal and hilar
that rotate around the patient to lymphadenopathy
produce cross-sectional views in a • Detect lymphomas, especially
three-dimensional fashion by detect- Hodgkin’s disease
ing and recording differences in tissue
density after having an x-ray beam • Detect tumor extension of neck mass
to thoracic area
passed through the tissues. These
density measurements are sent to a • Differentiate tumor from tuberculosis
computer that produces a digital (which appears as coin-sized, calcified
image of the anatomy, enabling a lesions)
physician to look at slices or thin • Detect bronchial abnormalities, such
sections of certain anatomic views of as stenosis, dilation, or tumor
the spine, spinal cord, and lung areas.
• Detect aortic aneurysms
Iodinated contrast medium is given
intravenously for blood vessel and • Differentiate aortic aneurysms from
vascular evaluation or orally for tumors near the aorta
esophageal evaluation. Images can be • Differentiate infectious from inflam-
recorded on photographic or x-ray matory processes (abscess, nodules, or
film or stored in digital format as digi- pneumonitis)
Computed Tomography, Thoracic 389
• Determine blood, fluid, or fat accumu- • Patients who are claustrophobic.

lation in tissues, pleuritic space, or
vessels
• Evaluate cardiac chambers and benefits of the procedure far outweigh
pulmonary vessels the risks to the fetus and mother.
• Evaluate the presence of plaque in • Elderly and other patients who are
cardiac vessels chronically dehydrated before
• Monitor and evaluate effectiveness of
medical or surgical therapeutic regi-
men • Patients who are in renal failure.
RESULT younger), unless the benefits of the x-
Normal Findings: exposure to high levels of radiation.
chest organs, tissues, and structures Factors that may impair clear
imaging include:
Abnormal Findings: • Inability of the patient to cooperate or
• Aortic aneurysm remain still during the procedure
• Chest lesions (benign lesions, neoplas- mental status
tic tumors, or metastatic mediastinal
lesions to ribs or spine) • Patients with extreme cases of claustro-
• Cysts or abscesses the study
• Enlarged lymph nodes • Improper adjustment of the radio-
• Esophageal pathology including graphic equipment to accommodate
tumors obese or thin patients, which can cause
• Hodgkin’s disease poor-quality study
• Pleural effusion • Patients who are very obese, who may
• Pneumonitis exceed the weight limit for the equip-
ment
This procedure is contraindicated • Metallic objects within the examina-
for: tion field (e.g., jewelry or body rings),
• Patients with allergies to shellfish or and can produce unclear images
medium used may cause a life- Other considerations:
with a known hypersensitivity to the • A consultation with a physician should
contrast medium may benefit from occur before the procedure for radia-
premedication with corticosteroids or tion safety concerns regarding infants
the use of nonionic contrast medium. of patients who are lactating.
• Risks associated with radiographic warmth, a salty or metallic taste, or

overexposure can result from frequent a transient headache after injection
x-ray procedures. Personnel in the of contrast medium, if given.
room with the patient should wear a Instruct the patient to take slow,
shield, or leave the area while the ➤ Restrict food and fluids for 6 to 8
examination is being done. Personnel hours, if contrast medium is to be
given.
badges that reveal their level of expo- Intratest:
sure to radiation. ➤ Administer sedative to a child or to
➤ Administer antianxiety agent, as
Nursing Implications and ordered, if the patient is experienc-
Procedure ● ● ● ● ● ● ● ● ● ● ●
ing claustrophobia.
Pretest: steroid, as ordered by a physician,
➤ Inform the patient that the proce- allergic reaction to the IV contrast
dure assesses the chest. medium.
➤ Inform the patient that the proce- ➤ Place the patient in a supine position
dure is performed in a radiology on a flat table with foam wedges
department by a technologist and a that help maintain position and
physician and takes approximately immobilization. Ask the patient
30 to 60 minutes. to lie still during the procedure
➤ Obtain a history of allergies or sensi- because movement produces
tivities to contrast medium or shell- unclear images. Make sure jewelry,
fish. watches, chains, belts, and any other
metallic objects have been removed.
patient is taking. ➤ As the table moves into the scanner,
instruct the patient to remain still.
respiratory and cardiac systems, as
rotates around the body. The patient
may be asked to take deep breaths
to facilitate visualization. A number
related tests, refer to the respiratory
and cardiovascular system tables.
reconstructs these images so they
➤ Determine previous laboratory can be reviewed.
➤ Administer a contrast medium, if
is obtained.
before the procedure. Post-test:
➤ Patients receiving metformin ➤ Instruct the patient to resume
(Glucophage) for non–insulin- normal activity, diet, and previous
dependent (type 2) diabetes should medication use, unless otherwise
discontinue the drug on the day of indicated. Renal function should be
the test and continue to withhold it assessed before metformin is
for 48 hours after the test. Failure to restarted.
do so may result in lactic acidosis. ➤ Instruct the patient to increase fluid
➤ Inform the patient that he or she intake to help eliminate contrast
may experience nausea, a feeling of medium, if used.
Coombs’ Antiglobulin, Direct 391
➤ Instruct the patient or caregiver to branch of medicine sends a written

note change in urinary output after report to the ordering provider, who
iodinated contrast medium adminis- discusses the results with the
tration in patients with impaired patient.
renal function.
➤ Observe for delayed allergic reac- the patient’s symptoms and other
tions, such as urticaria (hives), tests performed. Related diagnostic
headache, nausea, or vomiting, if tests include chest x-ray, magnetic
contrast enhancement was used. resonance imaging of the chest, and
➤ A physician specializing in this lung scan.
COOMBS’ ANTIGLOBULIN, DIRECT

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

SPECIMEN: Serum (1 mL) collected in a red-top tube. Whole blood (1 mL)
collected in lavender-top (ethylenediaminetetra-acetic acid [EDTA]) tube.
REFERENCE VALUE: (Method: Agglutination) Negative (no agglutination).
DESCRIPTION: Direct antiglobulin ment, or both. (See monograph titled

testing (DAT) detects in vivo anti- “Blood Groups and Antibodies” for
body sensitization of red blood cells more information regarding transfu-
(RBCs). Immunoglobulin G (IgG) sion reactions.) ■
produced in certain disease states or
in response to certain drugs can coat INDICATIONS:
the surface of RBCs, resulting in • Detect autoimmune hemolytic
cellular damage and hemolysis. When anemia or hemolytic disease of the
DAT is performed, RBCs are taken newborn
from the patient’s blood sample, • Evaluate suspected drug-induced
washed with saline to remove residual hemolytic anemia
globulins, and mixed with antihuman
• Evaluate transfusion reaction
globulin reagent. If the antihuman
globulin reagent causes agglutination RESULT
of the patient’s RBCs, specific
antiglobulin reagents can be used to Positive in:
determine whether the patient’s • Anemia (autoimmune hemolytic,
RBCs are coated with IgG, comple- drug-induced)
• Hemolytic disease of the newborn • Newborns’ cells may give negative

results in ABO hemolytic disease.
• Systemic lupus erythematosus and
other connective tissue immune disor- Nursing Implications and
ders Procedure ● ● ● ● ● ● ● ● ● ● ●
• Lymphomas
Pretest:
• Mycoplasma pneumonia
• 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
• 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
Negative in: nutritional supplements, and nutra-
• Samples in which sensitization of
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-
• 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
stibophen, sulfonamides, and tetracy- movement.
cline.
• Wharton’s jelly may cause a false- follow the general guidelines in
positive DAT. Appendix A. Perform a venipuncture,
• 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
Coombs’ Antiglobulin, Indirect 393
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.
➤ 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.
COOMBS’ ANTIGLOBULIN, INDIRECT

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SYNONYMS/ACRONYM: Indirect antiglobulin test (IAT), antibody screen.

REFERENCE VALUE: (Method: Agglutination) Negative (no agglutination).
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
globulin would cause the antibody- INTERFERING FACTORS:

coated RBCs to stick together or
• Drugs that may cause a positive IAT
agglutinate. (See monograph titled include penicillin, phenacetin, quini-
“Blood Groups and Antibodies” for dine, and rifampin.
more information regarding transfu-
sion reactions.) ■ • Recent administration of dextran,
whole blood or fractions, or intra-
INDICATIONS: venous contrast media can result in a
false-positive reaction.
• Detect other antibodies in maternal
blood that can be potentially harmful
to the fetus Nursing Implications and
• Determine antibody titers in Rh- Procedure ● ● ● ● ● ● ● ● ● ● ●
negative women sensitized by an Rh-

positive fetus Pretest:
• Screen for antibodies before blood ➤ Obtain a history of the patient’s
transfusions complaints, including a list of known
allergens.
• Test for the weak Rh-variant antigen ➤ Obtain a history of the patient’s
Du. hematopoietic system as well as
RESULT tests and procedures. For related
Positive in: system table.
➤ Obtain a list of all the medications
• Hemolytic anemia (drug-induced or the patient is taking, including herbs,
autoimmune) nutritional supplements, and
• Hemolytic disease of the newborn nutraceuticals. The requesting health
• Incompatible crossmatch should be advised if the patient
• Maternal-fetal Rh incompatibility that their effects can be taken into
Negative in: results.
• Samples in which sensitization of ➤ Note any recent procedures that can
erythrocytes has not occurred interfere with test results.
(complete absence of antibodies) ➤ There are no food, fluid, or medica-
• Samples in which reagent erythrocyte direction.
antigens are unable to detect low- ➤ Review the procedure with the
prevalence antibodies patient.
• Samples in which the patient’s anti- ➤ Inform the patient that specimen
bodies exhibit dosage effects (i.e., collection takes approximately 5 to
stronger reaction with homozygous 10 minutes.
than with heterozygous expression of
an antigen) and reagent erythrocyte Intratest:
antigens contain single-dose expres- ➤ Direct the patient to breathe
sions of the corresponding antigen normally and to avoid unnecessary
(heterozygous) movement.
CRITICAL VALUES: N/A follow the general guidelines in
Copper 395
Appendix A. Perform a venipuncture, weeks to rule out the presence of an

and collect the specimen in a 5-mL antibody.
red-top tube.
➤ Positive test results in pregnant
➤ Label the specimen, and promptly women after 28 weeks’ gestation
transport it to the laboratory. indicate the need for antibody identi-
fication testing.
Post-test:
➤ Observe venipuncture site for bleed- the patient’s symptoms and other
ing or hematoma formation. Apply tests performed. Related laboratory
pressure bandage. tests include blood group and type,
➤ Inform pregnant women that nega- bilirubin, Coombs’ direct antiglobulin
tive tests during the first 12 weeks’ (DAT), haptoglobin, hematocrit, and
gestation should be repeated at 28 hemoglobin.
COPPER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cu.
SPECIMEN: Serum (1 mL) collected in a royal blue–top, trace element–free
tube.
REFERENCE VALUE: (Method: Atomic absorption spectrophotometry)
SI Units
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.
DESCRIPTION: Copper is an impor- component of coagulation factor V,

tant cofactor for the enzymes that assists in the oxidation of glucose, is
participate in the formation of hemo- required for melanin pigment forma-
globin and collagen. Copper is also a tion, is used to synthesize ceruloplas-
min, and is necessary for maintenance • Pregnancy

of myelin sheaths. Copper levels vary • Pulmonary tuberculosis
with intake. This mineral is absorbed
in the stomach and duodenum, stored • Rheumatic fever
in the liver, and excreted in urine and • Rheumatoid arthritis
in feces with bile salts. Copper • Systemic lupus erythematosus
deficiency results in neutropenia
and a hypochromic, microcytic • Thalassemias
anemia that is not responsive to iron • Trauma
therapy. Other signs and symptoms of • Thyroid disease (hypothyroid or
copper deficiency include osteoporo- hyperthyroid)
sis, depigmentation of skin and hair,
• Typhoid fever
impaired immune system response,
and possible neurologic and cardiac • Use of copper intrauterine device
abnormalities. ■
Decreased in:
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
• Infections
• 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
valproic acid.
• Pellagra
• Excessive therapeutic intake of zinc
• Poisoning from copper-contaminated may interfere with intestinal absorp-
solutions or insecticides tion of copper.
Cortisol and Challenge Tests 397

Nursing Implications and movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
➤ Obtain a history of the patient’s and collect the specimen in a 5-mL
complaints, including a list of known royal blue–top, trace element–free
allergens. tube.
hematopoietic, hepatobiliary, and transport it to the laboratory.
immune systems, as well as results
procedures. For related tests, refer Post-test:
to the hematopoietic, hepatobiliary,
and immune system tables. ➤ Observe venipuncture site for bleed-
➤ Obtain a list of medications the ing or hematoma formation. Apply
patient is taking, including herbs, pressure bandage.
nutritional supplements, and nutra- ➤ Instruct the patient to avoid or
ceuticals. The requesting health care increase intake of foods rich in
practitioner and laboratory should be copper, as appropriate. Organ
advised if the patient regularly uses meats, shellfish, nuts, and legumes
these products so that their effects are good sources of dietary copper.
can be taken into consideration High intake of zinc, iron, calcium,
when reviewing results. and manganese interferes with
➤ There are no food, fluid, or medica- copper absorption. Copper defi-
tion restrictions unless by medical ciency does not normally occur in
direction. adults, but patients receiving long-
term total parenteral nutrition should
be evaluated if signs and symptoms
patient.
of copper deficiency appear.
collection takes approximately 5 to ➤ Evaluate test results in relation
10 minutes. to the patient’s symptoms and
other tests performed. Related labo-
Intratest: ratory tests include ceruloplasmin,
complete blood count, liver biopsy,
➤ Direct the patient to breathe and zinc.
CORTISOL AND CHALLENGE TESTS

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

mL) collected in green-top (heparin) tube is also acceptable. Care must be
taken to use the same type of collection container if serial measurements are
to be taken.
Medication Recommended
Procedure Administered Collection Times
ACTH 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.

Cortisol
8 a.m. 5–25 g/dL 138–690 nmol/L
4 p.m. 3–16 g/dL 83–442 nmol/L
ACTH Challenge Tests
CRH stimulation 2–4 fold increase over 2–4 fold increase over
baseline ACTH or baseline values
cortisol level
Dexamethasone Suppressed
3 g/dL next day
ACTH (Cosyntropin) Stimulated
Cortisol greater than Greater than
20 g/dL 552 nmol/L
Cortisol and Challenge Tests 399

Metyrapone Stimulated
ACTH greater than Greater than 33
150 pg/mL pmol/L
3 g/dL next day
ACTH adrenocorticotropic hormone; CRH corticotropin-releasing hormone.
DESCRIPTION: Cortisol (hydrocorti- • Detect adrenal hypofunction

sone) is the predominant glucocorti- (Addison’s disease)
coid secreted in response to stimula-
tion by the hypothalamus and RESULT: The dexamethasone suppres-
pituitary adrenocorticotropic hor- sion test is useful in differentiating the
mone (ACTH). Cortisol stimulates causes for increased cortisol levels.
gluconeogenesis, mobilizes fats and Dexamethasone is a synthetic steroid that
proteins, antagonizes insulin, and suppresses secretion of ACTH. With this
test, a baseline morning cortisol level is
suppresses inflammation. Measuring
collected, and the patient is given a 1-mg
levels of cortisol in blood is the best dose of dexamethasone at bedtime. A
indicator of adrenal function. Corti- second specimen is collected the follow-
sol secretion varies diurnally, with ing morning. If cortisol levels have not
highest levels occurring on awakening been suppressed, adrenal adenoma may
and lowest levels occurring late in the be suspected. The dexamethasone
day. Bursts of cortisol excretion can suppression test also produces abnormal
occur at night. Cortisol and ACTH results in patients with psychiatric
test results are evaluated together illnesses.
because they each control the other’s The corticotropin-releasing hormone
(CRH) stimulation test works as well as
concentrations (i.e., any change
the dexamethasone suppression test in
in one causes a change in the distinguishing Cushing’s disease from
other). ACTH levels exhibit a diurnal conditions in which ACTH is secreted
variation, peaking between 6 and ectopically. In this test, cortisol levels are
8 a.m. and reaching the lowest point measured after an injection of CRH. A
between 6 and 11 p.m. Evening fourfold increase in cortisol levels above
levels are generally one-half to two- baseline is seen in Cushing’s disease. No
thirds lower than morning levels. increase in cortisol is seen if ectopic
(See monograph titled “Adreno- ACTH secretion is the cause.
corticotropic Hormone [and Chal- The cosyntropin test is used when
adrenal insufficiency is suspected.
lenge Tests].”) ■
Cosyntropin is a synthetic form of
ACTH. A baseline cortisol level is
INDICATIONS: collected before the injection of cosyn-
• Detect adrenal hyperfunction tropin. Specimens are subsequently
(Cushing’s syndrome) collected at 30- and 60-minute intervals.
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
• Adrenogenital syndrome complaints, including a list of known
allergens.
• Hypopituitarism
CRITICAL VALUES: N/A endocrine system as well as results
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
one, opiates, oral contraceptives, pred-
nisolone, ranitidine, spironolactone,
tetracosactrin, and vasopressin. ➤ There are no food, fluid, or medica-
• Drugs and substances that may direction.
Creatine Kinase and Isoenzymes 401
➤ Review the procedure with the ➤ Observe standard precautions and

patient. Inform the patient that follow the general guidelines in
multiple specimens may be Appendix A. Perform a venipuncture,
required. and collect the specimen in a 5-mL
➤ Instruct the patient to minimize red- or tiger-top tube.
stress to avoid raising cortisol levels. ➤ Label the specimen, noting collec-
➤ Inform the patient that specimen tion time on the label, and promptly
collection takes approximately 5 to transport it to the laboratory.
10 minutes.
Post-test:
Intratest: ➤ Observe venipuncture site for bleed-
➤ Direct the patient to breathe pressure bandage.
➤ Collect specimen between 6 and tests performed. Related laboratory
8 a.m., when cortisol levels are tests include ACTH, glucose, and
highest. glucose tolerance test.
CREATINE KINASE AND ISOENZYMES

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

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

zymes; enzyme immunoassay techniques are in common use for CK-MB)
SI Units
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
CK isoenzymes by
electrophoresis
CK-BB Absent
CK-MB Less than 4–6%
CK-MM 94–96%
CK-MB by
immunoassay Less than 10 ng/mL
CK creatine kinase; CK-BB CK isoenzyme in brain; CK-MB CK isoenzyme in
heart; CK-MM CK isoenzyme in skeletal muscle.
DESCRIPTION: Creatine kinase (CK) Differences in total CK with age and

is an enzyme that exists almost exclu- gender relate to the fact that the
sively in skeletal muscle, heart muscle, predominant isoenzyme is muscle in
and, in smaller amounts, in the brain. origin. Body builders have higher
This enzyme is important in intracel- values, whereas older individuals have
lular storage and energy release. Three lower values because of deterioration
isoenzymes, based on primary loca- of muscle mass.
tion, have been identified by elec- The use of the mass assay for CK-
trophoresis: brain CK-BB, cardiac MB with cardiac troponin I, in the
CK-MB, and skeletal muscle CK- assessment of MI has largely replaced
MM. When injury to these tissues the use of CK isoenzymes by elec-
occurs, the enzymes are released into trophoresis. CK-MB mass assays are
the bloodstream. Levels increase and more sensitive and rapid than elec-
decrease in a predictable time frame. trophoresis. The evaluation of serial
Measuring the serum levels can help samples for CK-MB is highly recom-
determine the extent and timing of mended. ■
the damage. Noting the presence of
the specific isoenzyme helps deter- INDICATIONS:
mine the location of the tissue • Assist in the diagnosis of acute MI and
damage. evaluate cardiac ischemia (CK-MB)
Acute myocardial infarction (MI) • Detect musculoskeletal disorders that
releases CK into the serum within the do not have a neurological basis, such
first 48 hours; values return to normal as dermatomyosis or Duchenne’s
in about 3 days. The isoenzyme CK- muscular dystrophy (CK-MM)
MB appears in the first 6 to 24 hours • Determine the success of coronary
and is usually gone in 72 hours. artery reperfusion after streptokinase
Recurrent elevation of CK suggests infusion or percutaneous transluminal
reinfarction or extension of ischemic angioplasty, as evidenced by a decrease
damage. Significant elevations of CK in CK-MB
are expected in early phases of muscu-
lar dystrophy, even before the clinical RESULT
signs and symptoms appear. CK
Increased in:
elevation diminishes as the disease
progresses and muscle mass decreases. • Alcoholism
Creatine Kinase and Isoenzymes 403
• Brain infarction (extensive) preparations because of tissue trauma

caused by injection.
• Drugs that may decrease total CK
• Delirium tremens
levels include dantrolene and dobesi-
• Dermatomyositis late.
• Head injury
• Hypothyroidism Nursing Implications and
• Hypoxic shock Procedure ● ● ● ● ● ● ● ● ● ● ●
• Infectious diseases Pretest:

• Gastrointestinal (GI) tract infarction ➤ Obtain a history of the patient’s
• Loss of blood supply to any muscle complaints, including a list of known
allergens.
• Malignant hyperpyrexia ➤ Obtain a history of the patient’s
• Muscular dystrophies cardiovascular and musculoskeletal
• MI ously performed tests and proce-
• Myocarditis cardiovascular and musculoskeletal
• Neoplasms of the prostate, bladder, system tables.
and GI tract ➤ Obtain a list of the medications
• Polymyositis herbs, nutritional supplements, and
• Pregnancy nutraceuticals. The requesting health
• Prolonged hypothermia should be advised if the patient is
regularly using these products so
• Pulmonary edema that their effects can be taken
• Pulmonary embolism into consideration when reviewing
results.
• Reye’s syndrome ➤ There are no food, fluid, or medica-
• Rhabdomyolysis tion restrictions unless by medical
direction.
• Surgery ➤ Review the procedure with the
• Tachycardia patient. Inform the patient that a
series of samples will be required.
• Tetanus (Samples at time of admission, 2 to
4 hours, 6 to 8 hours, and 12 hours
• Trauma after admission are the minimal
recommendations. Additional sam-
Decreased in: ples may be requested.)
• Small stature ➤ Inform the patient that specimen
• Sedentary lifestyle 10 minutes.

INTERFERING FACTORS: normally and to avoid unnecessary
• Drugs that may increase total CK levels movement.
include any intramuscularly injected ➤ Observe standard precautions and
follow the general guidelines in may be helpful in achieving a goal of

Appendix A. Perform a venipuncture, lowering total cholesterol and triglyc-
and collect the specimen in a 5-mL eride levels. The Step 1 diet empha-
red- or tiger-top tube. sizes a reduction in foods high in
➤ Label the specimen, and promptly saturated fats and cholesterol. Red
transport it to the laboratory. meats, eggs, and dairy products are
the major sources of saturated fats
and cholesterol. If triglycerides are
Post-test: also elevated, the patient should be
advised to eliminate or reduce alco-
➤ Observe venipuncture site for bleed- hol and simple carbohydrates from
ing or hematoma formation. Apply the diet. The Step 2 diet recom-
pressure bandage. mends stricter reductions.
➤ Increased CK levels may be associ- ➤ Evaluate test results in relation to
ated with coronary artery disease the patient’s symptoms and other
(CAD). Nutritional therapy is recom- tests performed. Related laboratory
mended for individuals identified tests include aspartate aminotrans-
to be at high risk for developing ferase, C-reactive protein, calcium,
CAD. If overweight, the patient ionized calcium, electrolytes, homo-
should be encouraged to achieve a cysteine, lactate dehydrogenase and
normal weight. The American Heart isoenzymes, magnesium, myoglo-
Association Step 1 and Step 2 diets bin, and troponin.
CREATININE, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
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
DESCRIPTION: Creatinine is the end in energy-requiring metabolic reac-

product of creatine metabolism. tions. In these processes, a small
Creatine resides almost exclusively in amount of creatine is irreversibly
skeletal muscle, where it participates converted to creatinine, which then
Creatinine, Serum 405
circulates to the kidneys and is • Poliomyelitis

excreted. The amount of creatinine • Renal disease, acute and chronic renal
generated in an individual is propor- failure
tional to the mass of skeletal muscle
present and remains fairly constant, • Rhabdomyolysis
unless there is massive muscle • Shock
damage resulting from crushing
injury or degenerative muscle disease. Decreased in:
Creatinine values also decrease with • Decreased muscle mass owing to debil-
age owing to diminishing muscle itating disease or increasing age
mass. Blood urea nitrogen (BUN) is
• Inadequate protein intake
often ordered with creatinine for
comparison. The BUN/creatinine • Liver disease (severe)
ratio is also a useful indicator of • Muscular dystrophy
disease. The ratio should be between
10:1 and 20:1. Creatinine is the ideal • Pregnancy
substance for determining renal clear- • Small stature
ance because a fairly constant quan-
tity is produced within the body. The CRITICAL VALUES:
creatinine clearance test measures a Potential critical value is greater
blood sample and a urine sample to than 15 mg/dL (nondialysis
patient).
determine the rate at which the
Possible interventions may include
kidneys are clearing creatinine from
renal or peritoneal dialysis and
the blood; this accurately reflects the organ transplant, but early
glomerular filtration rate. (See mono- discovery of the cause of
graph titled “Creatinine, Urine, and elevated creatinine levels might
Creatinine Clearance, Urine” for avoid such drastic interventions.
additional information.) ■
INDICATIONS: • Drugs and substances that may
increase creatinine levels include aceb-
• Assess a known or suspected disorder utolol, acetaminophen (overdose),
involving muscles in the absence of aldatense, amikacin, amiodarone,
renal disease amphotericin B, arginine, arsenicals,
• Evaluate known or suspected impair- ascorbic acid, asparaginase, acetylsali-
ment of renal function cylic acid, barbiturates, capreomycin,
captopril, carbutamide, carvedilol,
RESULT cephalothin, chlorthalidone, cimeti-
dine, cisplatin, clofibrate, colistin, corn
Increased in: oil (Lipomul), cyclosporine, dextran,
doxycycline, enalapril, ethylene glycol,
• Acromegaly gentamicin, indomethacin, ipodate,
kanamycin, levodopa, mannitol,
methicillin, methoxyflurane, mito-
• Dehydration mycin, neomycin, netilmycin, nitro-
furantoin, nonsteroidal anti-
• Gigantism
inflammatory drugs, oxyphenbuta-
• Hyperthyroidism zone, paromomycin, penicillin,
pentamidine, phosphorus, plicamycin, excessive exercise for 8 hours

radiographic agents, semustine, strep- before the test.
tokinase, streptozocin, tetracycline, ➤ Review the procedure with the
thiazides, tobramycin, triamterene, patient.
vancomycin, vasopressin, viomycin, ➤ Inform the patient that specimen
and vitamin D. collection takes approximately 5 to
10 minutes.
• Drugs that may decrease creatinine
levels include citrates, dopamine, Intratest:
ibuprofen, and lisinopril.
• Bilirubin and glucose can cause false normally and to avoid unnecessary
decreases in creatinine. movement.
• A diet high in meat can cause increased ➤ Observe standard precautions and
creatinine levels. follow the general guidelines in
• Ketosis can cause a significant increase and collect the specimen in a 5-mL
in creatinine. red- or tiger-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Post-test:
complaints, including a list of known ➤ Increased creatinine levels may be
allergens. associated with kidney disease. The
➤ Obtain a history of the patient’s nutritional needs of patients with
genitourinary and musculoskeletal kidney disease vary widely and are
systems, as well as results of previ- in constant flux. Anorexia, nausea,
ously performed tests and proce- and vomiting commonly occur,
dures. For related tests, refer to the prompting the need for continuous
genitourinary and musculoskeletal nutritional monitoring for malnutri-
system tables. tion, especially among patients
receiving long-term hemodialysis
➤ Obtain a list of medications the therapy.
nutritional supplements, and nutra- ➤ Evaluate test results in relation to
ceuticals. The requesting health care the patient’s symptoms and other
practitioner and laboratory should be tests performed. Related laboratory
advised if the patient is regularly tests include anion gap, urine creati-
using these products so that their nine, creatinine clearance, serum
effects can be taken into considera- and urine electrolytes, gentamicin,
tion when reviewing results. kidney stone analysis, microalbumin,
serum and urine osmolality,
➤ There are no food, fluid, or medica- tobramycin, serum and urine uric
tion restrictions unless by medical acid, blood and urine urea nitro-
direction. gen, BUN/creatinine ratio, and
➤ Instruct the patient to refrain from vancomycin.
Creatinine, Urine, and Creatinine Clearance, Urine 407
CREATININE, URINE, AND

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

Urine Creatinine (Conversion Factor 8.84)
2–3 y 6–22 mg/kg/24 h 53–194 mol/kg/24 h
4–18 y 12–30 mg/kg/24 h 106–265 mol/kg/24 h
Adult male 14–26 mg/kg/24 h 124–230 mol/kg/24 h
Adult female 11–20 mg/kg/24 h 97–177 mol/kg/24 h
Creatinine Clearance (Conversion Factor 0.0167)
Children 70–140 mL/min/1.73 m2 1.17–2.33 mL/s/1.73 m2
Adult male 85–125 mL/min/1.73 m2 1.42–2.08 mL/s/1.73 m2
Adult female 75–115 mL/min/1.73 m2 1.25–1.92 mL/s/1.73 m2
For each decade Decrease of 6–7 Decrease of 0.06–0.07
after 40 y mL/min/1.73 m2 mL/s/1.73 m2
DESCRIPTION: Creatinine is the end with advancing age owing to dimin-

product of creatine metabolism. ishing muscle mass. Although the
Creatine resides almost exclusively in measurement of urine creatinine is an
skeletal muscle, where it participates effective indicator of renal function,
in energy-requiring metabolic reac- the creatinine clearance test is more
tions. In these processes, a small precise. The creatinine clearance test
amount of creatine is irreversibly measures a blood sample and a urine
converted to creatinine, which then sample to determine the rate at which
circulates to the kidneys and is the kidneys are clearing creatinine
excreted. The amount of creatinine from the blood; this accurately
generated in an individual is reflects the glomerular filtration rate
proportional to the mass of skeletal and is based on an estimate of body
muscle present and remains fairly surface. ■
constant, unless there is massive
muscle damage resulting from crush- INDICATIONS:
ing injury or degenerative muscle • Determine the extent of nephron
disease. Creatinine values decrease damage in known renal disease (at least
50 percent of functioning nephrons Decreased in:

must be lost before values are
decreased) • Acute or chronic glomerulonephritis
• Determine renal function before • Anemia

administering nephrotoxic drugs • Chronic bilateral pyelonephritis
• Evaluate accuracy of a 24-hour urine • Hyperthyroidism
collection, based on the constant level
of creatinine excretion • Leukemia
• Evaluate glomerular function • Muscle wasting diseases
• Monitor effectiveness of treatment in • Paralysis

renal disease • Polycystic kidney disease
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
Creatinine, Urine, and Creatinine Clearance, Urine 409
creatinine clearance include ampho- ➤ Instruct the patient to refrain from

tericin B, acetylsalicylic acid, carbenox- eating meat during the test.
olone, chlorthalidone, cimetidine, ➤ Review the procedure with the
cisplatin, cyclosporine, guancidine, patient. Provide a nonmetallic urinal,
ibuprofen, indomethacin, mitomycin, bedpan, or toilet-mounted collection
oxyphenbutazone, paromycin, device.
probenecid (coadministered with ➤ Usually a 24-hour time frame for
digoxin), and thiazides. urine collection is ordered. Inform
the patient that all urine must be
• Excessive ketones in urine may cause saved during that 24-hour period.
falsely decreased values. Instruct the patient not to void
directly into the laboratory collection
• Failure to follow proper technique in container. Instruct the patient to
collecting 24-hour specimen may avoid defecating in the collection
invalidate test results. device and to keep toilet tissue out
• Failure to refrigerate specimen contamination of the specimen.
throughout urine collection period Place a sign in the bathroom to
allows decomposition of creatinine, remind the patient to save all urine.
causing falsely decreased values. ➤ Instruct the patient to void all urine
• Consumption of large amounts of into the collection device and then to
meat, excessive exercise, and stress pour the urine into the laboratory
should be avoided for 24 hours before collection container. Alternatively
the test. collection device for a health care
staff member to add to the labora-
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest: with dietary preparations and other
Appendix A.
genitourinary system as well as Random specimen (collect in
results of previously performed early morning)
tests, refer to the genitourinary
system table. Clean-catch specimen:
➤ Obtain a list of medications the ➤ Instruct the male patient to (1) thor-
patient is taking, including herbs, oughly wash his hands, (2) cleanse
nutritional supplements, and the meatus, (3) void a small amount
nutraceuticals. The requesting health into the toilet, and (4) void directly
care practitioner and laboratory into the specimen container.
should be advised if the patient ➤ Instruct the female patient to (1)
regularly uses these products so thoroughly wash her hands; (2)
that their effects can be taken cleanse the labia from front to back;
into consideration when reviewing (3) while keeping the labia sepa-
results. rated, void a small amount into the
➤ There are no fluid or medication toilet; and (4) without interrupting
restrictions unless by medical direc- the urine stream, void directly into
tion. the specimen container.
Pediatric urine collector: kept on ice throughout the entire

collection period. If an indwelling
➤ Put on gloves. Appropriately cleanse urinary catheter is in place, the
the genital area and allow the area to drainage bag must be kept on ice.
dry. Remove the covering over the
adhesive strips on the collector bag ➤ Begin the test between 6 and 8
and apply over the genital area. a.m., if possible. Collect first voiding
Diaper the child. When specimen is and discard. Record the time the
obtained, place the entire collection specimen was discarded as the
bag in a sterile urine container. beginning of the timed collection
period. The next morning, ask the
Indwelling catheter: patient to void at the same time the
collection was started and add this
➤ Put on gloves. Empty drainage tube last voiding to the container.
of urine. It may be necessary to
clamp off the catheter for 15 to 30 ➤ If an indwelling catheter is in place,
minutes before specimen collection. replace the tubing and container
Cleanse specimen port with antisep- system at the start of the collection
tic swab, and then aspirate 5 mL of time. Keep the container system
urine with a 21- to 25-gauge needle on ice during the collection period,
and syringe. Transfer urine to a ster- or empty the urine into a larger
ile container. container periodically during the
collection period; monitor to ensure
Urinary catheterization: continued drainage, and conclude
the test the next morning at the
➤ Place female patient in lithotomy same hour the collection was
position or male patient in supine begun.
position. Using sterile technique,
➤ At the conclusion of the test,
open the straight urinary catheteriza-
tion kit and perform urinary catheter-
the urinary output record for the
ization. Place the retained urine in a
sterile specimen container.
less than what was recorded as
Suprapubic aspiration: output, some urine may have been
discarded, invalidating the test.
➤ Place the patient in a supine posi- ➤ Label the specimen, and promptly
tion. Cleanse the area with antisep- transport it to the laboratory. Include
tic and drape with sterile drapes. on the label the amount of urine,
Using sterile technique, insert test start and stop times, and inges-
needle and remove sterile sample. tion of any foods or medications that
Place the returned sample in a ster- can affect test results.
ile specimen container. Place a dry
sterile dressing over the site. Post-test:
➤ Do not collect urine from the pouch
from the patient with a urinary diver- ➤ Evaluate test results in relation to
sion (e.g., ilieal conduit). Instead the patient’s symptoms and other
perform catheterization through the tests performed. Related laboratory
stoma. tests include anion gap, creatinine,
serum and urine electrolytes,
gentamicin, kidney stone analysis,
Timed specimen:
microalbumin, serum and urine
➤ Obtain a clean 3-L urine specimen osmolality, tobramycin, serum and
container, toilet-mounted collection urine uric acid, blood and urine urea
device, and plastic bag (for transport nitrogen, blood urea nitrogen
of the specimen container). The (BUN)/creatinine ratio, and vanco-
specimen must be refrigerated or mycin.
Cryoglobulin 411
CRYOGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cryo.
REFERENCE VALUE: (Method: Visual observation for changes in appearance)
Negative.
DESCRIPTION: Cryoglobulins are RESULT

abnormal serum proteins that cannot
be detected by protein electrophore- Increased in:
sis. Cryoglobulins cause vascular • Type I cryoglobulin (monoclonal)
problems because they can precipitate Chronic lymphocytic leukemia
in the blood vessels of the fingers Lymphoma
when exposed to cold, causing Multiple myeloma
Raynaud’s phenomenon. They are
usually associated with immunologic • Type II cryoglobulin (mixtures of
monoclonal immunoglobulin M
disease. The laboratory procedure
[IgM] and polyclonal IgG)
to detect cryoglobulins is a two-
Autoimmune hepatitis
step process. The serum sample is
Rheumatoid arthritis
observed for cold precipitation after
Sjögren’s syndrome
72 hours of storage at 4C. True cryo-
globulins disappear on warming to Waldenström’s macroglobulinemia
room temperature, so in the second • Type III cryoglobulin (mixtures of
step of the procedure, the sample is polyclonal IgM and IgG)
rewarmed to confirm reversibility of Acute poststreptococcal
the reaction. ■ glomerulonephritis
Chronic infection (especially
INDICATIONS: hepatitis C)
Cirrhosis
• Assist in diagnosis of neoplastic Endocarditis
diseases, acute and chronic infections,
and collagen diseases Infectious mononucleosis
Polymyalgia rheumatica
• Detect cryoglobulinemia in patients Rheumatoid arthritis
with symptoms indicating or mimick-
Sarcoidosis
ing Raynaud’s disease
Systemic lupus erythematosus
• Monitor course of collagen and rheu-
matic disorders Decreased in: N/A
CRITICAL VALUES: N/A into consideration when reviewing

results.
• Testing the sample prematurely (before direction.
total precipitation) may yield incorrect ➤ Review the procedure with the
results. patient.
• Failure to maintain sample at normal ➤ Inform the patient that specimen
body temperature before centrifuga- collection takes approximately 5 to
tion can affect results. 10 minutes.
• A recent fatty meal can increase turbid- Intratest:

ity of the blood, decreasing visibility.
movement.
Procedure ● ● ● ● ● ● ● ● ● ● ● follow the general guidelines in
Pretest: and collect the specimen in a 5-mL
red-top tube.
immune system as well as results of
previously performed tests and ➤ Observe venipuncture site for bleed-
procedures. For related tests, refer ing or hematoma formation. Apply
to the immune system table. pressure bandage.
➤ Obtain a list of the medications ➤ Evaluate test results in relation to
the patient is taking, including the patient’s symptoms and other
herbs, nutritional supplements, and tests performed. Related laboratory
nutraceuticals. The requesting health tests include antinuclear antibody,
care practitioner and laboratory hepatitis C antibody, immunofixation
should be advised if the patient electrophoresis, IgA, IgG, IgM, pro-
regularly uses these products so tein, protein electrophoresis, and
that their effects can be taken rheumatoid factor.
CULTURE AND SMEAR,

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

culosis (TB) culture and smear, Mycobacterium culture and smear.
Culture and Smear, Mycobacteria 413
SPECIMEN: Sputum (5 to 10 mL), bronchopulmonary lavage, tissue, mate-

rial from fine-needle aspiration, bone marrow, cerebrospinal fluid (CSF),
gastric aspiration, urine, and stool.
REFERENCE VALUE: (Method: Culture on selected media, microscopic

examination of sputum by acid-fast or auramine-rhodamine fluorochrome
stain) Rapid methods include: chemiluminescent-labeled DNA probes that
target ribosomal RNA of the Mycobacterium, radiometric carbon dioxide
detection from 14C-labeled media, polymerase chain reaction/amplification
techniques.
Culture: No growth
Smear: Negative for AFB
DESCRIPTION: A culture and smear mation, cough, fever, and hemoptysis.

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

(AIDS) tuberculosis
• Assist in the differentiation of tubercu- • Monitor the response to treatment for
losis from carcinoma or bronchiectasis pulmonary tuberculosis
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.
CRITICAL VALUES: significant organisms for proper evalu-

Smear: Positive for AFB ation.
Culture: Growth of pathogenic • Inadequate or improper (e.g., saliva)
bacteria samples should be rejected.
• Specimen collection after initiation of Nursing Implications and
treatment with antituberculosis drug Procedure ● ● ● ● ● ● ● ● ● ● ●
therapy may result in inhibited or no

growth of organisms. Pretest:
• Contamination of the sterile container ➤ Obtain a history of the patient’s
with organisms from an exogenous complaints and exposure to TB.
source may produce misleading results. Obtain a list of known allergens.
• Specimens received on a dry swab immune and respiratory systems, as
should be rejected: A dry swab indi- well as results of previously
cates that the sample is unlikely to have performed tests and procedures. For
been collected properly or unlikely to related tests, refer to the immune
contain a representative quantity of and respiratory system tables.
Culture and Smear, Mycobacteria 415
➤ Obtain a list of medications the Intratest:

nutritional supplements, and ➤ Ensure that the patient has complied
nutraceuticals. The requesting health with dietary preparations and other
care practitioner and laboratory pretesting restrictions before bron-
should be advised if the patient is choscopy.
regularly using these products so ➤ If the patient is to undergo bron-
that their effects can be taken into choscopy, record baseline vital
consideration when reviewing signs.
results. ➤ Instructions regarding the appropri-
➤ Note any recent procedures that can ate transport for bone marrow, body
interfere with test results. fluids, tissue, urine, and stool should
be obtained from the laboratory.
Culture after bronchoscopy:
➤ The patient should fast and refrain follow the general guidelines in
from drinking liquids from midnight Appendix A.
the night before the procedure.
➤ Other than antimicrobial drugs, there Bronchoscopy:
are no medication restrictions, ➤ Record baseline vital signs. The
unless by medical direction. patient is positioned in relation to
➤ Assess if the patient has an allergy the type of anesthesia being used.
to local anesthetics, and inform If local anesthesia is used, the
the health care practitioner accord- patient is seated and the tongue
ingly. and oropharynx are sprayed and
➤ Obtain written and informed swabbed with anesthetic before
consent before bronchoscopy is the bronchoscope is inserted. For
performed. general anesthesia, the patient is
placed in a supine position with the
Expectorated specimen: neck hyperextended. The patient is
helped to a supine or side-lying posi-
➤ There are no food or fluid restriction and the bronchoscope is
tions. inserted. After inspection, the tissue
➤ Other than antimicrobial drugs, there samples are collected from suspi-
are no medication restrictions, cious sites by bronchial brush or
unless by medical direction. biopsy forceps.
➤ Additional liquids the night before
may assist in liquefying secretions Expectorated specimen:
during expectoration the following ➤ Ask the patient to sit upright, with
morning. assistance and support (e.g., with an
➤ Assist patient with oral cleaning overbed table) as needed.
before sample collection to reduce ➤ Ask the patient to take two or three
the amount of sample contamina- deep breaths and cough deeply. Any
tion by organisms that normally sputum raised should be expecto-
inhabit the mouth. rated directly into a sterile sputum
collection container.
General:
➤ If the patient is unable to produce
➤ Review the procedure with the the desired amount of sputum,
patient. Inform the patient that the several strategies may be at-
culture results will not be reported tempted. One approach is to have
for 3 to 8 weeks. the patient drink two glasses of
➤ The time it takes to collect a proper water, and then assume the position
specimen varies according to the for postural drainage of the upper
level of cooperation of the patient and middle lung segments. Effective
and the specimen collection site. coughing may be assisted by placing
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.
➤ 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.
Culture, Fungal 417
➤ Inform the patient of smoking cessa- support resources to assist in coping

tion programs, as appropriate. with chronic illness and possible
➤ Recognize anxiety related to test early death.
results and provide support. Provide ➤ Evaluate test results in relation to
teaching and information regarding the patient’s symptoms and other
the clinical implications of the test tests performed. Related laboratory
results, as appropriate. Inform the tests include arterial/alveolar oxygen
patient of the importance of medical ratio, blood gases, complete blood
follow-up and suggest ongoing count, and relevant cultures.
CULTURE, FUNGAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Hair, skin, nail, pus, sterile fluids, blood, bone marrow, stool,
bronchial washings, sputum, or tissue samples collected in a sterile plastic,
tightly capped container.
REFERENCE VALUE: (Method: Culture on selective media; macroscopic and

microscopic examination) No presence of fungi.
DESCRIPTION: Fungi, organisms that INDICATIONS:

normally live in soil, can be intro- • Determine antimicrobial sensitivity of
duced into humans through the the organism
accidental inhalation of spores or
inoculation of spores into tissue • Isolate and identify organisms respon-
through trauma. Individuals most sible for nail infections or abnormali-
susceptible to fungal infection usually ties
are debilitated by chronic disease, are • Isolate and identify organisms respon-
receiving prolonged antibiotic ther- sible for skin eruptions, drainage, or
apy, or have impaired immune other evidence of infection
systems. Fungal diseases may be clas-
sified according to the involved tissue
type: dermatophytoses involve super-
RESULT
ficial and cutaneous tissue; there are
also subcutaneous and systemic
mycoses. ■ • Blood
Candida albicans ➤ Obtain a history of the patient’s

Histoplasma capsulatum immune system as well as results of
• Cerebrospinal fluid procedures. For related tests, refer
Coccidioides immitis to the immune system table.
Cryptococcus neoformans ➤ Obtain a list of medications
Members of the order Mucorales the patient is taking, including
Paracoccidioides brasiliensis nutraceuticals. The requesting health
Sporothrix schenckii care practitioner and laboratory
• Hair should be advised that the patient
Epidermophyton that their effects can be taken
Microsporum into consideration when reviewing
Trichophyton results.
• Nails ➤ There are no food, fluid, or medica-
Candida albicans
direction.
Cephalosporium
Epidermophyton patient.
Trichophyton ➤ Inform the patient that specimen
• Skin collection may vary depending on
Actinomyces israelii collection site but usually takes
approximately 5 to 10 minutes.
Candida albicans
Coccidioides immitis Intratest:
Epidermophyton
Microsporum normally and to avoid unnecessary
Trichophyton movement.
• Tissue ➤ Observe standard precautions and
A. israelii follow the general guidelines in
Appendix A. Instructions regarding
Aspergillus the appropriate transport materials
Candida albicans for blood, bone marrow, bronchial
Nocardia washings, sputum, sterile fluids,
P. brasiliensis stool, and tissue samples should be
obtained from the laboratory.
CRITICAL VALUES: N/A Skin:
➤ Clean the collection site with 70%
INTERFERING FACTORS: Prompt and alcohol. Scrape the peripheral
proper specimen processing, storage, and margin of the collection site with a
analysis are important to achieve accurate sterile scalpel or wooden spatula.
results. Place the scrapings in a sterile
Hair:
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
Culture, Viral 419
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Urine, semen, blood, body fluid, stool, tissue, or swabs from
the affected site.
REFERENCE VALUE: (Method: Culture in special media, enzyme-linked

immunoassays, direct fluorescent antibody techniques, latex agglutination,
immunoperoxidase techniques) No virus isolated.
DESCRIPTION: Viruses, the most INDICATIONS: Assist in the identifica-

common cause of human infection, tion of viral infection
are submicroscopic organisms that
invade living cells. They can be classi- RESULT
fied as either RNA- or DNA-type
viruses. Viral titers are highest in the
early stages of disease before the host
has begun to manufacture significant • Acquired immunodeficiency syndrome
antibodies against the invader. Human immunodeficiency virus
Specimens need to be collected as (HIV)
early on in the disease process as • Acute respiratory failure
possible. ■ Hantavirus
• Anorectal infections • Hemorrhagic fever

Herpes simplex virus (HSV) Ebola virus
Human papillomavirus Hantavirus
• Bronchitis Lassa virus
Parainfluenza virus Marburg virus
Respiratory syncytial virus (RSV) • Herpangina
• Condylomata Coxsackievirus (group A)
Human papilloma DNA virus • Infectious mononucleosis
Cytomegalovirus
• Conjunctivitis/keratitis
Epstein-Barr virus
Adenovirus
Epstein-Barr virus • Meningitis
HSV Coxsackieviruses
Measles virus Echovirus
Parvovirus HSV-2
Rubella virus Lymphocytic choriomeningitis virus
Varicella zoster virus • Myocarditis/pericarditis
• Croup Coxsackievirus
Parainfluenza virus Echovirus
RSV • Parotitis
Mumps virus
• Cutaneous infection with rash
Parainfluenza virus
Enteroviruses
HSV • Pharyngitis
Varicella zoster virus Adenovirus
Coxsackievirus (group A)
• Encephalitis
Epstein-Barr virus
Enteroviruses
HSV
Flaviviruses
Influenza virus
HSV
Parainfluenza virus
HIV
Rhinovirus
Measles virus
Rabies virus
• Pleurodynia
Coxsackievirus (group B)
Togaviruses
• Pneumonia
• Febrile illness with rash
Adenovirus
Coxsackieviruses
Influenza virus
Echovirus
Parainfluenza virus
• Gastroenteritis RSV
Norwalk virus
• Upper respiratory tract infection
Rotavirus
Adenovirus
• Genital herpes Corona virus
HSV-1 Influenza virus
HSV-2 Parainfluenza virus
• Hemorrhagic cystitis RSV
Adenovirus Rhinovirus
Culture, Viral 421
CRITICAL VALUES: Positive RSV ➤ Inform the patient that specimen

culture should be reported immediately collection takes approximately 5 to
10 minutes.
to the requesting health care practi-
tioner.
Intratest:
INTERFERING FACTORS: Viral specimens
are unstable. Prompt and proper
specimen processing, storage, and analy- movement.
sis are important to achieve accurate
results. ➤ Observe standard precautions and
Appendix A. Instructions regarding
the appropriate transport materials
Nursing Implications and for blood, bronchial washings,
sputum, sterile fluids, stool, and
Procedure ● ● ● ● ● ● ● ● ● ● ●
tissue samples should be obtained
from the laboratory. The type of
Pretest: applicator used to obtain swabs
➤ Obtain a history of the patient’s should be verified by consultation
complaints, including a list of known with the testing laboratory person-
allergens. nel.
➤ Obtain a history of the patient’s ➤ The appropriate viral transport
gastrointestinal, genitourinary, imm- material should be obtained from
une, reproductive, and respiratory the laboratory. Nasopharyngeal
systems, as well as results of previ- washings for RSV testing should be
ously performed tests and proce- immediately placed in cold viral
dures. For related tests, refer to transport media.
the gastrointestinal, genitourinary, ➤ Label the specimen with the exact
immune, reproductive, and respira- site, date, and time of collec-
tory system tables. tion; contact person for notifica-
➤ Obtain a list of the medications tion of results; and other pertinent
the patient is taking, including information (e.g., patient immuno-
herbs, nutritional supplements, and compromised owing to organ trans-
nutraceuticals. The requesting health plant, radiation, or chemotherapy).
care practitioner and laboratory Promptly transport the specimen to
should be advised if the patient the laboratory.
results.
➤ There are no food, fluid, or medica- to the patient’s symptoms and
tion restrictions unless by medical other tests performed. Related
direction. tests include relevant tissue biopsy,
➤ Review the procedure with the bacterial cultures, and viral serology
patient. tests.
CYSTOMETRY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Urodynamic testing of bladder function, CMG.

AREA OF APPLICATION: Bladder, urethra.
CONTRAST: None.
DESCRIPTION: Cystometry evaluates pelvic muscles), total (continuous and

the motor and sensory function of the unpredictable), urge (involuntary when
bladder when incontinence is present urgency is sensed), and psychological
or neurological bladder dysfunction is (e.g., dementia, confusion affecting
awareness)
suspected and monitors the effects of
treatment for the abnormalities. This • Determine type of neurogenic bladder
noninvasive manometric study meas- (motor or sensory)
ures the bladder pressure volume • Evaluate the management of neurolog-
characteristics in centimeters of water ical bladder before surgical interven-
(cm H2O) during the filling and tion
emptying phases. The test provides • Evaluate the usefulness of drug therapy
information about bladder structure on detrusor muscle function and tonic-
and function that can lead to unin- ity and on internal and external
hibited bladder contractions, sensa- sphincter function
tions of bladder fullness and need to
• Determine cause of urinary retention
void, and ability to inhibit voiding.
These abnormalities cause inconti- • Detect congenital urinary abnormali-
nence and other impaired patterns ties
of micturition. Cystometry can be • Determine the cause of recurrent
performed with cystoscopy and urinary tract infections (UTIs)
sphincter electromyography. ■ • Evaluate postprostatectomy inconti-
nence
INDICATIONS: • Evaluate voiding disorders associated
• Determine cause of bladder dysfunc- with spinal cord injury
tion and pathology • Evaluate urinary obstruction in male
• Evaluate signs and symptoms of patients experiencing urinary retention
urinary elimination pattern dysfunc-
tion RESULT
• Determine the type of incontinence: Normal Findings:
functional (involuntary and unpre-
dictable), reflex (involuntary when a • Normal sensory perception of bladder
specific volume is reached), stress (weak fullness, desire to void and ability to
Cystometry 423
inhibit urination, and appropriate • Patients with urethral obstruction

response to temperature (hot and cold)
• Patients with cervical cord lesions
• Normal bladder capacity: 350 to 750 because patients may exhibit auto-
mL for men and 250 to 550 mL for nomic dysreflexia, as seen by bradycar-
women dia, flushing, hypertension, dia-
phoresis, and headache
• Normal functioning bladder pressure:
8 to 15 cm H2O • Inability to catheterize the patient
• Normal sensation of fullness: 40 to 100
Factors that may impair examina-
cm H2O or 300 to 500 mL tion results:
• Normal bladder pressure during void-
ing: 30 to 40 cm H2O
• Normal detrusor pressure: less than 10 because of age, significant pain, or
cm H2O mental status
• Normal urge to void: 150 to 450 mL • Inability to void in a supine position or
straining to void during the study
• Urethral pressure that is higher than
bladder pressure, ensuring continence • A high level of patient anxiety or
embarrassment, which may interfere
• Normal filling pattern
with the study, making it difficult to
• Absence of residual urine (0 mL) distinguish whether the results are due
to stress or organic pathology
Abnormal Findings:
• Administration of drugs that affect
• Flaccid bladder that fills without bladder function, such as muscle relax-
contracting ants or antihistamines
• Inability to perceive bladder fullness Other considerations:
• Inability to initiate or maintain urina-
tion without applying external pressure
before the procedure may cause
• Sensory or motor paralysis of bladder the procedure to be canceled or
repeated.
• Total loss of conscious sensation and
vesical control or uncontrollable
micturition (incontinence)
CRITICAL VALUES: N/A Procedure ● ● ● ● ● ● ● ● ● ● ●
INTERFERING FACTORS: Pretest:

This procedure is contraindicated dure is performed in a special urol-
for: ogy room or in a clinic setting by the
• Patients with acute UTIs because the physician.
study can cause infection to spread to ➤ Obtain a history of the patient’s
the kidneys complaints and medication usage
(e.g., antihistamines and muscle
• Patients who are pregnant or suspected relaxants).
of being pregnant, unless the potential ➤ Obtain a history of the patient’s
benefits of the procedure far outweigh genitourinary system as well as
the risks to the fetus and mother results of previously performed
medical and surgical therapeutic the stream; volume voided; pres-

interventions. For related tests, refer ence of dribbling, straining, or hesi-
to the genitourinary and renal tancy; and stop time.
system tables. ➤ A urinary catheter is inserted into
➤ Determine date of last menstrual the bladder under sterile conditions,
period and the possibility of preg- and residual urine is measured
nancy in perimenopausal women. and recorded. A test for sensory
➤ Determine the patient’s allergies or response to temperature is done by
sensitivities to anesthetics, anal- instilling 30 mL of room-temperature
gesics, antibiotics, and latex. sterile water followed by 30 mL of
warm sterile water. Sensations are
➤ Assess hematologic status, blood- assessed and recorded.
clotting ability, and urinalysis findings
for abnormalities. ➤ Fluid is removed from the bladder,
and the catheter is connected to a
➤ Inform the patient that the only cystometer that measures the pres-
discomfort he or she will experience sure. Sterile normal saline or distilled
is the insertion of the urethral water or carbon dioxide gas is
catheter, and that there may be instilled in controlled amounts into
some sensation of pressure and/or the bladder. When the client indi-
having to void. cates the urge to void, the bladder is
➤ Obtain a written, informed consent considered full; urination amounts
for the procedure from the patient. as well as start and stop times are
➤ Instruct the patient to report pain, then recorded.
sweating, nausea, headache, and ➤ Pressure and volume readings are
the urge to void during the study. recorded and graphed for response
➤ Explain that patient cooperation with to heat, full bladder, urge to void,
positioning and activity before and and ability to inhibit voiding. The
during the test is crucial for achiev- patient is requested to void without
ing accurate results. straining, and pressures are taken
and recorded during this activity.
tion restrictions unless by medical ➤ After completion of voiding, the
direction. bladder is emptied of any other fluid,
and the catheter is withdrawn,
➤ Review the procedure with the unless further testing is planned.
patient.
➤ If further testing is done to deter-
➤ Inform the patient that the proce- mine if abnormal bladder function is
dure takes approximately 30 to 45 being caused by muscle incompe-
minutes. tence or interruption in innervation,
anticholinergic medication (e.g.,
Intratest: atropine) or cholinergic medication
(e.g., bethanechol [Urecholine]) can
➤ Give the patient a gown and robe to be injected and the study repeated
wear; ensure that the patient is in 20 or 30 minutes.
draped during the procedure to avoid
unnecessary exposure. Post-test:
➤ Position the patient in a supine or
lithotomy position on the examining ➤ Inform the patient that further exam-
table. If spinal cord injury is present, inations may be necessary.
the patient can remain on a stretcher ➤ Monitor fluid intake and urinary
in a supine position and be draped output for 24 hours after the proce-
appropriately. dure.
➤ Ask the patient to void and lie still ➤ Monitor vital signs after the proce-
during the procedure. During void- dure every 15 minutes for 2 hours or
ing, note characteristics such as as directed. Elevated temperature
start time; force and continuity of may indicate infection.
Cystoscopy 425
➤ Inform the patient that he or she ➤ A physician specializing in this

may experience burning or discom- branch of medicine sends a written
fort on urination for a few voidings report to the ordering provider, who
after the procedure. discusses the results with the
➤ Emphasize that persistent flank or patient.
suprapubic pain, fever, chills, blood ➤ Evaluate test results in relation to
in urine, difficulty urinating, or the patient’s symptoms and other
change in urinary pattern must be re- tests performed. Related diagnostic
ported to the physician immediately. tests include pelvic ultrasound, intra-
➤ Determine if the patient or family venous pyelography, and computed
members have any further ques- tomography and magnetic reso-
tions or concerns. nance imaging of the pelvis.
CYSTOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Cystoureterography, cystourethrography, prostatog-

raphy.
AREA OF APPLICATION: Bladder, urethra, ureteral orifices.

CONTRAST: None.
DESCRIPTION: Cystoscopy provides during urethroscopy or retrograde

direct visualization of the urethra, pyelography. ■
urinary bladder, and ureteral
orifices—areas not usually visible INDICATIONS:
with x-ray procedures. This proce- • Differentiate, through tissue biopsy,
dure is also used to obtain specimens between benign and cancerous lesions
and treat pathology associated involving the bladder
with the aforementioned structures. • Evaluate the function of each kidney
Cystoscopy is accomplished by by obtaining urine samples via ureteral
transurethral insertion of a cystoscope catheters
into the bladder. Rigid cystoscopes
• Evaluate changes in urinary elimina-
contain an obturator and a telescope
tion patterns
with a lens and light system; there are
also flexible cystoscopes, which use • Determine the source of hematuria of
fiberoptic technology. The procedure unknown cause
may be performed during or after • Determine the possible source of
ultrasonography or radiography, or persistent urinary tract infections
• Evaluate the extent of prostatic hyper- • Renal calculi

plasia and degree of obstruction
• Tumors
• Identify congenital anomalies, such as
• Ureteral or urethral stricture
duplicate ureters, ureteroceles, urethral
or ureteral strictures, diverticula, and • Urinary tract malformation and
areas of inflammation or ulceration congenital anomalies
• Remove renal calculi from the bladder
or ureters CRITICAL VALUES: N/A
• Place ureteral catheters to drain urine INTERFERING FACTORS:
from the renal pelvis or for retrograde
pyelography This procedure is contraindicated
• Identify and remove polyps and small for:
tumors (including fulguration) from • Patients who are pregnant or suspected
the bladder of being pregnant, unless the potential
• Evacuate blood clots and perform benefits of the procedure far outweigh
fulguration of bleeding sites within the the risks to the fetus and mother
lower urinary tract • Patients with bleeding disorders
• Implant radioactive seeds because instrumentation may lead to
excessive bleeding from the lower
• Evaluate urinary tract abnormalities urinary tract
such as dysuria, frequency, retention,
inadequate stream, urgency, and incon- • Patients with acute cystitis or urethritis
tinence because instrumentation could allow
bacteria to enter the bloodstream,
• Resect small tumors resulting in septicemia
• Dilate the urethra and ureters
Factors that may impair examina-
• Coagulate bleeding areas tion results:
• Place ureteral stents and resect prostate
• Inability of the patient to cooperate
gland tissue (transurethral resection of
or remain still during the procedure
the prostate)
mental status
RESULT
Normal Findings:
• Normal ureters, bladder, and urethra before the procedure may cause the
structure procedure to be canceled or repeated.
Abnormal Findings:
• Diverticulum of the bladder, fistula,

stones, and strictures Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• 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.
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.
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
immediately transport them to the ➤ Inform the patient that burning or

laboratory. discomfort on urination can be expe-
rienced for a few voidings after the
Post-test: procedure and that the urine may be
blood-tinged for the first and second
➤ Monitor vital and neurological signs voidings after the procedure.
until they return to preprocedure ➤ Emphasize that persistent flank or
levels. suprapubic pain, fever, chills, blood
➤ Inform the patient that further examin urine, difficulty urinating, or
inations may be necessary to evalu- change in urinary pattern must be re-
ate progression of the disease ported immediately to the physician.
process or to determine the need for ➤ Determine if the patient or family
a change in therapy. members have any further ques-
➤ Instruct the patient to resume his or tions or concerns.
her usual diet and medications, as ➤ A physician specializing in this
directed by the health care provider. branch of medicine sends a written
➤ Encourage the patient to drink report to the ordering provider, who
increased amounts of fluids (125 discusses the results with the
mL/h for 24 hours) after the proce- patient.
dure. ➤ Evaluate test results in relation to
➤ Monitor fluid intake and urinary the patient’s symptoms and other
output for 24 hours after the proce- tests performed. Related diagnostic
dure. Decreased urine output may tests include pelvic ultrasound, intra-
indicate bladder edema or perfora- venous pyelography, and computed
tion caused by forceful advance- tomography and magnetic reso-
ment of instrumentation. nance imaging of the pelvis.
CYSTOURETHROGRAPHY, VOIDING
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Voiding cystography.

AREA OF APPLICATION: Bladder, urethra.
CONTRAST: Radiopaque iodine–based contrast medium.
D E S C R I P T I O N : Vo i d i n g excretion of the contrast medium.

cystourethrography involves visuali- Excretion or micturition is recorded
zation of the bladder filled with electronically or on videotape for
contrast medium instilled through a confirmation or exclusion of ureteral
catheter by use of a syringe or gravity, reflux and evaluation of the urethra.
and after the catheter is removed, the Fluoroscopic films or plain radio-
Cystourethrography, Voiding 429
graphs may also be taken to record CRITICAL VALUES: N/A

bladder filling and emptying. This
procedure is often used to evaluate INTERFERING FACTORS:
chronic urinary tract infections
(UTIs). ■ This procedure is contraindicated
for:
INDICATIONS: • Patients with allergies to shellfish or
• Evaluate possible cause of frequent iodinated dye. The contrast
UTIs medium used may cause a life-
• Confirm the diagnosis of congenital
lower urinary tract anomaly
• Evaluate abnormal bladder emptying premedication with corticosteroids or
and incontinence the use of nonionic contrast medium.
• Assess hypertrophy of the prostate • Patients with bleeding disorders.
lobes
• Assess ureteral stricture of being pregnant, unless the potential
• Evaluate the effects of bladder trauma
• Assess the degree of compromise of a
• Patients with UTI, obstruction, or
stenotic prostatic urethra
injury.
• Evaluate the presence and extent of
ureteral reflux
• Evaluate the urethra for obstruction the test, because of their risk of
and strictures contrast-induced renal failure.
RESULT
Normal Findings: Factors that may impair clear
imaging:
• Normal bladder and urethra structure
and function • Inability of the patient to cooperate or
Abnormal Findings: because of age, significant pain, or
mental status
• Bladder trauma
• Bladder tumors graphic equipment to accommodate
• Hematomas obese or thin patients, which can cause
• Neurogenic bladder poor-quality study
• Pelvic tumors • Patients who are very obese, who may
• Prostatic enlargement exceed the weight limit for the equip-
ment
• Ureteral stricture
• Ureterocele which may produce poor visualization
• Urethral diverticula of the area to be examined
• Vesicoureteral reflux • Gas or feces in the gastrointestinal tract
resulting from inadequate cleansing or ➤ Determine date of last menstrual

failure to restrict food intake before the period and possibility of pregnancy
study in perimenopausal women.
• Retained barium from a previous for the procedure from the patient.
radiologic procedure
• Metallic objects within the examina- intake the day before the test, but
tion field (e.g., jewelry or body rings), to have only clear fluids 8 hours
which may inhibit organ visualization before the test.
and can produce unclear images ➤ Inform the patient that he or she
may feel some pressure when the
catheter is inserted and when the
Other considerations: contrast medium is instilled through
the catheter.
occur before the procedure for radia- ➤ Inform the patient that he or she
tion safety concerns regarding infants may receive a laxative the night
before the test or an enema or a
cathartic the morning of the test, as
• Risks associated with radiographic ordered.
overexposure can result from frequent ➤ Schedule gastrointestinal or any
x-ray procedures. Personnel in the barium studies after this study.
room with the patient should wear a ➤ Inform the patient that the proce-
protective lead apron, stand behind a dure is done by a radiologist and
shield, or leave the area while the support staff.
examination is being done. Personnel ➤ Insert a Foley catheter before the
working in the area where the exami- procedure, if ordered.
nation is being done should wear ➤ Review the procedure with the
badges that reveal their level of expo- patient.
sure to radiation. ➤ Inform the patient that the proce-
dure takes approximately 30
minutes.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Remove patient’s clothing and

Pretest: metallic objects from the lower
abdominal area.
purpose of the procedure, the need ➤ Give the patient a gown and robe to
to remain still, and the need to hold wear; ensure that the patient is
his or her breath for short periods. draped during the procedure to avoid
unnecessary exposure.
suspected hypersensitivity to radio- ➤ Have the patient void before the
graphic contrast medium or shell- procedure.
fish. ➤ Administer an antihistamine or
➤ Obtain a history of the patient’s steroid, as ordered by a physician,
complaints. for patients with a known significant
➤ Obtain a history of the patient’s gen- medium.
itourinary and abdominal systems as
well as results of previously per- ➤ Place the patient on the table in a
formed tests and procedures. For supine or lithotomy position.
related tests, refer to the genitouri- ➤ A kidney, ureter, and bladder (KUB)
nary system table. film or plain radiograph is taken to
Cytology Sputum 431
ensure that no barium or stool ate progression of the disease

obscures visualization of the urinary process or to determine the need for
system. a change in therapy.
➤ A catheter is filled with contrast ➤ Instruct the patient to resume his or
medium to eliminate air pockets and her usual diet and medications, as
is inserted until the balloon reaches directed by the health care provider.
the meatus. The patient is placed in
➤ Maintain the patient on adequate
the right posterior oblique position
hydration after the procedure
with the thigh drawn up to a 90°
Encourage the patient to drink
angle and, in men, the penis placed
increased amounts of fluids (125
along its axis.
mL/h for 24 hours) after the proce-
➤ When three-fourths of the contrast dure to prevent stasis and bacterial
medium has been injected, another buildup.
radiographic exposure is made while
➤ Monitor fluid intake and urinary
the remainder of the contrast
output for 24 hours after the proce-
medium is injected.
dure. Decreased urinary output may
➤ Left lateral and oblique views may indicate impending renal failure or
be necessary to visualize the area in edema caused by instrumentation.
question.
➤ Monitor for signs of sepsis—fever,
➤ If the patient is able to void, the chills, and severe pelvic pain.
catheter is removed and the patient
is asked to urinate while films are ➤ Determine if the patient or family
taken or radiographic images of the members have any further ques-
bladder and urethra are recorded. tions or concerns.
➤ The procedure may be done on ➤ A physician specializing in this
women using a double balloon to branch of medicine sends a written
occlude the bladder neck from above report to the ordering provider, who
and below the external meatus. discusses the results with the
patient.
➤ Monitor vital and neurological signs tests performed. Related diagnostic
until they return to preprocedure tests include pelvic ultrasound, intra-
levels. venous pyelography, and computed
➤ Inform the patient that further exam- tomography and magnetic reso-
inations may be necessary to evalu- nance imaging of the pelvis.
CYTOLOGY, SPUTUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Sputum (10 to 15 mL) collected on 3 to 5 consecutive first-
morning, deep-cough expectorations.
REFERENCE VALUE: (Method: Macroscopic and microscopic examination)

Negative for abnormal cells, fungi, ova, and parasites.
DESCRIPTION: Cytology is the study • Lipoid or aspiration pneumonia, as

of the origin, structure, function, and seen by lipid droplets contained in
pathology of cells. In clinical practice, macrophages
cytologic examinations are generally • Neoplasms
performed to detect cell changes
• Viral infections and lung disease
resulting from neoplastic or inflam-
matory conditions. Sputum speci-
CRITICAL VALUES:
mens for cytologic examinations may
If the patient becomes hypoxic or
be collected by expectoration alone, cyanotic, remove catheter
by suctioning, by lung biopsy, during immediately and administer
bronchoscopy, or by expectoration oxygen.
after bronchoscopy. A description If patient has asthma or chronic
of the method of specimen collection bronchitis, watch for aggravated
by bronchoscopy and biopsy is found bronchospasms with use of
in the monograph titled “Biopsy, normal saline or acetylcysteine
in an aerosol.
Lung.” ■

• Assist in the diagnosis of lung cancer • Improper specimen fixation may be
cause for specimen rejection.
• Assist in the diagnosis of Pneumocystis
carinii in persons with acquired • Improper technique used to obtain
immunodeficiency syndrome (AIDS) bronchial washing may be cause for
specimen rejection.
• Detect known or suspected fungal or
parasitic infection involving the lung
• Detect known or suspected viral Nursing Implications and
disease involving the lung Procedure ● ● ● ● ● ● ● ● ● ● ●
• Screen cigarette smokers for neoplastic

(nonmalignant) cellular changes Pretest:
• Screen patients with history of acute or ➤ Obtain a history of the patient’s
chronic inflammatory or infectious complaints, including a list of known
allergens.
lung disorders, which may lead to
benign atypical or metaplastic changes ➤ Obtain a history of the patient’s
immune and respiratory systems, as
RESULT: (Method: Microscopic exami- performed tests and procedures. For
nation) The method of reporting results related tests, refer to the immune
of cytology examinations varies according and respiratory system tables.
to the laboratory performing the test.
Terms used to report results may include the patient is taking, including
negative (no abnormal cells seen), inflam- herbs, nutritional supplements, and
matory, benign atypical, suspect for nutraceuticals. The requesting health
neoplasm, and positive for neoplasm. care practitioner and laboratory
Positive findings in: is regularly using these products
so that their effects can be taken
• Infections caused by fungi, ova, or into consideration when reviewing
parasites results.
Cytology Sputum 433
➤ For specimens collected by suction- procedure if the specimen is to be

ing or expectoration without bron- obtained by tracheal suctioning.
choscopy, there are no food, fluid, or ➤ Assist in providing extra fluids,
medication restrictions unless by unless contraindicated, and proper
medical direction. humidification to decrease tenacious
➤ Instruct the patient to fast and secretions. Inform the patient that
refrain from taking liquids from increasing fluid intake before retiring
midnight the night before if bron- on the night before the test aids in
choscopy or biopsy is to be liquefying secretions and may make
performed. it easier to expectorate in the morn-
ing. Also explain that humidifying
➤ Address concerns about pain related inspired air also helps to liquefy
to the procedure. Explain that a secretions.
sedative and/or anesthetic is admin-
➤ Assist with mouth care (brushing
istered before the procedure to
teeth or rinsing mouth with water), if
promote relaxation and reduce
needed, before collection so as not
discomfort during the procedure,
to contaminate the specimen by oral
and that general anesthesia is
secretions.
administered for open biopsy.
Atropine is usually given before ➤ Instruct the patient not to touch the
bronchoscopy examinations to edge or inside of the specimen
reduce bronchial secretions and to container with the hands or mouth.
prevent vagally induced bradycardia. ➤ Review the procedure with the
Meperidine (Demerol) or morphine patient. If the laboratory has pro-
may be given as a sedative. vided a container with fixative,
Lidocaine is sprayed in the patient’s instruct the patient that the fixative
throat to reduce discomfort caused contents of the specimen collection
by the presence of the tube. container should not be ingested or
➤ Assess if the patient has an allergy otherwise removed.
to local anesthetics, and inform the ➤ Inform the patient that three
health care practitioner accordingly. samples may be required, on three
separate mornings, either by pass-
➤ Ensure that nonallergy to anesthesia
ing a small tube (tracheal catheter)
is confirmed before bronchoscopy or
and adding suction or by expectora-
biopsy procedure is performed
tion.
under general anesthesia.
➤ The time it takes to collect a proper
➤ Obtain written and informed specimen varies according to the
consent before bronchoscopy or level of cooperation of the patient
biopsy is performed. and the specimen collection proce-
➤ Inform the patient that the test helps dure.
identify cellular changes associated
with neoplasms or organisms that Intratest:
result in respiratory tract infections.
When the actual infectious organ- ➤ Ensure that the patient has complied
isms are identified by cytology, tell with dietary restrictions before bron-
the patient that the findings will be choscopy or biopsy.
confirmed by culture. Emphasize ➤ Observe standard precautions and
that sputum and saliva are not the follow the general guidelines in
same. Appendix A.
➤ Reassure the patient that he or she ➤ Administer ordered premedication
will be able to breathe during the 30 to 60 minutes before the proce-
procedure if specimen collected is dure.
accomplished via suction method.
Bronchoscopy:
Ensure that oxygen has been admin-
istered 20 to 30 minutes before the ➤ Record baseline vital signs. The
patient is positioned in relation to the patient is still unable to raise

the type of anesthesia being used. sputum, the use of an ultrasonic
If local anesthesia is used, the nebulizer (“induced sputum”) may
patient is seated, and the tongue be necessary; this is usually done by
and oropharynx are sprayed and a respiratory therapist.
swabbed with anesthetic before
the bronchoscope is inserted. For Tracheal suctioning:
general anesthesia, the patient is
➤ Obtain the necessary equipment,
placed in a supine position with the
including a suction device, suction
neck hyperextended. The patient is
kit, and Lukens tube or in-line trap.
helped to a supine or side-lying posi-
tion, and the bronchoscope is ➤ Position the patient with head
inserted. After inspection, the tissue elevated as high as tolerated.
samples are collected from suspi- ➤ Put on sterile gloves. Maintain the
cious sites by bronchial brush or dominant hand as sterile and the
biopsy forceps. nondominant hand as clean.
➤ Using the sterile hand, attach the
Expectorated specimen: suction catheter to the rubber tubing
➤ Ask the patient to sit upright, with of the Lukens tube or in-line trap.
assistance and support (e.g., with an Then attach the suction tubing to the
overbed table) as needed. male adapter of the trap with the
clean hand. Lubricate the suction
➤ Ask the patient to take two or three
catheter with sterile saline.
deep breaths and cough deeply. Any
sputum raised should be expecto- ➤ Tell nonintubated patients to
rated directly into a sterile sputum protrude the tongue and to take a
collection container. deep breath as the suction catheter
is passed through the nostril. When
➤ If the patient is unable to produce
the catheter enters the trachea, a
the desired amount of sputum,
reflex cough is stimulated; immedi-
several strategies may be attemp-
ately advance the catheter into
ted. One approach is to have the
the trachea and apply suction.
patient drink two glasses of water,
Maintain suction for approximately
and then assume the position for
10 seconds, but never longer than 15
postural drainage of the upper
seconds. Withdraw the catheter
and middle lung segments. Effec-
without applying suction. Separate
tive coughing may be assisted by
the suction catheter and suction
placing either the hands or a pillow
tubing from the trap, and place the
over the diaphragmatic area and
rubber tubing over the male adapter
applying slight pressure. Another
to seal the unit.
approach is to place a vaporizer or
other humidifying device at the ➤ For intubated patients or patients
bedside. with a tracheostomy, the previous
procedure is followed except that
➤ After sufficient exposure to
the suction catheter is passed
adequate humidification, postural
through the existing endotracheal
drainage of the upper and middle
or tracheostomy tube rather than
lung segments may be repeated
through the nostril. The patient
before attempting to obtain the
should be hyperoxygenated before
specimen. Other methods may
and after the procedure in accor-
include obtaining an order for an
dance with standard protocols for
expectorant to be administered with
suctioning these patients.
additional water approximately 2
hours before attempting to obtain
General:
the specimen. Chest percussion
and postural drainage of all lung ➤ Label the specimen, and promptly
segments may also be employed. If transport it to the laboratory. Note
Cytology, Urine 435
antimicrobial therapy on the collec- gargles, inhalants, and warm moist

tion container. Cytology specimens applications. A cool beverage may
may also be expressed onto a glass aid in relieving throat irritation
slide and sprayed with a fixative or caused by coughing or suctioning.
95% alcohol. ➤ Instruct the patient to notify some-
one immediately if he or she begins
Post-test: to have difficulty breathing or if
➤ After general anesthesia, monitor bleeding occurs.
vital signs every 15 minutes for an ➤ Observe the patient’s color and
hour, and then every 2 hours for 4 respiratory rate. Administer oxygen,
hours, and as ordered. Take temper- as necessary.
ature every 4 hours for 24 hours. ➤ Inform the patient of smoking cessa-
➤ After local anesthesia, monitor vital tion programs, as appropriate.
signs and compare with baseline ➤ Recognize anxiety related to test
values. results and offer support. Provide
➤ To avoid accidental aspiration, teaching and information regarding
instruct the patient not to eat or the clinical implications of the test
drink until the effects of the anes- results, as appropriate. Inform the
thesia have worn off and the gag patient with abnormal findings of
reflex has returned. the importance of medical follow-
➤ Instruct the patient to resume usual up, and suggest ongoing support
diet as directed by the health care resources to assist in coping with
practitioner. chronic illness and possible early
death.
➤ Note the color, consistency, and
volume of the specimen collected. ➤ Evaluate test results in relation to
➤ Instruct the patient to perform tests performed. Related laboratory
mouth care after the specimen has tests include arterial/alveolar oxygen
been obtained. ratio, blood gases, complete blood
➤ Provide comfort measures and treat- count, Gram stain, and relevant
ment as needed, such as antiseptic cultures.
CYTOLOGY, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Urine (180 mL for an adult or at least 10 mL for a child)
collected in a clean wide-mouth plastic container.
REFERENCE VALUE: (Method: Microscopic examination) No abnormal cells

or inclusions seen.
DESCRIPTION: Cells from the epithe- into consideration when reviewing

results.
lial lining of the urinary tract can be
found in the urine. Examination of ➤ There are no food, fluid, or medica-
these cells for abnormalities is useful direction.
with suspected infection, inflamma-
tory conditions, or malignancy. ■ patient. If a catheterized specimen is
to be collected, explain this proce-
INDICATIONS: Assist in the diagnosis of dure to the patient and obtain a
urinary tract diseases, such as cancer, catheterization tray.
cytomegalovirus infection, and other ➤ Inform the patient that specimen
inflammatory conditions collection takes approximately 5 to
10 minutes.
RESULT
Intratest:
Positive findings in: ➤ Observe standard precautions and
• Cancer of the urinary tract Appendix A.
• Cytomegalic inclusion disease ➤ Instruct the patient to obtain a urine
• Inflammatory disease of the urinary specimen.
tract Clean-catch specimen:
Negative findings in: N/A ➤ Instruct the male patient to (1) thor-
oughly wash his hands, (2) cleanse
the meatus, (3) void a small amount
CRITICAL VALUES: N/A into the toilet, and (4) void directly
into the specimen container.
INTERFERING FACTORS: N/A ➤ Instruct the female patient to (1)
Nursing Implications and (3) while keeping the labia sepa-
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: the specimen container.
complaints, including a list of known Pediatric urine collector:
allergens. ➤ Put on gloves. Appropriately cleanse
➤ Obtain a history of the patient’s the genital area and allow the area to
genitourinary and immune systems, dry. Remove the covering over the
as well as results of previously adhesive strips on the collector bag
performed tests and procedures. For and apply over the genital area.
related tests, refer to the genitouri- Diaper the child. After obtaining the
nary and immune system tables. specimen, place the entire collection
bag in a sterile urine container.
patient is taking, including herbs, Indwelling catheter:
nutraceuticals. The requesting health ➤ Put on gloves. Empty drainage tube
care practitioner and laboratory of urine. It may be necessary to
should be advised if the patient clamp off the catheter for 15 to 30
regularly uses these products so minutes before specimen collection.
that their effects can be taken Cleanse specimen port with antisep-
Cytomegalovirus, Immunoglobulin G and Immunoglobulin M 437
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.
Suprapubic aspiration: Post-test:

➤ Place the patient in a supine posi- ➤ Evaluate test results in relation to
tion. Cleanse the area with antisep- the patient’s symptoms and other
tic and drape with sterile drapes. tests performed. Related laboratory
Using sterile technique, insert tests include bladder cancer mark-
needle and remove sterile sample. ers, kidney biopsy, and Papanicolaou
Place the returned sample in a ster- smear.
CYTOMEGALOVIRUS,
IMMUNOGLOBULIN G AND
IMMUNOGLOBULIN M
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: CMV.
SPECIMEN: Serum (1 mL) collected in a plain red top tube.
less than a fourfold increase in titer.
D ESCRIPTION : Cytomegalovirus received an organ transplant. Blood

(CMV) is a double-stranded DNA units are sometimes tested for the
herpesvirus. The incubation period presence of CMV if patients in these
for primary infection is 4 to 8 weeks. high-risk categories are the transfu-
Transmission may occur by direct sion recipients. CMV serology is part
contact with oral, respiratory, or of the TORCH (toxoplasmosis, other
venereal secretions and excretions. [congenital syphilis and viruses],
CMV infection is of primary concern rubella, CMV, and herpesvirus type
in pregnant or immunocompromised 2) panel used to test pregnant
patients or patients who have recently women. CMV, as well as these other
infectious agents, can cross the immune and reproductive systems,

placenta and result in congenital as well as results of previously
malformations, abortion, or stillbirth. related tests, refer to the immune
The presence of immunoglobulin M and reproductive system tables.
(IgM) antibodies indicates acute ➤ Obtain a list of the medications
infection. The presence of IgG anti- the patient is taking, including
bodies indicates current or past infec- herbs, nutritional supplements, and
tion. ■ nutraceuticals. The requesting health
INDICATIONS: is regularly using these products
so that their effects can be taken
• Assist in the diagnosis of congenital into consideration when reviewing
CMV infection in newborns results.
• Determine susceptibility, particularly ➤ There are no food, fluid, or medica-
in pregnant women, immunocompro- tion restrictions unless by medical
mised patients, and patients who direction.
recently have received an organ trans- ➤ Review the procedure with the
plant patient.
➤ Inform the patient that multiple
• Screen blood for high-risk-category specimens may be required. Any
transfusion recipients individual positive result should be
repeated in 7 to 14 days to monitor a
change in titer.
RESULT
Positive findings in: CMV infection men collection takes approximately
5 to 10 minutes.
Negative findings in: N/A Intratest:

CRITICAL VALUES: N/A normally and to avoid unnecessary
movement.
INTERFERING FACTORS: ➤ Observe standard precautions and
• False-positive results may occur in the Appendix A. Perform a venipuncture,
presence of rheumatoid factor. and collect the specimen in a 5-mL
red-top tube.
• False-negative results may occur if
treatment was begun before antibodies transport it to the laboratory.
developed or if the test was done less
than 6 days after exposure to the virus. Post-test:
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Instruct the patient in isolation
precautions during time of commu-
Pretest: nicability or contagion.
➤ Obtain a history of the patient’s ➤ Emphasize the need to return to
complaints and history of exposure. have a convalescent blood sample
Obtain a list of known allergens. taken in 7 to 14 days.
➤ Obtain a history of the patient’s ➤ Warn the patient that there is a
D-Dimer 439
possibility of false-negative or false- regarding access to counseling serv-

positive results. ices.
➤ Recognize anxiety related to test ➤ Evaluate test results in relation to
results if the patient is pregnant and the patient’s symptoms and other
offer support. Provide teaching and tests performed. Related labora-
information regarding the clinical tory tests include herpesvirus,
implications of the test results, as rubella antibody, and Toxoplasma
appropriate. Educate the patient antibody.
D-DIMER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Dimer, fibrin degradation fragment.

SPECIMEN: Plasma (1 mL) collected in a completely filled blue-top
(sodium citrate) tube.
REFERENCE VALUE: (Method: Latex semiquantitative screen or quantitative

enzyme-linked immunosorbent assay [ELISA])
Semiquantitative: No fragments detected
Quantitative: Less than 250 ng/mL
DESCRIPTION: The D-dimer is an • Assist in the evaluation of pulmonary

asymmetric carbon compound embolism
formed by a crosslink between two
identical fibrin molecules. The test is RESULT: The sensitivity and specificity
specific for secondary fibrinolysis of the assay varies among test kits and
between test methods (e.g., latex vs.
because the crosslinkage occurs with
ELISA).
fibrin and not fibrinogen. A positive
test is presumptive evidence of
Increased in:
disseminated intravascular coagula-
• Arterial or venous thrombosis
tion (DIC). ■
• DVT
INDICATIONS: • DIC
• Assist in the detection of DIC and
deep venous thrombosis (DVT) • Neoplastic disease
• Assist in the evaluation of myocardial • Pre-eclampsia
infarction and unstable angina
• Pregnancy (late and postpartum)
• Assist in the evaluation of possible
• Pulmonary embolism
veno-occlusive disease associated with
sequelae of bone marrow transplant • Recent surgery (within 2 days)
• Secondary fibrinolysis ➤ Obtain a history of hematologic

diseases and recent surgery.
Decreased in: N/A ➤ Obtain a history of the patient’s
cardiovascular, hematopoietic, and
respiratory systems, as well as
CRITICAL VALUES: N/A results of previously performed
INTERFERING FACTORS: tests, refer to the cardiovascular,
• High rheumatoid factor titers can hematopoietic, and respiratory
cause a false-positive result. system tables.
• Increased CA 125 levels can cause a
false-positive result. nutritional supplements, and
• Drugs that may cause an increase in nutraceuticals. The requesting health
plasma D-dimer include those adminis- care practitioner and laboratory
should be advised if the patient is
tered for antiplatelet therapy.
• Drugs that may cause a decrease in that their effects can be taken into
plasma D-dimer include pravastatin consideration when reviewing
and warfarin. results.
• Placement of tourniquet for longer tion restrictions unless by medical
than 1 minute can result in venous direction.
stasis and changes in the concentration ➤ Review the procedure with the
of plasma proteins to be measured. patient.
Platelet activation may also occur
under these conditions, causing erro- collection takes approximately 5 to
neous results. 10 minutes.
• Vascular injury during phlebotomy can
activate platelets and coagulation Intratest:
factors, causing erroneous results. ➤ Direct the patient to breathe
• Hemolyzed specimens must be rejected movement.
because hemolysis is an indication of
platelet and coagulation factor activa-
tion. Appendix A. Perform a venipuncture,
• Incompletely filled tubes contaminated and collect the specimen in a
with heparin or clotted specimens 5-mL blue-top tube. Fill the tube
completely. Important note: Two
must be rejected.
different concentrations of sodium
• Icteric or lipemic specimens interfere citrate preservative are currently
with optical testing methods, produc- added to blue-top tubes for coagula-
ing erroneous results. tion studies: 3.2% and 3.8%. The
National Committee for Clinical
Laboratory Standards (NCCLS)
guideline for sodium citrate is 3.2%
Nursing Implications and Laboratories establish reference
Procedure ● ● ● ● ● ● ● ● ● ● ● ranges for coagulation testing based
on numerous factors, including
Pretest: sodium citrate concentration, test
equipment, and test reagents. It is
➤ Obtain a history of the patient’s important to inquire from the labora-
complaints, including a list of known tory which concentration it recom-
allergens. mends, because each concentration
D-Xylose Tolerance Test 441
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
specimen with tissue thromboplas-
tin, which can falsely decrease
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.
D-XYLOSE TOLERANCE TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Plasma (1 mL) collected in gray-top (fluoride/oxalate) tube and
urine (10 mL from a 5-hour collection) from a timed collection in a clean
amber plastic container.
Dose by Age Conventional Units SI Units

Plasma (Conversion Factor 0.0666)
Adult dose
25 g Greater than 25 mg/dL Greater than 1.7 mmol/L
5g Greater than 20 mg/dL Greater than 1.3 mmol/L
Pediatric dose
0.5 g/kg Greater than 30 mg/dL Greater than 2.0 mmol/L
(max. 25 g)

Dose by Age Conventional Units SI Units

Urine (Conversion Factor 6.66)
Adult dose
25 g Greater than 4 g/5 h Greater than 26.6 mmol/5 h
collection
5g Greater than 1.2 g/5 h Greater than 8 mmol/5 h
collection
Pediatric dose
0.5 g/kg Greater than 16–33% Greater than 16–33%
(max. 25 g) of dose of dose
DESCRIPTION: The D-xylose toler- • Scleroderma

ance test is used to screen for intes- • Small bowel ischemia
tinal malabsorption of carbohydrates.
D-xylose is a pentose sugar not
• Tropical sprue
normally present in the blood in • Whipple’s disease
significant amounts. It is partially • Zollinger-Ellison disease
absorbed when ingested and normally
passes unmetabolized in the urine. ■ CRITICAL VALUES: N/A
INDICATIONS: Assist in the diagnosis of INTERFERING FACTORS:
malabsorption syndromes • Drugs that may increase urine D-xylose
levels include phenazopyridine.
RESULT • Drugs and substances that may
decrease urine D-xylose levels include
Increased in: N/A acetylsalicylic acid, aminosalicylic acid,
arsenicals, colchicine, digitalis, ethion-
Decreased in: amide, gold, indomethacin, isocarbox-
azid, kanamycin, monoamine oxidase
• Postoperative period after massive
(MAO) inhibitors, neomycin, and
resection of the intestine
phenelzine.
• Amyloidosis
• Poor renal function or vomiting may
• Bacterial overgrowth cause low urine values.
• Eosinophilic gastroenteritis
• Lymphoma Nursing Implications and
• Nontropical sprue (celiac disease, Procedure ● ● ● ● ● ● ● ● ● ● ●
gluten-induced enteropathy)
Pretest:
• Parasitic infestations (Giardia, schisto-
somiasis, hookworm) ➤ Obtain a history of the patient’s
• Radiation enteritis allergens.
D-Xylose Tolerance Test 443
➤ Obtain a history of the patient’s collection device for a health care

gastrointestinal system, as well as staff member to add to the labora-
results of previously performed tory collection container.
tests and procedures. For related ➤ Inform the patient that blood speci-
tests, refer to the gastrointestinal men collection takes approximately
system table. 5 to 10 minutes.
Intratest:
nutraceuticals. The requesting health ➤ Ensure that the patient has complied
care practitioner and laboratory with dietary preparations and other
should be advised if the patient pretesting restrictions.
into consideration when reviewing
Appendix A.
results.
➤ The patient should fast for at least 12 Timed specimen:
hours before the test. In addition,
the patient should refrain from ➤ Obtain a clean 3-L urine specimen
eating foods containing pentose container, toilet-mounted collection
sugars such as fruits, jams, jellies, device, and plastic bag (for transport
and pastries. of the specimen container). The
➤ Numerous medications (e.g., acetyl- specimen must be refrigerated or
salicylic acid, indomethacin, neo- kept on ice throughout the entire
mycin) interfere with the test and collection period. If an indwelling
should be withheld, by medical urinary catheter is in place, the
direction, for 24 hours before test- drainage bag must be kept on ice.
ing. ➤ Begin the test between 6 a.m. and 8
➤ There are no fluid restrictions unless a.m., if possible. Remind the patient
by medical direction. to remain supine and at rest
throughout the duration of the test.
➤ Review the procedure with the Instruct the patient to collect all
patient. Inform the patient that activ- urine for a 5-hour period after admin-
ity will be restricted during the test. istration of the D-xylose.
Obtain the pediatric patient’s weight
to calculate dose of D-xylose to be ➤ Adults are given a 25-g dose of D-
administered. xylose dissolved in 250 mL of water
to take orally. The dose for pediatric
➤ Inform the patient that all urine for a patient is calculated by weight up to
5-hour period must be saved. a maximum of 25 g. The patient
Provide a nonmetallic urinal, bedpan, should drink an additional 250 mL of
or toilet-mounted collection device. water as soon as the D-xylose solu-
➤ Instruct the patient not to void tion has been taken. Some adult
directly into the laboratory collection patients with severe symptoms may
container. Instruct the patient to be given a 5-g dose, but the test
avoid defecating in the collection results are less sensitive at the
device and to keep toilet tissue out lower dose.
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
➤ Instruct the patient to void all urine on ice during the collection period
into the collection device and then to or 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.
➤ 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.
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.
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: DHEAS.
mL) collected in lavender-top (ethylenediaminetetra-acetic [EDTA]) tube is
also acceptable.

Dehydroepiandrosterone Sulfate 445
SI Units
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
D ESCRIPTION : Dehydroepiandro- hyperplasia, adrenal tumor, and Stein-

sterone sulfate (DHEAS) is the Leventhal syndrome
major precursor of 17-ketosteroids. • Evaluate women with infertility, amen-
DHEAS is a metabolite of DHEA, orrhea, or hirsutism
the principal adrenal androgen.
DHEAS is primarily synthesized in RESULT
the adrenal gland with a small
amount secreted by the ovaries. It is Increased in:
secreted in concert with cortisol, • Anovulation
under the control of adrenocorti- • Cushing’s syndrome
cotropic hormone (ACTH) and
• Ectopic ACTH-producing tumors
prolactin. Excessive production causes
masculinization in women and chil- • Hirsutism
dren. DHEAS has replaced measure- • Hyperprolactinemia
ment of urinary 17-ketosteroids in
• Polycystic ovary
the estimation of adrenal androgen
production. ■ • Stein-Leventhal syndrome
• Virilizing adrenal tumors
INDICATIONS:
• Assist in the evaluation of androgen Decreased in:
excess, including congenital adrenal • Addison’s disease
• Adrenal insufficiency (primary or ➤ Obtain a list of the medications the

secondary) patient is taking, including herbs,
• Aging adults ceuticals. The requesting health care
• Hyperlipidemia advised if the patient regularly uses
• Pregnancy these products so that their effects
• Psoriasis when reviewing results.
• Psychosis ➤ Note any recent procedures that can
CRITICAL VALUES: N/A ➤ There are no food, fluid, or medica-
INTERFERING FACTORS: direction.
• Drugs that may increase DHEAS levels ➤ Review the procedure with the
include clomiphene, corticotropin, patient.
danazol, DHEA, mifepristone, and ➤ Inform the patient that specimen
nitrendipine. collection takes approximately 5 to
10 minutes.
• Drugs that may decrease DHEAS
levels include carbamazepine, dexa-
Intratest:
methasone, ketoconazole, oral contra-
ceptives, and phenytoin. ➤ Direct the patient to breathe
• Recent radioactive scans or radiation movement.
fere with test results when radioim- follow the general guidelines in
munoassay is the test method. Appendix A. Perform a venipuncture,
Procedure ● ● ● ● ● ● ● ● ● ● ● transport it to the laboratory.
Pretest: Post-test:
➤ 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.
Drugs of Abuse 447
DRUGS OF ABUSE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Amphetamines Ethanol
Barbiturates Opiates
Benzodiazepines Phencyclidine
Cannabinoids Tricyclic Antidepressants
Cocaine
SYNONYMS/ACRONYMS: Amphetamines, barbiturates, benzodiazepines

(tranquilizers), cannabinoids (THC), cocaine, ethanol (alcohol, ethyl alco-
hol, EtOH), phencyclidine (PCP), opiates (heroin), tricyclic antidepressants
(TCA)
SPECIMEN: For ethanol, serum (1 mL) collected in a red-top tube or

plasma (1 mL) collected in gray-top (sodium fluoride/potassium oxalate)
tube is also acceptable. For drug screen, urine (15 mL) collected in a clean
plastic container. Gastric contents (20 mL) may also be submitted for test-
ing.
Workplace drug-screening programs, because of the potential medicolegal
consequences associated with them, require collection of urine and blood
specimens using a chain of custody protocol. The protocol provides securing
the sample in a sealed transport device in the presence of the donor and a
representative of the donor’s employer, such that tampering would be obvi-
ous. The protocol also provides a written document of specimen transfer
from donor to specimen collection personnel, to storage, to analyst, and to
disposal.
REFERENCE VALUE: (Method: Spectrophotometry for ethanol; immunoas-

say for drugs of abuse)
Ethanol: None detected
Drug screen: None detected
DESCRIPTION: Drug abuse contin- clidines (PCPs) as the most

ues to be one of the most significant commonly abused illicit drugs.
social and economic problems in Ethanol is the most commonly
the United States. The National encountered legal substance of abuse.
Institute for Drug Abuse (NIDA) has Chronic alcohol abuse can lead to
identified opiates, cocaine, cannabi- liver disease, high blood pressure,
noids, amphetamines, and phency- cardiac disease, and birth defects. ■
INDICATIONS: • Investigate suspected noncompliance

• Differentiate alcohol intoxication from with drug or alcohol treatment
diabetic coma, cerebral trauma, or program
drug overdose • Monitor ethanol levels when adminis-
• Investigate suspected drug abuse tered to treat methanol intoxication
• Investigate suspected drug overdose • Routine workplace screening
Cutoff Concentrations for Drugs of Abuse Recommended by NIDA

Amphetamines 1000 ng/mL
Barbiturates 300 ng/mL
Benzodiazepines 300 ng/mL
Cannabinoids 50 ng/mL
Cocaine 300 ng/mL
Opiates 300 ng/mL
Phencyclidine 25 ng/mL
Tricyclic antidepressants 1000 ng/mL
RESULT: A urine screen merely identifies 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
Drugs of Abuse 449
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 ● ● ● ● ● ● ● ● ● ● ●
nia, tachycardia, dysrhythmias, impo-

tence, cerebrovascular accident, and Pretest:
respiratory failure. Possible interventions ➤ Obtain a history of the patient’s
include emesis (if orally ingested and if complaints, including a list of known
the patient has a gag reflex and normal allergens.
CNS function), administration of acti- ➤ For related tests, refer to the thera-
vated charcoal followed by magnesium peutic/toxicology table.
citrate cathartic, acidification of the urine ➤ Obtain a list of the medications the
to promote excretion, and administration patient is taking, including herbs,
of liquids to promote urinary output. nutritional supplements, and
Heroin is an opiate that at toxic levels nutraceuticals. The requesting health
causes bradycardia, flushing, itching, care practitioner and laboratory
hypotension, hypothermia, and respira- should be advised if the patient
tory depression. Possible interventions
include airway protection and the admin- consideration when reviewing
istration of naloxone (Narcan). results.
Tricyclic antidepressant intoxication
causes confusion, agitation, hallucina- tion restrictions.
tions, seizures, dysrhythmias, hyperther-
➤ Review the entire procedure with
mia, dilation of the pupils, and coma.
the patient, especially if the circum-
Possible interventions may include stances require collection of urine
administration of activated charcoal, and blood specimens using a chain
gastric lavage with saline, intravenous of custody protocol.
administration of physostigmine (to ➤ Obtain a written and informed
counteract coma, hypertension, respira- consent, as appropriate.
tory depression, and seizures), adminis-
tration of bicarbonate (to control collection takes approximately 5 to
dysrhythmia), administration of propra- 10 minutes but may vary depending
nolol, lidocaine or phenytoin to control on the level of patient cooperation.
convulsions, and monitoring cardiac
function. Intratest:
• Codeine-containing cough medicines movement.
and antidiarrheal preparations, as well ➤ Observe standard precautions and
as ingestion of large amounts of poppy follow the general guidelines in
seeds, may produce a false-positive Appendix A. For ethanol, use a
opiate result. non–alcohol-containing solution to
cleanse the venipuncture site before
• Adulterants such as bleach or other specimen collection.
➤ Perform a venipuncture, and collect if required. Monitor specimen collec-

the specimen in a 5-mL red-top tion, labeling, and packaging to
tube. Cadaver blood is taken from prevent tampering. This protocol
the aorta. may vary by institution.
➤ For a drug screen, instruct the ➤ Label the specimen, and promptly
patient to obtain clean-catch urine transport it to the laboratory.
specimen.
Clean-catch specimen: Post-test:
➤ Instruct the male patient to (1) thor- ➤ Observe venipuncture site for bleed-
oughly wash his hands, (2) cleanse ing or hematoma formation. Apply
the meatus, (3) void a small amount pressure bandage.
into the specimen container. ➤ Ensure that results are communi-
cated to the proper individual, as
➤ Instruct the female patient to (1) indicated in the chain of custody
thoroughly wash her hands; (2) protocol.
(3) while keeping the labia sepa- ➤ Provide support and information
rated, void a small amount into the regarding detoxification programs,
toilet; and (4) without interrupting as appropriate.
the urine stream, void directly into ➤ Evaluate test results in relation to
the specimen container. the patient’s symptoms and other
➤ Follow the chain of custody protocol, tests performed.
ECHOCARDIOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Doppler echo, Doppler ultrasound of the heart,

echo.
AREA OF APPLICATION: Chest/thorax.

CONTRAST: Can be done with or without noniodinated contrast medium
(microspheres).
DESCRIPTION: Echocardiography, a allows visualization of the size, shape,

noninvasive ultrasound procedure, position, thickness, and movement of
uses high-frequency sound waves of all four valves, atria, ventricular and
various intensities to assist in diag- atria septa, papillary muscles, chordae
nosing cardiovascular disorders. The tendineae, and ventricles. This study
procedure records the echoes created can also determine blood-flow veloc-
by the deflection of an ultrasonic ity, direction, and the presence of
beam off the cardiac structures and pericardial effusion during the move-
Echocardiography 451
ment of the transducer over areas of • Detect ventricular or atrial mural

the chest. Electrocardiography and thrombi and evaluate cardiac wall
phonocardiography can be done motion after myocardial infarction
simultaneously to correlate the find- • Detect subaortic stenosis as evidenced
ings with the cardiac cycle. These either by displacement of the anterior
procedures can be done at the bedside atrial leaflet or by a reduction in aortic
or in a specialized department, physi- valve flow, depending on the obstruc-
cian office, or clinic. tion
Included in the study are the M- • Evaluate unexplained chest pain, elec-
mode method, which produces a trocardiographic changes, and abnor-
linear tracing of timed motions of the mal chest x-ray (e.g., enlarged cardiac
heart, its structures, and associated silhouette)
measurements over time; and the • Evaluate or monitor prosthetic valve
two-dimensional method, using real- function
time Doppler color-flow imaging
• Evaluate endocarditis
with pulsed and continuous wave
Doppler spectral tracings, which • Evaluate ventricular aneurysms and/or
produces a cross-section of the struc- thrombus
tures of the heart and their relation- • Establish the presence of shunt flow
ship to one another, changes in the and continuity of the aorta and
coronary vasculature, velocity and pulmonary artery
direction of blood flow, and areas of
eccentric blood flow. Doppler color- RESULT
flow imaging may also be helpful in
depicting the function of biological Normal Findings:
and prosthetic valves. • Normal appearance in the size, posi-
Cardiac contrast medium is used to tion, structure, and movements of the
heart valves visualized and recorded in
aid in the diagnosis of intracardiac
a combination of ultrasound modes;
shunt and tricuspid valve regurgita- and normal heart muscle walls of
tion. The contrast agent is injected both ventricles and left atrium, with
intravenously and outlines the cham- adequate blood filling. Established
bers of the heart. ■ values for the measurement of heart
activities obtained by the study may
vary by physician and institution.
INDICATIONS:
• Determine the severity of valvular Abnormal Findings:
abnormalities such as stenosis,
• Aortic valve abnormalities
prolapse, and regurgitation
• Cardiac neoplasm
• Measure the size of the heart’s cham-
bers and determine if hypertrophic • Cardiomyopathy
cardiomyopathy or congestive heart
• Congenital heart defect
failure is present
• Evaluate congenital heart disorders
• Coronary artery disease
• Detect atrial tumors (myxomas)
• Endocarditis
• Determine the presence of pericardial
effusion, tamponade, and pericarditis • Mitral valve abnormalities
• Myxoma
• Pericardial effusion, tamponade, and Procedure ● ● ● ● ● ● ● ● ● ● ●
pericarditis
Pretest:
• Pulmonary hypertension
• 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
• 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.
➤ 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).
Echocardiography, Transesophageal 453
➤ To obtain different views or informa- ➤ Instruct the patient to resume

tion about heart function, position normal activity and diet, unless
the patient on the left side and/or sit- otherwise indicated.
ting up, or request that the patient
breathe slowly or hold breath during ➤ A physician specializing in this
the procedure. To evaluate heart branch of medicine sends a written
function changes, the patient may report to the ordering provider, who
be asked to inhale amyl nitrate (va- discusses the results with the
sodilator). patient.
➤ Administer contrast medium, if
ordered. A second series of images ➤ Evaluate test results in relation
is obtained. to the patient’s symptoms and
other tests performed. Related
Post-test: diagnostic tests include posi-
tron emission tomography and
➤ Cleanse the patient’s skin of remain- nuclear thallium scanning of the
ing gel or mineral oil. heart.
ECHOCARDIOGRAPHY,
TRANSESOPHAGEAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Echo, TEE.

CONTRAST: Can be done with or without noniodinated contrast medium
(microspheres).
D ESCRIPTION : Transesophageal the heart, including the atrium and

echocardiography (TEE) is perfor- aorta. It is done with a transducer
med to assist in the diagnosis of attached to a gastroscope that is
cardiovascular disorders when nonin- inserted into the esophagus. The
vasive echocardiography is contra- transducer and the ultrasound instru-
indicated or does not reveal enough ment allow the beam to be directed to
information to confirm a diagnosis. the back of the heart. The echoes are
Noninvasive echocardiography may amplified and recorded on a screen
be an inadequate procedure for for visualization and recorded on
patients who are obese, have chest graph paper or videotape. The depth
wall structure abnormalities, or have of the endoscope and movement of
chronic obstructive pulmonary the transducer is controlled to obtain
disease (COPD). TEE provides a various images of the heart structures.
better view of the posterior aspect of TEE is usually performed during
surgery; it is also used on patients • Monitor cardiac function during open

who are in the intensive care unit, in heart surgery (most sensitive method
whom the transmission of waves to for monitoring ischemia)
and from the chest has been compro- • Reevaluate after inadequate visualiza-
mised and more definitive information with conventional echocardiogra-
tion is needed. The images obtained phy as a result of obesity, trauma to or
by TEE have better resolution than deformity of the chest wall, or lung
those obtained by routine transtho- hyperinflation associated with COPD
racic echocardiography because TEE • Evaluate septal defects
uses higher frequency sound waves
• Evaluate aneurysms and ventricular
and offers closer proximity of the
thrombus
transducer to the cardiac structures.
Cardiac contrast medium is used to RESULT
improve the visualization of viable
myocardial tissue within the heart. ■ Normal Findings:
• Normal appearance of the size, posi-
INDICATIONS: tion, structure, movements of the
• Confirm diagnosis if conventional heart valves and heart muscle walls,
echocardiography does not correlate and chamber blood filling; and no
with other findings evidence of valvular stenosis or insuffi-
• Monitor cardiac function during open ciency, cardiac tumor, foreign bodies,
heart surgery or CAD. The established values for
the measurement of heart activities
• Detect or determine the severity of obtained by the study may vary by
valvular abnormalities and regurgita- physician and institution.
tion
• Measure the size of the heart’s cham- Abnormal Findings:
bers and determine if hypertrophic • Aneurysm
cardiomyopathy or congestive heart
failure is present • Aortic valve abnormalities
• Detect and evaluate congenital heart • Cardiomyopathy
disorders • CAD
• Detect atrial tumors (myxomas) • Congenital heart defects
• Determine the presence of pericardial • Congestive heart failure
effusion
• Mitral valve abnormalities
• Detect ventricular or atrial mural
thrombi and evaluate cardiac wall • Myocardial infarction
motion after myocardial infarction • Myxoma
• Detect subaortic stenosis as evidenced • Pericardial effusion
by displacement of the anterior atrial
leaflet and reduction in aortic valve • Pulmonary hypertension
flow, depending on the obstruction • Pulmonary valve abnormalities
• Detect thoracic aortic dissection and
• Septal defects
coronary artery disease (CAD)
• Shunting of blood flow
• Evaluate or monitor biological and
prosthetic valve function • Thrombus
Echocardiography, Transesophageal 455
• Ventricular or atrial mural thrombi dure is performed in a special

department by a technologist and
• Ventricular hypertrophy takes approximately 30 to 60
minutes, and that there is no risk of
CRITICAL VALUES: N/A radiation from the study.
INTERFERING FACTORS: patient is taking.
➤ Obtain pertinent patient history of
This procedure is contraindicated cardiac tests and procedures, pres-
for: ent cardiac conditions or abnormali-
• Patients with significant esophageal ties, and therapy received for cardiac
pathology (procedure may cause bleed- condition. For related tests, refer to
the cardiovascular system table.
ing)
Factors that may impair clear for the procedure from the patient.
imaging: ➤ Obtain baseline vital signs.
• Inability of the patient to cooperate ➤ Establish an intravenous access line
or remain still during the procedure for the administration of medications
because of age, significant pain, or and contrast medium.
mental status ➤ Remove dentures from the patient’s
mouth.
exceed the weight limit for the equip- ➤ Monitor pulse oximetry to deter-
mine oxygen saturation in sedated
ment patients.
• Incorrect positioning of the patient, ➤ Restrict food and fluids 8 to 12 hours
which may produce poor visualization before the procedure.
of the area to be examined ➤ Explain that some discomfort will be
• Incorrect placement of the transducer experienced during insertion of the
scope.
over the desired test site
• Laryngospasm, dysrhythmias, or Intratest:
esophageal bleeding
➤ Spray or swab the patient’s throat
• Known upper esophageal pathology with a local anesthetic, and place the
oral bridge device in the mouth to
• Conditions such as esophageal dyspha- prevent biting of the endoscope.
gia and irradiation of the mediastinum ➤ Place the patient in a left side-lying
position on a flat table with foam
Other considerations: wedges that will help maintain
• Failure to follow dietary restrictions position and immobilization. Ask the
before the procedure may cause the patient to lie very still during the
procedure to be canceled or repeated. procedure because movement will
produce unclear images. The pharyn-
geal area is anesthetized and the
endoscope with the ultrasound
Nursing Implications and device attached to its tip is inserted
Procedure ● ● ● ● ● ● ● ● ● ● ●
30 to 50 cm to the posterior area of
the heart, as in any esophagoscopy
Pretest: procedure.
➤ Ask the patient to swallow as the
➤ Inform the patient that the proce- scope is inserted. When the trans-
dure assesses the heart. ducer is in place, the scope is
➤ Inform the patient that the proce- manipulated by controls on the
handle to obtain scanning that after the test, unless otherwise

provides real-time images of the indicated.
heart motion and recordings of the
➤ Instruct patient to treat throat
images for viewing. Actual scanning
discomfort with lozenges and warm
is usually limited to 15 minutes or
gargles when the gag reflex returns.
until the desired number of image
planes is obtained at different ➤ A physician specializing in this
depths of the scope. branch of medicine sends a written
➤ The images can be viewed immedi- report to the ordering provider, who
ately and recorded on film, elec- discusses the results with the
tronic media, or videotape. patient.
➤ Administer a contrast medium, if ➤ Evaluate test results in relation to
ordered. A second series of images the patient’s symptoms and other
is obtained. test performed. Related diagnostic
tests include chest or cardiac
Post-test: computed tomography, chest or
cardiac magnetic resonance imag-
➤ Instruct the patient to resume ing, and nuclear medicine cardiac
normal activity and diet 4 to 6 hours perfusion study.
ELECTROCARDIOGRAM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: ECG, VCG, ECG.

CONTRAST: None.
DESCRIPTION: The cardiac muscle muscle cells have a characteristic rate

consists of three layers of cells—the of contraction called depolarization.
inner layer called the endocardium, Therefore, the heart will maintain a
the middle layer called the predetermined heart rate unless other
myocardium, and the outer layer stimuli are received.
called the epicardium. The systolic The electrocardiogram (ECG), a
phase reflects the contraction of the noninvasive study, measures the elec-
myocardium, whereas the diastolic trical currents or impulses that the
phase takes place when the heart heart generates during a cardiac cycle
relaxes to allow blood to rush in. All (see figure of a normal ECG). The
Electrocardiogram 457
monitoring of pulse and blood pres- depressed. An abnormal rhythm is

sure evaluates the mechanical activity called an arrhythmia. Electrical
of the heart. The ECG is a graphic impulses travel through a conduction
display of the electrical activity of the system beginning with the SA node to
heart, which is analyzed by time inter- the AV node via internodal pathways.
vals and segments. Continuous trac- From the AV node, the impulses
ing of the cardiac cycle activities is travel to the bundle of His and
captured as heart cells are electrically onward to the right and left bundle
stimulated, causing depolarization branches. These bundles are located
and movement of the activity through within the right and left ventricles.
the cells of the myocardium. The The impulses continue to the cardiac
ECG study is completed by using 12 muscle cells by terminal fibers called
electrodes attached to the skin surface Purkinje fibers. ■
to obtain the total electrical activity of
the heart. Each lead records the elec- INDICATIONS:
trical potential between the limbs or • Detect arrhythmias, as evidenced by
between the heart and limbs. The abnormal wave deflections
ECG machine records and marks the • Monitor ECG changes during an exer-
12 leads on the strip of paper in the cise test
machine in proper sequence, usually • Monitor rhythm changes during the
6 inches of the strip for each lead. The recovery phase after a myocardial
ECG pattern, called a heart rhythm, is infarction (MI)
recorded by a machine as a series of • Assess global cardiac function
waves, intervals, and segments, each
of which pertains to a specific occur- • Assess the extent of MI or ischemia, as
rence during the contraction of the indicated by abnormal S-T wave, inter-
val times, and amplitudes
heart. The ECG tracings are recorded
on graph paper with vertical and hori- • Detect pericarditis, shown by S-T
zontal lines for analysis and calcula- segment changes or shortened P-R
tions of time measured by the vertical interval
lines (1 mm apart and 0.04 seconds • Assess the function of heart valves
per line) and of voltage measured by
• Assess the extent of congenital heart
the horizontal lines (1 mm apart and disease
0.5 mV per 5 squares). A pulse rate
can be calculated from the ECG strip • Determine electrolyte imbalances, as
evidenced by short or prolonged Q-T
to obtain the beats per minute. The P
interval
wave represents the depolarization of
the atrial myocardium; the QRS wave • Evaluate and monitor the effect of
represents the depolarization of the drugs, such as digitalis antiarrhythmic,
ventricular myocardium; the P-R or vasodilating agents
interval represents the beginning of • Evaluate and monitor cardiac pace-
the excitation of the atrium to the maker function
beginning of the ventricular excita- • Determine hypertrophy of the
tion; and the S-T segment has no chamber of the heart or heart hyper-
deflection from baseline, but in an trophy, as evidenced by P or R wave
abnormal state may be elevated or deflections
RESULT indicates myocardial ischemia. An

elevated S-T segment may indicate an
Normal Findings: acute MI or pericarditis. A prolonged
• Normal heart rate according to age: S-T segment may indicate hypocal-
range of 60 to 100 beats/min in adults. cemia or hypokalemia (short segment).
• Normal, regular rhythm and wave • T wave: A flat or inverted T wave may
deflections with normal measurement indicate myocardial ischemia, infarc-
of ranges of cycle components and tion, or hypokalemia. A tall T wave
height, depth, and duration of may indicate hyperkalemia.
complexes as follows:
P wave: 0.12 seconds or 3 small CRITICAL VALUES: N/A
blocks with amplitude of 2.5 mm
Q wave: less than 0.04 mm INTERFERING FACTORS:
R wave: 5 to 27 mm amplitude,
depending on lead Factors that may impair the
results of the examination:
T wave: 1 to 13 mm amplitude,
depending on lead
• Improper placement of electrodes or
inadequate contact between skin and
QRS complex: 0.12 seconds or 3 electrodes by insufficient conductive
small blocks
gel or poor placement, which can cause
S-T segment: 1 mm ECG tracing problems
Abnormal Findings: • ECG machine malfunction or interfer-

ence from electromagnetic waves in the
• Atrial or ventricular hypertrophy.
vicinity
• Bundle branch block.
• Inability of the patient to remain still
• Arrhythmias. during the procedure, because move-
ment, muscle tremor, or twitching can
• MI or ischemia.
affect accurate test recording
• Pericarditis.
• Strenuous exercise before the proce-
• Pulmonary infarction. dure
• Electrolyte imbalances. • Anatomic variation of the heart (i.e.,
the heart may be rotated in both the
• P wave: An enlarged P wave deflection
horizontal and frontal planes)
could indicate atrial enlargement. An
absent or altered P wave could suggest • Increased patient anxiety, causing
that the electrical impulse did not hyperventilation or deep respirations
come from the SA node.
• Distortion of cardiac cycles due to
• P-R interval: An increased interval age, sex, weight, or a medical condition
could imply a conduction delay in the (e.g., infants, women [may exhibit
AV node. slight S-T segment depression], obese
patients, pregnant patients, patients
• QRS complex: An enlarged Q wave
with ascites)
may indicate an old infarction; an
enlarged deflection could indicate • Medications such as barbiturates and
ventricular hypertrophy. Increased digitalis
time duration may indicate a bundle
• High intake of carbohydrates or elec-
branch block.
trolyte imbalances of potassium or
• S-T segment: A depressed S-T segment calcium
Electrocardiogram 459
anterior axillary line at the level of V4

Nursing Implications and horizontally, and V6 at the level of V4
Procedure ● ● ● ● ● ● ● ● ● ● ● horizontally and at the left midaxil-
lary line. The wires are connected to
Pretest: the matched electrodes and the
ECG machine. Chest leads (V1, V2,
➤ Obtain a history of the patient’s V3, V4, V5, and V6) record data from
cardiac disease and present cardio- the horizontal plane of the heart.
vascular status. For related tests,
refer to the cardiovascular system ➤ Place three limb bipolar leads (two
table. electrodes combined for each) on
the arms and legs. Lead I is the
➤ Obtain patient’s vital signs. combination of two arm electrodes,
➤ Obtain a list of the medications the lead II is the combination of right
patient is taking. arm and left leg electrodes, and lead
➤ List previous tests and procedures III is the combination of left arm and
performed. left leg electrodes.
➤ Obtain a written, informed consent ➤ Limb leads (I, II, III, AVL, AVF, and
for the procedure from the patient, if AVR) record data from the frontal
indicated. plane of the heart.
➤ Review the procedure with the ➤ If the patient has any chest discom-
patient. fort or pain during the procedure,
mark the ECG strip indicating that
➤ Recognize anxiety related to the test occurrence.
results.
➤ Instruct the patient to lie very still in
➤ Ask if the patient has had a heart a relaxed position during the study
transplant or pacemaker implanted. and to refrain from tensing muscles
➤ No food, fluid, or medication restric- after electrode placement. The
tions exist unless by medical direc- machine is set and turned on after
tion. the electrodes, grounding, connec-
➤ Inform the patient that the procedure tions, paper supply, computer, and
takes approximately 15 minutes. data storage device are checked.
normally and to avoid touching the
Intratest: bed or couch.
➤ Have the patient remove clothing to
the waist and any hosiery. Patients Post-test:
may want to wear a gown (open to
the front). ➤ When the procedure is complete,
remove the electrodes and clean the
➤ Place patient in a supine position. skin where the electrode pad was
Expose and appropriately drape the applied.
chest, arms, and legs.
➤ Evaluate the results in relation to
➤ Prepare the skin surface with alcohol previously performed ECGs.
and remove excess hair. Shaving
may be necessary. Dry skin sites. ➤ Denote cardiac rhythm abnormali-
ties on the strip.
➤ Apply the electrodes in the proper
position. When placing the six unipo- ➤ Instruct the person to immediately
lar chest leads, place V1 at the fourth notify a physician of chest pain,
intercostal space at the border of changes in pulse rate, or shortness
the right sternum, V2 at the fourth of breath.
intercostal space at the border of ➤ Instruct the patient or caregiver
the left sternum, V3 between V2 and regarding the correct administration
V4, V4 at the fifth intercostal space at of heart medications and their possi-
the midclavicular line, V5 at the left ble side effects.

branch of medicine sends a written tests performed. Related diagnostic
report to the ordering provider, who tests include echocardiogram, posi-
discusses the results with the tron emission tomography scan of
patient. the heart, and nuclear thallium scan
➤ Evaluate test results in relation to of the heart.
R
5 mm (0.2 sec)
PR (1 mm)
Segment
0.04
ST sec
Segment
PR Interval Q
S
QRS
Complex
QT Interval
ELECTROENCEPHALOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Sonogram (for sleep disturbances), EEG.

CONTRAST: None.
Electroencephalography 461
D ESCRIPTION : Electroencephalo- evidenced by abnormal spikes and

graphy (EEG) is a noninvasive study waves recorded on the graph
that measures the brain’s electrical • Detect intracranial cerebrovascular
activity and records that activity on lesions, such as hemorrhages and
graph paper. These electrical impulses infarcts
arise from the brain cells of the cere- • Determine the presence of tumors,
bral cortex. Electrodes, placed at 8 to abscesses, or infection
20 sites (or pairs of sites) on the
patient’s scalp, transmit the different • Confirm suspicion of increased
intracranial pressure caused by trauma
frequencies and amplitudes of the
or disease
brain’s electrical activity to the EEG
machine, which records the results in • Identify area of abnormality in demen-
graph form on a moving paper strip. tia
This procedure can evaluate responses • Evaluate sleeping disorders, such as
to various stimuli, such as flickering sleep apnea and narcolepsy
light, hyperventilation, auditory • Evaluate the effect of drug intoxication
signals, or somatosensory signals on the brain
generated by skin electrodes. The
procedure is usually performed in a • Detect cerebral ischemia during
endarterectomy
room designed to eliminate electrical
interference and minimize distrac- • Confirm brain death
tions. EEG can be done at bedside,
especially to confirm brain death. A RESULT
physician analyzes the waveforms.
Normal Findings:
The test is used to detect epilepsy,
• Normal occurrences of alpha, beta,
intracranial abscesses, or tumors; to
theta, and delta waves (rhythms vary-
evaluate cerebral involvement as a ing depending on the patent’s age)
result of head injury or meningitis;
and to monitor for cerebral tissue • Normal frequency, amplitude, and
ischemia during surgery when cere- characteristics of brain waves
bral vessels must be occluded. EEG is
Abnormal Findings:
also used to confirm brain death,
• Abscess
which can be defined as absence of
electrical activity in the brain. To eval- • Brain death
uate abnormal EEG waves further, • Cerebral infarct
the patient may be connected to an
ambulatory EEG system similar to a • Encephalitis
Holter monitor for the heart. Patients • Glioblastoma and other brain tumors
keep a journal of their activities and • Head injury
any symptoms that occur during the
monitoring period. ■ • Hypocalcemia or hypoglycemia
• Intracranial hemorrhage
INDICATIONS: • Meningitis
• Detect seizure disorders and identify
focus of seizure and seizure activity, as • Migraine headaches
• Narcolepsy ➤ Ensure that the patient is able to

relax; report any extreme anxiety or
• Seizure disorders (grand mal, focal, restlessness.
temporal lobe, myoclonic, petit mal) ➤ Ensure that hair is clean and free of
• Sleep apnea hair sprays, creams, or solutions.
➤ Ensure that caffeine-containing
CRITICAL VALUES: N/A beverages were withheld for 8 hours
before the procedure, and that a
INTERFERING FACTORS: meal was ingested before the study.
Factors that may impair the patient is taking, including herbs,
results of the examination: nutritional supplements, and
nutraceuticals, and ensure that all
substances with the potential to
remain still during the procedure interfere with test results are with-
because of age, significant pain, or held for 24 to 48 hours before the
mental status test.
• Drugs and substances such as sedatives, ➤ Instruct the patient to limit sleep to 5
anticonvulsants, anxiolytics, alcohol, hours for an adult and 7 hours for a
and stimulants such as caffeine and child the night before the study.
Young infants and children should
nicotine
not be allowed to nap before the
• Hypoglycemic or hypothermic states study.
➤ Assure the patient that there is no
• Hair that is dirty, oily, or sprayed or
discomfort during the procedure.
treated with hair preparations Encourage relaxation during the
procedure. Indicate to the patient
that if needle electrodes are used, a
slight pinch may be felt.
➤ Explain that electricity flows from
Procedure ● ● ● ● ● ● ● ● ● ● ●
the patient’s body, not into the body,
Pretest: ➤ Explain that the procedure reveals
➤ Review the procedure with the brain activity only, not thoughts, feel-
patient. Inform the patient that the ings, or intelligence.
procedure is performed in a special ➤ Obtain a written, informed consent
laboratory by a technician trained to for the procedure from the patient, if
do the procedure, and that the required.
results are interpreted by a physician. ➤ Inform the patient that he or she
➤ Inform the patient that the proce- may be asked to alter breathing
dure is performed to measure elec- pattern; be asked to follow simple
trical activity of the brain and takes commands such as opening or clos-
approximately 1 to 2 hours to ing eyes, blinking, or swallowing; be
complete. stimulated with bright light; or be
given a drug to induce sleep during
➤ Obtain a history and assessment of
the study.
the patient’s neurological system,
known or suspected seizure condi- ➤ The test recordings are stopped
tions, intracranial abnormalities, trau- about every 5 minutes to allow the
matic incidents to head, and sleep patient to move.
disorders, as well as the results of
previously performed tests, surger- Intratest:
ies, treatments, and procedures. For
related tests, refer to the muscu- ➤ Place the patient in the supine posi-
loskeletal system table. tion in a bed or semi-Fowler’s posi-
Electromyography 463
tion on a recliner in a special room out abnormal electrical activity or

protected from any noise or electri- other brain abnormalities.
cal interferences that could affect ➤ Observations for seizure activity are
the tracings. carried out during the study, and a
➤ Remind the patient to relax and not description and time of activity is
to move any muscles or parts of the noted by the technician.
face or head. The technician should
be able to observe the patient for
movements or other interferences Post-test:
through a window into the test ➤ When the procedure is complete,
room. remove electrodes from the hair and
➤ The electrodes are prepared and remove paste by cleansing with oil
applied to the scalp. Electrodes are or witch hazel.
placed in as many as 16 locations ➤ If a sedative was given during the
over the frontal, temporal, parietal, test, allow the patient to recover.
and occipital areas, and amplifier Bedside rails are put in the raised
wires are attached. An electrode is position for safety.
also attached to each ear lobe as
grounding electrodes. At this time, a ➤ Inform the patient to resume
baseline recording can be made with medications, as directed.
the patient at rest. ➤ Instruct the patient to report any
➤ Recordings are made with the seizure activity.
patient at rest and with eyes closed. ➤ A physician specializing in this
Recordings are also made during a branch of medicine sends a written
drowsy and sleep period, depending report to the ordering provider, who
on the patient’s clinical condition and discusses the results with the
symptoms. patient.
➤ Procedures (e.g., stroboscopic light ➤ Evaluate test results in relation to
stimulation, hyperventilation to the patient’s symptoms and other
induce alkalosis, and sleep induction tests performed. Related diagnostic
by administration of sedative to tests include computed tomography
detect abnormalities that occur only and magnetic resonance imaging of
during sleep) may be done to bring the brain.
ELECTROMYOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Electrodiagnostic study, neuromuscular junction

testing, EMG.
AREA OF APPLICATION: Muscles.

CONTRAST: None.
D ESCRIPTION : Electromyography tromyoneurography. The examina-

(EMG) measures skeletal muscle tion’s major use lies in differentiating
activity during rest, voluntary among the following disease classes:
contraction, and electrical stimula- primary myopathy, peripheral motor
tion. Percutaneous extracellular neuron disease, and disease of the
needle electrodes containing fine neuromuscular junction. ■
wires are inserted into selected muscle
groups to detect neuromuscular INDICATIONS:
abnormalities and measure nerve and • Assess primary muscle diseases affect-
electrical conduction properties of ing striated muscle fibers or cell mem-
skeletal muscles. The electrical poten- brane, such as muscular dystrophy or
tials are amplified, displayed on a myasthenia gravis
screen in waveforms, and electroni- • Differentiate secondary muscle disor-
cally recorded, similar to electrocar- ders caused by polymyositis, sarcoido-
diography. Comparison and analysis sis, hypocalcemia, thyroid toxicity,
of the amplitude, duration, number, tetanus, and other disorders
and configuration of the muscle
• Detect neuromuscular disorders, such
activity provide diagnostic informa-
as peripheral neuropathy caused by
tion about the extent of nerve and diabetes or alcoholism, and locate the
muscle involvement in the detection site of the abnormality
of primary muscle diseases including
lower motor neuron, anterior horn • Detect muscle disorders caused by
cell, or neuromuscular junction diseases of the lower motor neuron
diseases; defective transmission at involving the motor neuron on the
anterior horn of the spinal cord, such
the neuromuscular junction; and
as anterior poliomyelitis, amyotrophic
peripheral nerve damage or disease. lateral sclerosis, amyotonia, and spinal
Responses of a relaxed muscle are tumors
electrically silent, but spontaneous
muscle movement such as fibrillation • Detect muscle disorders caused by
and fasciculation can be detected in diseases of the lower motor neuron
involving the nerve root, such as
a relaxed, denervated muscle. Muscle
Guillain-Barré syndrome, herniated
action potentials are detected with disc, or spinal stenosis
minimal or maximal muscle contrac-
tions. The differences in the size and • Differentiate between primary and
numbers of activity potentials during secondary muscle disorders or between
voluntary contractions determine neuropathy and myopathy
whether the muscle weakness is a • Determine if a muscle abnormality is
disease of the striated muscle fibers or caused by the toxic effects of drugs
cell membranes (myogenic), or a (e.g., antibiotics, chemotherapy) or
disease of the lower motor neuron toxins (e.g., Clostridium botulinum,
(neurogenic). Nerve conduction snake venom, heavy metals)
studies (electroneurography) are • Monitor and evaluate progression of
commonly done in conjunction with myopathies or neuropathies, including
electromyelography; the combination confirmation of diagnosis of carpal
of the procedures is known as elec- tunnel syndrome
Electromyography 465
RESULT • Age-related decreases in electrical

activity
Normal Findings:
• Medications such as muscle relaxants,
• Normal muscle electrical activity cholinergics, and anticholinergics
during rest and contraction states
• Improper placement of surface or
Abnormal Findings and possible needle electrodes
meanings:
• Evidence of neuromuscular disorders
or primary muscle disease (note: find- Nursing Implications and
ings must be correlated with the
Procedure ● ● ● ● ● ● ● ● ● ● ●
patient’s history, clinical features, and
results of other neurodiagnostic tests):
Pretest:
Amyotrophic lateral sclerosis
Bell’s palsy ➤ Review the procedure with the
patient, indicating that the proce-
Beriberi dure is performed in a special labo-
Carpal tunnel syndrome ratory by a physician and is done to
Dermatomyositis evaluate electrical activity of
Diabetic peripheral neuropathy muscles. This test takes 1 hour to
complete, but can take up to 3 hours
Eaton-Lambert syndrome depending on the patient’s condi-
Guillain-Barré syndrome tion.
Multiple sclerosis ➤ Obtain a list of the medications the
Muscular dystrophy patient is taking.
Myasthenia gravis ➤ Obtain a history and assessment of
Myopathy neuromuscular and neurosensory
Polymyositis status, disease, or conditions that
affect muscle function, level of
Radiculopathy muscular function and range of
Traumatic injury motion, traumatic events, and the
CRITICAL VALUES: N/A tests, surgeries, and procedures. For
related tests, refer to the muscu-
INTERFERING FACTORS: loskeletal system table.
➤ Ensure that the patient has re-
This procedure is contraindicated frained from smoking and caffeine-
for: containing beverages for 3 hours
• Patients with extensive skin infection before the procedure.
• Patients receiving anticoagulant ther- ➤ Inform the patient that as many as

10 electrodes may be inserted at
apy
various locations on the body. Warn
• Patients with an infection at the sites of the patient that the procedure may
electrode placement be uncomfortable, but that an anal-
gesic or sedative will be adminis-
Factors that may impair the tered.
results of the examination: ➤ Ask the patient to remain very
• Inability of the patient to cooperate still and relaxed and to cooperate
or remain still during the procedure with instructions given to contract
because of age, significant pain, or muscles during the procedure.
mental status ➤ Ensure that medications such as
muscle relaxants, cholinergics, and on a screen, and electronically

anticholinergics have been withheld, recorded.
as ordered. ➤ During the test, muscle activity is
➤ Assess for compliance with direc- tested while the patient is at rest,
tions given for exercising during the during incremental needle insertion,
test. and during varying degrees of
➤ Appropriate hematologic studies muscle contraction.
should be ordered to assess coagu- ➤ Ask the patient to alternate between
lopathy. a relaxed and a contracted muscle
➤ Obtain a written, informed consent state, or to perform progressive
for the procedure from the patient, if muscle contractions while the
necessary. potentials are being measured.
➤ Have patient remove clothing and ➤ When the procedure is complete,

any hosiery. Patients may want to remove the electrodes and clean the
wear a gown and void. skin where the electrode was
applied.
➤ Administer mild analgesic (adult) or
sedative (children), as ordered, to ➤ Monitor electrode sites for
promote a restful state before the hematoma or inflammation.
procedure. ➤ If residual pain is noted after the
➤ Place the patient in a supine or procedure, instruct the patient to
sitting position depending on the apply warm compresses and to take
location of the muscle to be tested. analgesics, as ordered.
Ensure that the area or room is ➤ Instruct the patient to resume
protected from noise or metallic normal activity, diet, and previous
interference that may affect the test medication use, unless otherwise
results. indicated.
➤ Cleanse the skin thoroughly with ➤ A physician specializing in this
alcohol pads, as necessary. branch of medicine sends a written
➤ An electrode is applied to the skin to report to the ordering provider, who
ground the patient, and then 24- discusses the results with the
gauge needles containing a fine-wire patient.
electrode are inserted into the ➤ Evaluate test results in relation to
muscle. The electrical potentials of the patient’s symptoms and any
the muscle are amplified, displayed related tests performed.
ELECTROMYOGRAPHY,
PELVIC FLOOR SPHINCTER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Electrodiagnostic study, rectal electromyography.

Electromyography, Pelvic Floor Sphincter 467
AREA OF APPLICATION: Sphincter muscles.

CONTRAST: None.
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.
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.
Post-test: as dysuria, persistent or pro-

longed hematuria, and urinary
➤ Advise the patient to take a warm frequency.
sitz bath.
➤ Encourage fluids unless contraindi- branch of medicine sends a written
cated. report to the ordering provider, who
➤ If tested with needle electrodes, discusses the results with the
warn female patients to expect patient.
hematuria after the first voiding. ➤ Evaluate test results in relation to
➤ Advise the patient to report symp- the patient’s symptoms and any
toms of urethral irritation, such related tests performed.
ELECTRONEUROGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Electrodiagnostic study, nerve conduction study,

ENG.
AREA OF APPLICATION: Muscles.

CONTRAST: None.
DESCRIPTION: Electroneurography ing the distance in meters between

(ENG) is performed to identify the stimulation point and the
peripheral nerve injury, to differenti- response point, by the time between
ate primary peripheral nerve pathol- the stimulus and response. Traumatic
ogy from muscular injury, and to nerve transection, contusion, or
monitor response of the nerve injury neuropathy will usually cause maxi-
to treatment. A stimulus is applied mal slowing of conduction velocity
through a surface electrode over a in the affected side compared with
nerve. After a nerve is electrically that in the normal side. A velocity
stimulated proximally, the time for greater than normal does not indi-
the impulse to travel to a second or cate a pathologic condition. This
distal site is measured. Because the test is usually performed in conjunc-
conduction study of a nerve can vary tion with electromyography in a
from nerve to nerve, it is important combined test called electromyoneu-
to compare the results of the affected rography. ■
side to those of the contralateral side.
The results of the stimulation are
shown on a monitor, but the actual INDICATIONS: Confirm diagnosis of
velocity must be calculated by divid- peripheral nerve damage or trauma
Electroneurography 469
RESULT dure is performed in a special labo-

ratory by a physiatrist or neurologist
and is done to evaluate electrical
Normal Findings:
activity of muscles. Inform the
• No evidence of peripheral nerve injury patient that the procedure may be
or disease. Variable readings depend on uncomfortable because of a mild
the nerve being tested. For patients electrical shock, but that the electri-
aged 3 years and older, the maximum cal shock is brief and is not harmful.
conduction velocity is 40 to 80 ➤ Obtain a list of the medications
milliseconds; for infants and the the patient is taking, including
elderly, the values are divided by 2. herbs, nutritional supplements, and
nutraceuticals.
Abnormal Findings: ➤ Obtain a history and assessment of
• Carpal tunnel syndrome neuromuscular and neurosensory
status, disease, or conditions that
• Diabetic neuropathy affect the peripheral neurological
system, as well as results of previ-
• Guillain-Barré syndrome ously performed tests, surgeries,
• Herniated disc disease and procedures. For related tests,
refer to the musculoskeletal system
• Muscular dystrophy table.
• Myasthenia gravis ➤ Obtain a written, informed consent
• Poliomyelitis ➤ Inform the patient that the proce-
• Tarsal tunnel syndrome dure takes approximately 15
minutes to complete, but can take
• Thoracic outlet syndrome longer depending on the patient’s
condition.
Intratest:
INTERFERING FACTORS: ➤ Place the patient in a supine or
sitting position, depending on the
Factors that may impair the location of the muscle to be tested.
results of the examination: ➤ Shave the extremity in the area to be
• Inability of the patient to cooperate or stimulated, and cleanse the skin
remain still during the procedure thoroughly with alcohol pads.
because of age, significant pain, or ➤ Apply electrode gel and place a
mental status recording electrode at a known
distance from the stimulation point.
• Age-related decreases in electrical activ- Measure the distance between the
ity stimulation point and the site of the
• Poor electrode conduction or failure to recording electrode in centimeters.
obtain contralateral value for compari- ➤ Place a reference electrode nearby
son on the skin surface.
➤ The nerve is electrically stimulated
by a shock-emitter device; the
Nursing Implications and time between nerve impulse and
electrical contraction, measured in
Procedure ● ● ● ● ● ● ● ● ● ● ●
milliseconds (distal latency), is
shown on a monitor.
Pretest:
➤ The nerve is also electrically stimu-
➤ Review the procedure with the lated at a location proximal to the
patient, indicating that the proce- area of suspected injury or disease.
➤ 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)]
[total latency – branch of medicine sends a written
distal latency] report to the ordering provider,
who discusses the results with the
patient.
Post-test:
➤ When the procedure is complete, the patient’s symptoms and any
remove the electrodes and clean the related tests performed.
EOSINOPHIL COUNT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Eos count, total eosinophil count.

SPECIMEN: Whole blood (1 mL) collected in a lavender-top (ethylenedi-
aminetetra-acetic acid [EDTA]) tube.
REFERENCE VALUE: (Method: Manual count using eosinophil stain and

hemocytometer or automated analyzer)
Absolute count: 50 to 350/mm3
Relative percentage: 1 to 4 percent
DESCRIPTION: Eosinophils are cells in the body. Eosinophils also

white blood cells whose function is contain proteolytic substances that
phagocytosis of antigen-antibody damage parasitic worms. The binding
complexes and response to allergy- of histamine to receptor sites on cells
inducing substances and parasites. results in smooth muscle contraction
Eosinophils have granules that in the bronchioles and upper respira-
contain histamine used to kill foreign tory tract, constriction of pulmonary
Eosinophil Count 471
vessels, increased mucus production, Decreased in:

and secretion of acid by the cells that • Aplastic anemia
line the stomach. Eosinophil counts • Eclampsia
can increase to greater than 30
percent of normal in parasitic infec- • Infections (shift to the left)
tions; however, a significant percent- • Stress
age of children with visceral larva
migrans infestations have normal CRITICAL VALUES: N/A
eosinophil counts. ■
• Numerous drugs and substances can
INDICATIONS: Assist in the diagnosis of cause an increase in eosinophil levels
conditions such as allergies, parasitic as a result of an allergic response
infections, drug reactions, collagen or hypersensitivity reaction. These
diseases, Hodgkin’s disease, and myelo- include acetophenazine, allopurinol,
proliferative disorders aminosalicylic acid, ampicillin, buta-
perazine, capreomycin, carisoprodol,
RESULT cephaloglycin, cephaloridine,
cephalosporins, cephapirin, cephra-
Increased in: dine, chloramphenicol, clindamycin,
cloxacillin, dapsone, epicillin, erythro-
mycin, fluorides, gold, imipramine,
• Allergy iodides, kanamycin, mefenamic acid,
methicillin, methyldopa, minocycline,
• Asthma
nalidixic acid, niridazole, nitrofurans
• Cancer (including nitrofurantoin), non-
steroidal anti-inflammatory drugs,
• Dermatitis
nystatin, oxamniquine, penicillin,
• Drug reactions penicillin G, procainamide, ristocetin,
streptokinase, streptomycin, tetracy-
• Eczema
cline, triamterene, tryptophan, and
• Hay fever viomycin.
• Hodgkin’s disease • Drugs that can cause a decrease in
eosinophil levels include amphotericin
• Hypereosinophilic syndrome
B, acetylsalicylic acid, corticotropin,
• Löffler’s syndrome desipramine, glucocorticoids, hydro-
cortisone, interferon, niacin, pred-
• Myeloproliferative disorders
nisone, and procainamide.
• Parasitic infection (visceral larva
• Clotted specimens should be rejected
migrans)
for analysis.
• Specimens more than 4 hours old
• Polycythemia vera should be rejected for analysis.
• Rheumatoid arthritis • There is a diurnal variation in
eosinophil counts. The count is lowest
• Rhinitis
in the morning and continues to rise
• Sarcoidosis throughout the day until midnight.
Therefore, serial measurements should
• Splenectomy
be performed at the same time of day
• Tuberculosis for the purposes of continuity.

Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: Appendix A. Perform a venipuncture,
➤ Obtain a history of the patient’s collect the specimen in a 5-mL
complaints, including a list of known lavender-top (EDTA) tube.
hematopoietic, immune, and respira-
tory systems, as well as results of
previously performed tests and Post-test:
to the hematopoietic, immune, and ➤ Observe venipuncture site for bleed-
respiratory system tables. ing or hematoma formation. Apply
pressure bandage.
patient is taking, including herbs, ➤ Consideration should be given to
nutritional supplements, and nutra- diet if food allergies are present.
ceuticals. The requesting health care ➤ Instruct the patient with an elevated
practitioner and laboratory should be eosinophil count to report any signs
advised if the patient regularly uses or symptoms of infection, such as
these products so that their effects fever.
can be taken into consideration ➤ Instruct the patient with an elevated
when reviewing results. count to rest and take medications
➤ There are no food, fluid, or medica- as prescribed, to increase fluid
tion restrictions unless by medical intake as appropriate, and to monitor
direction. temperature.
collection takes approximately 5 to tests include allergen-specific
10 minutes. immunoglobulin E (IgE), IgE,
complete blood count, hypersensi-
Intratest: tivity pneumonitis screen, fecal
analysis, ova and parasites, and stool
➤ Direct the patient to breathe culture.
ERYTHROCYTE
PROTOPORPHYRIN, FREE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Free erythrocyte protoporphyrin (FEP).

SPECIMEN: Whole blood (1 mL) collected in lavender-top (ethylenedi-
aminetetra-acetic acid [EDTA]) or green-top (heparin) tube.
Erythrocyte Protoporphyrin, Free 473
REFERENCE VALUE: (Method: Fluorometry)

17–77 g/dL of packed cells 0.3–1.37 mol/L of packed cells
DESCRIPTION: The free erythrocyte • Some sideroblastic anemias

protoporphyrin test measures the • Conditions with marked erythro-
concentration of protoporphyrin poiesis (e.g., hemolytic anemias)
in red blood cells. Protoporphyrin
• Erythropoietic protoporphyria
comprises the predominant por-
phyrin in red blood cells, which • Lead poisoning
combines with iron to form the heme
Decreased in: N/A
portion of hemoglobin. Proto-
porphyrin converts to bilirubin,
combines with albumin, and remains
unconjugated in the circulation after INTERFERING FACTORS:
hemoglobin breakdown. Increased • Drugs that may increase erythrocyte
amounts of protoporphyrin can be protoporphyrin levels include barbitu-
detected in erythrocytes, urine, and rates, chlorpropamide, oral contracep-
stool in conditions interfering with tives, sulfomethane, and tolbutamide.
heme synthesis. Protoporphyria is • The test is unreliable in infants less
an autosomal-dominant disorder in than 6 months of age.
which increased amounts of proto-
porphyrin are secreted and excreted;
the disorder is thought to be the result Nursing Implications and
of an enzyme deficiency. Proto- Procedure ● ● ● ● ● ● ● ● ● ● ●
porphyria causes photosensitivity and

may lead to cirrhosis of the liver and Pretest:
cholelithiasis as a result of protopor- ➤ Obtain a history of the patient’s
phyrin deposits. ■ complaints, including a list of known
allergens.
INDICATIONS: hematopoietic system, as well as
• Assist in the diagnosis of erythropoietic results of previously performed
protoporphyrias tests and procedures. For related
• Assist in the differential diagnosis of
system table.
iron deficiency in pediatric patients
• Evaluate lead poisoning the patient is taking, including
RESULT care practitioner and laboratory
• Anemia of chronic disease that their effects can be taken into
• Iron-deficiency anemias results.
➤ There are no food, fluid, or medica- and collect the specimen in a

tion restrictions unless by medical 5-mL lavender-top tube. Specimens
direction. should be protected from light.
➤ Review the procedure with the ➤ Label the specimen, and promptly
patient. transport it to the laboratory.
collection takes approximately 5 to Post-test:
10 minutes.
pressure bandage.
➤ Observe standard precautions and tests include hematocrit, hemoglo-
follow the general guidelines in bin, iron/total iron-binding capacity,
Appendix A. Perform a venipuncture, lead, and urine porphyrins.
ERYTHROCYTE
SEDIMENTATION RATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Sed rate, ESR.

aminetetra-acetic acid [EDTA]) tube for the modified Westergren method
or gray-top (3.8% sodium citrate) tube for the original Westergren method.
REFERENCE VALUE: (Method: Westergren)
Age Male Female

Newborn 0–2 mm/h 0–2 mm/h
Less than 50 y 0–15 mm/h 0–25 mm/h
50 y and older 0–20 mm/h 0–30 mm/h
DESCRIPTION: The erythrocyte sedi- ESR test is the alteration of blood

mentation rate (ESR) is a measure of proteins by inflammatory and
the rate of sedimentation of red blood necrotic processes that cause the
cells (RBCs) in an anticoagulated RBCs to stick together, become heav-
whole blood sample over a specified ier, and rapidly settle at the bottom of
period of time. The basis of the a vertically held, calibrated tube over
Erythrocyte Sedimentation Rate 475
time. In general, relatively little • Carcinoma

settling occurs in normal blood • Collagen diseases including systemic
because normal RBCs do not form lupus erythematosus (SLE)
rouleaux and would not stack
together increasing their mass and • Crohn’s disease
rate of sedimentation. The sedimenta- • Endocarditis
tion rate is proportional to the size or • Heavy metal poisoning
mass of the falling RBCs and is
inversely proportional to plasma • Increased plasma protein level
viscosity. The test is a nonspecific • Infections (e.g., pneumonia, syphilis)
indicator of disease but is fairly sensi-
• Inflammatory diseases
tive and is frequently the earliest indi-
cator of widespread inflammatory • Lymphoma
reaction due to infection or autoim- • Lymphosarcoma
mune disorders. Prolonged elevations
• Multiple myeloma
are also present in malignant disease.
The ESR can also be used to monitor • Nephritis
the course of a disease and the effec- • Pregnancy
tiveness of therapy. The two most
commonly used methods to measure • Pulmonary embolism
the ESR are the Westergren (or modi- • Rheumatic fever
fied Westergren) method and the • Rheumatoid arthritis
Wintrobe hematocrit method. ■
• Subacute bacterial endocarditis
INDICATIONS: • Temporal arteritis
• Assist in the diagnosis of acute infec-
tion, such as tuberculosis or tissue • Toxemia
necrosis • Tuberculosis
• Assist in the diagnosis of acute inflam- • Waldenström’s macroglobulinemia
matory processes
• Assist in the diagnosis of chronic infec- Normal in:
tions • Congestive heart failure
• Assist in the diagnosis of rheumatoid • Glucose-6-phosphate dehydrogenase
or autoimmune disorders deficiency
• Assist in the diagnosis of temporal • Hemoglobin C disease
arthritis and polymyalgia rheumatica
• Hypofibrinogenemia
• Monitor inflammatory and malignant
• Polycythemia
disease
• Sickle cell anemia
RESULT • Spherocytosis
Increased in:
Decreased in:
• Acute myocardial infarction (MI) • Conditions resulting in high hemoglo-
• Anemia bin and RBC count
• Cat scratch fever • Elevated blood glucose
CRITICAL VALUES: N/A should be brought to room tempera-

ture before testing.
• Some drugs cause an SLE-like
syndrome that results in a physiologic Nursing Implications and
increase in ESR. These include anti- Procedure ● ● ● ● ● ● ● ● ● ● ●
convulsants, hydrazine derivatives,

nitrofurantoin, procainamide, and Pretest:
quinidine. Other drugs that may cause ➤ Obtain a history of the patient’s
an increased ESR include acetylsali- complaints, including a list of known
cylic acid, cephalothin, cephapirin, allergens.
cyclosporine A, dextran, and oral ➤ Obtain a history of infectious,
contraceptives. autoimmune, or neoplastic diseases.
• Drugs that may cause a decrease in ➤ Obtain a history of the patient’s
ESR include aurothiomalate, corti- hematopoietic, immune, and respira-
cotropin, cortisone, and quinine. tory systems, as well as results of
• Menstruation may cause falsely procedures. For related tests, refer
increased test results. to the hematopoietic, immune, and
• Prolonged tourniquet constriction
around the arm may cause hemocon- patient is taking, including herbs,
centration and falsely low values. nutritional supplements, and nutra-
• The Westergren and modified ceuticals. The requesting health care
Westergren method are affected by practitioner and laboratory should be
heparin, which causes a false elevation these products so that their effects
in values. can be taken into consideration
• Bubbles in the Westergren tube or when reviewing results.
pipette, or tilting the measurement ➤ There are no food, fluid, or medica-
column more than 3º from vertical will tion restrictions unless by medical
falsely increase the values. direction.
• Movement or vibration of the surface patient.
on which the test is being conducted ➤ Inform the patient that specimen
will affect the results. collection takes approximately 5 to
• Inaccurate timing will invalidate test 10 minutes.
results.
Intratest:
• Specimens that are clotted, hemolyzed,
or insufficient in volume should be normally and to avoid unnecessary
rejected for analysis. movement.
• The test should be performed within 4 ➤ Observe standard precautions and
hours of collection when the specimen follow the general guidelines in
has been stored at room temperature; Appendix A. Perform a venipuncture
delays in testing may result in and collect the specimen in a 5-mL
decreased values. If a delay in testing is gray-top (sodium citrate) tube if the
Westergren method will be used.
anticipated, refrigerate the sample at Collect the specimen in a 5-mL
2C to 4C; stability at refrigerated purple-top (EDTA) tube if the modi-
temperature is reported to be extended fied Westergren method will be
up to 12 hours. Refrigerated specimens used.
Erythropoietin 477
➤ Label the specimen, and promptly ➤ Evaluate test results in relation to

Post-test: tests include complete blood count,
C-reactive protein, rheumatoid
➤ Observe venipuncture site for bleed- factor, microorganism-specific sero-
ing or hematoma formation. Apply logies, and related cultures.
pressure bandage.
ERYTHROPOIETIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: EPO.

5–36 mU/mL 5–36 U/L
D E S C R I P T I O N : Er ythropoietin • Evaluate the presence of rare anemias

(EPO) is a glycoprotein produced • Monitor patients receiving EPO ther-
mainly by the kidney. Its function is apy
to stimulate the bone marrow to
make red blood cells. EPO levels fall RESULT
after removal of the kidney but do
not disappear completely. It is Increased in:
thought that small amounts of EPO • Anemias
may be produced by the liver.
• After moderate bleeding in an other-
Erythropoiesis is regulated by EPO wise healthy patient
and tissue pO2. When pO2 is normal,
EPO levels decrease; when pO2 falls, • Hepatoma
EPO secretion occurs and EPO levels • Kidney transplant rejection
increase. ■
• Nephroblastoma
INDICATIONS: • Pheochromocytoma
• Assist in assessment of anemia of
• Secondary polycythemia (high-altitude
end-stage renal disease
hypoxia, chronic obstructive pulmo-
• Assist in the diagnosis of EPO- nary disease [COPD], pulmonary
producing tumors fibrosis)
• Polycystic kidney disease ➤ Obtain a list of the medications the

• Pregnancy nutritional supplements, and nutra-
Decreased in: practitioner and laboratory should be
• Chemotherapy advised if the patient regularly uses
• Primary polycythemia can be taken into consideration
• Renal failure
• Drugs that may increase EPO levels
include anabolic steroids. ➤ Review the procedure with the
patient.
• Drugs that may decrease EPO levels ➤ Inform the patient that specimen
include amphotericin B, cisplatin, collection takes approximately 5 to
enalapril, estrogens, and theophylline. 10 minutes.
• Blood transfusions may also decrease
Intratest:
EPO levels.
• Recent radioactive scans or radiation normally and to avoid unnecessary
within 1 week before the test can inter- movement.
munoassay is the test method. follow the general guidelines in
Nursing Implications and red- or tiger-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Label the specimen, and promptly
Pretest:
Post-test:
hematopoietic and genitourinary ➤ Evaluate test results in relation to
systems, as well as results of previ- the patient’s symptoms and other
ously performed tests and proce- tests performed. Related laboratory
dures. For related tests, refer to the tests include complete blood count,
hematopoietic and genitourinary ferritin, iron/total iron-binding capac-
system tables. ity, and vitamin B12.
Esophageal Manometry 479
ESOPHAGEAL MANOMETRY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Esophageal function study, esophageal acid study

(Tuttle test), acid reflux test, Bernstein test (aid perfusion), esophageal
motility study.
AREA OF APPLICATION: Esophagus.

CONTRAST: Done with or without noniodinated contrast medium.
DESCRIPTION: Esophageal manome- • Aid in the diagnosis of esophagitis,

try (EM) consists of a group of evidenced by decreased motility
invasive studies performed to assist • Aid in the diagnosis of achalasia,
in diagnosing abnormalities of evidenced by increased pressure in EM
esophageal muscle function and
• Aid in the diagnosis of chalasia in chil-
esophageal structure. These studies dren, evidenced by decreased pressure
measure esophageal pressure, the in EM
effects of gastric acid in the esopha-
gus, lower esophageal sphincter pres- • Aid in the diagnosis of esophageal scle-
roderma, evidenced by decreased pres-
sure, and motility patterns that result
sure in EM
during swallowing. EM can be used
to document and quantify gastro- • Differentiate between esophagitis or
esophageal reflux (GER). It is indi- cardiac condition as the cause of
cated when a patient is experiencing epigastric pain
difficulty swallowing, heartburn,
RESULT
regurgitation, or vomiting; or has
chest pain for which no diagnosis has Normal Findings:
been found. Tests performed in • Esophageal sphincter pressure: 10 to
combination with EM include the 20 mm Hg
acid reflux, acid clearing, and acid • Esophageal secretions: pH 5 to 6
perfusion (Bernstein) tests. ■
• Acid reflux: no regurgitation into the
esophagus
INDICATIONS:
• Evaluate pyrosis and dysphagia to • Acid perfusion: no GER
determine if the cause is GER or • Acid clearing: fewer than 10 swallows
esophagitis
• Bernstein test: negative
• Aid in the diagnosis of GER, evidenced
by low pressure in EM, decreased pH Abnormal Findings:
in acidity test, and pain in acid reflux • Achalasia (sphincter pressure of 50 mm
and perfusion tests Hg)
• Chalasia usually takes 30 to 60 minutes to

complete.
• Esophageal scleroderma
➤ Explain to the patient the purpose of
• Esophagitis the study and how the procedure is
performed.
• GER (sphincter pressure of 0 to 5 mm
Hg, pH of 1 to 3) for the procedure from the patient.
• Hiatal hernia ➤ Obtain a history of upper GI distress
or disorders, hiatal hernia, and
• Progressive systemic sclerosis (sclero- related symptoms.
derma)
➤ Obtain the results of previously
• Spasms performed tests, treatments, surger-
ies, and procedures done to diag-
CRITICAL VALUES: N/A nose or treat disorders of the upper
GI system. For related tests, refer to
the gastrointestinal system table.
This procedure is contraindicated period and possibility of pregnancy
for: in perimenopausal women.
• Patients with unstable cardiopul- ➤ Inform the patient that there will be
some discomfort and gagging when
monary status, blood coagulation
the tube is inserted, but there are no
defects, recent gastrointestinal complications resulting from the
(GI) surgery, esophageal varices, or procedure and the throat will be
bleeding should not have this test anesthetized with a spray or swab.
performed. ➤ Inform the patient that dentures and
eyewear will be removed before the
Factors that may impair the test.
results of the examination:
➤ Inform the patient that he or she will
• Inability of the patient to cooperate or not be able to speak during the
remain still during the procedure procedure, but that breathing will
because of age, significant pain, or not be affected.
mental status ➤ Restrict food, fluids, and smoking for
• Administration of medications (e.g., 8 hours before the procedure.
sedatives, antacids, anticholinergics, ➤ Ensure that medications are with-
cholinergics, corticosteroids) that can held for 24 hours before the study;
change pH or relax the sphincter special arrangements may be neces-
muscle, causing inaccurate results sary for diabetic patients.
➤ Resuscitation and suctioning equip-
Other considerations: ment should be readily available.
• Failure to follow dietary restrictions ➤ Obtain and record baseline vital
before the procedure may cause the signs.
Intratest:
➤ During the procedure, monitor the
Nursing Implications and patient to prevent aspiration of
stomach contents into the lungs.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Note any change in respirations
(dyspnea, tachypnea, adventitious
Pretest: sounds).
➤ Explain that the procedure is gener- ➤ Suction mouth, pharynx, and
ally performed in an endoscopy suite trachea, and administer oxygen as
by a physician with support staff and ordered.
Esophageal Manometry 481
➤ 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.
➤ One or more small tubes are Post-test:

inserted through the nose into the
esophagus and stomach. ➤ Tell the patient to expect some
throat soreness and possible
➤ A small transducer is attached to the
hoarseness. Advise the patient
ends of the tubes; pressures are
to use warm gargles, lozenges,
measured at the lower esophageal
or ice packs to the neck; or to drink
sphincter, and intraluminal pressures
cool fluids to alleviate throat discom-
as well as regularity and duration of
fort.
peristaltic contractions are meas-
ured. ➤ Monitor the patient for signs of
respiratory depression (less than 15
➤ The patient is asked to swallow
respirations per minute). Re-
small amounts of water or flavored
suscitation equipment should be
gelatin.
available.
➤ Pressures are taken and recorded,
➤ Observe the patient for indications
and a motility pattern is recorded on
of perforation: painful swallowing
a graph.
with neck movement, substernal
pain with respiration, shoulder pain,
Esophageal acid and clearing dyspnea, abdominal or back pain,
(Tuttle test): cyanosis, and fever.
➤ With the tube in place, a pH elec- ➤ Emphasize that any severe pain,
trode probe is inserted into the fever, difficulty breathing, or expec-
esophagus with Valsalva maneuvers toration of blood must be reported
performed to stimulate reflux of to the physician immediately.
stomach contents into the esopha-
➤ Do not allow the patient to eat or
gus.
drink until the gag reflex returns;
➤ If acid reflux is absent, 100 mL of then allow the patient to eat lightly
0.1% hydrochloric acid is instilled for 12 to 24 hours.
into the stomach during a 3-minute
➤ Instruct the patient to resume
period, and then the pH measure-
normal activity, medication, and diet
ment is repeated.
24 hours after the examination or as
➤ To determine acid clearing, tolerated, unless otherwise indi-
hydrochloric acid is instilled into the cated.
esophagus and the patient is asked
to swallow while the probe meas-
ures the pH.
discusses the results with the
Acid perfusion (Bernstein
patient.
test):
➤ Inform the patient that an abnormal
➤ A catheter is inserted through the examination may indicate the need
nose into the esophagus and the for further studies.
patient is asked to inform the techni- ➤ Evaluate test results in relation to
cian when pain is experienced. the patient’s symptoms and any
➤ Normal saline solution is allowed to related tests performed.
ESOPHAGOGASTRODUODENOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Esophagoscopy, gastroscopy, upper GI endoscopy,

EGD.
AREA OF APPLICATION: Esophagus, stomach, and upper duodenum.

CONTRAST: Done without contrast.
DESCRIPTION: Esophagogastroduo- • Evaluate the extent of esophageal

denoscopy (EGD) allows direct visu- injury after ingestion of chemicals
alization of the upper gastrointestinal • Detect gastric or duodenal ulcers
(GI) tract mucosa, which includes the
esophagus, stomach, and upper • Evaluate stomach or duodenum after
portion of the duodenum, by means surgical procedures
of a flexible endoscope. The standard • Determine the presence and location
flexible fiberoptic endoscope contains of acute upper GI bleeding
three channels that allow passage of
the instruments needed to perform • Evaluate suspected gastric outlet
therapeutic or diagnostic procedures, obstruction
such as biopsies or cytology washings. • Identify tissue abnormalities and
The endoscope, a multichannel obtain biopsy specimens
instrument, allows visualization of the
GI tract linings, insufflation of air, • Investigate the cause of dysphagia,
aspiration of fluid, removal of foreign dyspepsia, and epigastric pain
bodies by suction or by snare or
forceps, and passage of a laser beam RESULT
for obliteration of abnormal tissue or
control of bleeding. Direct visualiza- Normal Findings:
tion yields greater diagnostic data • Esophageal mucosa is normally yellow-
than is possible through radiologic pink. At about 9 inches from the inci-
procedures, and therefore EGD is sor teeth, a pulsation indicates the
rapidly replacing upper GI as the location of the aortic arch. The gastric
mucosa is orange-red and contains
diagnostic procedure of choice. ■
rugae. The proximal duodenum is
reddish and contains a few longitudi-
INDICATIONS: nal folds, whereas the distal duodenum
has circular folds lined with villi. No
benign and neoplastic tumors
abnormal structures or functions are
• Detect upper GI inflammatory observed in the esophagus, stomach, or
disease duodenum.
Esophagogastroduodenoscopy 483
Abnormal Findings: from inadequate cleansing or failure to

• Acute and chronic gastric and duode- restrict food intake before the study
nal ulcers • Retained barium from a previous radi-
• Diverticular disease ologic procedure
• Duodenitis • Patients who are very obese, who may
• Esophagitis or strictures ment
• Esophageal varices • Incorrect positioning of the patient,
• Esophageal or pyloric stenosis which may produce poor visualization
• Gastritis
• Barium swallow or upper GI series
• Hiatal hernia within the preceding 48 hours, which
• Mallory-Weiss syndrome can hinder adequate visualization
• Tumors (benign or malignant) • Severe upper GI bleeding or the pres-
ence of blood or clots
INTERFERING FACTORS: • Failure to follow dietary restrictions
This procedure is contraindicated procedure to be canceled or repeated.
for: • Consultation with a physician should
• Patients who have had surgery involv- occur before the procedure for radia-
ing the stomach or duodenum, which tion safety concerns regarding infants
can make locating the duodenal papilla of patients who are lactating.
difficult
• Patients with a bleeding disorder overexposure can result from frequent
• Patients with unstable cardiopul- x-ray procedures. Personnel in the
monary status, blood coagulation room with the patient should wear a
defects, or cholangitis, unless the protective lead apron, stand behind a
patient received prophylactic antibiotic shield, or leave the area while the
therapy before the test (otherwise the examination is being done. Personnel
examination must be rescheduled) working in the area where the exami-
• Patients with unstable cardiopul- badges that reveal their level of expo-
monary status, blood coagulation sure to radiation.
defects, known aortic arch aneurysm,
large esophageal Zenker’s diverticulum,
recent GI surgery, esophageal varices, Nursing Implications and
or known esophageal perforation Procedure ● ● ● ● ● ● ● ● ● ● ●
Factors that may impair clear Pretest:

imaging:
• Inability of the patient to cooperate or ➤ Explain to the patient the purpose of
performed.
mental status ➤ Explain that the procedure usually
takes 30 to 60 minutes to complete
• Gas or feces in the GI tract resulting and is generally performed in an
endoscopy suite by a physician and because the gag reflex may be

support staff. impaired.
➤ Obtain a written, informed consent ➤ Place the patient on an examination
for the procedure from the patient. table in the left lateral decubitus
➤ Obtain a history of GI disorders and position with the neck slightly flexed
related symptoms. forward.
➤ Obtain the results of previously ➤ The endoscope is passed through
performed tests, treatments, surger- the mouth with a dental suction
ies, and procedures done to diag- device in place to drain secretions. A
nose or treat disorders of the upper side-viewing flexible, fiberoptic
GI system. For related tests, refer to endoscope is advanced and visuali-
the gastrointestinal system table. zation of the GI tract is started.
➤ Determine date of last menstrual ➤ Air is insufflated to distend the upper
period and possibility of pregnancy GI tract, as needed. Biopsy speci-
in perimenopausal women. mens are obtained and/or endo-
scopic surgery is performed.
dure is not painful and that the throat ➤ Label the specimens, and promptly
will be anesthetized with a spray or transport them to the laboratory.
swab. ➤ At the end of the procedure, excess
➤ Inform the patient that dentures and air and secretions are aspirated
eyewear will be removed before the through the scope and the endo-
test. scope is removed.
➤ Inform the patient that he or she will Post-test:
not be able to speak during the
procedure, but that breathing will ➤ Do not allow the patient to eat or
not be affected. drink until the gag reflex returns;
➤ Restrict food and fluids for 8 hours then allow the patient to eat lightly
before the procedure. for 12 to 24 hours. Instruct
the patient to resume normal
➤ Note recent administration of activity, medication, and diet in
barium because it can obscure the 24 hours or as tolerated after the
area to be examined. examination, unless otherwise
➤ Make resuscitation and suctioning indicated.
equipment readily available. ➤ Inform the patient that he or she
➤ Obtain and record baseline vital may experience some throat sore-
signs. ness and hoarseness. Instruct
patient to treat throat discomfort
Intratest: with lozenges and warm gargles
when the gag reflex returns.
➤ Have the patient put on a hospital
gown and void. ➤ Monitor the patient for signs of
respiratory depression (less than 15
➤ Wear gloves throughout the proce- respirations per minute).
dure.
➤ Observe the patient until the effects
➤ An intravenous (IV) line may be of the sedation have worn off.
started to allow for the infusion of a
sedative or IV fluids. ➤ Observe the patient for indications
of esophageal perforation (i.e.,
➤ Administer ordered sedation. painful swallowing with neck move-
➤ Spray or swab the oropharynx with a ment, substernal pain with respira-
topical local anesthetic. tion, shoulder pain or dyspnea, and
➤ Provide an emesis basin for the abdominal or back pain, cyanosis,
increased saliva and encourage fever).
the patient to spit out the saliva ➤ Inform the patient that any belching,
Estradiol 485
bloating, or flatulence is the result of discusses the results with the

air insufflation and is temporary. patient.
➤ Emphasize that any severe pain,
fever, difficulty breathing, or expec-
toration of blood must be immedi-
for further studies.
ately reported to the physician.
➤ A physician specializing in this ➤ Evaluate test results in relation to
branch of medicine sends a written the patient’s symptoms and any
report to the ordering provider, who related tests performed.
ESTRADIOL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: E2.
SI Units (Conversion
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
estrogens. Estrone (E1) is the immedi- phenytoin, tamoxifen, and trolean-

ate precursor of estradiol (E2). Estriol domycin.
(E3) is secreted in large amounts from • Drugs that may decrease estradiol
the placenta during pregnancy from levels include aminoglutethimide,
precursors produced by the fetal chemotherapy drugs, cimetidine, dana-
liver. ■ zol, fadrozole, formestane, goserelin,
leuprolide, megestrol, mepartricin,
INDICATIONS: mifepristone (pregnant women with
• Assist in determining the presence of expulsion of fetus), nafarelin (women
gonadal dysfunction being treated for endometriosis), and
• Evaluate menstrual abnormalities, oral contraceptives.
fertility problems, and estrogen- • Estradiol is secreted in a biphasic
producing tumors in women, and pattern during normal menstruation.
testicular or adrenal tumors and femi- Knowledge of the phase of the
nization disorders in men menstrual cycle may assist interpreta-
• Monitor menotropin (Pergonal) ther- tion of estradiol levels.
apy. Menotropin is a preparation of
follicle-stimulating hormone (FSH)
and luteinizing hormone (LH) used to Nursing Implications and
induce ovulation and increase the Procedure ● ● ● ● ● ● ● ● ● ● ●
chance of pregnancy
Pretest:
RESULT
Increased in: complaints, including a list of known
allergens.
• Adrenal tumors
• 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.
Decreased in: patient is taking, including herbs,
• Ovarian failure nutritional supplements, and nutra-
• Primary and secondary hypogonadism
• Turner’s syndrome advised if the patient regularly uses
• 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.
Estrogen and Progesterone Receptor Assays 487
➤ 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.
ESTROGEN AND PROGESTERONE

RECEPTOR ASSAYS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Estrogen receptor protein (ERP), progesterone

receptor protein (PRP).
SPECIMEN: Breast tissue.

REFERENCE VALUE: (Method: Cytochemical or immunocytochemical)
Interpretation of results is subjective depending on the intensity of staining
and the number of cells classified as positive. More recently, immunoperoxi-
dase methods employing monoclonal antibodies have been introduced.
These antibodies have greater specificity and are not subject to interference
by exogenous hormones.
Cytochemical Findings Values

Favorable findings Greater than 20% of cell nuclei are stained
Borderline findings 11–20% of cell nuclei are stained
Unfavorable findings Less than 10% of cell nuclei are stained
DESCRIPTION: Estrogen and proges- estrogen-deprivation (antiestrogen)

terone receptor assays are used to therapy or removal of the ovaries.
identify patients with a type of breast Patients with these types of tumors
cancer that may be more responsive generally have a better prognosis.
than other types of tumors to DNA ploidy testing by flow cytome-
try may also be performed on suspi-

cious tissue. Cancer cells contain
abnormal amounts of DNA. The
Procedure ● ● ● ● ● ● ● ● ● ● ●
higher the grade of tumor cells, the Pretest:

more likely abnormal DNA will be
detected. The ploidy or number of ➤ Obtain a history of the patient’s
chromosome sets in the nucleus is an allergens.
indication of the speed of cell replica-
tion and tumor growth. ■ endocrine, immune, and reproduc-
tive systems, as well as results of
• Identify patients with breast or procedures. For related tests, refer
other types of cancer that may res- to the endocrine, immune, and
pond to hormone or antihormone reproductive system tables.
therapy ➤ Obtain a list of the medications
• Monitor responsiveness to hormone or herbs, nutritional supplements, and
antihormone therapy nutraceuticals. The requesting health
RESULT should be advised if the patient
• Hormonal therapy results.
• Receptor-positive tumors ➤ Ensure that the patient has not
received antiestrogen therapy within
Negative findings in: 2 months of the test.
• Receptor-negative tumors ➤ Inform the patient that the excision
is considered a surgical procedure
and that fasting for 8 hours before
CRITICAL VALUES: N/A the procedure is required.
INTERFERING FACTORS: patient.
• Antiestrogen preparations (e.g., tamox-
ifen) ingested 2 months before tissue ➤ Assess if the patient has an allergy
sampling will affect test results.
• Tissue specimens contaminated with ➤ Ensure that nonallergy to anesthesia
formalin or failure to freeze the is confirmed before open biopsy
specimen adequately using liquid procedure is performed under
nitrogen or dry ice will falsely decrease general anesthesia.
results. ➤ Obtain a written and informed
• Massive tumor necrosis or tumors with medications prior to the procedure.
low cellular composition falsely
decrease results.
• Failure to transport specimen to the 20 minutes.
laboratory immediately can result in
degradation of receptor sites. Prompt Intratest:
and proper specimen processing, stor- ➤ Ensure that the patient has complied
age, and analysis are important to with dietary preparation and other
achieve accurate results. pretesting restrictions.
Evoked Brain Potentials 489
➤ Record baseline vital signs. ➤ Instruct the patient in proper cleans-

➤ Administer preoperative sedation, as ing of the site and of the importance
ordered. of a follow-up appointment for
suture removal, as appropriate.
➤ Assemble supplies and prepare the
patient for surgical biopsy or resec- ➤ Instruct the patient to report exces-
tion. Supplies should include a sive bleeding, redness, edema, or
waxed cardboard specimen pain at the biopsy site.
container without preservatives. ➤ Administer analgesics and antibi-
➤ Observe standard precautions and otics as ordered, and instruct the
follow the general guidelines in patient in the importance of
Appendix A. completing the entire course of
antibiotic therapy even if no symp-
➤ Using needle biopsy or resection, toms are present.
the health care practitioner obtains
a tissue specimen weighing at least ➤ Teach the patient how to perform a
200 mg. Place the specimen in a monthly breast self-examination,
labeled formalin-free container. and instruct her to have a mammo-
Label the specimen indicating loca- gram performed annually.
tion (e.g., left or right), and promptly ➤ Recognize anxiety related to test
transport it to the laboratory. results and offer support. Provide
Post-test: the clinical implications of the test
➤ Instruct the patient to resume usual patient regarding access to counsel-
diet and medication as directed by ing services.
the health care practitioner. ➤ Inform the patient about hormone
➤ After open biopsy, monitor vital therapy, as appropriate based on
signs every 15 minutes for 1 hour, test results.
and then every 2 hours for 4 hours, ➤ Evaluate test results in relation to
and as ordered. Take temperature the patient’s symptoms and other
every 4 hours for 24 hours. tests performed. Related laboratory
➤ After local anesthesia, monitor vital tests include breast biopsy, CA 15-3,
signs and compare with baseline HER-2/neu oncoprotein, and carci-
values. noembryonic antigen.
EVOKED BRAIN POTENTIALS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: EP studies, brain stem auditory evoked potentials

(BAEP), brain stem auditory evoked responses (BAER).

CONTRAST: None.
DESCRIPTION: Evoked brain poten- allows objective diagnostic informa-

tials, also known as evoked potential tion about visual or auditory disorders
(EP) responses, are electrophysiologic affecting infants and children, and
studies performed to measure the allows differentiation between organic
brain’s electrical responses to various brain and psychological disorders in
visual, auditory, and somatosensory adults. EP studies are also used to
stimuli. EP studies help diagnose monitor the progression of or the
lesions of the nervous system by eval- effectiveness of treatment for deterio-
uating the integrity of the visual, rating neurological diseases such as
somatosensory, and auditory nerve multiple sclerosis. ■
pathways. Three response types are
measured: visual evoked response INDICATIONS
(VER), auditory brain stem response
VER (potentials):
(ABR), and somatosensory evoked
• Detect neurological disorders such as
response (SER). The stimuli activate multiple sclerosis, Parkinson’s disease,
the nerve tracts that connect the and Huntington’s chorea
stimulated (receptor) area with the
cortical (visual and somatosensory) or • Detect cryptic or past retrobulbar
neuritis
midbrain (auditory) sensory area. A
number of stimuli are given and then • Evaluate optic pathway lesions and
electronically displayed in waveforms, visual cortex defects
recorded, and computer analyzed. • Detect lesions of the eye or optic
Abnormalities are determined by a nerves
delay in time, measured in millisec-
• Evaluate binocularity in infants
onds, between the stimulus and the
response. This is known as increased ABR (potentials):
latency. VER provides information • Detect abnormalities or lesions in the
about visual pathway function to brain stem or auditory nerve areas
identify lesions of the optic nerves,
• Screen or evaluate neonates, infants,
optic tracts, and demyelinating children, and adults for auditory prob-
diseases such as multiple sclerosis. lems (EP studies may be indicated
ABR provides information about when a child falls below growth chart
auditory pathways to identify hearing norms)
loss and lesions of the brain stem.
• Early detection of brain stem tumors
SER provides information about the and acoustic neuromas
somatosensory pathways to identify
lesions at various levels of the central SER (potentials):
nervous system (spinal cord and • Evaluate spinal cord and brain injury
brain) and peripheral nerve disease. and function
EP studies are especially useful in
• Detect sensorimotor neuropathies and
patients with problems and those cervical pathology
unable to speak or respond to instruc-
tions during the test, because they do • Detect multiple sclerosis and Guillain-
not require voluntary cooperation or Barré syndrome
participation in the activity. This • Monitor sensory potentials to deter-
Evoked Brain Potentials 491
mine spinal cord function during a Abnormal lower limb latencies

surgical procedure or medical regimen suggest peripheral nerve root
disease such as Guillain-Barré
ERP (potentials): syndrome, multiple sclerosis,
• Differentiate between organic brain transverse myelitis, or traumatic
disorder and cognitive function abnor- spinal cord injuries.
mality
• Detect suspected psychosis or
dementia
INTERFERING FACTORS
RESULT
Factors that may impair the
Normal Findings: results of the examination:
VER and ABR: Normal latency in
recorded cortical and brain stem remain still during the procedure
waveforms depending on age, because of age, significant pain, or
sex, and stature mental status (note: significant behav-
ERP: Normal recognition and
ioral problems may limit the ability to
attention span complete the test)
SER: No loss of consciousness or • Improper placement of electrodes
presence of weakness
• Patient stress, which can affect brain
Abnormal Findings: chemistry thus making it difficult to
• VER (potentials): distinguish whether the results are due
to the patient’s emotional reaction or
P100 latencies (extended) confined to organic pathology
to one eye suggest a lesion
anterior to the optic chiasm. • Extremely poor visual acuity, which
Bilateral abnormal P100 latencies can hinder accurate determination of
indicate multiple sclerosis, optic VER
neuritis, retinopathies,
• Severe hearing loss, which can interfere
spinocerebellar degeneration,
sarcoidosis, Parkinson’s disease,
with accurate determination of ABR
adrenoleukodystrophy,
Huntington’s chorea, and
amblyopias. Nursing Implications and
• ABR (potentials):
Procedure ● ● ● ● ● ● ● ● ● ● ●
Normal response at high Pretest:

intensities; wave V may occur
slightly later. Earlier wave ➤ Inform the patient that this proce-
distortions suggest cochlear dure measures electrical activity in
lesion. the nervous system.
Absent or late waves at high ➤ Inform the patient that the proce-
intensities; increased amplitude dure is performed in a special labo-
of wave V suggests retrocochlear ratory by a technologist and takes
lesion. approximately 30 minutes to 2
hours, depending on the test.
• SER (potentials): ➤ Obtain a history and assessment of
Abnormal upper-limb latencies the neurological system, known or
suggest cervical spondylosis or suspected neurological conditions,
intracerebral lesions. and trauma to the head or spinal
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.
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
sensory cortex of the hemisphere
patient is taking including herbs,
on the opposite side (the electrode
that picks up the response and deliv-
ers it to the recorder). Additional
electrodes can be positioned at the
cervical or lumbar vertebrae for
upper or lower limb stimulation. The
rate at which the electric shock stim-
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:
➤ 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.
Exercise Stress Test 493
➤ Evaluate test results in relation to phy as well as magnetic resonance

the patient’s symptoms and other imaging and computed tomography
tests performed. Related diagnostic of the brain.
tests include electroencephalogra-
EXERCISE STRESS TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Exercise electrocardiogram (ECG, EKG), graded

exercise tolerance test, stress testing, treadmill test.

CONTRAST: None.
DESCRIPTION: The exercise stress those experiencing frequent angina

test is a noninvasive study to measure episodes before the test. Although
cardiac function during physical useful, this procedure is not as accu-
stress. Exercise electrocardiography is rate as cardiac nuclear scans for
primarily useful in determining the diagnosing coronary artery disease
extent of coronary artery occlusion by (CAD).
the heart’s ability to meet the need for For patients unable to complete
additional oxygen in response to the the test, pharmacologic stress testing
stress of exercising in a safe environ- can be done. Medications used to
ment. The patient exercises on a increase the patient’s heart include
treadmill or pedals a stationary bicy- vasodilators such as dipyridamole and
cle to increase the heart rate to 80 to beta-agonists such as dobutamine. ■
90 percent of maximal heart rate
determined by age and sex, known as INDICATIONS:
the target heart rate. Every 2 to 3 • Evaluate suspected CAD in the pres-
ence of chest pain and other symptoms
minutes the speed and/or grade of the
treadmill is increased to yield an • Screen for CAD in the absence of
increment of stress. The patient’s elec- pain and other symptoms in patients
trocardiogram (ECG) and blood at risk
pressure are monitored during the • Detect dysrhythmias during exercis-
test. The test proceeds until the ing, as evidenced by ECG changes
patient reaches the target heart rate or • Evaluate cardiac function after
experiences chest pain or fatigue. The myocardial infarction or cardiac
risks involved in the procedure are surgery to determine safe exercise
possible myocardial infarction (1 in levels for cardiac rehabilitation as well
500) and death (1 in 10,000) in as work limitations
• Determine exercise-induced hyperten- • Improper electrode placement

sion
• High food intake or smoking before
• Detect peripheral arterial occlusive testing
disease (intermittent claudication), as
• Drugs such as beta blockers, cardiac
evidenced by leg pain or cramping
glycosides, calcium channel blockers,
during exercising
coronary vasodilators, and barbiturates
• Evaluate effectiveness of medication
• Potassium or calcium imbalance
regimens, such as antianginals or
antiarrhythmics • Hypertension, hypoxia, left bundle
branch block, and ventricular hyper-
RESULT trophy
• Wolff-Parkinson-White syndrome
Normal Findings:
(anomalous atrioventricular excitation)
• Normal heart rate during physical exer-
cise. Heart rate and systolic blood pres- • Anxiety or panic attack
sure rise in direct proportion to
workload and metabolic oxygen
demand, which is based on age and Nursing Implications and
exercise protocol. Maximal heart rate Procedure ● ● ● ● ● ● ● ● ● ● ●
for adults is normally 150 to 200

beats/min. Pretest:
➤ Inform the patient that the test
Abnormal Findings: assesses the heart’s ability to
• Activity intolerance related to oxygen respond to an increasing workload.
supply and demand imbalance ➤ Advise the patient to wear comfort-
able shoes and clothing for the exer-
• Bradycardia cise.
• Chest pain related to ischemia or ➤ Inform the patient that the proce-
inflammation dure is performed in a special
department by a technician and
• CAD takes approximately 30 to 60
• Decreased cardiac output minutes.
➤ Assure the patient that the test has
• Dysrhythmias very few risks and that exercising
• Hypertension can be terminated if extreme symp-
toms occur.
• Peripheral arterial occlusive disease ➤ Obtain a list of medications the
• S-T segment depression of 1 mm patient is taking including herbs,
(considered a positive test), indicating nutritional supplements, and
myocardial ischemia care practitioner and laboratory
• Tachycardia should be advised if the patient
CRITICAL VALUES: N/A consideration when reviewing
results.
INTERFERING FACTORS: The following ➤ Obtain a pertinent history of the
factors may impair interpretation of results of previously performed
examination results because they create cardiac tests and procedures, pres-
an artificial state that makes it difficult to ent cardiac conditions or abnormali-
determine true physiologic function: ties, and therapies received for the
Exercise Stress Test 495
cardiac conditions. For related tests, fatigue is severe; maximum heart

refer to the cardiovascular system rate under stress is attained; signs
table. of ischemia are present; maximum
➤ Obtain a written, informed consent effort has been achieved; or dysp-
for the procedure from the patient. nea, hypertension (systolic blood
pressure greater than 250 mm Hg),
➤ Ask the patient if he or she has had tachycardia (greater than 200
any chest pain within the prior 48 beats/minute minus person’s age),
hours, or has a history of anginal new dysrhythmias, chest pain that
attacks several times a day; if either begins or worsens, faintness,
of these is the case, inform the extreme dizziness, or confusion
physician immediately because the develop.
stress test may be too risky and
should be rescheduled in 4 to 6 ➤ The patient is asked to step onto the
weeks. treadmill and is instructed to use the
handrails to maintain balance.
➤ Record a baseline 12-lead ECG and
vital signs, if these recordings were ➤ The treadmill is turned on to a slow
not already obtained or are not avail- speed, but is increased in speed and
able. elevation to increase the patient’s
heart rate. Stress is increased until
➤ Ensure that the patient has the patient’s predicted target heart
abstained from food, fluids, and rate is reached.
smoking for at least 4 hours before
the test and that the patient has ➤ After the exercise period, a 3- to 15-
discontinued specific medications minute rest period is given with the
that can interfere with test results, patient in a sitting position. During
as ordered. this period the ECG, blood pressure,
and heart rate monitoring is contin-
ued.
Intratest:
➤ Ask the patient to remove clothing Post-test:
from the waist up (give women a
hospital gown that opens in the ➤ Remove the electrodes and cleanse
front). the skin of any remaining gel or ECG
electrode adhesive.
➤ Electrodes are placed in appropriate
positions on the patient, a blood ➤ Instruct the patient to call the physi-
pressure cuff connected to a moni- cian to report any anginal pain or
toring device is applied, and if the other discomforts experienced after
patient’s oxygen consumption is the test.
continuously monitored, the patient ➤ Instruct the patient regarding special
is connected to a machine via a dietary intake and medication regi-
mouthpiece or to a pulse oximeter men, as needed.
via a finger lead. ➤ Instruct the patient to resume activi-
➤ The patient is asked to walk on a ties discontinued before the test.
treadmill (most commonly used) or ➤ A physician specializing in this
to peddle a bicycle. As the stress is branch of medicine sends a written
increased, the patient is asked to report to the ordering provider, who
report any symptoms, such as chest discusses the results with the
or leg pain, dyspnea, or fatigue. patient.
➤ An intravenous access may be ➤ Evaluate test results in relation to
established for emergency use. the patient’s symptoms and other
➤ Instruct the patient to report symp- tests performed. Related diagnostic
toms such as dizziness, sweating, tests include ECG, as well as
breathlessness, or nausea, which positron emission tomography scan-
can be normal as speed increases. ning and nuclear thallium scanning
The test is terminated if pain or of the heart.
FECAL ANALYSIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Stool.
REFERENCE VALUE: (Method: Macroscopic examination, for appearance
and color; microscopic examination, for cell count and presence of meat
fibers; leukocyte esterase, for leukocytes; Clinitest [Bayer Corporation,
Pittsburgh, Pennsylvania] for reducing substances; guaiac, for occult blood;
x-ray paper, for trypsin)
Characteristic Normal Result

Appearance Solid and formed
Color Brown
Epithelial cells Few to moderate
Fecal fat See fecal fat monograph
Leukocytes (WBCs) Negative
Meat fibers Negative
Occult blood Negative
Reducing substances Negative
Trypsin 2 to 4
DESCRIPTION: Feces consist mainly odor, shape, color, consistency,

of cellulose and other undigested presence of mucus), microscopic
foodstuffs, bacteria, and water. Other examination (leukocytes, epithelial
substances normally found in feces cells, meat fibers), and chemical
include epithelial cells shed from tests for specific substances (occult
the gastrointestinal (GI) tract, small blood, trypsin, estimation of carbohy-
amounts of fats, bile pigments in drate). ■
the form of urobilinogen, GI and
pancreatic secretions, electrolytes, INDICATIONS:
and trypsin. Trypsin is a proteolytic • Assist in diagnosing disorders associ-
enzyme produced in the pancreas. ated with GI bleeding or drug therapy
that leads to bleeding
The average adult excretes 100 to 300
g of fecal material per day, the residue • Assist in the diagnosis of pseudomem-
of approximately 10 L of liquid mate- branous enterocolitis after use of
rial that enters the tract each day. The broad-spectrum antibiotic therapy
laboratory analysis of feces includes • Assist in the diagnosis of suspected
macroscopic examination (volume, inflammatory bowel disorder
Fecal Analysis 497
• Detect altered protein digestion gastritis, hemorrhoids, infectious diar-

rheas, inflammatory bowel disease,
• Detect intestinal parasitic infestation,
Mallory-Weiss tears, polyps, tumors,
as indicated by diarrhea of unknown
ulcers
cause
• Investigate diarrhea of unknown cause Decreased:
• Monitor effectiveness of therapy for • Leukocytes: Amebic colitis, cholera,
intestinal malabsorption or pancreatic disorders resulting from toxins, para-
insufficiency sites, viral diarrhea
• Screen for cystic fibrosis • Trypsin: Cystic fibrosis, malabsorption

syndromes, pancreatic deficiency
Unusual Appearance:
• Bloody: Excessive intestinal wall irrita- • Drugs that can cause positive results
tion or malignancy for occult blood include acetylsali-
• Bulky or frothy: Malabsorption cylic acid, anticoagulants, colchicine,
corticosteroids, iron preparations, and
• Mucous: Inflammation of intestinal phenylbutazone.
walls
• Ingestion of a diet high in red meat,
• Slender or ribbonlike: Obstruction certain vegetables, and bananas can
cause false-positive results for occult
Unusual Color: blood.
• Black: Bismuth (antacid) or charcoal
ingestion, iron therapy, upper GI bleed • Large doses of vitamin C can cause
false-negative occult blood.
• Grayish white: Barium ingestion, bile
duct obstruction • Constipated stools may not indicate
any trypsin activity owing to extended
• Green: Antibiotics, biliverdin, green exposure to intestinal bacteria.
vegetables
• Red: Beets and food coloring, lower GI
bleed, phenazopyridine hydrochloride Nursing Implications and
compounds, rifampin Procedure ● ● ● ● ● ● ● ● ● ● ●
• Yellow: Rhubarb Pretest:

Increased: ➤ Obtain a history of the patient’s
• Carbohydrates/reducing substances: complaints, including a list of known
allergens.
Malabsorption syndromes
➤ Obtain a history of the patient’s GI
• Epithelial cells: Inflammatory bowel system as well as results of previ-
disorders ously performed tests and proce-
• Leukocytes: Bacterial infections of the gastrointestinal system table.
intestinal wall, salmonellosis, shigel-
losis, and ulcerative colitis patient is taking, including herbs,
• Meat fibers: Altered protein digestion nutritional supplements, and
• Occult blood: Anal fissure, diverticular care practitioner and laboratory
disease, esophageal varices, esophagitis, should be advised if the patient
regularly uses these products so pint waterproof container with a

that their effects can be taken into tight-fitting lid; if the patient is not
consideration when reviewing ambulatory, collect it in a clean, dry
results. bedpan. Use a tongue blade to trans-
➤ Instruct the patient to follow a fer the specimen to the container,
normal diet for several days before and include any mucoid and bloody
the test. portions. Collect specimen from the
first, middle, and last portion of the
➤ Inform the patient of the procedure stool. The specimen should be refrig-
for collecting a stool sample, includ- erated if it will not be transported to
ing the importance of good hand- the laboratory within 4 hours after
washing techniques. The patient collection.
should place the sample in a tightly
covered container. ➤ To collect specimen by rectal swab,
insert the swab past the anal sphinc-
➤ Instruct the patient not to use laxa- ter, rotate gently, and withdraw.
tives, enemas, or suppositories for 3 Place the swab in the appropriate
days before the test. container.
➤ Instruct the patient not to contami- ➤ Label the specimen, place it in a
nate the specimen with urine, water, leak-proof bag, and promptly trans-
or toilet tissue. port it to the laboratory. Make sure
➤ There are no food, fluid, or medica- the label includes the date and time
tion restrictions unless by medical of collection and suspected cause of
direction. enteritis, noting any current or
➤ Review the procedure with the recent antibiotic therapy.
patient.
Post-test:
Intratest: ➤ Evaluate test results in relation to
➤ Ensure that the patient has complied the patient’s symptoms and other
with dietary preparations and other tests performed. Related laboratory
pretesting restrictions. tests include 1-antitrypsin/pheno-
typing, intestinal biopsy, sweat
➤ Observe standard precautions and chloride, stool culture, D-xylose toler-
follow the general guidelines in ance, fecal fat, gliadin antibody,
Appendix A. lactose tolerance, and ova and para-
➤ Collect a stool specimen in a half- sites.
FECAL FAT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Stool fat, fecal fat stain.

SPECIMEN: Stool (80 mL) aliquot from an unpreserved and homogenized
24- to 72-hour timed collection. Random specimens may also be submitted.
REFERENCE VALUE: (Method: Stain with Sudan black or oil red O.

Treatment with ethanol identifies neutral fats; treatment with acetic acid
identifies fatty acids.)
Fecal Fat 499
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.
DESCRIPTION: Fecal fat primarily fat. The quantitative method, which

consists of triglycerides (neutral fats), requires a 72-hour stool collection,
fatty acids, and fatty acid salts. measures the amount of fat present in
Through microscopic examination, grams. ■
the number and size of fat droplets
can be determined as well as the type INDICATIONS:
of fat present. Excretion of greater • Assist in the diagnosis of malabsorp-
than 7 g of fecal fat in a 24-hour tion or pancreatic insufficiency, as indi-
period is abnormal but nonspecific cated by elevated fat levels
for disease. Increases in excretion of • Monitor the effectiveness of therapy
neutral fats are associated with
pancreatic exocrine insufficiency, RESULT
whereas decreases are related to small
bowel disease. An increase in triglyc- Increased in:
erides indicates that insufficient • A--lipoprotein deficiency
pancreatic enzymes are available to • Addison’s disease
convert the triglycerides into fatty
• Amyloidosis
acids. Patients with malabsorption
conditions have normal amounts of • Bile salt deficiency
triglycerides but an increase in total • Carcinoid syndrome
fecal fat because the fats are not • Celiac disease
absorbed through the intestine.
• Crohn’s disease
Malabsorption disorders (e.g., cystic
fibrosis) cause blockage of the pancre- • Cystic fibrosis
atic ducts by mucus, which prevents • Diabetes
the enzymes from reaching the • Enteritis
duodenum and results in lack of fat
digestion. Without digestion, the fats • Malnutrition
cannot be absorbed, and steatorrhea • Multiple sclerosis
results. The appearance and odor of • Pancreatic insufficiency or obstruction
stool from patients with steatorrhea is
• Peptic ulcer disease
typically foamy, greasy, soft, and foul-
smelling. The semiquantitative test is • Pernicious anemia
used to screen for the presence of fecal • Progressive systemic sclerosis
• Tropical sprue related to GI dysfunction, pain

related to tissue inflammation or irri-
• Thyrotoxicosis tation, alteration in diet resulting
• Viral hepatitis from an inability to digest certain
foods, or fluid volume deficit related
• Whipple’s disease to active loss.
• Zollinger-Ellison syndrome ➤ Obtain a list of known allergens.
➤ Obtain a history of the patient’s GI
Decreased in: N/A and respiratory systems, as well as
CRITICAL VALUES: N/A tests, refer to the gastrointestinal
INTERFERING FACTORS: ➤ Obtain a list of the medications the
• Cimetidine has been associated with patient is taking, including herbs,
decreased fecal fat in some patients nutritional supplements, and nutra-
with cystic fibrosis who are also receiv- ceuticals. The requesting health care
ing pancreatic enzyme therapy. practitioner and laboratory should be
• Some drugs cause steatorrhea as a these products so that their effects
result of mucosal damage. These can be taken into consideration
include colchicine, kanamycin, linco- when reviewing results.
mycin, methotrexate, and neomycin. ➤ Note any recent procedures that can
Other drugs that can cause an increase interfere with test results.
in fecal fat include aminosalicylic ➤ Instruct the patient not to use laxa-
acid, bisacodyl and phenolphthalein tives, enemas, or suppositories for 3
(observed in laxative abusers), and days before the test.
cholestyramine (in high doses). ➤ There are no fluid restrictions unless
• Use of suppositories, oily lubricants, by medical direction.
or mineral oil in the perianal area for ➤ Stress the importance of collecting
3 days before the test can falsely all stools for the quantitative test,
increase neutral fats. including diarrhea, over the timed
specimen-collection period.
• Use of herbals with laxative effects, ➤ Inform the patient not to urinate in
including cascara, psyllium, and senna, the stool-collection container and
for 3 days before the test can falsely not to put toilet paper in the
increase neutral fats. container.
• Barium interferes with test results. ➤ Review the procedure with the
patient. Instruct the patient to ingest
• Failure to collect all stools may reflect a diet containing 50 to 150 g of fat
falsely decreased results. for at least 3 days before beginning
specimen collection. This approach
• Ingestion of a diet too high or low in does not work well with children;
fats may alter the results. instruct the caregiver to record the
child’s dietary intake to provide a
basis from which an estimate of fat
Nursing Implications and intake can be made.
Procedure ● ● ● ● ● ● ● ● ● ● ●
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
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
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
DESCRIPTION: Ferritin, a protein • Hepatocellular disease (acute or

manufactured in the liver, spleen, and chronic)
bone marrow, consists of a protein • Hodgkin’s disease
shell, apoferritin, and an iron core.
• Hyperthyroidism
The amount of ferritin in the circula-
tion is usually proportional to the • Infection (acute or chronic)
amount of stored iron (ferritin and • Inflammatory diseases
hemosiderin) in body tissues. Levels
vary according to age and gender, but • Leukemias
they are not affected by exogenous • Oral or parenteral administration of
iron intake or subject to diurnal vari- iron
ations. Compared to iron and total • Thalassemia
iron-binding capacity, ferritin is a
more sensitive and specific test for Decreased in:
diagnosing iron-deficiency anemia. • Hemodialysis
Iron-deficiency anemia in adults is
• Iron-deficiency anemia
indicated at ferritin levels less than 10
ng/mL; hemochromatosis or hemo- CRITICAL VALUES: N/A
siderosis is indicated at levels greater
than 400 ng/mL. ■ INTERFERING FACTORS:
• Drugs that may increase ferritin levels
INDICATIONS: include ethanol, ferric polymaltose,
• Assist in the diagnosis of iron- iron, and oral contraceptives.
deficiency anemia • Drugs that may decrease ferritin levels
• Assist in the differential diagnosis of include erythropoietin, methimazole,
microcytic, hypochromic anemias propylthiouracil, and thiamazole.
• Recent transfusion can elevate serum
• Monitor hematologic responses during
ferritin.
pregnancy, when serum iron is usually
decreased and ferritin may be
decreased
• Support diagnosis of hemochromatosis Procedure ● ● ● ● ● ● ● ● ● ● ●
or other disorders of iron metabolism

and storage Pretest:
allergens.
• Alcoholism (active abusers) hematopoietic system as well as
• Breast cancer tests and procedures. For related
• Fasting tests, refer to the hematopoietic
system table.
• Hemochromatosis ➤ Obtain a list of the medications
• Hemolytic anemia the patient is taking, including
• Hemosiderosis nutraceuticals. The requesting health
Fetal Fibronectin 503
care practitioner and laboratory and collect the specimen in a 5-mL

should be advised if the patient red- or tiger-top tube.
regularly uses these products so ➤ Label the specimen, and promptly
that their effects can be taken into transport it to the laboratory.
results. Post-test:
interfere with test results. ➤ Observe venipuncture site for bleed-
direction. ➤ Nutritional therapy may be indicated
for patients with decreased ferritin
➤ Review the procedure with the values because this may indicate
patient. corresponding iron deficiency.
➤ Inform the patient that specimen Instruct these patients in the dietary
collection takes approximately 5 to inclusion of iron-rich foods and in
10 minutes. the administration of iron supple-
ments, including side effects, as
Intratest: appropriate.
movement. tests include bone marrow biopsy,
➤ Observe standard precautions and complete blood count, erythropoi-
follow the general guidelines in etin, iron/total iron-binding capacity,
Appendix A. Perform a venipuncture, and liver biopsy.
FETAL FIBRONECTIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: fFN.
SPECIMEN: Swab of vaginal secretions.
DESCRIPTION: Fibronectin is a of gestation; if it is detected in vaginal

protein found in the vaginal secretions secretions at this gestational age, deliv-
of pregnant women. It is first secreted ery may happen prematurely. The test
early in pregnancy and is believed to is a useful marker for impending
help implantation of the fertilized egg membrane rupture within 7 to 14
to the uterus. Fibronectin is not days if the level rises to greater than
detectable again until 22 to 34 weeks 0.05 g/mL. ■
INDICATIONS: Investigate signs of can be taken into consideration

premature labor when reviewing results.
RESULT tion restrictions unless by medical
direction.
Positive in: Premature labor ➤ Review the procedure with the
Negative in: N/A modesty, is important in providing
INTERFERING FACTORS: If signs and 10 minutes.
symptoms persist in light of negative test
Intratest:
results, repeat testing may be necessary.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Position the patient on the gyneco-
logic examination table with the feet
Pretest: up in stirrups. Drape the patient’s
legs to provide privacy and to reduce
➤ Obtain a history of the patient’s chilling.
allergens. Ensure that the patient follow the general guidelines in
knows the symptoms of premature Appendix A. Collect a small amount
labor, which include uterine contrac- of vaginal secretion using a special
tions (with or without pain) lasting swab from a fetal fibronectin kit.
20 seconds or longer or increasing in
frequency, menstrual-like cramping ➤ Label the specimen, and promptly
(intermittent or continuous), pelvic transport it to the laboratory.
pressure, lower back pain that
does not dissipate with a change in Post-test:
position, persistent diarrhea, intes- ➤ Reinforce education on signs and
tinal cramps, changes in vaginal symptoms of labor, as appropriate.
discharge, or a feeling that some- Inform the patient that hospitaliza-
thing is wrong. tion or more frequent prenatal
➤ The health care practitioner should be checks may be ordered. Other thera-
informed if contractions occur more pies may also be administered, such
frequently than 4 times per hour. as antibiotics, corticosteroids, and
➤ Obtain a history of the patient’s intravenous tocolytics. Instruct the
reproductive system as well as patient in the importance of
results of previously performed completing the entire course of
tests and procedures. For related antibiotic therapy, if ordered, even if
tests, refer to the reproductive no symptoms are present.
system table. ➤ Explain the possible causes and
➤ Obtain a list of the medications the increased risks associated with
patient is taking, including herbs, premature labor and delivery.
nutritional supplements, and nutra- ➤ Recognize anxiety related to test
ceuticals. The requesting health care results and provide support. Provide
practitioner and laboratory should be teaching and information regarding
advised if the patient regularly uses the clinical implications of the test
these products so that their effects results, as appropriate.
1-Fetoprotein 505
➤ Evaluate test results in relation to tests include amniotic fluid analysis,

the patient’s symptoms and other chorionic villus biopsy, and lecithin/
tests performed. Related laboratory sphingomyelin ratio.
1-FETOPROTEIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: AFP.
SPECIMEN: Serum (1 mL for tumor marker in men and nonpregnant
women; 3 mL for maternal triple-marker testing), collected in a red- or
tiger-top tube. For maternal triple-marker testing, include human chorionic
gonadotropin and free estriol measurement.
REFERENCE VALUE: (Method: Immunoassay for tumor marker, radioim-

munoassay for maternal triple-marker testing)
Tumor Marker, Men and Women
AFP
Fetus, first-trimester peak 200–400 mg/dL
Cord blood Less than 5 mg/dL
AFP in White Black Hispanic Asian

Maternal AFP AFP AFP AFP
Serum (Median) (Median) (Median) (Median)
Low risk Less than Less than Less than Less than
2 MoM 2 MoM 2 MoM 2 MoM
Gestational
Age (wk)
14 19.9 ng/mL 23.2 ng/mL 18.3 ng/mL 22.4 ng/mL
MoM = multiples of the median.
HCG and Estriol HCG (Second Free Estriol

in Maternal Serum Trimester) (Second Trimester)
Gestational Age (wk) Median Value Median Value
14 41.5 IU/mL 0.5 ng/mL
15 36.0 IU/mL 0.7 ng/mL
16 31.0 IU/mL 0.9 ng/mL
17 27.0 IU/mL 1.1 ng/mL
18 24.0 IU/mL 1.4 ng/mL
19 21.0 IU/mL 1.8 ng/mL
20 18.0 IU/mL 2.3 ng/mL
21 16.0 IU/mL 2.8 ng/mL
22 14.0 IU/mL 3.6 ng/mL
Results vary widely from laboratory to laboratory and method to method.
HCG = human chorionic gonadotropin.
DESCRIPTION: 1-Fetoprotein (AFP) amounts is abnormal in adults. AFP

is a glycoprotein produced in the fetal measurements are used as a tumor
liver, gastrointestinal tract, and yolk marker to assist in the diagnosis of
sac. AFP is the major serum protein cancer. ■
produced for 10 weeks in early fetal
life. (See amniotic fluid analysis INDICATIONS:
monograph for measurement of AFP • Assist in the diagnosis of primary hepa-
levels in amniotic fluid.) After 10 tocellular carcinoma or metastatic
weeks of gestation, levels of fetal AFP lesions involving the liver, as indicated
can be detected in maternal blood, by highly elevated levels (30 to 50
percent of Americans with liver cancer
with peak levels occurring at 16 to 18
do not have elevated AFP levels)
weeks. Elevated maternal levels of
AFP on two tests taken 1 week apart • Investigate suspected hepatitis or
suggest further investigation into fetal cirrhosis, indicated by slightly to
well-being by ultrasound or amnio- moderately elevated levels
centesis. Human chorionic go- • Monitor response to treatment for
nadotropin (HCG), a hormone se- hepatic carcinoma, with successful
creted by the placenta, stimulates treatment indicated by an immediate
secretion of progesterone by the cor- decrease in levels
pus luteum. (The use of HCG as a • Monitor for recurrence of hepatic
triple marker is also discussed in the carcinoma, with elevated levels occur-
monograph titled “Human Chorionic ring 1 to 6 months before the patient
Gonadotropin.”) During intrauterine becomes symptomatic
development, the normal fetus and • Support diagnosis of embryonal go-
placenta produce estriol, a portion of nadal teratoblastoma, hepatoblastoma,
which passes into maternal circula- and testicular or ovarian carcinomas
tion. Decreased estriol levels are an in- • Routine prenatal screening at 13 to 16
dependent indicator of neural tube weeks of pregnancy for fetal neural
defects. The incidence of neural tube tube defects and other disorders, as
defects is about 1 in 1000 births. indicated by elevated levels in maternal
The presence of AFP in excessive serum and amniotic fluid
1-Fetoprotein 507
• Investigate suspected intrauterine fetal Overestimation of gestational age

death, as indicated by elevated levels Pseudopregnancy
Spontaneous abortion
RESULT: Maternal serum AFP test
results report actual values and multiples CRITICAL VALUES: N/A
of the median (MoM) by gestational age
(in weeks). MoM are calculated by divid- INTERFERING FACTORS:
ing the patient’s AFP by the midpoint (or • Drugs that may decrease AFP levels in
median) of values expected for a large pregnant women include acetamino-
population of unaffected women at the phen, acetylsalicylic acid, and
same gestational age in weeks. MoM phenacetin.
should be corrected for maternal weight.
The MoM should also be corrected for • Recent radioactive scans or radiation
maternal insulin requirement (achieved within 1 week before the test can inter-
by dividing MoM by 1.1 for diabetic fere with test results when radioim-
African-American patients and by 0.8 for munoassay is the test method.
diabetic patients of other races) and • Multiple fetuses can cause increased
multiple fetuses (multiply by 2.13 for levels.
twins). Some laboratories also provide
additional statistical information regard- • Gestational age must be between 15
ing Down’s syndrome risk. and 22 weeks for initial and follow-up
testing. The most common cause of an
Increased in: abnormal MoM is inaccurate estima-
• Pregnant women: tion of gestational age (defined as
weeks from the first day of the last
Congenital nephrosis
menstrual period).
Fetal abdominal wall defects
Fetal distress • Maternal AFP levels vary by race.
Fetal neural tube defects (e.g.,
anencephaly, spina bifida,
myelomeningocele) Nursing Implications and
Low birth weight Procedure ● ● ● ● ● ● ● ● ● ● ●
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
menstrual period, estimated date of women is believed to increase the

delivery, and whether the patient risk of neural tube defects. Elevated
has insulin-dependent (type 1) levels of homocysteine are thought
diabetes. to chemically damage the exposed
➤ Obtain a list of the medications neural tissue of the developing
the patient is taking, including fetus. As appropriate, instruct preg-
herbs, nutritional supplements, and nant women to eat foods rich in
nutraceuticals. The requesting health folate, such as liver, salmon, eggs,
care practitioner and laboratory asparagus, green leafy vegetables,
should be advised if the patient is broccoli, sweet potatoes, beans,
regularly using these products so and whole wheat.
that their effects can be taken into ➤ Inform the pregnant patient that an
consideration when reviewing ultrasound may be performed and
results. AFP levels in amniotic fluid may be
➤ Note any recent procedures that can analyzed if maternal blood levels are
interfere with test results. elevated in two samples obtained 1
week apart.
tion restrictions unless by medical ➤ Recognize anxiety related to test
direction. results, and encourage the family to
seek counseling if concerned with
➤ Review the procedure with the pregnancy termination or to seek
patient. genetic counseling if a chromosomal
➤ Inform the patient that specimen abnormality is determined. Provide
collection takes approximately 5 to teaching and information regarding
10 minutes. the clinical implications of the test
➤ Obtain written and informed results, as appropriate. Decisions
consent before specimen collection. regarding elective abortion should
take place in the presence of both
parents. Provide a nonjudgmental,
Intratest: nonthreatening atmosphere for
➤ Direct the patient to breathe discussing the risks and difficulties
normally and to avoid unnecessary of delivering and raising an abnormal
movement. infant, as well as exploring other
options (termination of pregnancy or
➤ Observe standard precautions and adoption). It is also important to
follow the general guidelines in discuss feelings the mother and
Appendix A. Perform a venipuncture, father may experience (e.g., guilt,
and collect the specimen in a 5-mL depression, anger) if fetal abnormali-
red-top tube. ties are detected.
➤ The sample may be collected ➤ In patients with carcinoma, recog-
directly from the cord using a nize anxiety related to test results
syringe and transferred to a red-top and offer support. Provide teaching
tube. and information regarding the clinical
➤ Label the specimen, and promptly implications of the test results, as
transport it to the laboratory. appropriate. Educate the patient
regarding access to counseling serv-
Post-test: ices, as appropriate.
➤ Observe venipuncture site for bleed- the patient’s symptoms and other
ing or hematoma formation. Apply tests performed. Related laboratory
pressure bandage. tests include amniotic fluid analysis,
➤ Hyperhomocysteinemia resulting carcinoembryonic antigen, folic acid,
from folate deficiency in pregnant and homocysteine.
Fibrin Degradation Products 509
FIBRIN DEGRADATION PRODUCTS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Fibrin split products, fibrin breakdown products,

FDP, FSP, FBP.
SPECIMEN: Plasma (1mL) collected in special blue-top tube containing

thrombin and a protease inhibitor.
REFERENCE VALUE: (Method: Latex agglutination)

Less than 10 g/mL Less than 10 mg/dL
DESCRIPTION: This coagulation test trauma, extensive surgery, obstetric

evaluates fibrin split products or complications, and disorders such as
fibrin/fibrinogen degradation prod- liver or renal disease
ucts that interfere with normal
coagulation and formation of the RESULT
hemostatic platelet plug. After a fibrin
Increased in:
clot has formed, the fibrinolytic
• DIC
system prevents excessive clotting.
In the fibrinolytic system, plasmin • Excessive bleeding
digests fibrin. Fibrinogen also can be • Liver disease
degraded if there is a disproportion
• Myocardial infarct
among plasmin, fibrin, and fibrino-
gen. Seven substances labeled A, B, C, • Obstetric complications, such as
D, E, X, and Y result from this degra- preeclampsia, abruptio placentae,
dation, which can indicate abnormal intrauterine fetal death
coagulation. Under normal condi- • Post–cardiothoracic surgery period
tions, the liver and reticuloendothelial
• Pulmonary embolism
system remove fibrin split products
from the circulation. ■ • Renal disease
• Renal transplant rejection
INDICATIONS:
• Assist in the diagnosis of suspected CRITICAL VALUES: Greater than
disseminated intravascular coagulation 40 g/mL.
(DIC)
• Evaluate response to therapy with fibri-
• Traumatic venipunctures and excessive
nolytic drugs
agitation of the sample can alter test
• Monitor the effects on hemostasis of results.
• 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
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:
Nursing Implications and normally and to avoid unnecessary
movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●

➤ Obtain a history of the patient’s and collect the specimen in a special
complaints, including a list of known blue-top tube.
cardiovascular and hematopoietic
systems, any bleeding disorders,
and results of previously performed Post-test:
bleeding time, clotting time, ➤ Observe venipuncture site for bleed-
complete blood count, partial throm- ing or hematoma formation. Apply
boplastin time, platelets, and pressure bandage.
prothrombin time. For related tests, ➤ Tell the patient to report bleeding
refer to the cardiovascular and from skin or mucous membranes.
hematopoietic system tables. ➤ Inform the patient with increased
➤ Obtain a list of medications the levels of fibrin degradation products
patient takes, including anticoagu- of the importance of taking precau-
lant therapy, acetylsalicylic acid, tions against bruising and bleeding,
herbals, and nutraceuticals known including the use of a soft bristle
to affect coagulation. It is recom- toothbrush, use of an electric razor,
mended that use of these products avoidance of constipation, avoidance
be discontinued 14 days before of acetylsalicylic acid and similar
dental or surgical procedures. The products, and avoidance of intra-
requesting health care practitioner muscular injections.
and laboratory should be advised if ➤ Evaluate test results in relation to
the patient regularly uses these the patient’s symptoms and other
products so that their effects can be tests performed. Related laboratory
taken into consideration when tests include D-dimer, fibrinogen,
reviewing results. activated partial thromboplastin
➤ Note any recent procedures that can time, plasminogen, and platelet
interfere with test results. count.
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
Newborn 125–300 mg/dL 1.25–3.00 g/L
Adult 200–400 mg/dL 2.00–4.00 g/L
DESCRIPTION: Fibrinogen (factor I) • Cancer

is synthesized in the liver. In the • Eclampsia
common final pathway of the coagu-
lation sequence, thrombin converts • Hodgkin’s disease
fibrinogen to fibrin, which then • Inflammation
clots blood as it combines with • Multiple myeloma
platelets. In normal, healthy individu-
als, the serum should contain no • Nephrotic syndrome
residual fibrinogen after clotting has • Pregnancy
occurred. ■
• Tissue necrosis
INDICATIONS:
Decreased in:
• Assist in the diagnosis of suspected
disseminated intravascular coagulation • Congenital fibrinogen deficiency
(DIC), as indicated by decreased (rare)
fibrinogen levels • DIC
• Evaluate congenital or acquired dysfi- • Dysfibrinogenemia
brinogenemias
• Monitor hemostasis in disorders associ-
ated with low fibrinogen levels or • Primary fibrinolysis
elevated levels that can predispose
patients to excessive thrombosis CRITICAL VALUE: Less than 100
mg/dL. Signs and symptoms of microvas-
RESULT cular thrombosis include acral cyanosis,
ischemic tissue necrosis, hemorrhagic
Increased in: necrosis, tachypnea, dyspnea, pulmonary
• Acute myocardial infarction emboli, venous distention, abdominal
pain, and oliguria. Possible interventions

include identification and treatment of Nursing Implications and
the underlying cause, support through Procedure ● ● ● ● ● ● ● ● ● ● ●
administration of required blood pro-

ducts (platelets, cryoprecipitate, or fresh Pretest:
frozen plasma), and administration of ➤ Obtain a history of the patient’s
heparin. complaints, including a list of known
allergens.
INTERFERING FACTORS: ➤ Obtain a history of the patient’s
• Drugs that may increase fibrinogen hematopoietic and hepatobiliary
levels include acetylsalicylic acid, systems, as well as results of previ-
norethandrolone, oral contraceptives, ously performed tests and proce-
oxandrolone, and oxymetholone. dures. For related tests, refer to the
hematopoietic and hepatobiliary
• Drugs that may decrease fibrinogen system tables.
levels include anabolic steroids, ➤ Obtain a list of medications the
asparaginase, bezafibrate, danazol, patient is taking, including herbs,
dextran, fenofibrate, fish oils, gemfi- nutritional supplements, and
brozil, lovastatin, pentoxifylline, phos- nutraceuticals. The requesting health
phorus, and ticlopidine. care practitioner and laboratory
• Transfusions of whole blood, plasma, regularly takes these products so
or fractions within 4 weeks of the test that their effects can be taken into
invalidate results.
results.
• Placement of tourniquet for longer ➤ Note any recent procedures that can
than 1 minute can result in venous interfere with test results.
stasis and changes in the concentration ➤ There are no food, fluid, or medica-
of plasma proteins to be measured. tion restrictions unless by medical
Platelet activation may also occur direction.
under these conditions, causing erro- ➤ Review the procedure with the
neous results. patient.
• Vascular injury during phlebotomy can
activate platelets and coagulation 10 minutes.
factors, causing erroneous results.
• Hemolyzed specimens must be rejected Intratest:
because hemolysis is an indication of ➤ Direct the patient to breathe
platelet and coagulation factor activa- normally and to avoid unnecessary
tion. movement.
• Incompletely filled tubes contaminated follow the general guidelines in
with heparin or clotted specimens Appendix A. Perform a venipuncture,
must be rejected. and collect the specimen in a
5-mL blue-top tube. Fill the tube
• Icteric or lipemic specimens interfere completely. Important note: Two
with optical testing methods, produc- different concentrations of sodium
ing erroneous results. citrate preservative are currently
added to blue-top tubes for coagu-
• Traumatic venipuncture and excessive lation studies: 3.2% and 3.8%.
agitation of the sample can alter test The National Committee for Clini-
results. cal Laboratory Standards (NCCLS)
Folate 513
guideline for sodium citrate is 3.2%. Post-test:

Laboratories establish reference
ranges for coagulation testing based ➤ Observe venipuncture site for bleed-
on numerous factors, including ing or hematoma formation. Apply
sodium citrate concentration, test pressure bandage.
equipment, and test reagents. It is ➤ Tell the patient to report bruising,
important to inquire from the labora- petechiae, and bleeding from
tory which concentration it recom- mucous membranes.
mends, because each concentration ➤ Inform the patient with a decreased
will have its own specific reference fibrinogen level of the importance of
range. taking precautions against bruising
➤ When multiple specimens are and bleeding, including the use of a
drawn, the blue-top tube should be soft bristle toothbrush, use of an
collected after sterile (i.e., blood electric razor, avoidance of constipa-
culture) and red-top tubes. When tion, avoidance of acetylsalicylic acid
coagulation testing is the only work and similar products, and avoidance
to be done, an extra red-top tube of intramuscular injections.
should be collected before the blue- ➤ Evaluate test results in relation to
top tube to avoid contaminating the the patient’s symptoms and other
specimen with tissue thromboplas- tests performed. Related laboratory
tin, which can falsely decrease tests include activated partial throm-
values. boplastin time, alanine aminotrans-
➤ Label the specimen, and promptly ferase, albumin, alkaline phos-
transport it to the laboratory. phatase, aspartate aminotrans-
The NCCLS recommendation for ferase, bilirubin, liver biopsy, clot
processed and unprocessed speci- retraction, D-dimer, erythrocyte sedi-
mens stored in unopened tubes is mentation rate, fibrin degradation
that testing should be completed products, -glutamyl transpeptidase,
within 1 to 4 hours of collection. plasminogen, and prothrombin time.
FOLATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Folic acid.

SI Units
Newborn–1 y 5–21 ng/mL 11–48 nmol/L
Adult Greater than 2.5 ng/mL Greater than 5.7 nmol/L
DESCRIPTION: Folate, a water- • Hemolytic anemias

soluble vitamin, is produced by bacte- • Infantile hyperthyroidism
ria in the intestines and stored in
• Liver disease
small amounts in the liver. Dietary
folate is absorbed through the intes- • Malnutrition
tinal mucosa and stored in the liver. • Megaloblastic anemia
Folate is necessary for normal red • Myelofibrosis
blood cell and white blood cell func-
• Neoplasms
tion, DNA replication, and cell divi-
sion. Folate levels are often measured • Pregnancy
in association with serum vitamin • Regional enteritis
B12 determinations. Hyperhomo- • Scurvy
cysteinemia resulting from folate defi-
ciency in pregnant women is believed • Sideroblastic anemias
to increase the risk of neural tube • Sprue
defects. Elevated levels of homocys- • Ulcerative colitis
teine are thought to cause chemical
• Whipple’s disease
damage to the exposed neural tissue
of the developing fetus. ■ CRITICAL VALUES: N/A
• Assist in the diagnosis of megaloblastic • Drugs that may decrease folate levels
anemia resulting from deficient folate include aminopterin, ampicillin,
intake or increased folate requirements, antacids, anticonvulsants, barbiturates,
such as in pregnancy and hemolytic chloramphenicol, chloroguanide,
anemia ethanol, erythromycin, glutethimide,
• Monitor the effects of prolonged lincomycin, metformin, methotrexate,
parenteral nutrition nitrofurans, oral contraceptives, peni-
cillin, pentamidine, phenytoin,
• Monitor response to disorders that pyrimethamine, tetracycline, and
may lead to folate deficiency or triamterene.
decreased absorption and storage
RESULT fere with test results when radioim-
Increased in: munoassay is the test method.
• Vitamin B12 deficiency
• Blind loop syndrome Nursing Implications and
• Distal small bowel disease Procedure ● ● ● ● ● ● ● ● ● ● ●
• Excessive dietary intake of folate or Pretest:

folate supplements
• Pernicious anemia complaints, including a list of known
allergens.
Decreased in:
• Chronic alcoholism gastrointestinal and hematopoietic
• Crohn’s disease systems, as well as results of previ-
• Exfoliative dermatitis dures. For related tests, refer to the
Follicle-Stimulating Hormone 515
gastrointestinal and hematopoietic ➤ Observe standard precautions and

system tables. follow the general guidelines in
➤ Obtain a list of medications the Appendix A. Perform a venipuncture,
patient is taking, including herbs, and collect the specimen in a 5-mL
nutritional supplements, and nutra- red- or tiger-top tube. Protect the
ceuticals. The requesting health care specimen from light.
practitioner and laboratory should be ➤ Label the specimen, and promptly
advised if the patient regularly uses transport it to the laboratory.
Post-test:
➤ Note any recent procedures that can ➤ Observe venipuncture site for bleed-
interfere with test results. ing or hematoma formation. Apply
pressure bandage.
tion restrictions unless by medical ➤ Instruct the folate-deficient patient
direction. (especially pregnant women), as
appropriate, to eat foods rich in
folate, such as liver, salmon, eggs,
patient.
asparagus, green leafy vegetables,
➤ Inform the patient that specimen broccoli, sweet potatoes, beans,
collection takes approximately 5 to and whole wheat.
10 minutes.
Intratest: to the patient’s symptoms and
➤ Direct the patient to breathe laboratory tests include complete
normally and to avoid unnecessary blood count, homocysteine, and
movement. vitamin B12.
FOLLICLE-STIMULATING HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Follitropin, FSH.

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
DESCRIPTION: Follicle-stimulating • Gonadal failure

hormone (FSH) is produced and • Gonadotropin-secreting pituitary
stored in the anterior portion of the tumors
pituitary gland. In women, FSH
• Klinefelter’s syndrome
promotes maturation of the graafian
(germinal) follicle, causing estrogen • Menopause
secretion and allowing the ovum to • Orchitis
mature. In men, FSH partially
controls spermatogenesis, but the • Precocious puberty in children
presence of testosterone is also • Primary hypogonadism
necessary. Gonadotropin-releasing • Reifenstein’s syndrome
hormone secretion is stimulated
by a decrease in estrogen and testos- • Turner’s syndrome
terone levels. Gonadotropin-releasing
Decreased in:
hormone secretion stimulates FSH
secretion. FSH production is inhib-
ited by an increase in estrogen and • Anterior pituitary hypofunction
testosterone levels. FSH production is • Hemochromatosis
pulsatile, episodic, cyclic, and is
subject to diurnal variation. Serial • Hyperprolactinemia
measurement is often required. ■ • Hypothalamic disorders
• Polycystic ovary disease
INDICATIONS:
• Assist in distinguishing between • Pregnancy
primary and secondary (pituitary or
hypothalamic) gonadal failure
• Define menstrual cycle phases as a part CRITICAL VALUES: N/A
of infertility testing
• Evaluate ambiguous sexual differentia- INTERFERING FACTORS:
tion in infants • Drugs that may increase FSH levels
• Evaluate early sexual development in include cimetidine, clomiphene, digi-
girls younger than age 9 or boys talis, gonadotropin-releasing hormone,
younger than age 10 (precocious ketoconazole, levodopa, nafarelin,
puberty associated with elevated levels) naloxone, nilutamide, oxcarbazepine,
and pravastatin.
• Evaluate failure of sexual maturation in
adolescence • Drugs that may decrease FSH levels
include anabolic steroids, anticon-
• Evaluate testicular dysfunction vulsants, buserelin, estrogens, corti-
• Investigate impotence, gynecomastia, cotropin-releasing hormone, goserelin,
and menstrual disturbances megestrol, mestranol, oral contra-
ceptives, phenothiazine, pimozide,
RESULT pravastatin, progesterone, stanozolol,
tamoxifen, toremifene, and valproic
Increased in: acid.
• Alcoholism • In menstruating women, values vary in
• Castration relation to the phase of the menstrual
Fructosamine 517
cycle. Values are higher in post- Intratest:

menopausal women.
movement.
endocrine and reproductive sys- Post-test:
tems, as well as phase of menstrual ➤ Observe venipuncture site for bleed-
cycle and results of previously ing or hematoma formation. Apply
performed tests and procedures. For pressure bandage.
related tests, refer to the endocrine
and reproductive system tables. ➤ Inform the patient that multiple
specimens may be required.
patient is taking, including herbs, ➤ Recognize anxiety related to test
nutritional supplements, and nutra- results. Provide teaching and
ceuticals. The requesting health care information regarding the clinical
practitioner and laboratory should be implications of the test results, as
advised if the patient regularly uses appropriate. Provide a supportive,
these products so that their effects nonjudgmental environment when
can be taken into consideration assisting a patient through the
when reviewing results. process of fertility testing. Educate
the patient and partner regarding
➤ There are no food, fluid, or medica- access to counseling services, as
tion restrictions unless by medical appropriate.
direction.
➤ Review the procedure with the the patient’s symptoms and other
patient. tests performed. Related laboratory
➤ Inform the patient that specimen tests include estradiol, luteinizing
collection takes approximately 5 to hormone, prolactin, and testos-
10 minutes. terone.
FRUCTOSAMINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Glycated albumin.

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
DESCRIPTION: Fructosamine is the Nursing Implications and

result of a covalent linkage between Procedure ● ● ● ● ● ● ● ● ● ● ●
glucose and albumin or other

proteins. Similar to glycated hemo- Pretest:
globin, fructosamine can be used to ➤ Obtain a history of the patient’s
monitor long-term control of glucose complaints, especially related to
in diabetics. It has a shorter half-life diabetic control. Obtain a list of
than glycated hemoglobin and is known allergens.
thought to be more sensitive to short- ➤ Obtain a history of the patient’s
term fluctuations in glucose concen- endocrine and gastrointestinal
trations. Some glycated hemoglobin ously performed tests and proce-
methods are affected by hemoglobin dures. For related tests, refer to the
variants. Fructosamine is not subject endocrine and gastrointestinal
to this interference. ■ system tables.
INDICATIONS: Evaluate diabetic control nutritional supplements, and nutra-
RESULT practitioner and laboratory should
be advised if the patient regularly
uses these products so that their
Increased in: Diabetic patients with effects can be taken into considera-
poor glucose control tion when reviewing results.
Decreased in: Severe hypoproteine- tion restrictions unless by medical
mia direction.
patient.
INTERFERING FACTORS: 10 minutes.
• Drugs that may increase fructosamine
levels include bendroflumethiazide Intratest:
and captopril. ➤ Direct the patient to breathe
• Drugs that may decrease fructosamine normally and to avoid unnecessary
levels include ascorbic acid, pyridox- movement.
ine, and terazosin. ➤ Observe standard precautions and
• Decreased albumin levels may result Appendix A. Perform a venipunc-
in falsely decreased fructosamine ture, collect the specimen in a 5-mL
levels. red- or tiger-top tube.
Gallium Scan 519
➤ Label the specimen, and promptly diabetic patient must be determined

transport it to the laboratory. individually with the appropriate
health care professionals, particu-
larly professionals trained in nutri-
Post-test: tion.
➤ Observe venipuncture site for bleed- ➤ Instruct the patient and caregiver
ing or hematoma formation. Apply to report signs and symptoms of
pressure bandage. hypoglycemia (weakness, confu-
➤ Abnormal fructosamine levels may sion, diaphoresis, rapid pulse) or
be associated with conditions result- hyperglycemia (thirst, polyuria,
ing from poor glucose control. hunger, lethargy). Emphasize, as
Instruct the diabetic patient, as appropriate, that good control of
appropriate, in nutritional manage- glucose levels delays the onset
ment of the disease. Patients who and slows the progression of
adhere to dietary recommendations diabetic retinopathy, nephropathy,
report a better general feeling of and neuropathy.
health, better weight management, ➤ Evaluate test results in relation to
greater control of glucose and lipid the patient’s symptoms and other
values, and improved use of insulin. tests performed. Related laboratory
There is no “diabetic diet”; however, tests include C-peptide, cortisol,
many meal-planning approaches glucose, glycated hemoglobin A1C,
with nutritional goals are endorsed glucose tolerance test, insulin,
by the American Dietetic Asso- insulin antibodies, ketones, and
ciation. The nutritional needs of each microalbumin.
GALLIUM SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gallium scan, tumor; gallium scan, abscess;

gallium scan, fever of undetermined origin.
AREA OF APPLICATION: Whole body.

CONTRAST: Intravenous radioactive gallium-67 citrate.
DESCRIPTION: Gallium imaging is a Gallium imaging is sensitive in

nuclear medicine study that assists in detecting abscesses, pneumonia,
diagnosing neoplasm and inflamma- pyelonephritis, active sarcoidosis, and
tion activity. Gallium, which has active tuberculosis. In immunocom-
90 percent sensitivity for inflamma- promised patients, such as patients
tory disease, is readily distributed with acquired immunodeficiency
throughout plasma and body tissues. syndrome (AIDS), gallium imaging
can detect complications such as CRITICAL VALUES: N/A

Pneumocystis carinii pneumonitis.
Gallium imaging is useful but less INTERFERING FACTORS:
commonly performed in the diagno-
sis and staging of some neoplasms, This procedure is contraindicated
including Hodgkin’s disease, lym- for:
phoma, melanoma, and leukemia. • Patients who are pregnant or suspec-
Imaging can be performed 6 to ted of being pregnant, unless the
potential benefits of the procedure far
72 hours after gallium injection. A
outweigh the risks to the fetus and
gamma camera detects the radiation mother
emitted from the injected radioactive
material, and a representative image Factors that may impair clear
of the distribution of the radioactive imaging:
material is obtained. The nonspeci- • Inability of the patient to cooperate
ficity of gallium imaging requires or remain still during the procedure
correlation with other diagnostic because of age, significant pain, or
studies, such as computed tomogra- mental status
phy, magnetic resonance imaging, • Improper adjustment of the radi-
and ultrasonography. ■ ographic equipment to accommodate
INDICATIONS: overexposure or underexposure and a
• Aid in the diagnosis of infectious or poor-quality study
inflammatory diseases • Metallic objects within the examina-
• Evaluate lymphomas tion field (e.g., jewelry or body rings),
• Evaluate recurrent lymphomas or and can produce unclear images
tumors after radiation therapy or
chemotherapy • Patients who are very obese, who may
• Perform as a screening examination for ment
fever of undetermined origin
RESULT which may produce poor visualization
Normal Findings: • Performance of other nuclear scans
• Normal distribution of gallium. Some within the preceding 24 to 48 hours
localization of the radionuclide within
• Administration of certain medications
the liver, spleen, bone, nasopharynx,
(e.g., gastrin, cholecystokinin), which
lacrimal glands, breast, and bowel is
may interfere with gastric emptying
expected.
Abnormal Findings:
• Abscess
• Infection procedure to be canceled or repeated.
• Inflammation • Consultation with a physician should
• Lymphoma
• Tumor of patients who are lactating.
Gallium Scan 521
sure jewelry, watches, chains, belts,

Nursing Implications and and any other metallic objects have
Procedure ● ● ● ● ● ● ● ● ● ● ● been removed.
➤ The radionuclide is administered
Pretest: intravenously. Delayed views may be
➤ Inform the patient that the test taken at 6, 24, 48, and 72 hours after
detects inflammation, infection, or the injection.
tumor. ➤ If an abdominal abscess or infection
➤ Inform the patient that the proce- is suspected, laxatives or enemas
dure is performed in a special may be ordered before delayed
nuclear medicine department by a imaging at 48 or 72 hours after the
technologist and usually takes injection.
approximately 60 to 90 minutes. ➤ Wear gloves during the radionuclide
Delayed images need 72 hours after administration and while handling
the initial injection. The patient may the patient’s urine.
leave the department and return
later for the imaging procedure. Post-test:
➤ Obtain a list of known allergens.
➤ Obtain a medical history of the normal activity, medications, and
patient’s complaints as well as diet after imaging is complete,
results of previously performed unless otherwise indicated.
tests, treatments, and surgical
procedures. For related tests, refer ➤ Advise the patient to drink increased
to the immunologic, respiratory, and amounts of fluids for several days to
gastrointestinal system tables. eliminate the radionuclide from the
body, unless contraindicated. Tell
➤ Obtain a list of medications the the patient the radionuclide is elimi-
patient is taking. nated from the body within 48 to 72
➤ Determine date of last menstrual hours.
period and possibility of pregnancy ➤ Inform the patient to flush the toilet
in perimenopausal women. immediately after each voiding
➤ Inform the patient that the technolo- following the procedure and to wash
gist will inject gallium in an arm vein hands meticulously with soap and
and ask the patient to return later for water after each voiding for 72 hours
the imaging procedure, at which after the procedure.
time the patient will be placed in a ➤ Tell all caregivers to wear gloves
supine position on a flat table. when discarding urine for 48 hours
➤ Fasting before the scan is not after the procedure. Wash gloved
required, unless indicated. hands with soap and water before
➤ Inform the patient that gallium is removing gloves. Then wash
excreted by the kidneys and colon in ungloved hands after removing the
48 to 72 hours. gloves.
➤ A physician specializing in this branch
Intratest: of medicine sends a written report to
the ordering provider, who discusses
➤ Ask the patient to void before the the results with the patient.
procedure. Have the patient put on a
hospital gown. ➤ Evaluate test results in relation to
➤ Administer sedative to a child or to tests performed. Related diagnostic
an uncooperative adult, as ordered. tests are listed by the specific body
➤ Ask the patient to lie still during area in the computed tomography
the procedure because movement and magnetic resonance imaging
produces unclear images. Make monographs.
GASTRIC ACID STIMULATION TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Gastric fluid collected in eight plastic tubes at 15-minute
intervals.
REFERENCE VALUE: (Method: Volume measurement and pH by ion-

selective electrode)
Basal acid output (BAO) Male: 0–10.5 mmol/h

Female: 0–5.6 mmol/h
Peak acid output (PAO) Male: 12–60 mmol/h
Female: 8–40 mmol/h
Peak response time Pentagastrin, intramuscular: 15–45 min
Pentagastrin, subcutaneous: 10–30 min
BAO/PAO ratio Less than 0.20
DESCRIPTION: The gastric acid stim- INDICATIONS:

ulation test is performed to determine • Detect duodenal ulcer
the response to substances adminis- • Detect gastric carcinoma
tered to induce increased gastric acid
production. Pentagastrin is the usual • Detect pernicious anemia
drug of choice to induce gastric secre- • Detect Zollinger-Ellison syndrome
tion because it has no major side • Evaluate effectiveness of vagotomy in
effects. The samples obtained from the treatment of peptic ulcer disease
gastric acid stimulation tests are
examined for volume, pH, and RESULT
amount of acid secreted. First, basal
acid output (BAO) is determined by Increased:
averaging the results of gastric • BAO
samples collected before the adminis- Basophilic leukemia
tration of a gastric stimulant. Then a Duodenal ulcer
gastric stimulant is administered and G-cell hyperplasia
peak acid output (PAO) is deter-
Recurring peptic ulcer
mined by adding together the gastric
Retained antrum syndrome
acid output of the highest two
Systemic mastocytosis
consecutive 15-minute stimulation
Vagal hyperfunction
samples. Finally, BAO and PAO are
Zollinger-Ellison syndrome
compared as a ratio, which is
normally less than 0.20. ■ • PAO
Gastric Acid Stimulation Test 523
Duodenal ulcer thought of food immediately before

Zollinger-Ellison syndrome and during the test may result in stim-
ulation of gastric secretions.
Decreased:
• BAO
Gastric ulcer Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• 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
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
• 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
• Exposure to the sight, smell, or medications prior to the procedure.
➤ 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.
movement. Post-test:
➤ Record baseline vital signs.
➤ 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.
GASTRIC EMPTYING SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gastric emptying quantitation, gastric emptying

scintigraphy.
AREA OF APPLICATION: Esophagus, stomach, small bowel.

CONTRAST: Radioactive technetium-99m sulfur colloid.
Gastric Emptying Scan 525
DESCRIPTION: A gastric emptying Gastric outlet obstruction

scan quantifies gastric emptying Hypokalemia, hypomagnesemia
physiology. The procedure is indi- Post–gastric surgery period
cated for patients with gastric motility Postoperative ileus
symptoms, including diabetic gastro- Post–radiation therapy period
paresis, anorexia nervosa, gastric Scleroderma
outlet obstruction syndromes, post-
vagotomy and postgastrectomy syn- CRITICAL VALUES: N/A
dromes, and assessment of medical
and surgical treatments for diseases INTERFERING FACTORS:
known to affect gastric motility. A
radionuclide is administered, and the for:
clearance of solids and liquids may be • Patients who are pregnant or suspected
evaluated. The images are recorded of being pregnant, unless the potential
electronically, showing the gastric benefits of the procedure far outweigh
emptying function over time. ■ the risks to the fetus and mother
• Patients with esophageal motor disor-
INDICATIONS: ders or swallowing difficulties
• Measure gastric emptying rate
• Investigate the cause of rapid or slow Factors that may impair clear
rate of gastric emptying imaging:
RESULT remain still during the procedure
Normal Findings: mental status
• No delay in gastric emptying rate
• Mean time emptying of liquid graphic equipment to accommodate
phase: 30 minutes (range, 11 to 49 obese or thin patients, which can cause
minutes) a poor-quality study
• Mean time emptying of solid phase: 40 • Metallic objects within the examina-
minutes (range, 28 to 80 minutes) tion field (e.g., jewelry or body rings),
Abnormal Findings: and can produce unclear images
• Decreased rate:
Dumping syndrome exceed the weight limit for the equip-
Duodenal ulcer ment
Malabsorption syndromes
Zollinger-Ellison syndrome which may produce poor visualization
• Increased rate: of the area to be examined
Amyloidosis • Performance of other nuclear scans
Anorexia nervosa within the preceding 24 to 48 hours
Diabetes
• Administration of certain medica-
Gastric ulcer tions (e.g., gastrin, cholecystokinin),
Gastroenteritis which may interfere with gastric
Gastroesophageal reflux emptying
Other considerations: Intratest:

• Failure to follow dietary restrictions ➤ Ask the patient to void before the
before the procedure may cause the procedure. Have the patient put on a
procedure to be canceled or repeated. hospital gown.
• Consultation with a physician should ➤ Administer sedative to a child or
occur before the procedure for radia- to an uncooperative adult, as
tion safety concerns regarding infants ordered.
of patients who are lactating. ➤ Ask the patient to lie still during
produces unclear images. Make
Nursing Implications and and any other metallic objects have
Procedure ● ● ● ● ● ● ● ● ● ● ● been removed.
➤ Place the patient in an upright posi-
Pretest: tion in front of the gamma camera.
➤ Inform the patient that the proce- ➤ Ask the patient to take the radionu-
dure assesses gastric emptying. clide orally, combined with eggs or
as a liquid.
dure is performed in a nuclear medi- ➤ Images are recorded and evaluated
cine department by a technologist with regard to the amount of time it
and usually takes 30 to 120 minutes takes the stomach to empty.
to complete. ➤ Wear gloves during the radionuclide
➤ Obtain a history of the patient’s administration and while handling
complaints, including a list of known the patient’s urine.
allergens.
➤ Obtain a history of signs and symp- Post-test:
toms of gastrointestinal disorders as
well as results of previously ➤ Evaluate the patient’s vital signs.
performed tests, treatments, and ➤ Instruct the patient to resume
surgical procedures. For related normal activity, medications, and
tests, refer to the gastrointestinal diet, unless otherwise indicated.
system table. ➤ Advise the patient to drink increased
➤ Obtain a list of medications the amounts of fluids for 24 to 48 hours
patient is taking. to eliminate the radionuclide from
➤ Determine date of last menstrual the body, unless contraindicated. Tell
period and possibility of pregnancy the patient that radionuclide is elimi-
in perimenopausal women. nated from the body within 6 to 24
hours.
➤ Assure the patient that the proce-
dure is painless and easily tolerated. ➤ Inform the patient to flush the toilet
immediately after each voiding
➤ Inform the patient that the technolo- following the procedure and to wash
gist will place him or her in an hands meticulously with soap and
upright position in front of the water after each voiding for 24 hours
gamma camera (scanner). after the procedure.
➤ Reassure the patient that the ➤ Tell all caregivers to wear gloves
radionuclide poses no radioactive when discarding urine for 24 hours
hazard and rarely produces side after the procedure. Wash gloved
effects. hands with soap and water before
➤ Restrict food and fluids for 6 to 8 removing gloves. Then wash hands
hours before the scan. after removing the gloves.
➤ Obtain and record baseline vital ➤ A physician specializing in this
signs. branch of medicine sends a written
Gastrin and Gastrin Stimulation Test 527
report of it to the ordering provider, the patient’s symptoms and other

who discusses the results with the tests performed. A related diagnos-
patient. tic test is the upper gastrointestinal
➤ Evaluate test results in relation to and small bowel series.
GASTRIN AND GASTRIN

STIMULATION TEST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Gastrin Level
SI Units
Infant 120–183 pg/mL 120–183 ng/L
Child Less than 10–125 Less than 10–125 ng/L
pg/mL
Adult
Up to 60 y 25–90 pg/mL 25–90 ng/L
60 y and older Less than 100 pg/mL Less than 100 ng/L
Stimulation Tests
Gastrin stimulation test No response or slight
with calcium or increase over
secretin baseline
DESCRIPTION: Gastrin is a hormone and intrinsic factor secretion. Gastrin

secreted by the stomach and duode- stimulation tests can be performed
num in response to vagal stimulation; after a test meal or intravenous infu-
the presence of food, alcohol, or sion of calcium or secretin. ■
calcium in the stomach; and the alka-
linity of gastric secretions. After its INDICATIONS:
absorption into the circulation, • Assist in the diagnosis of gastric carci-
gastrin returns to the stomach and acts noma, pernicious anemia, or G-cell
as a stimulant for acid, insulin, pepsin, hyperplasia
• Assist in the diagnosis of Zollinger-

Ellison syndrome Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Assist in the differential diagnosis

of ulcers from other gastrointestinal Pretest:
peptic disorders
RESULT allergens.
Increased in: endocrine and gastrointestinal
• Chronic gastritis systems, as well as results of previ-
• Chronic renal failure dures. For related tests, refer to the
• G-cell hyperplasia endocrine and gastrointestinal
system tables.
• Gastric carcinoma ➤ Obtain a list of medications the
• Gastric and duodenal ulcers patient is taking, including herbs,
• Hyperparathyroidism nutraceuticals. The requesting health
• Pernicious anemia should be advised if the patient
• Pyloric obstruction regularly uses these products so
• Retained antrum consideration when reviewing
results.
• Zollinger-Ellison syndrome
Decreased in:
• Hypothyroidism ➤ Instruct the patient to fast for 12
hours before the test.
• Vagotomy ➤ Withhold medications and alcohol
for 12 to 24 hours, as ordered by the
CRITICAL VALUES: N/A health care practitioner.
INTERFERING FACTORS: by medical direction.
• Drugs and substances that may ➤ Review the procedure with the
increase gastrin levels include amino patient.
acids, cimetidine, catecholamines, ➤ Inform the patient that specimen
insulin, morphine, omeprazole, panto- collection takes approximately 5 to
prazole, sufotidine, terbutaline, 10 minutes.
calcium products, and coffee.
Intratest:
• Drugs that may decrease gastrin levels
include atropine, enprostil, glucagon, with dietary preparations and other
secretin, streptozocin, and tolbu- pretesting restrictions.
tamide.
• In some cases, protein ingestion normally and to avoid unnecessary
elevates serum gastrin levels. movement.
• Recent radioactive scans or radiation follow the general guidelines in
within 1 week before the test can inter- Appendix A. Perform a venipuncture,
fere with test results when radioim- and collect the specimen in a 5-mL
munoassay is the test method. red- or tiger-top tube.
Gastroesophageal Reflux Scan 529
➤ Administer gastrin stimulators as diet and medication as directed by

appropriate. the health care practitioner. Nutri-
➤ Label the specimen, and promptly tional support with calcium, iron, and
transport it to the laboratory. vitamin B12 supplementation may be
ordered, as appropriate.
➤ Observe venipuncture site for bleed- tests performed. Related labora-
ing or hematoma formation. Apply tory tests include complete blood
pressure bandage. count, gastric acid stimulation, and
➤ Instruct the patient to resume usual Helicobacter pylori.
GASTROESOPHAGEAL REFLUX SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Aspiration scan, GE reflux scan.

AREA OF APPLICATION: Esophagus and stomach.
CONTRAST: Radioactive technetium-99m sulfur colloid.
DESCRIPTION: The gastroesophageal tion determines the amount of reflux

(GE) reflux scan assesses gastric reflux into the esophagus at each of these
across the esophageal sphincter. abdominal pressures as recorded on
Symptoms of GE reflux include the images. For aspiration scans,
heartburn, regurgitation, vomiting, images are taken over the lungs to
dysphagia, and a bitter taste in the detect tracheoesophageal aspiration
mouth. This procedure may be used of the radionuclide.
to evaluate the medical or surgical In infants, the study distinguishes
treatment of patients with GE reflux between vomiting and reflux. Reflux
and to detect aspiration of gastric occurs predominantly in infants
contents into the lungs. A radionu- younger than age 2, who are mainly
clide such as technetium-99m sulfur on a milk diet. This procedure is in-
colloid is ingested orally in orange dicated when an infant has symptoms
juice. Scanning studies are done im- such as failure to thrive, feeding
mediately to assess the amount of problems, and episodes of wheezing
liquid that has reached the stomach. with chest infection. The radionu-
An abdominal binder is applied and clide is added to the infant’s milk, im-
then tightened gradually to obtain ages are obtained of the gastric
images at increasing degrees of ab- and esophageal area, and the images
dominal pressure: 0, 20, 40, 60, 80, are evaluated visually and by com-
and 100 mm Hg. Computer calcula- puter. ■
INDICATIONS: • Incorrect positioning of the patient,

• Aid in the diagnosis of GE reflux in which may produce poor visualization
patients with unexplained nausea and of the area to be examined
vomiting • Other nuclear scans done within the
• Distinguish between vomiting and previous 24 to 48 hours
reflux in infants with failure to thrive,
feeding problems, and wheezing
combined with chest infection
RESULT
Normal Findings: Other considerations:
• Reflux less than or equal to 4 percent • Failure to follow dietary restrictions
across the esophageal sphincter before the procedure may cause the
Abnormal Findings: • Consultation with a physician should
• Reflux of greater than 4 percent at any occur before the procedure for radia-
pressure level tion safety concerns regarding infants
• Pulmonary aspiration of patients who are lactating.

INTERFERING FACTORS: Procedure ● ● ● ● ● ● ● ● ● ● ●
This procedure is contraindicated Pretest:

for:
• Patients who are pregnant or suspected ➤ Inform the patient that the proce-
of being pregnant, unless the potential dure evaluates gastric reflux.
benefits of the procedure far outweigh ➤ Inform the patient that the proce-
the risks to the fetus and mother dure is performed in a nuclear medi-
cine department by a technologist
• Patients with hiatal hernia, esophageal and usually takes approximately 60
motor disorders, or swallowing diffi- minutes to complete.
culties ➤ Obtain a history of the patient’s
Factors that may impair clear allergens.
imaging:
➤ Obtain a history of signs and symp-
• Inability of the patient to cooperate or toms of gastrointestinal disorders
remain still during the procedure as well as results of previously
because of age, significant pain, or performed tests, treatments, and
mental status surgical procedures. For related
tests, refer to the gastrointestinal
• Improper adjustment of the radio- system table.
graphic equipment to accommodate ➤ Obtain a list of medications the
obese or thin patients, which can cause patient is taking.
poor-quality study
• Patients who are very obese, who may in perimenopausal women.
exceed the weight limit for the equip- ➤ Reassure the patient that the
ment radionuclide poses no radioactive
Gastrointestinal Blood Loss Scan 531
hazard and rarely produces side administration and while handling

effects. the patient’s urine.
➤ Fasting before the scan is not
required; the patient may be encour- Post-test:
aged to eat a full meal before the
procedure. ➤ Evaluate the patient’s vital signs.
➤ Obtain and record baseline vital ➤ Instruct the patient to resume
signs. normal activity, medications, and
diet, unless otherwise indicated.
Intratest: ➤ Advise the patient to drink increased
➤ Ask the patient to void before the amounts of fluids for 24 to 48 hours
procedure. Have the patient put on a to eliminate the radionuclide from
hospital gown. the body, unless contraindicated. Tell
the patient that radionuclide is elimi-
➤ Administer sedative to a child or to nated from the body within 6 to 24
an uncooperative adult, as ordered. hours.
➤ Ask the patient to lie still during
➤ Inform the patient to flush the
toilet immediately after each voiding
following the procedure and to wash
hands meticulously with soap and
and any other metallic objects have
water after each voiding for 24 hours
been removed.
➤ Ask the patient to drink approxi-
mately 300 mL of orange juice that
when discarding urine for 24 hours
contains the radionuclide.
after the procedure. Wash gloved
➤ Place the patient in a supine position hands with soap and water before
on a flat table with foam wedges to removing gloves. Then wash hands
help maintain position and immobi- after the gloves are removed.
lization. An image is recorded to
confirm swallowing of the liquid and ➤ A physician specializing in this
emptying into the stomach. branch of medicine sends a written
➤ The abdominal binder is applied, and discusses the results with the
scans are taken as the binder is patient.
tightened at various pressures, as
described previously. ➤ Evaluate test results in relation to
➤ If reflux occurs at lower pressures, tests performed. Related diagnostic
an additional 30 mL of water may be tests include upper gastrointestinal
given to clear the esophagus. series and gastric emptying exami-
➤ Wear gloves during the radionuclide nations.
GASTROINTESTINAL BLOOD LOSS SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gastrointestinal bleed localization study, GI bleed

scintigraphy, lower GI blood loss scan, GI scintigram.

CONTRAST: Intravenous radioactive technetium-99m–labeled red
blood cells.
DESCRIPTION: Gastrointestinal (GI) • Inflammatory bowel disease

blood loss scan is a nuclear medicine • Polyps
study that assists in detecting and
localizing active GI tract bleeding (2 • GI bleeding
or 3 mL/min) for the purpose of • Tumor
better directing endoscopic or angio- • Ulcer
graphic studies. This procedure can
detect bleeding if the rate is greater CRITICAL VALUES: N/A
than 0.5 mL/min, but it is not
specific for site localization or cause INTERFERING FACTORS:
of bleeding. Endoscopy is the proce-
dure of choice for diagnosing upper
for:
GI bleeding. After injection of
technetium-99m–labeled red blood of being pregnant, unless the poten-
cells, immediate and delayed images tial benefits of the procedure far
of various views of the abdomen are outweigh the risks to the fetus and
obtained. The radionuclide remains mother
in the circulation long enough to
extravasate and accumulate within the Factors that may impair clear
bowel lumen at the site of active imaging:
bleeding. This procedure is valuable • Inability of the patient to cooperate or
for the detection and localization remain still during the procedure
of recent non-GI intra-abdominal
mental status
hemorrhage. Images may be taken
over an extended period to show • Retained barium from a previous radi-
intermittent bleeding. ■ ologic procedure
INDICATIONS: Diagnose unexplained tion field (e.g., jewelry or body rings),
abdominal pain and GI bleeding which may inhibit organ visualization
RESULT • Improper adjustment of the radio-
Normal Findings: obese or thin patients, which can cause
• Normal distribution of radionuclide in overexposure or underexposure and a
the large vessels with no extravascular poor-quality study
activity
Abnormal Findings:
ment
• Angiodysplasia
• Aortoduodenal fistula which may produce poor visualization
• Diverticulosis of the area to be examined
Gastrointestinal Blood Loss Scan 533
• Other nuclear scans done within the

previous 24 to 48 hours Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Inaccurate timing of imaging after the

radionuclide injection Pretest:
Other considerations: dure evaluates GI bleeding.
• The examination detects only active or ➤ Inform the patient that the proce-
intermittent bleeding. dure is performed in a special
• The procedure is of little value in nuclear medicine department by a
patients with chronic anemia or slowly technologist and usually takes
approximately 60 minutes to
decreasing hematocrit. complete, with additional images
• The scan is less accurate for localiza- taken periodically over 24 hours.
tion of bleeding sites in the upper GI ➤ Obtain a history of the patient’s
tract. complaints, including a list of known
allergens.
allows the tracer to seep deep into the toms of GI bleeding, pain, intussus-
muscle tissue, producing erroneous hot ception, volvulus, or diverticulitis as
spots. well as results of previously
• The test is not specific and does not performed tests, treatments, and
surgical procedures. For related
indicate the exact pathologic condition tests, refer to the GI and cardiovas-
causing the bleeding and may miss cular system tables.
small sites of bleeding (less than 0.5
mL/min) caused by diverticular disease patient is taking.
or angiodysplasia.
• Physiologically unstable patients may period and possibility of pregnancy
be unable to be scanned over long peri- in perimenopausal women.
ods or may need to go to surgery before ➤ Fasting before the scan is not
the procedure is complete. needed, unless otherwise indicated.
• Failure to follow dietary restrictions ➤ Obtain and record baseline vital signs.
procedure to be canceled or repeated. Intratest:
• Consultation with a physician should ➤ Ask the patient to void before the
occur before the procedure for radia- procedure. Have the patient put on a
tion safety concerns regarding infants hospital gown.
of patients who are lactating. ➤ Administer sedative to a child or to
• Risks associated with radiographic ➤ Ask the patient to lie still during the
overexposure can result from frequent procedure because movement
x-ray procedures. Personnel in the produces unclear images. Make
room with the patient should wear a sure jewelry, watches, chains, belts,
protective lead apron, stand behind a and any other metallic objects have
shield, or leave the area while the been removed.
examination is being done. Personnel ➤ Inform the technologist doing the
working in the area where the exami- procedure to notify the nurse of all
nation is being done should wear bloody bowel movements that occur
badges that reveal their level of expo- during the procedure.
sure to radiation. ➤ Place the patient in a supine position
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
lesions that cause bleeding. Images
are taken every 5 minutes for the
next 60 minutes in the anterior,
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
Post-test: report to the ordering provider, who
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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
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
Glucagon 535
DESCRIPTION: Glucagon is a hor- renal failure or renal transplant rejec-

mone secreted by the alpha cells of tion
the islets of Langerhans in the pan-
creas in response to hypoglycemia. RESULT
This hormone acts primarily on
Increased in:
the liver to promote glucose produc-
tion and to control glucose storage. • Acromegaly
The coordinated release of insulin, • Acute pancreatitis
glucagon, and somatostatin ensures • Burns
an adequate fuel supply while main-
taining stable blood glucose. Patients • Cirrhosis
with glucagonoma have values greater • Cushing’s syndrome
than 500 ng/L. Values greater than
• Diabetes (uncontrolled)
1000 ng/L are diagnostic for this con-
dition. Glucagonoma causes three dif- • Glucagonoma
ferent syndromes: • Hyperlipoproteinemia types III
1. Syndrome 1: A characteristic skin and IV
rash, diabetes or impaired glucose
tolerance, weight loss, anemia, and • Hypoglycemia
venous thrombosis • Infections
2. Syndrome 2: Severe diabetes
3. Syndrome 3: Multiple endocrine • Kidney transplant rejection
neoplasia • Renal failure
A dramatic increase in glucagon • Stress
occurring soon after renal transplant
• Trauma
may indicate organ rejection. In the
case of kidney transplant rejection, Decreased in:
glucagon levels increase several days
• Chronic pancreatitis
before an increase in creatinine levels.
Glucagon deficiency can be con- • Cystic fibrosis
firmed by measuring glucagon levels • Postpancreatectomy period
before and after intravenous infusion
of 0.5 g arginine/kg. Glucagon defi- CRITICAL VALUES: N/A
ciency is confirmed when levels fail to
rise 30 to 60 minutes after infusion. INTERFERING FACTORS:
Newborn infants of diabetic mothers • Drugs that may increase glucagon
have impaired glucagon secretion, levels include amino acids (e.g.,
which may play a role in their hypo- arginine), cholecystokinin, danazol,
glycemia. ■ gastrin, glucocorticoids, insulin, and
nifedipine.
INDICATIONS: • Drugs that may decrease glucagon
• Assist in confirming glucagon defi- levels include atenolol, pindolol,
ciency propranolol, secretin, and verapamil.
• Assist in the diagnosis of suspected • Recent radioactive scans or radiation
glucagonoma (alpha islet-cell neoplas- within 1 week before the test can inter-
tic tumor) fere with test results when radioim-
• Assist in the diagnosis of suspected munoassay is the test method.

Nursing Implications and tightly capped sample should be
Procedure ● ● ● ● ● ● ● ● ● ● ● placed in an ice slurry immediately
Pretest:
from water in the ice slurry if the
➤ Obtain a history of the patient’s specimen is first placed in a protec-
complaints, including a list of known tive plastic bag.
allergens.
endocrine system as well as results
pressure bandage.
practitioner.
ceuticals. The requesting health care ➤ Instruct the diabetic patient, as
practitioner and laboratory should be appropriate, in nutritional manage-
advised if the patient regularly uses ment of the disease. Patients who
these products so that their effects adhere to dietary recommendations
can be taken into consideration report a better general feeling of
when reviewing results. health, better weight management,
greater control of glucose and lipid
values, and improved use of insulin.
There is no “diabetic diet”; however,
➤ There are no fluid or medication many meal-planning approaches
restrictions unless by medical direc- with nutritional goals are endorsed
tion. by the American Dietetic Associa-
➤ Instruct the patient to fast at least 12 tion. The nutritional needs of each
hours before specimen collection for diabetic patient must be determined
baseline values. Diabetic patients individually with the appropriate
should be in good glycemic control health care professionals, particu-
before testing. larly professionals trained in nutri-
tion.
patient. ➤ Increased glucagon levels may be
associated with diabetes. Instruct
the patient and caregiver to report
signs and symptoms of hypo-
10 minutes.
glycemia (weakness, confusion,
diaphoresis, rapid pulse) or hyper-
Intratest: glycemia (thirst, polyuria, hunger,
lethargy).
with dietary preparations and other ➤ Emphasize, as appropriate, that
pretesting restrictions. good glycemic control delays the
onset and slows the progression of
➤ Direct the patient to breathe diabetic retinopathy, nephropathy,
normally and to avoid unnecessary and neuropathy.
movement.
Appendix A. Perform a venipuncture, tests include glucose, glucose toler-
and collect the specimen in a chilled ance tests, glycated hemoglobin
5-mL lavender-top tube. A1C, insulin, insulin antibodies, and
➤ Label the specimen, and promptly microalbumin.
Glucose 537
GLUCOSE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Blood sugar, fasting blood sugar (FBS), postpran-

dial glucose, 2-hour PC.

mL) collected in gray-top (sodium fluoride) or green-top (heparin) tube is
also acceptable.
SI Units
Fasting
Cord blood 45–96 mg/dL 2.5–5.3 mmol/L
Premature infant 20–60 mg/dL 1.1–3.3 mmol/L
Neonate 30–60 mg/dL 1.7–3.3 mmol/L
Newborn 1 d 40–60 mg/dL 2.2–3.3 mmol/L
Newborn 2 d 2 y 50–80 mg/dL 2.8–4.4 mmol/L
Child 60–100 mg/dL 3.3–5.6 mmol/L
Adult 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
DESCRIPTION: Glucose, a simple six- evated glucose levels. Hyperglycemia

carbon sugar (monosaccharide), results from a defect in insulin secre-
enters the diet as part of the sugars tion (type 1 diabetes), a defect in in-
sucrose, lactose, and maltose and as sulin action, or a combination of de-
the major constituent of the complex fects in secretion and action (type
polysaccharide called dietary starch. 2 diabetes). The chronic hyper-
The body acquires most of its energy glycemia of diabetes may result over
from the oxidative metabolism of time in damage, dysfunction, and
glucose. Excess glucose is stored in eventually failure of the eyes, kidneys,
the liver or in muscle tissue as glyco- nerves, heart, and blood vessels. The
gen. American Diabetes Association’s
Diabetes is a group of diseases 1998 revised criteria for diagnosing
characterized by hyperglycemia or el- diabetes include any combination of
the following findings or confirma- • Renal disease (severe)

tion of any of the individual findings • Shock, trauma
by repetition on a subsequent day:
• Somatostatinoma
• Symptoms of diabetes (e.g.,
polyuria, polydipsia, unexplained • Strenuous exercise
weight loss) in addition to a • Thyrotoxicosis
random glucose level greater than • Vitamin B1 deficiency
200 mg/dL
• Fasting blood glucose greater than Decreased in:
126 mg/dL, after a minimum of an • Acute alcohol ingestion
8-hour fast
• Glucose level greater than 200
mg/dL 2 hours after glucose chal- • Ectopic insulin production from
lenge with standardized 75-mg tumors (adrenal carcinoma, carcinoma
load ■ of the stomach, fibrosarcoma)
• Excess insulin by injection
INDICATIONS: • Galactosemia
• Assist in the diagnosis of insulinoma • Glucagon deficiency
• Determine insulin requirements • Glycogen storage diseases
• Evaluate disorders of carbohydrate • Hereditary fructose intolerance
metabolism
• Hypopituitarism
• Identify hypoglycemia
• Hypothyroidism
• Screen for diabetes
• Insulinoma
RESULT • Malabsorption syndromes

• Maple syrup urine disease
Increased in:
• Poisoning resulting in severe liver
• Acromegaly, gigantism disease
• Acute stress reaction • Postgastrectomy
• Cerebrovascular accident • Starvation
• Cushing’s syndrome • von Gierke disease
• Diabetes
CRITICAL VALUES:
• Glucagonoma Less than 40 mg/dL
• Hemochromatosis Greater than 400 mg/dL
Symptoms of decreased glucose levels
include headache, confusion, hunger,
• Myocardial infarction irritability, nervousness, restlessness,
sweating, and weakness. Possible inter-
• Pancreatic adenoma
ventions include oral or intravenous (IV)
• Pancreatitis (acute and chronic) administration of glucose, IV or intra-
muscular injection of glucagon, and
• Pancreatitis due to mumps
continuous glucose monitoring.
• Pheochromocytoma Symptoms of elevated glucose levels
Glucose 539
include abdominal pain, fatigue, muscle counts can lead to falsely decreased
cramps, nausea, vomiting, polyuria, and glucose values.
thirst. Possible interventions include
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 ● ● ● ● ● ● ● ● ● ● ●
pancreozymin, phenelzine, phenylbu-

tazone, piperacetazine, polythiazide, Pretest:
prednisone, quinethazone, reserpine, ➤ Obtain a history of the patient’s
rifampin, ritodrine, salbutamol, complaints, including a list of known
secretin, somatostatin, thiazides, allergens.
thyroid hormone, and triamcinolone. ➤ Obtain a history of the patient’s
• Drugs that may decrease glucose levels endocrine system as well as results
include acarbose, acetylsalicylic acid, of previously performed tests and
acipimox, alanine, allopurinol, anti- procedures. For related tests, refer
mony compounds, arsenicals, ascorbic
acid, benzene, buformin, cannabis, ➤ Obtain a list of medications the
captopril, carbutamide, chloroform, patient is taking, including herbs,
nutritional supplements, nutraceuti-
clofibrate, dexfenfluramine, enalapril,
cals, insulin, and any other sub-
enprostil, erythromycin, fenfluramine, stances used to regulate glucose
gemfibrozil, glibornuride, glyburide, levels. The requesting health care
guanethidine, niceritrol, nitrazepam, practitioner and laboratory should be
oral contraceptives, oxandrolone, advised if the patient regularly uses
oxymetholone, phentolamine, phos- these products so that their effects
phorus, promethazine, ramipril, can be taken into consideration
rotenone, sulfonylureas, thiocarlide, when reviewing results.
tolbutamide, tromethamine, and vera- ➤ There are no fluid or medication
pamil. restrictions unless by medical direc-
tion.
• Elevated urea levels and uremia can
lead to falsely elevated glucose levels. ➤ For the fasting glucose test, the
patient should be fasting at least 12
• Extremely elevated white blood cell hours before specimen collection.
➤ The patient should follow the ➤ Increased glucose levels may be

instructions given for 2-hour post- associated with diabetes. Instruct
prandial glucose test. Some health the diabetic patient, as appropriate,
care practitioners may order admin- in nutritional management of the
istration of a standard glucose solu- disease. Patients who adhere to
tion, whereas others may instruct dietary recommendations report a
the patient to eat a meal with a better general feeling of health,
known carbohydrate composition. better weight management, greater
➤ Review the procedure with the control of glucose and lipid values,
patient. and improved use of insulin. There is
no “diabetic diet”; however, many
➤ Inform the patient that specimen meal-planning approaches with
collection takes approximately 5 to nutritional goals are endorsed by the
10 minutes. American Dietetic Association. The
nutritional needs of each diabetic
Intratest: patient must be determined individ-
➤ Ensure that the patient has complied ually with the appropriate health
with dietary preparations and other care professionals, particularly
pretesting restrictions. professionals trained in nutrition.
➤ Direct the patient to breathe ➤ Instruct the patient and caregiver to
normally and to avoid unnecessary report signs and symptoms of hypo-
movement. glycemia (weakness, confusion,
➤ Observe standard precautions and diaphoresis, rapid pulse) or hyper-
follow the general guidelines in glycemia (thirst, polyuria, hunger,
Appendix A. Perform a venipuncture, lethargy). Emphasize, as appropri-
and collect the specimen in a 5-mL ate, that good glycemic control
gray-top tube. delays the onset of and slows the
progression of diabetic retinopathy,
➤ Label the specimen, and promptly nephropathy, and neuropathy.
➤ Observe venipuncture site for bleed- tests include C-peptide, creatinine,
ing or hematoma formation. Apply fructosamine, glucose tolerance
pressure bandage. tests, glycated hemoglobin A1C,
➤ Instruct the patient to resume usual insulin, insulin antibodies, ketones,
diet as directed by the health care microalbumin, and blood urea nitro-
practitioner. gen (BUN).
GLUCOSE-6-PHOSPHATE
DEHYDROGENASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: G6PD.
Glucose-6-Phosphate Dehydrogenase 541
REFERENCE VALUE: (Method: Fluorescent) Qualitative assay—enzyme

activity detected; quantitative assay—the following table reflects enzyme
activity in units per gram of hemoglobin and in units per milliliter of
erythrocytes:

Newborn 7.8–14.4 U/g hemoglobin 0.5–0.93 MU/mol hemoglobin
Adult 5.5–9.3 U/g hemoglobin 0.35–0.60 MU/mol hemoglobin
Newborn 2.65–4.90 U/mL erythrocytes 2.65–4.90 kU/L erythrocytes
Adult 1.87–3.16 U/mL erythrocytes 1.87–3.16 kU/L erythrocytes
DESCRIPTION: Glucose-6-phosphate hemolytic anemia resulting from

dehydrogenase (G6PD) is a red enzyme deficiency
blood cell enzyme. It is involved
in the hexose monophosphate shunt, RESULT
and its function is to protect
Increased in:
hemoglobin from oxidation. G6PD
• Hepatic coma
deficiency is an inherited X-linked
abnormality; approximately 20 per- • Hyperthyroidism
cent of female carriers are heterozy- • Idiopathic thrombocytopenic purpura
gous. This deficiency results in
hemolysis of varying degrees and
acuity depending on the severity of • Pernicious anemia
the abnormality. There are three • Viral hepatitis
G6PD variants of high frequency in
different ethnic groups. G6PD A is Decreased in:
more common in African-Americans • Congenital nonspherocytic anemia
(10 percent of males). G6PD
• G6PD deficiency
Mediterranean is especially common
in Iraqis, Kurds, Sephardic Jews, • Nonimmunologic hemolytic disease of
and Lebanese and less common in the newborn
Greeks, Italians, Turks, North
Africans, Spaniards, Portuguese, and CRITICAL VALUES: N/A
Ashkenazic Jews. G6PD Mahidol is
common in Southeast Asians (22 • Sulfates may decrease G6PD levels.
percent of males). ■
• G6PD levels are increased in reticulo-
INDICATIONS: cytes; the test results may be falsely
• Assist in identifying the cause of positive when a patient is in a period of
hemolytic anemia resulting from drug acute hemolysis. G6PD levels can also
sensitivity, metabolic disorder, or infec- be affected by the presence of large
tion numbers of platelets and white blood
cells, which also contain significant
• Assist in identifying the cause of amounts of the enzyme.

Nursing Implications and Appendix A. Perform a venipuncture,
Procedure ● ● ● ● ● ● ● ● ● ● ● and collect the specimen in a 5-mL
lavender-top tube.
Pretest: ➤ Label the specimen, and promptly
allergens. Post-test:
hematopoietic system as well as ing or hematoma formation. Apply
results of previously performed pressure bandage.
tests and procedures. For related ➤ Educate the patient with G6PD defi-
tests, refer to the hematopoietic ciency, as appropriate, to avoid
system table. certain foods, vitamins, and drugs
➤ Obtain a list of medications the that may precipitate an acute
patient is taking, including herbs, episode of intravascular hemolysis,
nutritional supplements, and nutra- including fava beans, ascorbic acid
ceuticals. The requesting health care (large doses), acetanilid, antimalari-
practitioner and laboratory should be als, furazolidone, isobutyl nitrate,
advised if the patient regularly uses methylene blue, nalidixic acid, naph-
these products so that their effects thalene, niridazole, nitrofurantoin,
can be taken into consideration phenazopyridine, phenylhydrazine,
when reviewing results. primaquine, sulfacetamide, sulfa-
➤ There are no food, fluid, or medica- methoxazole, sulfanilamide, sulfa-
tion restrictions unless by medical pyridine, thiazolesulfone, toluidine
direction. blue, trinitrotoluene, and urate
oxidase.
patient. ➤ Evaluate test results in relation to
➤ Inform the patient that specimen tests performed. Related labora-
collection takes approximately 5 to tory tests include complete blood
10 minutes. count (including examination of
peripheral smear for red blood cell
Intratest: abnormalities and the presence
of Heinz bodies), bilirubin, Ham’s
➤ Direct the patient to breathe test, haptoglobin, hemosiderin,
normally and to avoid unnecessary osmotic fragility, reticulocyte count,
movement. and urinalysis (for hemoglobin and
➤ Observe standard precautions and urobilinogen).
GLUCOSE TOLERANCE TESTS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Standard oral tolerance test, standard gestational

screen, standard gestational tolerance test, GTT.
Glucose Tolerance Tests 543
SPECIMEN: Plasma (1 mL) collected in gray-top (sodium fluoride) tube.

Serum (1 mL) collected in a red- or tiger-top tube. Plasma collected in a
green-top (heparin) tube is also acceptable. It is important to use the same
type of collection container throughout the entire test.
SI Units
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
Plasma glucose values are reported to be 10–20% higher than serum values.
DESCRIPTION: The glucose tolerance results in damage, dysfunction,

test (GTT) measures glucose levels and eventually failure of the eyes,
after administration of an oral or kidneys, nerves, heart, and blood
intravenous carbohydrate challenge. vessels. The American Diabetes
Patients with diabetes are unable to Association’s 1998 revised criteria
metabolize glucose at a normal rate. for diagnosing diabetes include any
The oral GTT is used for individuals combination of the following findings
who are able to eat and who are or confirmation of any of the individ-
not known to have problems with ual findings by repetition on a subse-
gastrointestinal malabsorption. The quent day:
intravenous GTT is used for individu- • Symptoms of diabetes (e.g.,
als who are unable to tolerate oral polyuria, polydipsia, and unex-
glucose. plained weight loss) in addition to a
Diabetes is a group of diseases random glucose level greater than
characterized by hyperglycemia or 200 mg/dL
elevated glucose levels. Hyper- • Fasting blood glucose greater than
glycemia results from a defect in 126 mg/dL, after a minimum of an
insulin secretion (type 1 diabetes), a 8-hour fast
defect in insulin action, or a combi- • Glucose level greater than 200
nation of dysfunction secretion and mg/dL 2 hours after glucose
action (type 2 diabetes). The chronic challenge with standardized 75-mg
hyperglycemia of diabetes over time load ■
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
• 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
Glucose Tolerance Tests 545
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:
• Excessive physical activity before or with dietary preparations and other
during the test can lead to falsely pretesting restrictions.
decreased values.
• Smoking before or during the test can normally and to avoid unnecessary
lead to falsely increased values. movement.
• 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
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-
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.
-Glutamyltransferase 547
➤ Evaluate test results in relation to fructosamine, glucose, glycated

the patient’s symptoms and other hemoglobin A1C, insulin, insulin
tests performed. Related laboratory antibodies, ketones, microalbumin,
tests include C-peptide, creatinine, and blood urea nitrogen (BUN).
-GLUTAMYLTRANSFERASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Serum -glutamyltransferase, -glutamyl

transpeptidase, GGT, SGGT.

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
D ESCRIPTION : -Glutamyltrans- • Detect the presence of liver disease

ferase (GGT) assists with the reab- • Evaluate and monitor patients with
sorption of amino acids and peptides known or suspected alcohol abuse
from the glomerular filtrate and (levels rise after ingestion of small
intestinal lumen. Hepatobiliary, renal amounts of alcohol)
tubular, and pancreatic tissue contain
large amounts of GGT. Other sources RESULT
include the prostate gland, brain, and
Increased in:
heart. GGT is elevated in all types of
• Cirrhosis
liver disease and is more responsive to
biliary obstruction, cholangitis, or • Diabetes with hypertension
cholecystitis than any of the other • Hepatitis
enzymes used as markers for liver
• Hepatobiliary tract disorders
disease. ■
• Hepatocellular carcinoma
INDICATIONS: • Hyperthyroidism
• Assist in the diagnosis of obstructive
jaundice in neonates • Obstructive liver disease
• Pancreatitis ➤ Inform the patient that specimen

• Renal transplantation 10 minutes.
• Significant alcohol ingestion
Intratest:
Decreased in:
• Hypothyroidism normally and to avoid unnecessary
movement.
• Drugs that may increase GGT levels collect the specimen in a 5-mL red-
include acetaminophen, amino- or tiger-top tube.
glutethimide, anticonvulsants, barbitu-
rates, captopril, clotiazepam, disul- transport it to the laboratory.
firam, methyldopa, oral contraceptives,
phenothiazines, rifampin, and strep-
tokinase. Post-test:
• Drugs that may decrease GGT levels
include bezafibrate, cefotaxime, clofi- pressure bandage.
brate, fenofibrate, and ursodiol.
➤ Increased GGT levels may be associ-
Nursing Implications and and vary depending on the condition
Procedure ● ● ● ● ● ● ● ● ● ● ● and its severity. Currently, there are
no specific medications that can be
Pretest: given to cure hepatitis, but elimina-
tion of alcohol ingestion and a diet
➤ Obtain a history of the patient’s optimized for convalescence are
complaints, including a list of known commonly included in the treatment
allergens. plan. A high-calorie, high-protein,
➤ Obtain a history of the patient’s moderate-fat diet with a high fluid
hepatobiliary system as well as intake is often recommended for
results of previously performed patients with hepatitis. Treatment of
tests and procedures. For related cirrhosis is different because a low-
tests, refer to the hepatobiliary protein diet may be in order if the
system table. patient’s liver has lost the ability to
➤ Obtain a list of the medications process the end products of protein
the patient is taking, including metabolism. A diet of soft foods
herbs, nutritional supplements, and also may be required if esophageal
nutraceuticals. The requesting health varices have developed. Ammonia
care practitioner and laboratory levels may be used to determine
should be advised if the patient whether protein should be added to
regularly uses these products so or reduced from the diet. The patient
that their effects can be taken into should be encouraged to eat simple
consideration when reviewing carbohydrates and emulsified fats
results. (as in homogenized milk or eggs)
as opposed to complex carbohy-
➤ There are no food, fluid, or medica- drates (e.g., starch, fiber, and glyco-
tion restrictions unless by medical gen [animal carbohydrates]) and
direction. complex fats, which would require
➤ Review the procedure with the additional bile to emulsify it so that it
patient. could be used. The cirrhotic patient
Glycated Hemoglobin A1C 549
should also be carefully observed for ➤ Evaluate test results in relation to

the development of ascites, in which the patient’s symptoms and other
case fluid and electrolyte balance tests performed. Related laboratory
requires strict attention. The alco- tests include alanine aminotrans-
holic patient should be encouraged ferase, alkaline phosphatase and
to avoid alcohol and to seek appro- isoenzymes, ammonia, aspartate
priate counseling for substance aminotransferase, bilirubin, and elec-
abuse. trolytes.
GLYCATED HEMOGLOBIN A1C

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Hemoglobin A1C, A1C.

REFERENCE VALUE: (Method: Chromatography)
Total A1 4.0–7.0% hyperglycemia of diabetes over time

A1C 4.0–5.5% results in damage, dysfunction, and
Values vary widely by method. eventually failure of the eyes, kidneys,
nerves, heart, and blood vessels. He-
moglobin A1C levels are not age
DESCRIPTION: Glycosylated or gly- dependent and are not affected by
cated hemoglobin is a term used to
exercise, diabetic medications, or
describe the combination of glucose
nonfasting state before specimen
and hemoglobin into a ketamine; the
collection. ■
rate at which this occurs is propor-
tional to glucose concentration. The
average life span of a red blood cell is INDICATIONS: Assess long-term glucose
approximately 120 days; measure- control in diabetics
ment of glycated hemoglobin is a
way to monitor long-term diabetic
RESULT
management.
Diabetes is a group of diseases
Increased in:
characterized by hyperglycemia
• Diabetes (poorly controlled or uncon-
or elevated glucose levels. Hyper-
trolled)
glycemia results from a defect in
insulin secretion (type 1 diabetes), a
Decreased in:
defect in insulin action, or a combi-
nation of dysfunction secretion and • Chronic blood loss
action (type 2 diabetes). The chronic • Chronic renal failure
• 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.
10 minutes.
• Drugs that may increase glycated Intratest:
hemoglobin A1C values include
hydrochlorothiazide, indapamide, normally and to avoid unnecessary
insulin, morphine, propranolol, and movement.
sulfonylureas.
• 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.
• 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).
Gram Stain 551
➤ Emphasize, as appropriate, that to the patient’s symptoms and

good glycemic control delays the other tests performed. Related labo-
onset of and slows the progression ratory tests include C-peptide,
of diabetic retinopathy, nephropathy, fructosamine, glucose, glucose
and neuropathy. tolerance tests, insulin, insulin anti-
➤ Evaluate test results in relation bodies, ketones, and microalbumin.
GRAM STAIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Blood, biopsy specimen, or body fluid as collected for culture.
REFERENCE VALUE: N/A.
DESCRIPTION: Gram stain is a tech- the number of polymorphonuclear

nique commonly used to identify white blood cells, indicates contami-
bacterial organisms based on their nation of the specimen with saliva
specific staining characteristics. The and should be rejected for subsequent
method involves smearing a small culture. The occasional presence of
amount of specimen on a slide, and bacteria in an unspun urine Gram
then exposing it to gentian or crystal stain suggests a correlating colony
violet, iodine, alcohol, and safranin count of 10,000 bacteria/mL. The
O. Gram-positive bacteria retain the presence of bacteria in most
gentian or crystal violet and iodine fields is clinically significant and
stain complex after a decolorization suggests greater than 100,000
step and appear purple-blue in color. bacteria/mL of urine. ■
Gram-negative bacteria do not retain
the stain after decolorization but INDICATIONS:
can pick up the pink color of the • Provide a rapid determination of the
safranin O counterstain. Gram stain acceptability of the specimen for
results should be correlated with further analysis
culture results to interpret the • Provide rapid, presumptive informa-
significance of isolated organisms. tion about the type of potential
A sputum Gram stain showing pathogen present in the specimen (i.e.,
greater than 25 squamous epithelial gram-positive bacteria, gram-negative
cells per low-power field, regardless of bacteria, or yeast)
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.
CRITICAL VALUES: Organisms the gastrointestinal, genitourinary,

detected in cerebrospinal fluid or in immune, reproductive, and respira-
tory system tables.
specimens obtained by aseptic technique
should be reported immediately. ➤ Obtain a list of medications
INTERFERING FACTORS: Very young, nutraceuticals. The requesting health
very old, or dead cultures may react care practitioner and laboratory
atypically to the Gram stain technique. should be advised if the patient
Nursing Implications and results.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: direction.
➤ 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.
Group A Streptococcal Screen 553
➤ 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.
GROUP A STREPTOCOCCAL SCREEN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Strep screen, rapid strep screen, direct strep screen.

SPECIMEN: Throat swab (two swabs should be submitted so that a culture
can be performed if the screen is negative).
REFERENCE VALUE: (Method: Enzyme immunoassay or latex agglutination)

Negative.
DESCRIPTION: Rheumatic fever is a colonies on culture yield negative

possible sequela to an untreated results by the rapid screening
streptococcal infection. Early diagno- method. Evidence of group A strepto-
sis and treatment appear to lessen the cocci disappears rapidly after the
seriousness of symptoms during the initiation of antibiotic therapy. A
acute phase and overall duration of nucleic acid probe method has also
the infection and sequelae. The onset been developed for rapid detection of
of strep throat is sudden and includes group A streptococci. ■
symptoms such as chills, headache,
sore throat, malaise, and exudative INDICATIONS: Assist in the rapid deter-
gray-white patches on the tonsils or mination of the presence of group A
pharynx. The group A streptococcal streptococci
screen should not be ordered unless
the results would be available within RESULT
1 to 2 hours of specimen collection to
make rapid, effective therapeutic
• Rheumatic fever
decisions. A positive result can be a
reliable basis for the initiation of ther- • Scarlet fever
apy. A negative result is presumptive • Streptococcal glomerulonephritis
for infection and should be backed
up by culture results. In general, spec- • Strep throat
imens showing growth of less than 10 • Tonsillitis

• Polyester swabs are favored over cotton tion restrictions unless by medical
for best chance of detection. direction.
➤ Before specimen collection, verify
• Sensitivity of the method varies from with the laboratory whether wet or
manufacturer to manufacturer. dry swabs are preferred for collec-
tion.
• Adequate specimen collection in chil-
dren may be difficult to achieve, which ➤ Review the procedure with the
explains the higher percentage of false- patient.
negative results in this age group. ➤ Inform the patient that specimen
collection takes approximately 5
minutes.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●

Appendix A. Vigorous swabbing of
➤ Obtain a history of the patient’s both tonsillar pillars and the poste-
complaints, including a list of known rior throat enhances the probability
allergens. of streptococcal antigen detection.
immune and respiratory systems, transport it to the laboratory.
related tests, refer to the immune Post-test:
and respiratory system tables. ➤ Administer antibiotics as ordered,
➤ Obtain a history of prior antibiotic and emphasize to the patient the
therapy. importance of completing the entire
➤ Obtain a list of medications the course of antibiotic therapy even if
patient is taking, including herbs, no symptoms are present.
nutritional supplements, and nutra- ➤ Evaluate test results in relation to
ceuticals. The requesting health care the patient’s symptoms and other
practitioner and laboratory should be tests performed. Related laboratory
advised if the patient regularly uses tests include complete blood count,
these products so that their effects Gram stain, and relevant cultures.
GROWTH HORMONE, STIMULATION

AND SUPPRESSION TESTS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Somatotropic hormone, somatotropin, GH,

hGH.

Growth Hormone, Stimulation and Suppression Tests 555

Growth Hormone
SI Units
Cord blood 8–40 ng/mL 8–40 g/L
1d 5–50 ng/mL 5–50 g/L
1 wk 5–25 ng/mL 5–25 g/L
Child 2–10 ng/mL 2–10 g/L
Adult
Male 0–5 ng/mL 0–5 g/L
Female 0–10 ng/mL 0–10 g/L
Male older 0–10 ng/mL 0–10 g/L
than 60 y
Female older 0–14 ng/mL 0–14 g/L
than 60 y
Stimulation Tests
Rise above Greater than 5 ng/mL Greater than 5 g/L
baseline
Peak response Greater than 10 ng/mL Greater than 10 g/L
Suppression Tests
0–2 ng/mL 0–2 g/L
DESCRIPTION: Human growth hor- • Monitor response to treatment of

mone (GH) is secreted in episodic growth retardation
bursts by the anterior pituitary gland; • Detect suspected disorder associated
the highest level is usually secreted with decreased GH
during deep sleep. GH plays an
• Assist in establishing a diagnosis
integral role in growth from birth of gigantism in children with GH
to puberty. GH promotes skeletal increased levels, indicative of a pitu-
growth by stimulating hepatic pro- itary cause
duction of proteins; it also affects
lipid and glucose metabolism. Ran- RESULT
dom levels are rarely useful because
secretion of GH is episodic and pul- Increased in:
satile. Stimulation tests with arginine, • Acromegaly
glucagon, insulin, or L-dopa, as well
as suppression tests with glucose, pro- • Anorexia nervosa
vide useful information. ■ • Cirrhosis
• Diabetes (uncontrolled)
INDICATIONS:
• Assist in the diagnosis of acromegaly in • Ectopic GH secretion (neoplasms of
adults stomach, lung)
• Assist in establishing a diagnosis of • Exercise
dwarfism or growth retardation in chil-
• Gigantism (pituitary)
dren with decreased GH levels, indica-
tive of a pituitary cause • Hyperpituitarism
• Laron dwarfism procedures. For related tests, refer

• Malnutrition
• Renal failure patient is taking, including herbs,
• Stress ceuticals. The requesting health care
Decreased in: advised if the patient regularly uses
these products that so their effects
• Adrenocortical hyperfunction can be taken into consideration
• Dwarfism (pituitary) when reviewing results.
• Hypopituitarism interfere with test results.
CRITICAL VALUES: N/A restrictions unless by medical direc-
tion.
INTERFERING FACTORS: ➤ The patient should fast and avoid
• Drugs that may increase GH levels strenuous exercise for 12 hours
include alanine, anabolic steroids, before specimen collection.
angiotensin II, apomorphine, arginine, ➤ The patient should have bed rest for
clonidine, corticotropin, cyclic AMP, 1 hour before each sample is
desipramine dexamethasone, dopa- obtained.
mine, fenfluramine, galanin, glucagon, ➤ Record pertinent information related
GH-releasing hormone, levodopa, to diet, sleep pattern, and activity at
methamphetamine, methyldopa the time of the test.
hydrazine, metoclopramide, midazo- ➤ Review the procedure with the
lam, niacin, oral contraceptives, patient. Inform the patient that
phenytoin, propranolol, and vaso- multiple specimens may be
pressin. required.
• Drugs that may decrease GH levels
men collection takes approximately
include corticosteroids, corticotropin, 5 to 10 minutes.
hydrocortisone, octreotide, and piren-
zepine. Intratest:
• Recent radioactive scans or radiation ➤ Ensure that the patient has complied
within 1 week before the test can inter- with dietary preparations and other
fere with test results when radioim- pretesting restrictions.
munoassay is the test method. ➤ Direct the patient to breathe
movement.
➤ Obtain a history of the patient’s ➤ Test samples may be requested at
complaints, including a list of known baseline and 10-, 20-, 30-, 45-, and
allergens. 60-minute intervals after stimulation
➤ Obtain a history of the patient’s and at baseline and 30-, 60-, 90-, and
endocrine system as well as results 120-minute intervals after suppres-
of previously performed tests and sion.
Ham’s Test for Paroxysmal Nocturnal Hemoglobinuria 557
➤ Label the specimen, and promptly ➤ Instruct the patient to resume

transport it to the laboratory. normal diet as directed by the health
care practitioner.
➤ Observe venipuncture site for bleed- tests performed. A related labora-
ing or hematoma formation. Apply tory test is adrenocorticotropic
pressure bandage. hormone.
HAM’S TEST FOR PAROXYSMAL

NOCTURNAL HEMOGLOBINURIA
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Acid hemolysis test for PNH.

aminetetra-acetic acid [EDTA]) top tube and serum (3 mL) collected in red-
top tube.
REFERENCE VALUE: (Method: Acidified hemolysis) No hemolysis seen.
DESCRIPTION: Paroxysmal noctur- tive if 10 to 50 percent cell lysis

nal hemoglobinuria (PNH) is a occurs in the samples mixed with
condition in which the patient expe- patient and control acidified serum.
riences nocturnal hemoglobinuria, No hemolysis should occur in the
chronic hemolytic anemia, dimin- heated control serum. The sugar
ished or absent generation of new red water test can also be performed to
blood cells (RBCs), and a tendency to investigate the presence of PNH.
thrombose. It is caused by an Platelet and granulocyte membranes
acquired defect in hematopoietic are affected as well, but RBC hemol-
stem cells. In patients with PNH, ysis in a positive test is clear evidence
erythrocytes have an increased sensi- of PNH. ■
tivity to complement and will lyse
when mixed with acidified serum INDICATIONS:
containing complement. The • Evaluate hemolytic anemia, especially
patient’s RBCs are also mixed with with hemosiderinuria
fresh normal serum that is ABO
• Evaluate suspected congenital dys-
compatible with the patient’s cells. erythropoietic anemia, type II (also
Some of the control serum is acidi- known as HEMPAS [hereditary
fied, and some is heated to inactivate erythroblastic multinuclearity with
the complement. The result is posi- positive acidified serum test])
• Evaluate suspected PNH ➤ Obtain a list of the medications

RESULT herbs, nutritional supplements, and
Increased in:
• Paroxysmal nocturnal hemoglobinuria regularly uses these products so
• Congenital dyserythropoietic anemia,
type II results.
Decreased in: N/A
direction.
patient.
• False-positives may occur in the pres- collection takes approximately 5 to
ence of other disorders, such as aplastic 10 minutes.
anemia, HEMPAS, hereditary or
acquired spherocytosis, leukemia, and Intratest:
myeloproliferative syndromes. False-
positives may also occur with aged ➤ Direct the patient to breathe
RBCs. The sugar water test is negative
movement.
in HEMPAS.
• False-negatives can occur if the follow the general guidelines in
patient’s serum sample contains a low Appendix A. Perform a venipuncture,
level of complement. collect the specimen in a 5-mL
lavender-top and 5-mL red-top tube.
complaints, including a list of known ➤ Evaluate test results in relation to
allergens. the patient’s symptoms and other
hematopoietic system, as well as tests include bone marrow biopsy,
results of previously performed complete blood count, direct
tests and procedures. For related Coombs’ test, glucose-6-phosphate
tests refer to the hematopoietic dehydrogenase, hemosiderin, and
system table. osmotic fragility.
Haptoglobin 559
HAPTOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Hapto, HP, Hp.

SI Units
Newborn 5–48 mg/dL 0.05–0.48 g/L
6 mo–16 y 25–138 mg/dL 0.25–1.38 g/L
Adult 15–200 mg/dL 0.15–2.00 g/L
DESCRIPTION: Haptoglobin is an process or tissue destruction, as indi-

2-globulin produced in the liver. It cated by elevated levels
binds with the free hemoglobin
released when red blood cells (RBCs) RESULT
are lysed. If left unchecked, free Increased in:
hemoglobin in the plasma can cause • Biliary obstruction
renal damage; haptoglobin prevents it
from accumulating. In conditions • Disorders involving tissue destruction,
such as hemolytic anemia, so many such as cancers, burns, and acute
myocardial infarction
hemolyzed RBCs are available for
binding that the liver cannot compen- • Infection or inflammatory diseases,
sate by producing additional hapto- such as ulcerative colitis, arthritis, and
globin fast enough, resulting in low pyelonephritis
serum levels. ■ • Neoplasms
INDICATIONS: • Steroid therapy

• Assist in the investigation of suspected Decreased in:
transfusion reaction
• Autoimmune hemolysis
• Evaluate known or suspected chronic
• Hemolysis due to mechanical destruc-
liver disease, as indicated by decreased
tion (e.g., artificial heart valves, contact
levels
sports, subacute bacterial endocarditis)
• Evaluate known or suspected disorders
• Hemolysis due to drug reaction
characterized by excessive RBC hemol-
ysis, as indicated by decreased levels • Hemolysis due to RBC membrane or
metabolic defects
• Evaluate known or suspected disorders
involving a diffuse inflammatory • Hemolysis due to transfusion reaction
• Hypersplenism patient is taking, including herbs,

• Ineffective hematopoiesis due to condi- ceuticals. The requesting health care
tions such as folate deficiency or hemo- practitioner and laboratory should be
globinopathies advised if the patient regularly uses
• Liver disease can be taken into consideration
• Drugs that may increase haptoglobin ➤ Review the procedure with the
levels include anabolic steroids, dana- patient.
zol, ethylestrenol, fluoxymesterone,
methandrostenolone, norethan- collection takes approximately 5 to
drolone, oxandrolone, oxymetholone, 10 minutes.
and stanozolol.
• Drugs that may decrease haptoglobin Intratest:
levels include acetanilid, aminosalicylic
acid, chlorpromazine, dapsone, ➤ Direct the patient to breathe
dextran, diphenhydramine, furadal- movement.
tone, furazolidone, isoniazid, nitro-
furantoin, norethindrone, oral ➤ Observe standard precautions and
contraceptives, quinidine, resorcinol, Appendix A. Perform a venipuncture,
stibophen, tamoxifen, thiazolsulfone, and collect the specimen in a 5-mL
and tripelennamine. red-top tube.

complaints, including a list of known ➤ Instruct the patient to immediately
allergens. report symptoms of hemolysis,
➤ Obtain a history of the patient’s including chills, fever, flushing, back
hematopoietic, hepatobiliary, and pain, and fast heartbeat.
immune systems, as well as results ➤ Evaluate test results in relation to
of previously performed tests and the patient’s symptoms and other
procedures. For related tests, refer tests performed. Related laboratory
to the hematopoietic and immune tests include direct antiglobulin test,
system tables. indirect antiglobulin test, bilirubin,
➤ Obtain a list of the medications the and blood group and type.
Helicobacter pylori Antibody 561
HELICOBACTER PYLORI ANTIBODY

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: H. pylori.
SPECIMEN: Serum (1 mL) collected in a plain red-top tube.
REFERENCE VALUE: (Method: Enzyme-linked immunosorbent assay
[ELISA]) Negative.
DESCRIPTION: There is a strong asso- Negative findings in: N/A

ciation between Helicobacter pylori
infection and gastric cancer, duodenal CRITICAL VALUES: N/A
and gastric ulcer, and chronic gastri-
tis. Immunoglobulin G (IgG) anti- INTERFERING FACTORS: N/A
bodies can be detected for up to 1
year after treatment. The presence of
H. pylori can also be demonstrated by
a positive urea breath test, positive
Procedure ● ● ● ● ● ● ● ● ● ● ●
stool culture, or positive endoscopic Pretest:

biopsy. Patients with symptoms and
evidence of H. pylori infection are ➤ Obtain a history of the patient’s
considered to be infected with the allergens.
organism; patients who demonstrate ➤ Obtain a history of the patient’s
evidence of H. pylori but are without gastrointestinal and immune sys-
symptoms are said to be colonized. ■ tems, as well as results of previously
INDICATIONS: related tests, refer to the gastroin-
• Assist in differentiating between H. testinal and immune system tables.
pylori infection and nonsteroidal anti- ➤ Obtain a list of the medications the
inflammatory drug (NSAID) use as the patient is taking, including herbs,
cause of gastritis or peptic or duodenal nutritional supplements, and nutra-
ulcer ceuticals. The requesting health care
• Assist in establishing a diagnosis of advised if the patient regularly uses
gastritis, gastric carcinoma, or peptic or these products so that their effects
duodenal ulcer can be taken into consideration
RESULT ➤ There are no food, fluid, or medica-
Positive findings in: direction.
• H. pylori infection ➤ Inform the patient that each speci-
• H. pylori colonization 5 to 10 minutes.
➤ Direct the patient to breathe ➤ Observe venipuncture site for bleed-

normally and to avoid unnecessary ing or hematoma formation. Apply
movement. pressure bandage.
➤ Inform the patient that a positive
➤ Observe standard precautions and test result constitutes an independ-
follow the general guidelines in ent risk factor for gastric cancer.
and collect the specimen in a 5-mL ➤ Evaluate test results in relation to
red-top tube. the patient’s symptoms and other
➤ Label the specimen, and promptly tests include gastrin and gastric acid
transport it to the laboratory. stimulation.
HEMATOCRIT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Packed cell volume (PCV), Hct.

acetic acid [EDTA]) tube, Microtainer, or capillary. Whole blood from a
green-top (lithium or sodium heparin) tube may also be submitted.
REFERENCE VALUE: (Method: Automated, computerized, multichannel

analyzers)
Hematocrit
SI Unit (Volume Fraction,

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
Hematocrit 563
DESCRIPTION: Blood consists of a Hgb in African-Americans is 0.5 to

fluid portion (plasma) and a solid 1.0 g lower than in Caucasians. Mexi-
portion that includes red blood cells can-Americans and Asian-Americans
(RBCs), white blood cells, and have higher H&H values than
platelets. The hematocrit, or packed Caucasians. ■
cell volume, is the percentage of
RBCs in a volume of whole blood. INDICATIONS:
For example, a hematocrit (Hct) of 45 • Detect hematologic disorder, neo-
plasm, or immunological abnormality
percent means that a 100-mL sample
of blood contains 45 mL of packed • Determine the presence of hereditary
RBCs. Although Hct depends prima- hematologic abnormality
rily on the number of RBCs, the aver- • Evaluate known or suspected anemia
age size of the RBCs plays a role. and related treatment, in combination
Conditions that cause the RBCs to with Hgb
swell, such as when the serum sodium • Monitor blood loss and response to
concentration is elevated, may blood replacement, in combination
increase the Hct level. with Hgb
Hct level is included in the
• Monitor the effects of physical or
complete blood count (CBC) and is
emotional stress
generally tested together with hemo-
globin (Hgb). These levels parallel • Monitor fluid imbalances or their
each other and are the best determi- treatment
nant of the degree of anemia or poly- • Monitor hematologic status during
cythemia. Polycythemia is a term used pregnancy, in combination with Hgb
in conjunction with conditions result- • Monitor the progression of nonhema-
ing from an abnormal increase in Hgb, tologic disorders such as chronic
Hct, and RBC count. Anemia is a term obstructive pulmonary disease, malab-
associated with conditions resulting sorption syndromes, cancer, and renal
from an abnormal decrease in Hgb, disease
Hct, and RBC count. Results of the • Monitor response to drugs or
Hgb, Hct, and RBC count should be chemotherapy, and evaluate undesired
evaluated simultaneously because the reactions to drugs that may cause
same underlying conditions affect this blood dyscrasias
triad of tests similarly. The RBC count
• Provide screening as part of a CBC
multiplied by three should approxi- count in a general physical examina-
mate the Hgb concentration. The Hct tion, especially upon admission to a
should be within three times the Hgb health care facility or before surgery
if the RBC population is normal in
size and shape. The Hct plus six should RESULT
approximate the first two figures of the
RBC count within three (e.g., Hct is Increased in:
40 percent; therefore 40 6 46, • Erythrocytosis
and the RBC count should be • Hemoconcentration
4.3–4.9). There are some cultural vari-
• Polycythemia
ations in Hgb and Hct (H&H) values.
After the first decade of life, the mean • Shock
Decreased in: INTERFERING FACTORS:

• Anemia • Drugs and substances that may cause a
• Blood loss (acute and chronic) decrease in Hct include those that
induce hemolysis due to drug sensitiv-
• Bone marrow hyperplasia ity or enzyme deficiency, such as
• Burns (severe) aminopyrine, aminosalicylic acid,
amphetamine, anticonvulsants, anti-
• Chronic disease malarials, antipyretics, cephalothin,
• Hemolytic reactions chloroquine, chlorothiazide, chlorpro-
mazine, colchicine, corticosteroids,
dapsone, dimercaprol, diphenhy-
CRITICAL VALUES: dramine, dipyrone, glucosulfone, glyc-
Less than 18 percent erin, gold, mephytoin, methyldopa,
Greater than 54 percent nalidixic acid, neomycin, niridazole,
Note and report to the health care nitrobenzene, nitrofurantoin, novo-
practitioner any critically increased or biocin, penicillin, phenacemide,
decreased values and symptoms: pipobroman (intended effect for poly-
• Severe hemodilution can lead to cythemia), primaquine, probenecid,
cardiac failure and death. Symptoms of propranolol, pyrazolones, quinines,
hemodilution include rales, anxiety, streptomycin, sulfamethizole, sulfa-
restlessness, edema, hypertension, methoxypyridazine, sulfisoxazole,
jugular venous distention, and short- suramin, tolbutamide, trimethadione,
ness of breath. Possible interventions and tripelennamine.
include diuretics, restriction of fluids • Some drugs may also affect Hct values
and sodium, and careful monitoring of by increasing or decreasing the RBC
input and output. Symptoms of blood count (see monograph titled “Red
loss include bleeding, hypotension, Blood Cell Count”).
and hypoxia. Once the cause of blood
• The results of RBC counts may vary
loss has been identified, possible inter-
depending on the patient’s position:
ventions include blood transfusion and
Hct can decrease when the patient is
administration of vasopressin, omepra-
recumbent as a result of hemodilution
zole, or isotonic fluids.
and can increase when the patient rises
• Severe hemoconcentration can lead to as a result of hemoconcentration.
spontaneous blood clotting. Symptoms • Leaving the tourniquet in place for
of hemoconcentration include de- longer than 60 seconds can falsely
creased pulse pressure and volume, loss increase levels by 2 to 5 percent.
of skin turgor, dry mucous mem-
branes, low central venous pressure, or- • Traumatic venipuncture and hemolysis
thostatic hypotension, tachycardia, may result in falsely decreased values.
thirst, and weakness. Possible interven- • Failure to fill the tube sufficiently (i.e.,
tions include intravenous fluids and tube less than three-quarters full) may
discontinuance of diuretics if they are yield inadequate sample volume for
believed to be contributing to critically automated analyzers and may be
elevated Hct. Symptoms of poly- reason for specimen rejection.
cythemic overload crisis include signs
of thrombosis, pain and redness in ex- • Clotted specimens must be rejected for
tremities, facial flushing, and irritabil- analysis.
ity. Possible interventions include ther- • Care should be taken in evaluating the
apeutic phlebotomy and intravenous Hct during the first few hours after
fluids. transfusion or acute blood loss because
Hematocrit 565
the value may appear to be normal and collection takes approximately 5 to

may not be a reliable indicator of 10 minutes.
anemia.
Intratest:
• Abnormalities in the RBC size (macro-
cytes, microcytes) or shape (sphero- ➤ Direct the patient to breathe
cytes, sickle cells) may alter values, as normally and to avoid unnecessary
movement.
in diseases and conditions including
sickle cell anemia, hereditary spherocy- ➤ Observe standard precautions and
tosis, and iron deficiency follow the general guidelines in
• Elevated blood glucose or serum and collect the specimen in a 5-mL
sodium levels may produce elevated lavender-top (EDTA) tube. An EDTA
levels because of swelling of the Microtainer sample may be obtained
erythrocytes. from infants, children, and adults for
whom venipuncture may not be
mixed gently by inverting the tube 10
Nursing Implications and times. It is stable when stored for up
Procedure ● ● ● ● ● ● ● ● ● ● ● to 6 hours at room temperature or
24 hours if stored refrigerated. In
Pretest: addition, if it is anticipated that the
specimen will not be analyzed within
➤ Obtain a history of the patient’s 4 to 6 hours, two blood smears
complaints, including a list of known should be made immediately after
allergens. the venipuncture and submitted with
➤ Obtain a history of the patient’s the blood sample.
cardiovascular, gastrointestinal, ➤ Label the specimen, and promptly
hematopoietic, hepatobiliary, im- transport it to the laboratory.
mune, musculoskeletal, and respira-
tory systems, as well as results of Post-test:
procedures. For related tests, refer ➤ Observe venipuncture site for bleed-
to the cardiovascular, gastrointesti- ing or hematoma formation. Apply
nal, hematopoietic, hepatobiliary, pressure bandage.
immune, musculoskeletal, and respi- ➤ Nutritional therapy may be indicated
ratory system tables. for patients with decreased Hct. Iron
➤ Obtain a list of the medications deficiency is the most common
the patient is taking, including nutrient deficiency in the United
herbs, nutritional supplements, and States. Patients at risk (e.g., chil-
nutraceuticals. The requesting health dren, pregnant women and women
care practitioner and laboratory of childbearing age, low-income
should be advised if the patient populations) should be instructed to
regularly uses these products so include foods that are high in iron in
their that effects can be taken into their diet, such as meats (especially
consideration when reviewing liver), eggs, grains, vegetables, and
results. multivitamins with iron. Iron absorp-
➤ Note any recent procedures that can tion is affected by numerous factors
interfere with test results. (see monograph titled “Iron”).
➤ There are no food, fluid, or medica- ➤ Evaluate test results in relation to
tion restrictions unless by medical the patient’s symptoms and other
direction. tests performed. Related laboratory
tests include CBC count, erythropoi-
➤ Review the procedure with the etin, ferritin, iron/total iron-binding
patient. capacity, peripheral blood smear,
➤ Inform the patient that specimen and reticulocyte count.
HEMOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Hgb.
acetic acid [EDTA]) tube, Microtainer, or capillary. Whole blood from a
green-top (lithium or sodium heparin) tube may also be submitted.
SI Units
Cord blood 13.5–20.5 g/dL 135–205 mmol/L
2 wk 13.4–19.8 g/dL 134–198 mmol/L
1 mo 10.7–17.1 g/dL 107–171 mmol/L
6 mo 11.1–14.4 g/dL 111–144 mmol/L
1y 11.3–14.1 g/dL 113–141 mmol/L
9–14 y 12.0–14.4 g/dL 120–144 mmol/L
Adult
Male 13.2–17.3 g/dL 132–173 mmol/L
Female 11.7–15.5 g/dL 117–155 mmol/L
Older adult
(65–74 y)
Male 12.6–17.4 g/dL 126–174 mmol/L
Female 11.7–16.1 g/dL 117–161 mmol/L
DESCRIPTION: Hemoglobin (Hgb) glycerate (2,3-DPG), a substance

is the main intracellular protein of produced by anaerobic glycolysis to
erythrocytes. It carries oxygen (O2) to generate energy for the RBCs. When
and removes carbon dioxide (CO2) Hgb binds with 2,3-DPG, O2 affin-
from red blood cells (RBCs). It also ity decreases. The ability of Hgb to
serves as a buffer to maintain acid- bind and release O2 can be graphi-
base balance in the extracellular fluid. cally represented by an oxyhemoglo-
Each Hgb molecule consists of heme bin dissociation curve. The term shift
and globulin. Copper is a cofactor to the left is used to describe an
necessary for the enzymatic incorpo- increase in the affinity of Hgb for O2.
ration of iron molecules into heme. Conditions that can cause this left-
Heme contains iron and porphyrin ward shift include decreased body
molecules that have a high affinity for temperature, decreased 2,3-DPG,
O2. The affinity of Hgb molecules for decreased CO2 concentration, or
O2 is influenced by 2,3-diphospho- increased pH. Conversely, a shift to
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
RESULT ness of breath. Possible interventions

include diuretics, restriction of fluids
Increased in: and sodium, and careful monitoring of
input and output. Symptoms of blood
• Burns
loss include bleeding, hypotension,
• COPD and hypoxia. Once the cause of blood
loss has been identified, possible inter-
ventions include blood transfusion and
• Dehydration administration of vasopressin, omepra-
zole, or isotonic fluids.
• Erythrocytosis
• Severe hemoconcentration can lead
• Hemoconcentration
to spontaneous blood clotting.
• High altitudes Symptoms of hemoconcentration
include decreased pulse pressure and
volume, loss of skin turgor, dry
mucous membranes, low central
Decreased in: venous pressure, orthostatic hypoten-
• Anemias sion, tachycardia, thirst, and weakness.
• Carcinoma Possible interventions include intra-
venous fluids and discontinuance of
• Fluid retention diuretics if they are believed to be
• Hemolytic disorders contributing to critically elevated Hct.
Symptoms of polycythemic overload
• Hemoglobinopathies crisis include signs of thrombosis, pain
• Hemorrhage (acute and chronic) and redness in extremities, facial flush-
ing, and irritability. Possible interven-
• Hodgkin’s disease tions include therapeutic phlebotomy
• Incompatible blood transfusion and intravenous fluids.
• Intravenous overload INTERFERING FACTORS:
• Leukemia • Drugs and substances that may cause
a decrease in Hgb levels include
• Lymphomas those that induce hemolysis due to
• Nutritional deficit drug sensitivity or enzyme deficiency,
such as acetaminophen, aminopyrine,
• Pregnancy aminosalicylic acid, amphetamine,
• Splenomegaly antipyrine, arsenicals, benzene, busul-
fan, anticonvulsants, carbenicillin,
CRITICAL VALUES: cephalothin, chemotherapy, chlorate,
chloroquine, chlorothiazide, chlorpro-
Less than 6.0 g/dL mazine, colchicine, diphenhydra-
Greater than 18.0 g/dL mine, dipyrone, glucosulfone, gold,
Note and report critically increased or hydroflumethiazide, indomethacin,
decreased values and symptoms to the mephenytoin, nalidixic acid, neo-
health care practitioner: mycin, nitrofurantoin, penicillin,
• Severe hemodilution can lead to phenacemide, phenazopyridine,
cardiac failure and death. Symptoms of phenothiazines; and those that
hemodilution include rales, anxiety, result in anemia, such as micona-
restlessness, edema, hypertension, zole and penicillamine, phenylhy-
jugular venous distention, and short- drazine, primaquine, probenecid,
Hemoglobin 569
pyrazolones, pyrimethamine, quinines, corpuscular Hgb (MCH). This can be

streptomycin, sulfamethizole, sulfa- corrected by replacing the plasma with
methoxypyridazine, sulfisoxazole, saline, repeating the measurement, and
suramin, thioridazine, tolbutamide, manually correcting the Hgb, MCH,
trimethadione, and tripelennamine. and MCHC using specific mathemati-
cal formulas.
• Some drugs may also affect Hgb values
by increasing or decreasing the RBC
count (see monograph titled “Red
Blood Cell Count”). Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• The results of RBC counts may vary

depending on the patient’s position: Pretest:
Hct can decrease when the patient is
recumbent as a result of hemodilution
and can increase when the patient rises allergens.
as a result of hemoconcentration.
• Use of the neutraceutical liver extract is cardiovascular, gastrointestinal,
strongly contraindicated in iron- hematopoietic, hepatobiliary, im-
storage disorders, such as hemochro- mune, musculoskeletal, and respira-
matosis, because it is rich in heme (the tory systems, as well as results
iron-containing pigment in Hgb).
• A severe copper deficiency may result to the cardiovascular, gastrointesti-
in decreased Hgb levels. nal, hematopoietic, hepatobiliary,
immune, musculoskeletal, and respi-
• Cold agglutinins may falsely increase ratory system tables.
the mean corpuscular Hgb concentra- ➤ Obtain a list of the medications the
tion (MCHC) and decrease the RBC patient is taking, including herbs,
count, affecting Hgb values. This can nutritional supplements, and nutra-
be corrected by warming the blood or ceuticals. The requesting health care
replacing the plasma with warmed practitioner and laboratory should be
saline and repeating the analysis. advised if the patient regularly uses
• Leaving the tourniquet in place for can be taken into consideration
longer than 60 seconds can falsely when reviewing results.
increase levels by 2 to 5 percent. ➤ Note any recent procedures that can
• Failure to fill the tube sufficiently (i.e., interfere with test results.
tube less than three-quarters full) may ➤ There are no food, fluid, or medica-
yield inadequate sample volume for tion restrictions unless by medical
automated analyzers and may be direction.
reason for specimen rejection. ➤ Review the procedure with the
patient.
• Clotted specimens must be rejected for
analysis. ➤ Inform the patient that specimen
• Care should be taken in evaluating the 10 minutes.
Hct during the first few hours after
transfusion or acute blood loss because Intratest:
the value may appear to be normal.
• Lipemia will falsely increase the Hgb normally and to avoid unnecessary
measurement, also affecting the mean movement.
corpuscular volume (MCV) and mean ➤ Observe standard precautions and
follow the general guidelines in ing or hematoma formation. Apply

Appendix A. Perform a venipuncture, pressure bandage.
➤ Nutritional therapy may be indicated
lavender-top (EDTA) tube. An EDTA
for patients with decreased Hct. Iron
Microtainer sample may be obtained
deficiency is the most common
from infants, children, and adults for
nutrient deficiency in the United
whom venipuncture may not be
States. Patients at risk (e.g., chil-
dren, pregnant women and women
mixed gently by inverting the tube 10
of childbearing age, low-income
times. It is stable when stored for up
populations) should be instructed to
to 6 hours at room temperature or
include foods that are high in iron in
24 hours if stored refrigerated. In
their diet, such as meats (especially
addition, if it is anticipated that the
liver), eggs, grains, vegetables, and
multivitamins with iron. Iron absorp-
4 to 6 hours, two blood smears
tion is affected by numerous factors
should be made immediately after
(see monograph titled “Iron”).
the venipuncture and submitted with
the blood sample. ➤ Evaluate test results in relation to
➤ Label the specimen, and promptly the patient’s symptoms and other
transport it to the laboratory. tests performed. Related laboratory
tests include CBC, erythropoietin,
Post-test: ferritin, iron/total iron-binding capac-
ity, peripheral blood smear, and retic-
➤ Observe venipuncture site for bleed- ulocyte count.
HEMOGLOBIN ELECTROPHORESIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: N/A
REFERENCE VALUE: (Method: Electrophoresis)
Hgb A
Adult Greater than 95%
Hgb A2
Adult 1.5–3.7%
Hemoglobin Electrophoresis 571
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%
DESCRIPTION: Hemoglobin (Hgb) Hyperthyroidism

electrophoresis is a separation process Leakage of fetal blood into
used to identify normal and abnormal maternal circulation
forms of Hgb. Hgb A is the main Leukemia (acute or chronic)
form of Hgb in the normal adult. Myeloproliferative disorders
Hgb F is the main form of Hgb in the Sickle cell disease
fetus, the remainder being composed Thalassemias
of Hgb A1 and A2. Small amounts of
• -Chain substitutions:
Hgb F are normal in the adult. Hgb
Hgb C (second most common
D, E, H, S, and C result from abnor-
variant in the United States, it
mal amino acid substitutions during has a higher prevalence among
the formation of Hgb and are inher- African-Americans):
ited hemoglobinopathies. ■ • Hgb C disease
Hgb D (rare hemoglobinopathy that
INDICATIONS: may also be found in
• Assist in the diagnosis of Hgb C disease combination with Hgb S or
thalassemia):
• Assist in the diagnosis of thalassemia,
• Splenomegaly without other
especially in patients with a family
significant clinical implications
history positive for the disorder
Hgb E (second most common
• Differentiate among thalassemia types hemoglobinopathy in the world,
• Evaluate hemolytic anemia of occurs with the highest
unknown cause frequency in Southeast Asians
and African-Americans):
• Evaluate a positive sickle cell screening • Thalassemia-like condition
test to differentiate sickle cell trait from Hgb S (most common variant in
sickle cell disease the United States, occurs with a
frequency of about 8 percent
RESULT among African-Americans):
• Sickle cell trait or disease
Increased:
• Hgb A2: • -Chain substitutions:
Megaloblastic anemia Hgb H:
Thalassemias • Thalassemias
Bart’s Hgb:
• Hgb F: • Thalassemias
Acquired aplastic anemia • Hgb Bart’s hydrops fetalis
Hereditary persistence of fetal Hgb syndrome
Decreased: care practitioner and laboratory

• Hgb A2: regularly using these products so
Erythroleukemia: that their effects can be taken
• Hgb H disease into consideration when reviewing
• Iron-deficiency anemia (un- results.
treated) ➤ Note any recent procedures that can
• Sideroblastic anemia interfere with test results.
direction.
• High altitude and dehydration may patient. Sensitivity to cultural and
increase values. social issues is important in provid-
ing psychological support.
• Iron deficiency may decrease Hgb A2, ➤ Inform the patient that specimen
C, and S. collection takes approximately 5 to
• In patients less than 3 months of age, 10 minutes.
false-negative results for Hgb S occur
in coincidental polycythemia. Intratest:
• Red blood cell transfusion within 4 ➤ Direct the patient to breathe
months of test can mask abnormal normally and to avoid unnecessary
movement.
Hgb levels.
Procedure ● ● ● ● ● ● ● ● ● ● ● lavender-top tube.
hematopoietic system, as well as pressure bandage.
results of previously performed ➤ Evaluate test results in relation to
tests and procedures. For related the patient’s symptoms and other
tests, refer to the hematopoietic tests performed. Related laboratory
system table. tests include blood gases, complete
➤ Obtain a list of the medications blood count (including evaluation of
the patient is taking, including blood smear for RBC morphology),
herbs, nutritional supplements, and methemoglobin, and sickle cell
nutraceuticals. The requesting health screen.
Hemosiderin 573
HEMOSIDERIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Hemosiderin stain, Pappenheimer body stain, iron

stain.
SPECIMEN: Urine (5 mL) from a random first morning sample, collected in

a clean, plastic collection container.
REFERENCE VALUE: (Method: Microscopic examination of Prussian

blue–stained specimen) None seen.
DESCRIPTION: Hemosiderin stain is RESULT

used to indicate the presence of iron
storage granules called hemosiderin by Increased in:
microscopic examination of urine • Burns
sediment. Granules of hemosiderin • Cold hemagglutinin disease
stain blue when potassium ferro-
cyanide is added to the sample. • Hemochromatosis
Hemosiderin is normally found in the • Hemolytic transfusion reactions
liver, spleen, and bone marrow, but • Mechanical trauma to RBCs
not in the urine. Under normal
conditions, hemosiderin is absorbed • Megaloblastic anemia
by the renal tubules; however, in • Microangiopathic hemolytic anemia
extensive hemolysis, renal tubule
• Paroxysmal nocturnal hemoglobinuria
damage, or an iron metabolism disor-
der, hemosiderin filters its way into • Pernicious anemia
the urine. The Prussian blue stain • Sickle cell anemia
may also be used to identify sidero-
• Thalassemia major
cytes (iron-containing red blood cells
[RBCs]) in peripheral blood. The Decreased in: N/A
presence of siderocytes in circulating
RBCs is abnormal. ■ CRITICAL VALUES: N/A
INDICATIONS:
• Assist in the diagnosis of hemochro-
matosis (tissue damage caused by iron
toxicity) Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Detect excessive RBC hemolysis within

the systemic circulation Pretest:
• Evaluate renal tubule dysfunction ➤ Obtain a history of the patient’s
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.
care practitioner and laboratory Indwelling catheter:
➤ Put on gloves. Empty drainage tube
of urine. It may be necessary to
clamp off the catheter for 15 to 30
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.
10 minutes.
Post-test:
Intratest: ➤ Evaluate test results in relation to
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HAV serology.

REFERENCE VALUE: (Method: Enzyme immunoassay) Negative.
Hepatitis A Antibody 575
DESCRIPTION: The hepatitis A virus INTERFERING FACTORS: N/A

is classified as a picornavirus. Its
primary mode of transmission is by
the fecal-oral route under conditions Nursing Implications and
of poor personal hygiene or inade- Procedure ● ● ● ● ● ● ● ● ● ● ●
quate sanitation. The incubation

period is about 28 days, with a range Pretest:
of 15 to 50 days. Onset is usually ➤ Obtain a history of the patient’s
abrupt, with the acute disease lasting complaints, including a list of known
allergens.
about 1 week. Therapy is supportive
and there is no development of ➤ Obtain a history of the patient’s
hepatobiliary and immune systems,
chronic or carrier states. Assays for as well as results of previously
total (immunoglobulin G [IgG] and performed tests and procedures. For
IgM) hepatitis A antibody and IgM- related tests, refer to the hepatobil-
specific hepatitis A antibody assist in iary and immune system tables.
differentiating recent infection from ➤ Obtain a list of the medications the
prior exposure. If results from the patient is taking, including herbs,
IgM-specific or from both assays are ceuticals. The requesting health care
positive, recent infection is suspected. practitioner and laboratory should be
If the IgM-specific test results are advised if the patient regularly uses
negative and the total antibody test these products so that their effects
results are positive, past infection is
indicated. The clinically significant
assay—IgM-specific antibody—is tion restrictions unless by medical
often the only test requested. Jaundice direction.
occurs in 70 to 80 percent of adult ➤ Review the procedure with the
cases of HAV infection and in 70 patient.
percent of pediatric cases. ■ ➤ Inform the patient that specimen
10 minutes.
INDICATIONS:
• Screen individuals at high risk of expo-
sure, such as those in institutions or Intratest:
correctional facilities ➤ Direct the patient to breathe
• Screen individuals with suspected movement.
HAV infection
RESULT Appendix A. Perform a venipuncture,
Positive findings in: red- or tiger-top tube.
• Individuals with current hepatitis A ➤ Label the specimen, and promptly
infection transport it to the laboratory.
• Individuals with past hepatitis A infec- Post-test:

tion
➤ Dietary recommendations may be can be given before exposure (in the

indicated and will vary depending on case of individuals who may be trav-
the type and severity of the condi- eling to a location where the disease
tion. Elimination of alcohol ingestion is endemic) or after exposure, during
and a diet optimized for convales- the incubation period. Prophylaxis is
cence are commonly included in the most effective when administered 2
treatment plan. weeks after exposure.
➤ Recognize anxiety related to test ➤ Evaluate test results in relation to
results and offer support. Provide the patient’s symptoms and other
teaching and information regarding tests performed. Related laboratory
the clinical implications of the test tests include alanine aminotrans-
results, as appropriate. ferase, alkaline phosphatase, aspar-
tate aminotransferase, bilirubin,
➤ Counsel the patient, as appropriate, -glutamyl transpeptidase, and
regarding risk of transmission and hepatitis B and C antigens and anti-
proper prophylaxis. Immune globulin bodies.
HEPATITIS B, ANTIGEN AND

ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: HBeAg, HBeAb, HBcAb, HBsAb, HBsAg.

DESCRIPTION: The hepatitis B virus B surface antigen (HBsAg) is the first

(HBV) is classified as a double- marker to appear after infection. It is
stranded DNA retrovirus of the detectable 8 to 12 weeks after expo-
Hepadnaviridae family. Its primary sure and often precedes symptoms. At
modes of transmission are parenteral, about the time liver enzymes fall back
perinatal, and sexual contact. to normal levels, the HBsAg titer has
Serological profiles vary with differ- fallen to nondetectable levels. If the
ent scenarios (i.e., asymptomatic HBsAg remains detectable after 6
infection, acute/resolved infection, months, the patient will likely
coinfection, and chronic carrier become a chronic carrier who can
state). The formation and detectabil- transmit the virus. Hepatitis Be anti-
ity of markers is also dose dependent. gen (HBeAg) appears in the serum 10
The following description refers to to 12 weeks after exposure. HBeAg
HBV infection that becomes can be found in the serum of patients
resolved. The incubation period is with acute or chronic HBV infection
generally 6 to 16 weeks. The hepatitis and is a sign of active viral replication
Hepatitis B, Antigen and Antibody 577
and infectivity. Levels of hepatitis Be partners, persons with a history of

antibody (HBeAb) appear about 14 other sexually transmitted diseases,
weeks after exposure, suggesting reso- intravenous drug abusers, infants born
lution of the infection and reduction to infected mothers, individuals resid-
of the patient’s ability to transmit the ing in institutions or correctional facil-
ities, recipients of blood- or plasma-
disease. The more quickly HBeAg
derived products, allied health care
disappears, the shorter the acute workers, and public service employees
phase of the infection. IgM-specific who come in contact with blood and
hepatitis B core antibody (HBcAb) blood products.
appears 6 to 14 weeks after exposure
to HBsAg and continues to be RESULT
detectable either until the infection is
resolved or over the life span in Positive findings in:
patients who are in a chronic carrier • Patients currently infected with HBV
state. In some cases HBcAb may be
the only detectable marker; hence its • Patients with a past HBV infection
lone appearance has sometimes
been referred to as the core window.
HBcAb is not an indicator of recovery INTERFERING FACTORS: Drugs that may
or immunity; however, it does decrease HBeAb and HBsAb include
indicate current or previous infec- interferon.
tion. Hepatitis B surface antibody
(HBsAb) appears 2 to 16 weeks after
HBsAg disappears. Appearance of Nursing Implications and
HBsAb represents clinical recovery Procedure ● ● ● ● ● ● ● ● ● ● ●
and immunity to the virus. Onset of

HBV infection is usually insidious. Pretest:
Most children and half of infected
adults are asymptomatic. During the complaints, including a list of known
acute phase of infection, symptoms allergens.
range from mild to severe. Chronicity ➤ Obtain a history of the patient’s
decreases with age. HBsAg and hepatobiliary and immune systems,
HBcAb tests are used to screen as well as results of previously
donated blood before transfusion. performed tests and procedures. For
related tests, refer to the hepatobil-
HBsAg testing is often part of the iary and immune system tables.
routine prenatal screen. ■ ➤ Obtain a history of intravenous drug
use, high-risk sexual activity, or
occupational exposure.
INDICATIONS: ➤ Obtain a list of the medications
• Detect exposure to HBV the patient is taking, including
• Detect possible carrier status herbs, nutritional supplements, and
• Screen donated blood before transfu- care practitioner and laboratory
sion should be advised if the patient is
• Screen for individuals at high risk that their effects can be taken
of exposure, such as hemodialysis into consideration when reviewing
patients, persons with multiple sex results.
➤ 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.
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.
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.
Hepatitis C Antibody 579
HEPATITIS C ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: HCV serology, hepatitis non-A/non-B.

REFERENCE VALUE: (Method: Enzyme immunoassay, branch DNA
[bDNA], polymerase chain reaction [PCR], recombinant immunoblot assay
[RIBA]) Negative.
DESCRIPTION: The hepatitis C virus ity of prenatal transmission exists,

(HCV) causes the majority of blood- especially in the presence of human
borne non-A, non-B hepatitis. Its immunodeficiency virus (HIV)
primary modes of transmission are coinfection. Therefore, this test is
parenteral, perinatal, and sexual often included in prenatal testing
contact. The virus is thought to be a packages. ■
flavivirus and contains a single-
stranded RNA core. The incubation INDICATIONS:
period varies widely, from 2 to 52 • Assist in the diagnosis of non-A, non-B
weeks. Onset is insidious, and the risk viral hepatitis infection
of chronic liver disease after infection • Monitor patients suspected of HCV
is high. On average, antibodies to infection but who have not yet
hepatitis C are detectable in approxi- produced antibody
mately 45 percent of infected individ- • Screen donated blood before transfu-
uals within 6 weeks of infection. The sion
remaining 55 percent produce anti-
bodies within the next 6 to 12 RESULT
months. Once infected with HCV, 50
percent of patients will become Positive findings in:
chronic carriers. Infected individuals • Patients currently infected with HCV
and carriers have a high frequency of • Patients with a past HCV infection
chronic liver diseases such as cirrhosis
and chronic active hepatitis, and they Negative findings in: N/A
have a higher risk of developing hepa-
tocellular cancer. The transmission CRITICAL VALUES: N/A
of hepatitis C by blood transfusion
has decreased dramatically since it INTERFERING FACTORS: Drugs that may
became part of the routine screening decrease hepatitis C antibody levels in-
panel for blood donors. The possibil- clude interferon.
the type and severity of the condi-

Nursing Implications and tion. Currently, for example, there
Procedure ● ● ● ● ● ● ● ● ● ● ● are no specific medications that can
➤ Obtain a history of the patient’s be given to cure hepatitis; however,
complaints, including a list of known bed rest, elimination of alcohol
allergens. ingestion, and a diet optimized
for convalescence are commonly
➤ Obtain a history of the patient’s included in the treatment plan. A
hepatobiliary and immune systems, high-calorie, high-protein, moderate-
as well as results of previously fat diet with a high fluid intake is
performed tests and procedures. For often recommended for patients
related tests, refer to the hepatobil- with hepatitis.
iary and immune system tables.
➤ Recognize patient anxiety related to
➤ Obtain a history of intravenous drug test results and offer support.
use, high-risk sexual activity, or Provide teaching and information
occupational exposure. regarding the clinical implications of
➤ Obtain a list of the medications the the test results, as appropriate.
patient is taking, including herbs, Counsel the patient, as appropriate,
nutritional supplements, and nutra- regarding the risk of transmission
ceuticals. The requesting health care and proper prophylaxis. Alpha inter-
practitioner and laboratory should be feron was approved in 1991 by the
advised if the patient is regularly U.S. Food and Drug Administration
using these products so that their (FDA) for use as a therapeutic agent
effects can be taken into considera- in the treatment of chronic HCV
tion when reviewing results. infection.
➤ There are no food, fluid, or medica- ➤ Inform the patient that positive find-
tion restrictions unless by medical ings must be reported to local health
direction. department officials, who will ques-
➤ Review the procedure with the tion him or her regarding sexual part-
patient. ners.
➤ Inform the patient that specimen ➤ Offer support, as appropriate, to
collection takes approximately 5 to patients who may be the victims of
10 minutes. rape or other forms of sexual assault
including children and elderly individ-
Intratest: uals. Educate the patient regarding
access to counseling services.
➤ Direct the patient to breathe Provide a nonjudgmental, nonthreat-
normally and to avoid unnecessary ening atmosphere for a discussion
movement. during which risks of sexually trans-
➤ Observe standard precautions and mitted diseases are explained. It is
follow the general guidelines in also important to discuss problems
Appendix A. Perform a venipuncture, the patient may experience (e.g.,
and collect the specimen in a 5-mL guilt, depression, anger) if test
red- or tiger-top tube. results indicate the presence of
➤ Label the specimen, and promptly hepatitis C antibodies.
transport it to the laboratory. ➤ Evaluate test results in relation to
Post-test: tests performed. Related laboratory
tests include alanine aminotrans-
➤ Observe venipuncture site for bleed- ferase, alkaline phosphatase, aspar-
ing or hematoma formation. Apply tate aminotransferase, bilirubin, liver
pressure bandage. biopsy, -glutamyl transpeptidase,
➤ Dietary recommendations may be HIV serology, and hepatitis B serol-
indicated and will vary depending on ogy.
Hepatitis D Antibody 581
HEPATITIS D ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Delta hepatitis.

REFERENCE VALUE: (Method: Enzyme immunoassay, EIA) Negative.
DESCRIPTION: Symptoms of hepati- • Individuals with a past HDV infection

tis D virus (HDV) infection are simi-
lar but often more severe than those CRITICAL VALUES: N/A
of hepatitis B virus (HBV) infection.
As with HBV, the primary modes of INTERFERING FACTORS: Drugs that may
HDV transmission are parenteral, decrease hepatitis D antibody levels
perinatal, and sexual contact. The include interferon.
virus contains a single-stranded RNA
core. In order to replicate, it requires
the presence of the hepatitis B outer Nursing Implications and
coat. Therefore, HDV infection can Procedure ● ● ● ● ● ● ● ● ● ● ●
only occur with hepatitis B coinfec-

tion or superinfection. Onset is Pretest:
abrupt, after an incubation period of ➤ Obtain a history of the patient’s
3 to 13 weeks. Because of its depend- complaints, including a list of known
ence on HBV, prevention can be allergens.
accomplished by using the same pre- ➤ Obtain a history of the patient’s
exposure and postexposure protective hepatobiliary and immune systems,
measures used for HBV (see mono- performed tests and procedures. For
graph titled “Hepatitis B, Antigen related tests, refer to the hepatobil-
and Antibody.”) ■ iary and immune system tables.
➤ Obtain a history of intravenous drug
INDICATIONS: Establish the presence of use, high-risk sexual activity, or
coinfection or superinfection in patients occupational exposure.
with HBV (clinical course of superinfec- ➤ Obtain a list of the medications the
tion is more severe) patient is taking, including herbs,
RESULT ceuticals. The requesting health care
advised if the patient is regularly
Positive findings in: using these products so that their
• Individuals currently infected with effects can be taken into considera-
HDV tion when reviewing results.
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Hepatobiliary imaging, biliary tract radionuclide

scan, hepatobiliary scintigraphy, gallbladder scan, cholescintigraphy, HIDA
(a technetium-99m disopropyl analogue) scan.
AREA OF APPLICATION: Bile ducts.

CONTRAST: Intravenous contrast medium (aminodiacetic acid compounds),
usually combined with technetium-99m.
Hepatobiliary Scan 583
DESCRIPTION: The hepatobiliary • Postoperatively evaluate gastric surgical

scan is a nuclear medicine study of the procedures and abdominal trauma
hepatobiliary excretion system. It is
primarily used to determine the RESULT
patency of the cystic and common
bile ducts, but it can also be used to Normal Findings:
determine overall hepatic function, • Normal shape, size, and function of the
gallbladder function, presence of gall- gallbladder with patent cystic and
stones (indirectly), and sphincter of common bile ducts
Oddi dysfunction. Technetium (Tc-
Abnormal Findings:
99m) HIDA (tribromoethyl, an
• Acalculous cholecystitis
aminodiacetic acid) is injected intra-
venously (IV) and excreted into the • Acute cholecystitis
bile duct system. A gamma camera • Chronic cholecystitis
detects the radiation emitted from the
injected contrast medium, and a • Common bile duct obstruction
secondary to gallstones, tumor, or stric-
representative image of the duct
ture
system is obtained. The results are
correlated with other diagnostic stud- • Congenital biliary atresia or chole-
ies, such as IV cholangiography, dochal cyst
computed tomography (CT) scan of • Postoperative biliary leak, fistula, or
the gallbladder, and ultrasonography. obstruction
Gallbladder emptying or ejection • Trauma-induced bile leak or cyst
fraction can be determined by
administering a fatty meal or chole-
cystokinin to the patient. This
procedure can be used before and
after surgery to determine the extent INTERFERING FACTORS:
of bile reflux. ■
for:
• Aid in the diagnosis of suspected gall- of being pregnant, unless the potential
bladder disorders, such as inflamma- benefits of the procedure far outweigh
tion, perforation, or calculi the risks to the fetus and mother
• Aid in the diagnosis of acute and
chronic cholecystitis imaging:
• Determine common duct obstruction • Inability of the patient to cooperate or
caused by tumors or choledocholi- remain still during the procedure
thiasis because of age, significant pain, or
mental status
• Evaluate biliary enteric bypass patency
• Assess obstructive jaundice when done
in combination with radiography or
ultrasonography
• Assess enterogastric reflux poor-quality study
• 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-
• Incorrect positioning of the patient, badges that reveal their level of expo-
which may produce poor visualization sure to radiation.
ologic procedure Nursing Implications and
• Metallic objects within the examina- Procedure ● ● ● ● ● ● ● ● ● ● ●

which may inhibit organ visualization Pretest:
and can produce unclear images ➤ Inform the patient that the proce-
dure detects inflammation or
• Bilirubin levels greater than or equal to
obstruction of the gallbladder or bile
30 mg/dL, depending on the radionu- duct system.
clide used, which may decrease hepatic
uptake
• Other nuclear scans done within the nuclear medicine department by a
previous 24 to 48 hours technologist and usually takes
approximately 60 to 90 minutes, and
• Fasting for more than 24 hours before that delayed images are needed up
the procedure, total parenteral nutri- to 24 hours after the initial injection.
tion, and alcoholism The patient may leave the depart-
ment and return later to undergo
• Ingestion of food or liquids within 2 to delayed imaging.
4 hours before the scan ➤ Obtain a history of the patient’s
Other considerations: allergens.
• Failure to follow dietary restrictions ➤ Obtain a history of the patient’s gall-
before the procedure may cause the bladder and hepatobiliary systems,
performed tests, treatments, surger-
• Improper injection of the radionuclide ies, and procedures. For related
that allows the tracer to seep deep into tests, refer to the hepatobiliary
the muscle tissue can produce erro- system table.
neous hot spots. ➤ Obtain a list of the medications the
patient is taking.
• Inaccurate timing of imaging after the ➤ Determine date of last menstrual
radionuclide injection can affect the period and possibility of pregnancy
results. in perimenopausal women.
• Consultation with a physician should ➤ Inform the patient that the technolo-
occur before the procedure for radia- gist will place him or her in a supine
tion safety concerns regarding infants position on a flat table for the injec-
tion.
➤ Ask the patient to lie very still during
• Risks associated with radiographic the procedure because movement
overexposure can result from frequent will produce unclear images.
x-ray procedures. Personnel in the ➤ Ensure that the patient fasted for 4
room with the patient should wear a to 6 hours before the scan, unless
protective lead apron, stand behind a otherwise indicated.
Her-2/Neu Oncoprotein 585
Intratest: ➤ Wear gloves during the radionuclide

administration and while handling
➤ Ask the patient to void before the the patient’s urine.
hospital gown.
Post-test:
an uncooperative adult, as ordered. ➤ Instruct the patient to resume
normal activity, medications,
➤ Ask the patient to lie still during the
and diet, unless otherwise indi-
procedure because movement
cated.
sure jewelry, watches, chains, belts, ➤ Advise patient to drink increased
and any other metallic objects have amounts of fluids for 24 to 48 hours
been removed. to eliminate the radionuclide from
the body, unless contraindicated. Tell
on a flat table with foam wedges to
nated from the body within 6 to 24
help maintain position and immobi-
hours.
lization.
➤ Inform the patient to immediately
➤ IV radionuclide is administered, and
flush the toilet after each voiding
the upper-right quadrant of the
after the procedure and to meticu-
abdomen is scanned immediately
lously wash hands with soap and
with images taken every 5 minutes
for the first 30 minutes and every 10
minutes for the next 30 minutes.
Delayed views are taken in 2, 4, and ➤ Tell all caregivers to wear gloves
24 hours if the gallbladder cannot be when discarding urine for 24 hours
visualized, in order to differentiate after the procedure. Wash gloved
acute from chronic cholecystitis or to hands with soap and water before
detect the degree of obstruction. removing gloves. Then wash
➤ IV morphine may be administered ungloved hands after the gloves are
during the study to initiate spasms removed.
of the sphincter of Oddi, forcing the ➤ A physician specializing in this
radionuclide into the gallbladder if branch of medicine sends a written
the organ is not visualized within 1 report to the ordering health care
hour of injection of the radionuclide. provider, who discusses the results
Imaging is then done 20 to 50 with the patient.
minutes later to determine delayed ➤ Evaluate test results in relation to
visualization or nonvisualization of the patient’s symptoms and other
the gallbladder. tests performed. Related diagnostic
➤ If gallbladder function or bile reflux is tests include ultrasound of the
being assessed, the patient will be liver and bile ducts, and CT and
given a fatty meal or cholecystokinin magnetic resonance imaging of the
60 minutes after the injection. abdomen.
HER-2/NEU ONCOPROTEIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: c-erb-B2.
SPECIMEN: Breast tissue or cells.
REFERENCE VALUE: (Method: Immunocytochemical) Negative.
DESCRIPTION: Breast cancer is the Nursing Implications and

most common newly diagnosed Procedure ● ● ● ● ● ● ● ● ● ● ●
cancer in American women. It is the

Pretest:
second leading cause of cancer-related
death. The presence of abnormal ➤ Obtain a history of the patient’s
amounts of a protein called human complaints, including a list of known
allergens.
epidermal growth factor receptor 2
(HER-2/neu oncoprotein) is helpful
in establishing histologic evidence of as well as results of previously
metastatic breast cancer. Over- performed tests and procedures.
expression of this protein results from For related tests, refer to the
an acquired genetic mutation and immune and reproductive system
tables.
occurs in 25 to 30 percent of patients
with metastatic breast cancer.
Metastatic breast cancer patients with nutritional supplements, and
high levels of HER-2/neu oncopro- nutraceuticals. The requesting
tein have a poor prognosis: They have health care practitioner and labora-
rapid tumor progression, increased tory should be advised if the patient
rate of recurrence, poor response to that their effects can be taken into
standard therapies, and a lower consideration when reviewing
survival rate. results.
The specimen is collected by fine- ➤ There are no food, fluid, or medica-
needle or open biopsy. The tissue tion restrictions before fine-needle
sample is treated with a material that biopsy unless by medical direction;
however, food and fluids are
binds to HER-2/neu oncoprotein. A restricted for at least 12 hours
dye is added to the tissue sample; before an open biopsy.
areas of tissue that have large ➤ Review the procedure with the
amounts of HER-2/neu oncoprotein patient. Sensitivity to cultural and
are indicated by high-intensity color social issues, as well as concern for
on the tissue sample. ■ modesty, is important in providing
➤ Address concerns about pain
INDICATIONS: Evidence of breast lesion related to the procedure, and
by palpation, mammography, or ultra- explain that a sedative may be
sound administered to promote relaxation
RESULT ➤ Assess whether the patient has an
allergy to local anesthetics, and
Positive findings in: Breast cancer inform the health care practitioner
accordingly.
➤ Ensure that nonallergy to anesthesia
CRITICAL VALUES: N/A is confirmed before open biopsy
procedure is performed under
INTERFERING FACTORS: N/A general anesthesia.
Hexosaminidase A and B 587
➤ Obtain written and informed Post-test:

medications prior to the procedure. ➤ If the patient has undergone open
biopsy, monitor vital signs and
➤ Prophylactic antibiotics may be compare to baseline values.
administered before or after the
procedure in certain cases. ➤ Instruct the patient to resume usual
➤ Inform the patient that specimen diet and medication, if withheld, as
collection takes approximately 20 to directed by the health care practi-
30 minutes. tioner.
➤ Instruct the patient in proper cleans-
Intratest: ing of the site and of the importance
of a follow-up appointment for
➤ Observe standard precautions and suture removal, as appropriate.
Appendix A. ➤ Instruct the patient to report exces-
sive bleeding, redness, edema, or
Open biopsy: pain at the biopsy site.
➤ Record baseline vital signs. Ensure ➤ Administer analgesics and antibi-
that the patient is in compliance with otics as ordered, and instruct the
pretesting dietary restrictions before patient in the importance of
open biopsy. The specimen is completing the entire course of
obtained by surgical excision. antibiotic therapy, if prescribed, even
if no symptoms are present.
Needle biopsy:
➤ Instruct and educate the patient
➤ Assist the patient into a supine posi- regarding monthly breast self-
tion and cleanse the area undergo- examination, and emphasize, as
ing biopsy with an antiseptic. The appropriate, the importance of
local anesthetic is injected, and the having a mammogram performed
biopsy site is protected with sterile annually.
drapes. Direct the patient to breathe
normally and to avoid unnecessary ➤ Recognize anxiety related to test
movement. A needle is inserted into results and offer support. Provide
the mass, and tissue and fluid are teaching and information regarding
aspirated. the clinical implications of the test
General: patient regarding access to counsel-
ing services.
➤ Apply a sterile dressing to the site.
➤ Place the specimen in the appropri- the patient’s symptoms and other
ate containers. tests performed. Related laboratory
➤ Label the specimen, indicating loca- tests include breast biopsy, CA
tion (especially left or right), and 15-3, carcinoembryonic antigen, and
promptly transport it to the labora- estrogen and progesterone recep-
tory. tors.
HEXOSAMINIDASE A AND B
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Serum (3 mL) collected in a red-top tube. After the specimen is

collected it must be brought immediately to the laboratory. The specimen
must be allowed to clot for 1 to 1.5 hours in the refrigerator. The serum
should be removed and frozen immediately.
REFERENCE VALUE: (Method: Fluorometry)
Total 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)
Tay-Sachs 0 nmol/h/mL 0 U/L
homozygote
SI Units
Hexosaminidase B Conventional Units (Conversion Factor 0.0167)
Tay-Sachs Greater than Greater than 5.09 U/L
homozygote 305 nmol/h/mL
DESCRIPTION: Hexosaminidase is a trait have no hexosaminidase A and

lysosomal enzyme. There are three have greatly elevated levels of
predominant isoenzymes: hexos- hexosaminidase B; signs and symp-
aminidase A, B, and S. Deficiency toms include red spot in the retina,
results in the accumulation of blindness, and muscular weakness.
complex sphingolipids and ganglio- Tay-Sachs disease results in early
sides in the brain. There are more death, usually by age 3 or 4 years. ■
than 70 lysozymal enzyme disorders.
Testing for hexosaminidase A is done INDICATIONS:
• Assist in the diagnosis of Tay-Sachs
to determine the presence of Tay-
disease
Sachs disease, a genetic autosomal-
recessive condition characterized by • Identify carriers with hexosaminidase
early and progressive retardation of deficiency
physical and mental development.
RESULT
This enzyme deficiency is most
common among Ashkenazic Jews. Increased in:
Patients who are homozygous for this • Total
Hexosaminidase A and B 589
Gastric cancer nutritional supplements, and nutra-

Hepatic disease ceuticals. The requesting health care
Myeloma advised if the patient regularly uses
Myocardial infarct these products so that their effects
Pregnancy can be taken into consideration
Symptomatic porphyria when reviewing results.
Vascular complications of diabetes ➤ There are no food, fluid, or medica-
• Hexosaminidase A direction.
Diabetes ➤ Review the procedure with the
Pregnancy patient. Sensitivity to cultural and
social issues is important in provid-
• Hexosaminidase B ing psychological support.
Tay-Sachs disease ➤ Inform the patient that specimen
Decreased in: 10 minutes.
• Total
Intratest:
Sandhoff’s disease
• Hexosaminidase A normally and to avoid unnecessary
Tay-Sachs disease movement.
• Hexosaminidase B ➤ Observe standard precautions and
Sandhoff’s disease
CRITICAL VALUES: N/A red-top tube.
INTERFERING FACTORS: Drugs that may transport it to the laboratory.
increase hexosaminidase levels include
ethanol, isoniazid, oral contraceptives, Post-test:
and rifampin.
pressure bandage.
Procedure ● ● ● ● ● ● ● ● ● ● ● results and offer support. Provide
Pretest: the clinical implications of the test
results, as appropriate. Encourage
➤ Obtain a history of the patient’s the family to seek genetic counsel-
complaints, including a list of known ing if results are abnormal. It is also
allergens. important to discuss feelings the
➤ Obtain a history of the patient’s mother and father may experience
reproductive system and results of (e.g., guilt, depression, anger) if
previously performed tests and abnormalities are detected.
procedures. For related tests, refer ➤ Evaluate test results in relation to
to the reproductive system table. the patient’s symptoms and other
➤ Obtain a list of the medications the tests performed. A related labora-
patient is taking, including herbs, tory test is chromosomal analysis.
HOLTER MONITOR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Holter electrocardiography, ambulatory monitor-

ing, ambulatory electrocardiography, event recorder.

CONTRAST: None.
DESCRIPTION: The Holter monitor rhythmic medications for dosage

records electrical cardiac activity on a adjustment, if needed
continuous basis for 24 to 48 hours. • Monitor for ischemia and arrhythmias
This noninvasive study includes the after myocardial infarction or cardiac
use of a portable device worn around surgery before changing rehabilitation
the waist or over the shoulder that and other therapy regimens
records cardiac electrical impulses on • Evaluate pacemaker function
a magnetic tape. The recorder has a
clock that allows accurate time mark- • Evaluate chest pain, dizziness, syncope,
and palpitations
ings on the tape. The patient is asked
to keep a log or diary of daily activi- • Evaluate activity intolerance related
ties and to record any occurrence of to oxygen supply and demand imbal-
cardiac symptoms. When the client ance
pushes a button indicating that symp-
toms (e.g., pain, palpitations, dysp-
RESULT
nea, syncope) have occurred, an event Normal Findings:
marker is placed on the tape for later • Normal sinus rhythm
comparison with the cardiac activity
recordings and the daily activity log. Abnormal Findings:
Some recorders allow the data to be • Cardiomyopathy
transferred to the physician’s office by • Arrhythmias such as premature
telephone, where the tape is inter- ventricular contractions, bradyarrhyth-
preted by a computer to detect any mias, tachyarrhythmias, conduction
significantly abnormal variations in defects, bradycardia
the recorded waveform patterns. ■
• Hypoxic or ischemic changes
INDICATIONS: • Mitral valve abnormality
• Detect arrhythmias that occur during
• Palpitations
normal daily activities, and correlate
them with symptoms experienced by
the patient
• Evaluate the effectiveness of antiar- INTERFERING FACTORS:
Holter Monitor 591
Factors that may impair the tivity, bowel or urinary elimination,

results of the examination: cigarette smoking, emotional up-
• Improper placement of the electrodes sets, and medications, and to record
or movement of the electrodes them in an activity log.
➤ Instruct the patient to wear loose-
• Failure of the patient to maintain a fitting clothing over the electrodes
daily log of symptoms or to push the and not to disturb or disconnect the
button to produce a mark on the strip electrodes or wires.
when experiencing a symptom ➤ Ensure that the skin where elec-
trodes will be placed is cleansed
with an alcohol wipe.
Nursing Implications and ➤ Instruct the patient regarding record-
ing and pressing the button upon
Procedure ● ● ● ● ● ● ● ● ● ● ●
experiencing pain or discomfort.
Pretest: ➤ Advise the patient to report a light
signal on the monitor, which indi-
➤ Inform the patient that the proce- cates equipment malfunction or that
dure evaluates how the heart an electrode has come off.
responds to normal activity or to a
medication regimen.
Intratest:
➤ Explain that no electricity is deliv-
ered to the body during this proce- ➤ Ask the patient to void before the
dure and that no discomfort is procedure. Have the patient put on a
experienced during monitoring. hospital gown.
➤ Obtain a history of cardiac disease ➤ Place the patient in a supine posi-
and present cardiovascular status tion.
as well as results of previously ➤ Expose the chest; cleanse the skin
performed tests and procedures. For sites thoroughly with alcohol and rub
related tests, refer to the cardiovas- until red in color.
cular system table.
➤ Shave excessive hair at sites and
➤ Determine previous abnormalities in apply electropaste to the skin sites
laboratory tests and diagnostic to provide conduction between the
procedures. skin and electrodes, or apply disk
➤ Obtain a list of the medications electrodes that are prelubricated and
the patient is taking, including disposable.
herbs, nutritional supplements, and ➤ Apply two electrodes on the
nutraceuticals. manubrium (negative electrodes),
➤ Inform the patient that the electro- one in the V1 position (fourth inter-
cardiography (ECG) recorder is worn costal space at the border of the
for 24 to 48 hours, at which time the right sternum), and one at the V5
patient is to return to the laboratory position (level of the fifth intercostal
with an activity log to have the moni- space at the midclavicular line, hori-
tor and strip removed for interpreta- zontally and at the left axillary line). A
tion. ground electrode is also placed and
➤ Advise the patient to avoid contact secured to the skin of the chest or
with electrical devices that can abdomen.
affect the strip tracings (e.g., ➤ After checking to ensure that the
shavers, toothbrush, massager, blan- electrodes are secure, attach the
ket) and to avoid showers and tub electrode cable to the monitor
bathing. and the lead wires to the elec-
➤ Instruct the patient to perform nor- trodes.
mal activities, such as walking, ➤ Check the monitor for paper supply
sleeping, climbing stairs, sexual ac- and battery, insert the tape, and
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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.
REFERENCE VALUE: (Method: Chromatography) Homocysteine 8 to 20

mol/L; methylmalonic acid 80 to 560 mol/L.
DESCRIPTION: Homocysteine is an levels damage the endothelial lining

amino acid formed from methionine. of blood vessels; change coagulation
Normally homocysteine is rapidly factor levels, increasing the risk
remetabolized in a biochemical path- of blood clot formation; prevent
way that requires vitamin B12 and smaller arteries from dilating, increas-
folate, preventing the buildup of ing the risk of plaque formation;
homocysteine in the blood. Excess cause platelet aggregation; and cause
Homocysteine and Methylmalonic Acid 593
smooth muscle cells lining the arterial Increased in:

wall to multiply, promoting athero- • Chronic renal failure
sclerosis. • Folic acid deficiency
Approximately one-third of
patients with hyperhomocysteinuria • Homocystinuria
have normal fasting levels. Patients • Vitamin B12 deficiency
with a heterozygous biochemical • Coronary artery disease
enzyme defect in cystathionine B
synthase or with a nutritional defi- Decreased in: N/A
ciency in vitamin B6 can be identified
through the administration of a CRITICAL VALUES: N/A
methionine challenge or loading test.
Specimens are collected while fasting
• Drugs that may increase plasma homo-
and 2 hours later. An increase in cysteine levels include anticonvulsants,
homocysteine after 2 hours is indica- cycloserine, hydralazine, isoniazid,
tive of hyperhomocysteinuria. In methotrexate, theophylline, penicil-
patients with vitamin B12 deficiency, lamine, and phenelzine.
elevated levels of methylmalonic acid
• Specimens should be kept at a refriger-
and homocysteine develop fairly early ated temperature and delivered imme-
in the course of the disease. Unlike diately to the laboratory for processing.
vitamin B12 levels, homocysteine
levels will remain elevated for at least
24 hours after the start of vitamin Nursing Implications and
therapy. This may be useful if Procedure ● ● ● ● ● ● ● ● ● ● ●
vitamin therapy is inadvertently

begun before specimen collection. Pretest:
Patients with folate deficiency, for ➤ Obtain a history of the patient’s
the most part, will only develop complaints, including a list of known
elevated homocysteine levels. Hyper- allergens.
homocysteinemia due to folate ➤ Obtain a history of the patient’s
deficiency in pregnant women is cardiovascular and hematopoietic
believed to increase the risk of neural ously performed tests and proce-
tube defects. Elevated levels of homo- dures. For related tests, refer to the
cysteine are thought to chemically cardiovascular and hematopoietic
damage the exposed neural tissue of system tables.
the developing fetus. ■ ➤ Obtain a list of the medications
INDICATIONS: herbs, nutritional supplements, and
• Evaluate inherited enzyme deficiencies
that result in homocystinuria should be advised if the patient
• Evaluate the risk for cardiovascular regularly uses these products so
disease that their effects can be taken into
• Evaluate the risk for venous throm- results.
bosis ➤ There are no food, fluid, or medica-
RESULT direction.
➤ Review the procedure with the disease. If overweight, these

patient. patients should be encouraged to
➤ Inform the patient that specimen achieve a normal weight. The
collection takes approximately 5 to American Heart Association has
10 minutes. Step 1 and Step 2 diets that may be
helpful in achieving a goal of lower-
Intratest: ing total cholesterol and triglyceride
levels. The Step 1 diet emphasizes a
➤ Direct the patient to breathe reduction in foods high in saturated
normally and to avoid unnecessary fats and cholesterol. Red meats,
movement. eggs, and dairy products are the
➤ Observe standard precautions and major sources of saturated fats and
follow the general guidelines in cholesterol. If triglycerides are also
Appendix A. Perform a venipuncture, elevated, patients should be advised
and collect the specimen for to eliminate or reduce alcohol and
combined methylmalonic acid and simple carbohydrates from their
homocysteine studies in two 5-mL diet. The Step 2 diet recommends
red-, tiger-, or lavender-top tubes. If stricter reductions.
only homocysteine is to be meas-
➤ Diets rich in fruits, grains, and cere-
ured, a 5-mL red-, tiger-, or lavender-
als, in addition to a multivitamin
top tube is acceptable.
containing B12 and folate, may be
➤ Label the specimen, and promptly recommended for patients with
transport it to the laboratory. elevated homocysteine levels.
Processed and refined foods should
Post-test: be kept to a minimum.
➤ Observe venipuncture site for bleed- ➤ Evaluate test results in relation to
ing or hematoma formation. Apply the patient’s symptoms and other
pressure bandage. tests performed. Related laboratory
➤ Increased homocysteine levels may tests include C-reactive protein,
be associated with atherosclerosis complete blood count, creatine
and coronary artery disease. Nutri- kinase and isoenzymes, folate,
tional therapy is recommended for lactate dehydrogenase and isoen-
individuals identified to be at high zymes, myoglobin, troponin, and
risk for developing coronary artery vitamin B12.
HOMOVANILLIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HVA.
tic collection container with 6N HCl as a preservative.
REFERENCE VALUE: (Method: Chromatography)

Homovanillic Acid 595

Homovanillic acid
3–6 y 1.4–4.3 mg/24 h 8–24 mol/24 h
7–10 y 2.1–4.7 mg/24 h 12–26 mol/24 h
11–16 y 2.4–8.7 mg/24 h 13–48 mol/24 h
Adult 1.4–8.8 mg/24 h 8–48 mol/24 h
Vanillylmandelic Acid
3–6 y 1.0–2.6 mg/24 h 5–13 mol/24 h
7–10 y 2.0–3.2 mg/24 h 10–16 mol/24 h
11–16 y 2.3–5.2 mg/24 h 12–26 mol/24 h
Adult 1.4–6.5 mg/24 h 7–33 mol/24 h
DESCRIPTION: Homovanillic acid CRITICAL VALUES: N/A

(HVA) is the main terminal metabo-
lite of dopamine. Vanillylmandelic INTERFERING FACTORS:
acid (VMA) is a major metabolite of • Drugs that may increase HVA levels
epinephrine and norepinephrine. include acetylsalicylic acid, disulfiram,
levodopa, pyridoxine, and reserpine.
Both of these tests should be evalu-
ated together for the diagnosis of • Drugs that may decrease HVA levels
neuroblastoma. Excretion may be include moclobemide.
intermittent; therefore, a 24-hour • All urine voided for the timed collec-
specimen is preferred. Creatinine is tion period must be included in the
usually measured simultaneously to collection or else falsely decreased
ensure adequate collection and to values may be obtained. Compare
calculate an excretion ratio of output records with volume collected
metabolite to creatinine. ■ to verify that all voids were included in
the collection.
INDICATIONS:
• Assist in the diagnosis of pheochromo-
cytoma, neuroblastoma, and ganglio- Nursing Implications and
blastoma Procedure ● ● ● ● ● ● ● ● ● ● ●
• Monitor the course of therapy Pretest:

Increased in: allergens.
• Ganglioblastoma ➤ Obtain a history of the patient’s
endocrine system and results of
• Neuroblastoma previously performed tests and
• Pheochromocytoma procedures. For related tests, refer
• Riley-Day syndrome ➤ Obtain a list of the medications the
Decreased in: nutritional supplements, and nutra-
• Schizotypal personality disorders ceuticals. The requesting health care
practitioner and laboratory should be refrigerated or kept on ice through-

advised if the patient regularly uses out the entire collection period. If an
these products so that their effects indwelling urinary catheter is in
can be taken into consideration place, the drainage bag must be
when reviewing results. kept on ice.
➤ If possible, and with medical direc- ➤ Begin the test between 6 and 8
tion, patients should withhold acetyl- a.m., if possible. Collect first voiding
salicylic acid, disulfiram, pyridoxine, and discard. Record the time the
and reserpine for 2 days before specimen was discarded as the
specimen collection. Levodopa beginning of the timed collection
should be withheld for 2 weeks period. The next morning, ask the
before specimen collection. patient to void at the same time the
➤ There are no food or fluid restrictions collection was started and add this
unless by medical direction. last voiding to the container.
➤ Review the procedure with the ➤ If an indwelling catheter is in place,
patient. Provide a nonmetallic urinal, replace the tubing and container
bedpan, or toilet-mounted collection system at the start of the collection
device. time. Keep the container system on
ice during the collection period, or
➤ Usually a 24-hour time frame for empty the urine into a larger
urine collection is ordered. Inform container periodically during the
the patient that all urine must be collection period; monitor to ensure
saved during that 24-hour period. continued drainage, and conclude
Instruct the patient not to void the test the next morning at the
directly into the laboratory collection same hour the collection was
container. Instruct the patient to begun.
avoid defecating in the collection
device and to keep toilet tissue out ➤ At the conclusion of the test,
of the collection device to prevent compare the quantity of urine with
contamination of the specimen. the urinary output record for the
Place a sign in the bathroom to collection; if the specimen contains
remind the patient to save all urine. less than what was recorded as
output, some urine may have been
➤ Instruct the patient to void all urine discarded, invalidating the test.
into the collection device and then to
pour the urine into the laboratory ➤ Label the specimen, and promptly
collection container. Alternatively transport it to the laboratory. Include
the specimen can be left in the on the label the amount of urine,
collection device for a health care test start and stop times, and inges-
staff member to add to the labora- tion of any foods or medications that
tory collection container. can affect test results.
➤ 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.
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.
Human Chorionic Gonadotropin 597
HUMAN CHORIONIC GONADOTROPIN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Chorionic gonadotropin, pregnancy test, HCG,

hCG, -HCG, -subunit HCG.

SI Units
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
DESCRIPTION: Human chorionic pregnancy; a low rate of change

gonadotropin (HCG) is a hormone between serial specimens is predictive
secreted by the placenta beginning 8 of a nonviable fetus. As assays
to 10 days after conception, which improve in sensitivity over time,
coincides with implantation of the ectopic pregnancies are increasingly
fertilized ovum. It stimulates secre- being identified before rupture.
tion of progesterone by the corpus HCG is used along with estriol and
luteum. HCG levels peak at 8 to 12 1-fetoprotein in prenatal screening
weeks of gestation and then fall to less for neural tube defects. These prena-
than 10 percent of first trimester tal measurements are also known as
levels by the end of pregnancy. By triple markers. Serial measurements
postpartum week 2, levels are unde- are needed for an accurate estimate of
tectable. HCG levels increase at a gestational stage and determination
slower rate in ectopic pregnancy and of fetal viability. Triple marker testing
spontaneous abortion than in normal has also been used to screen for neural
tube defects and trisomy 21 (Down Decreased in:

syndrome). (To compare HCG to • Ectopic pregnancy
other tests in the triple marker screen- • Incomplete abortion
ing procedure, see monograph titled
“1-Fetoprotein.”) HCG is also • Intrauterine fetal demise
produced by some germ cell tumors. • Spontaneous abortion
Most assays measure both the intact
• Threatened abortion
and free -HCG subunit, but if
HCG is to be used as a tumor marker, CRITICAL VALUES: N/A
the assay must be capable of detecting
both intact and free -HCG. ■ INTERFERING FACTORS:
• Drugs that may decrease HCG levels
INDICATIONS: include epostane and mifepristone.
• Assist in the diagnosis of suspected • Results may vary widely depending on
HCG-producing tumors, such as the sensitivity and specificity of the
choriocarcinoma, germ cell tumors of assay. Performance of test too early in
the ovary and testes, or hydatidiform pregnancy may cause false-negative
moles results. HCG is composed of an alpha
• Confirm pregnancy, assist in the diag- and a beta subunit. The structure of
nosis of suspected ectopic pregnancy, the alpha subunit is essentially identi-
or determine threatened or incomplete cal to the alpha subunit of follicle-
abortion stimulating hormone, luteinizing
hormone, and thyroid-stimulating
• Determine adequacy of hormonal hormone. The structure of the beta
levels to maintain pregnancy subunit differentiates HCG from the
• Monitor effects of surgery or other hormones. False-positive results
chemotherapy can therefore be obtained if the HCG
assay does not detect beta subunit.
• Monitor ovulation induction treatment
• Prenatally detect neural tube defects
and trisomy 21 (Down’s syndrome) Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
RESULT
Pretest:
Increased in:
• 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-
• Erythroblastosis fetalis previously performed tests and
• Germ cell tumors (ovary and testes) to the endocrine, immune, and
• Hydatidiform mole reproductive system tables.
• Islet cell tumors patient is taking, including herbs,
• Multiple gestation pregnancy nutritional supplements, and nutra-
• Pregnancy practitioner and laboratory should be
Human Immunodeficiency Virus Type 1 and Type 2 Antibodies 599
advised if the patient regularly uses regarding elective abortion should

these products so that their effects take place in the presence of both
can be taken into consideration parents. Provide a nonjudgmental,
when reviewing results. nonthreatening atmosphere for
➤ There are no food, fluid, or medica- discussing the risks and difficulties
tion restrictions unless by medical of delivering and raising an abnormal
direction. infant, as well as exploring other
options (termination of pregnancy or
➤ Review the procedure with the adoption). It is also important to
patient. discuss feelings the mother and
➤ Inform the patient that specimen father may experience (e.g., guilt,
collection takes approximately 5 to depression, anger) if fetal abnormali-
10 minutes. ties are detected.
➤ Offer support, as appropriate, to
Intratest: patients who may be the victims of
rape or sexual assault. Educate the
➤ Direct the patient to breathe patient regarding access to counsel-
normally and to avoid unnecessary ing services. Provide a nonjudgmen-
movement. tal, nonthreatening atmosphere for a
➤ Observe standard precautions and discussion during which risks of
follow the general guidelines in sexually transmitted diseases are
Appendix A. Perform a venipuncture, explained. It is also important to
and collect the specimen in a 5-mL discuss problems the patient may
red- or tiger-top tube. experience (e.g., guilt, depression,
➤ Label the specimen, and promptly anger) if test results indicate the
transport it to the laboratory. presence of organisms responsible
for causing syphilis or if faced with
the possibility of pregnancy.
Post-test:
➤ In patients with carcinoma, recog-
➤ Observe venipuncture site for bleed- nize anxiety related to test results
ing or hematoma formation. Apply and offer support. Provide teaching
pressure bandage. and information regarding the clinical
➤ Recognize anxiety related to test implications of the test results, as
results, and encourage the family to appropriate. Educate the patient
seek counseling if concerned with regarding access to counseling serv-
pregnancy termination or to seek ices, as appropriate.
genetic counseling if a chromosomal ➤ Evaluate test results in relation to
abnormality is determined. Provide the patient’s symptoms and other
teaching and information regarding tests performed. Related laboratory
the clinical implications of the test tests include 1-fetoprotein and
results, as appropriate. Decisions progesterone.
HUMAN IMMUNODEFICIENCY VIRUS

TYPE 1 AND TYPE 2 ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HIV-1/HIV-2.

DESCRIPTION: Human immunodefi- INTERFERING FACTORS:

ciency virus (HIV) is the etiologic • Drugs that may decrease HIV anti-
agent of acquired immunodeficiency body levels include didanosine,
syndrome (AIDS) and is transmitted dideoxycytidine, zalcitabine, and
through bodily secretions, especially zidovudine.
by blood or sexual contact. The virus • Nonreactive HIV test results occur
preferentially binds to the T4 helper during the acute stage of the disease,
lymphocytes and replicates within the when the virus is present but antibod-
cells. Current assays detect several ies have not sufficiently developed to
be detected. It may take up to 6
viral proteins. Positive results should
months for the test to become positive.
be confirmed by Western Blot assay. During this stage, the test for HIV
This test is routinely recommended as antigen may not confirm an HIV
part of a prenatal workup and is infection.
required for evaluating donated blood
• Test kits for HIV are very sensitive. As
units before release for transfusion. ■ a result, nonspecific reactions may
occur, resulting in a false-positive
INDICATIONS: result.
• Evaluate donated blood units before
transfusion
• Perform as part of prenatal screening Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Screen organ transplant donors

• Test individuals who have documented Pretest:
and significant exposure to other ➤ Obtain a history of the patient’s
infected individuals complaints, including a list of known
allergens.
• Test exposed high-risk individuals for
detection of antibody (e.g., persons ➤ Obtain a history of the patient’s
with multiple sex partners, persons
a history of high-risk behaviors, and
with a history of other sexually trans- results of previously performed
mitted diseases, intravenous drug tests and procedures. For related
users, infants born to infected mothers, tests, refer to the immune and
allied health care workers, public serv- reproductive system tables.
ice employees who have contact with ➤ Obtain a list of the medications
blood and blood products) the patient is taking, including
RESULT nutraceuticals. The requesting health
Positive findings in: HIV-1 or HIV-
2 infection
CRITICAL VALUES: N/A results.
Human Leukocyte Antigen B27 601
➤ There are no food, fluid, or medica- teaching and information regarding

tion restrictions unless by medical the clinical implications of the test
direction. results, as appropriate. Educate the
➤ Review the procedure with the patient regarding access to counsel-
patient. ing services.
➤ Obtain written and informed ➤ Counsel the patient, as appropriate,
consent before the procedure is regarding risk of transmission and
initiated. proper prophylaxis, and reinforce the
importance of strict adherence to
the treatment regimen.
10 minutes. ➤ Inform patients that positive findings
must be reported to local health
Intratest: department officials, who will ques-
tion him or her regarding sexual part-
➤ Direct the patient to breathe ners.
movement. ➤ Offer support, as appropriate, to
➤ Observe standard precautions and patients who may be the victims of
follow the general guidelines in rape or sexual assault. Educate the
Appendix A. Perform a venipuncture, patient regarding access to counsel-
and collect the specimen in a 5-mL ing services. Provide a nonjudgmen-
red-top tube. tal, nonthreatening atmosphere for a
discussion during which risks of
➤ Label the specimen, and promptly sexually transmitted diseases are
transport it to the laboratory. explained. It is also important to
discuss problems the patient may
Post-test: experience (e.g., guilt, depression,
➤ Observe venipuncture site for bleed- anger) if test results indicate the
ing or hematoma formation. Apply presence of HIV.
pressure bandage. ➤ Inform the patient that retesting may
➤ Warn the patient that false-positive be necessary.
results occur and that the absence ➤ Evaluate test results in relation
of antibody does not guarantee to the patient’s symptoms and other
absence of infection, because the tests performed. Related laboratory
virus may be latent or may not have tests include 2-microglobulin,
produced detectable antibody at the complete blood count, CD4/ CD8
time of testing. enumeration, skin culture, cytom-
➤ Recognize anxiety related to test egalovirus, and human T-cell lympho-
results and offer support. Provide tropic virus types I and II.
HUMAN LEUKOCYTE ANTIGEN B27

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HLA-B27.
SPECIMEN: Whole blood (5 mL) collected in green-top (heparin) or

yellow-top (acid-citrate-dextrose [ACD]) tube.
REFERENCE VALUE: (Method: Flow cytometry) Negative (indicating

absence of the antigen).
DESCRIPTION: The human leuko- Nursing Implications and

cyte antigens (HLAs) are gene prod- Procedure ● ● ● ● ● ● ● ● ● ● ●
ucts of the major histocompatibility

complex, derived from their respec- Pretest:
tive loci on the short arm of chromo-
some six. There are more than 27 complaints, including a list of known
identified HLAs. HLA-B27 is an allergens.
allele (one of two or more genes for ➤ Obtain a history of the patient’s
an inheritable trait that occupy the immune and musculoskeletal
same location on each chromosome, systems as well as results of previ-
paternal and maternal) of the HLA-B ously performed tests and proce-
locus. The presence of HLA-B27 is immune and musculoskeletal
associated with several specific condi- system tables.
tions listed below, but HLA-B27 ➤ Obtain a list of the medications
should not be used as a screening test the patient is taking, including
for these conditions. ■ herbs, nutritional supplements, and
nutraceuticals. The requesting
health care practitioner and labora-
INDICATIONS: Assist in diagnosing tory should be advised if the patient
ankylosing spondylitis and Reiter’s regularly uses these products so
syndrome that their effects can be taken into
RESULT results.
Positive findings in: tion restrictions unless by medical
direction.
• Ankylosing spondylitis
• Juvenile rheumatoid arthritis patient.
• Psoriatic arthritis ➤ Inform the patient that specimen
• Reiter’s syndrome 10 minutes.

• The specimen should be stored at movement.
room temperature and should be ➤ Observe standard precautions and
received by the laboratory performing follow the general guidelines in
the assay within 24 hours of collection. Appendix A. Perform a venipunc-
It is highly recommended that the ture, and collect the specimen in a
laboratory be contacted before speci- 5-mL green- or yellow-top tube.
men collection to avoid specimen ➤ Label the specimen, and promptly
rejection. transport it to the laboratory.
Human T-Lymphotropic Virus Type I and Type II Antibodies 603
Post-test: the clinical implications of the test

➤ Observe venipuncture site for bleed- patient regarding access to counsel-
ing or hematoma formation. Apply ing services.
pressure bandage. ➤ Inform the patient that false-positive
➤ Recognize patient anxiety related test results occur and that retesting
to test results and offer support. may be required.
These diseases can be moderately ➤ Evaluate test results in relation to
to severely debilitating, resulting in the patient’s symptoms and other
significant lifestyle changes. Provide tests performed. A related labora-
teaching and information regarding tory test is rheumatoid factor.
HUMAN T-LYMPHOTROPIC VIRUS

TYPE I AND TYPE II ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: HTLV-I and HTLV-II.

DESCRIPTION: Human T-lympho- a requirement that all donated blood

tropic virus type I (HTLV-I) and type units be tested for HTLV-I/HTLV-II
II (HTLV-II) are two closely related before release for transfusion. ■
retroviruses known to remain latent
for extended periods before becoming INDICATIONS:
reactive. The viruses are transmitted • Distinguish HTLV-I/HTLV-II infec-
by sexual contact, contact with blood, tion from spastic myelopathy
placental transfer from mother to • Establish HTLV-I as the causative
fetus, or ingestion of breast milk. As agent in adult lymphoblastic (T-cell)
with human immunodeficiency virus leukemia
type 1 (HIV-1) and type 2 (HIV-2), • Evaluate donated blood units before
HTLV targets the T4 lymphocytes. transfusion
The disease is uncommon in the
• Evaluate HTLV-II as a contributing
United States, but retrospective stud- cause of chronic neuromuscular disease
ies conducted by the American Red
Cross demonstrated that a small RESULT
percentage of transfusion recipients
became infected by HTLV-positive Positive findings in: HTLV-I/
blood. The results of this study led to HTLV-II infection

INTERFERING FACTORS: N/A and collect the specimen in a 5-mL
red-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Post-test:
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.
Intratest: the patient’s symptoms and other
➤ 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.
5-Hydroxyindoleacetic Acid 605
5-HYDROXYINDOLEACETIC ACID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: 5-HIAA.
tic collection container with boric acid as a preservative.
REFERENCE VALUE: (Method: High-pressure liquid chromatography)

2–7 mg/24 h 10.5–36.6 mol/24 h
DESCRIPTION: Because 5-hydroxyin- Decreased in:

doleacetic acid (5-HIAA) is a metabo- • Depressive illnesses
lite of serotonin, 5-HIAA levels reflect • Hartnup disease
plasma serotonin concentrations.
• Mastocytosis
5-HIAA is excreted in the urine.
Increased urinary excretion occurs in • Phenylketonuria
the presence of carcinoid tumors. • Renal disease
This test, which replaces serotonin
measurement, is most accurate when • Small intestinal resection
obtained from a 24-hour urine speci-
men. ■
INDICATIONS: Detect early, small, INTERFERING FACTORS:

or intermittently secreting carcinoid • Drugs that may increase 5-HIAA levels
tumors include acetaminophen, cisplatin,
ephedrine, fluorouracil, cough syrups
RESULT containing glyceryl guaiacolate,
melphalan, mephenesin, methocar-
Increased in: bamol, naproxen, phenacetin,
pindolol, and rauwolfia alkaloids.
• Celiac and tropical sprue
• Drugs that may decrease 5-HIAA
• Cystic fibrosis
levels include corticotropin, ethanol,
• Foregut and midgut carcinoid tumors imipramine, isoniazid, levodopa,
monoamine oxidase inhibitors,
• Oat cell carcinoma of the bronchus
methenamine, methyldopa, and
• Ovarian carcinoid tumors phenothiazines.
• Whipple’s disease • Foods containing serotonin, such as
avocados, bananas, chocolate, egg- ➤ Review the procedure with the

plant, pineapples, plantain, red plums, patient. Provide a nonmetallic urinal,
tomatoes, and walnuts, can falsely bedpan, or toilet-mounted collection
elevate levels if ingested within 4 days device.
of specimen collection. ➤ Inform the patient that all urine
collected over a 24-hour period must
• Severe gastrointestinal disturbance or be saved; if a preservative has been
diarrhea can interfere with test results. added to the container, instruct the
patient not to discard the preserva-
• Failure to collect all the urine and tive. Instruct the patient not to void
store the specimen properly during the directly into the container. Instruct
24-hour test period invalidates the the patient to avoid defecating in the
results. collection device and to keep toilet
tissue out of the collection device to
prevent contamination of the speci-
men. Place a sign in the bathroom as
Nursing Implications and a reminder to save all urine.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Instruct the patient to void all urine
into the collection device, then pour
Pretest: the urine into the laboratory collec-
tion container. Alternatively, the
➤ Obtain a history of the patient’s specimen can be left in the collec-
complaints, including a list of known tion device for a health care staff
allergens. member to add to the laboratory
➤ Obtain a history of the patient’s collection container.
endocrine, gastrointestinal, and
immune system and results of previ- Intratest:
dures. For related tests, refer to the ➤ Ensure that the patient is in compli-
endocrine, gastrointestinal, and ance with dietary preparation and
immune system tables. other pretesting restrictions.
➤ Obtain a list of the medications the ➤ Observe standard precautions and
patient is taking, including herbs, follow the general guidelines in
nutritional supplements, and nutra- Appendix A.
ceuticals. Advise the requesting
Timed specimen:
tory that the patient regularly ➤ Obtain a clean 3-L urine specimen
uses these products so that their container, toilet-mounted collection
effects can be taken into considera- device, and plastic bag (for transport
tion when reviewing results. The of the specimen container). The
requesting health care practitioner specimen must be refrigerated or
and laboratory should be advised if kept on ice throughout the entire
the patient regularly uses these collection period. If an indwelling
products so that their effects can urinary catheter is in place, the
be taken into consideration when drainage bag must be kept on ice.
reviewing results. ➤ Begin the test between 6 and 8
➤ There are no fluid restrictions unless a.m., if possible. Collect first voiding
by medical direction. and discard. Record the time the
➤ Inform the patient that foods and specimen was discarded as the
medications (herbs, nutritional beginning of the timed collection
supplements, and nutraceuticals) period. The next morning, ask the
listed under “Interfering Factors” patient to void at the same time the
should be restricted by medical collection was started, and add this
direction for at least 4 days before last voiding to the container.
specimen collection. ➤ If an indwelling catheter is in place,
Hypersensitivity Pneumonitis Serology 607
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.
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.
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Farmer’s lung disease serology, extrinsic allergic

alveolitis.

REFERENCE VALUE: (Method: Immunodiffusion) Negative.
D ESCRIPTION : Hypersensitivity The combination of immune-

pneumonitis is a respiratory disease complexing and cell-mediated
caused by the inhalation of organisms immunopathogenesis results in a
from an organic source. Affected and chronic granulomatous pneumonitis
symptomatic individuals will demon- of the interstitial space of the lung.
strate acute bronchospastic reaction 4 Hypersensitivity pneumonitis serol-
to 6 hours after exposure to the ogy includes detection of antibodies
offending antigen. Inhalation of the to Aspergillus fumigatus, Micro-
antigen stimulates the production of polyspora faeni, Thermoactinomyces
immunoglobulin G (IgG) antibodies. vulgaris and T. candidus. A negative
test result does not rule out hypersen- regularly uses these products so
sitivity pneumonitis as a possible that their effects can be taken
diagnosis, nor does a positive test results.
result confirm the diagnosis. Also,
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
RESULT red-top tube.
Increased in: Hypersensitivity pneu- transport it to the laboratory.
monitis
Post-test:
CRITICAL VALUES: N/A ➤ Observe venipuncture site for bleed-
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.
Hysterosalpingography 609
➤ Inform the patient of smoking cessa- tory tests include allergen-specific

tion programs, as appropriate. IgE, arterial/alveolar oxygen ratio,
➤ Evaluate test results in relation to complete blood count, eosinophil
the patient’s symptoms and other count, lung biopsy, and sputum
tests performed. Related labora- culture.
HYSTEROSALPINGOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Uterography, uterosalpingography, hysterogram.

AREA OF APPLICATION: Uterus and fallopian tubes.
D ESCRIPTION : Hysterosalpingo- contrast medium, bleeding, and

graphy is generally performed as part pulmonary embolism. ■
of an infertility study to identify
anatomical abnormalities of the INDICATIONS:
uterus or occlusion of the fallopian • Confirm tubal abnormalities such as
adhesions and occlusions
tubes. The procedure allows visualiza-
tion of the uterine cavity, fallopian • Confirm uterine abnormalities such as
tubes, and peritubal area after the congenital malformation, traumatic
injection of contrast medium into the injuries, or the presence of foreign
cervix. The contrast medium should bodies
flow through the uterine cavity, • Confirm the presence of fistulas or
through the fallopian tubes, and into adhesions
the peritoneal cavity, where it can be • Detect bicornate uterus
absorbed if no obstruction exists.
Passage of the contrast medium • Evaluate adequacy of surgical tubal
ligation and reconstructive surgery
through the tubes may clear mucous
plugs, straighten kinked tubes, or RESULT
break up adhesions, thus restoring
fertility. This procedure is also used to Normal Findings:
evaluate the fallopian tubes after tubal • Normal position, shape, and size of the
ligation and to evaluate the results of uterine cavity
reconstructive surgery. Risks include • Contrast medium flowing freely into
uterine perforation, exposure to radi- the fallopian tubes and not leaking
ation, infection, allergic reaction to from the uterus
Abnormal Findings: unless the benefits of the x-ray diagno-

• Bicornate uterus sis outweigh the risks of exposure to
high levels of radiation.
• Developmental abnormalities
• Extrauterine pregnancy Factors that may impair clear
imaging:
• Internal scarring
• Kinking of the fallopian tubes due to remain still during the procedure
adhesions because of age, significant pain, or
• Partial or complete blockage of fallop- mental status
ian tube(s) • Retained barium from a previous radi-
• Tumors ologic procedure
• Uterine cavity anomalies • Metallic objects within the examina-

• Uterine fistulas which may inhibit organ visualization
• Uterine masses or foreign body and can produce unclear images
• Uterine fibroid tumors (leiomyomas) • Gas or feces in the gastrointestinal tract

INTERFERING FACTORS: study
This procedure is contraindicated medium
for:
• Patients with allergies to shellfish or • Excessive traction during the test or
iodinated dye. The contrast tubal spasm, which may cause the
medium used may cause a life- appearance of a stricture in an other-
threatening allergic reaction. Patients wise normal fallopian tube
contrast medium may benefit from Other considerations:
premedication with corticosteroids or • Excessive traction during the test may
the use of nonionic contrast medium. displace adhesions, making the fallop-
• Patients with bleeding disorders. ian tubes appear normal.
• Patients who are pregnant or suspected • Consultation with a physician should

of being pregnant, unless the potential occur before the procedure for radia-
benefits of the procedure far outweigh tion safety concerns regarding infants
the risks to the fetus and mother. of patients who are lactating.
• 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
• 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
• Young patients (17 years and younger), sure to radiation.
Hysterosalpingography 611
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Ask the patient to void before the
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.
➤ 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 patient may experience tempo-
rary sensations of nausea, dizziness,
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
need for further testing to evaluate be bloody, lasting 1 to 2 days after

her condition and determine the the test.
need for a change in therapy. ➤ Inform the patient that dizziness and
➤ Monitor the patient’s vital and neuro- cramping may follow this procedure.
logical signs per institution policy ➤ Inform the patient that analgesia
until stable. may be given if there is persistent
➤ Evaluate the patient for signs of cramping after the procedure.
hypersensitivity reaction to contrast ➤ Inform the patient to contact the
medium, such as urticaria, head- physician in the event of severe
ache, nausea, respiratory distress, cramping or profuse bleeding.
hypotension, edema, hives, rash, ➤ Determine if the patient or family
tachycardia, laryngeal stridor, or members have any further ques-
vomiting, and alert the patient to be tions or concerns.
watchful for these symptoms.
➤ Evaluate the patient for signs of branch of medicine sends a written
infection, such as pain, fever, report to the ordering provider, who
increased pulse rate, chills, flushing, discusses the results with the
abdominal pain, tachycardia, or patient.
muscle aches.
➤ Inform the patient that a vaginal the patient’s symptoms and any
discharge is common and that it may related tests performed.
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.
REFERENCE VALUE: (Method: Immunoprecipitation combined with elec-

trophoresis) Test results are interpreted by a pathologist. Normal placement
and intensity of staining provide information about the immunoglobulin
bands.
D ESCRIPTION : Immunofixation charges. Abnormalities are revealed

electrophoresis (IFE) is a qualitative by changes produced in the individ-
technique that provides a detailed ual bands, such as displacement,
separation of individual immuno- color, or absence of color. Urine IFE
globulins according to their electrical has replaced the Bence Jones screen-
Immunofixation Electrophoresis, Serum and Urine 613
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
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-
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
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.
into the collection device and then to
Nursing Implications and pour the urine into the laboratory
Procedure ● ● ● ● ● ● ● ● ● ● ●
collection container. Alternatively
Pretest: collection device for a health care
➤ 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.
Intratest: rated, void a small amount into the

➤ Direct the patient to breathe nor- the urine stream, void directly into
mally and to avoid unnecessary the specimen container.
movement. Observe standard pre-
cautions and follow the general
Blood or urine:
guidelines in Appendix A.
Blood: transport it to the laboratory.
the specimen in a 5-mL red-top Post-test:
tube.
Urine: ing or hematoma formation. Apply
pressure bandage.
➤ Instruct the male patient to (1) thor- the patient’s symptoms and other
oughly wash his hands, (2) cleanse tests performed. Related laboratory
the meatus, (3) void a small amount tests include bone marrow biopsy,
into the toilet, and (4) void directly lymph node biopsy, complete blood
into the specimen container. count with examination of peripheral
➤ Instruct the female patient to (1) smear, quantitative immunoglobulin
thoroughly wash her hands; (2) levels, protein, urine protein, protein
cleanse the labia from front to back; electrophoresis, urine protein elec-
(3) while keeping the labia sepa- trophoresis, and urinalysis.
IMMUNOGLOBULIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: IgE.
SI Unit
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
Immunoglobulin E 615
DESCRIPTION: Immunoglobulin E • Bronchopulmonary aspergillosis

(IgE) is an antibody whose primary • Dermatitis
response is to allergic reactions and
• Eczema
parasitic infections. Most of the
body’s IgE is bound to specialized • Hay fever
tissue cells; little is available in the • IgE myeloma
circulating blood. IgE binds to the • Parasitic infestation
membrane of special granulocytes
• Rhinitis
called basophils in the circulating
blood and mast cells in the tissues. • Sinusitis
Basophil and mast cell membranes • Wiskott-Aldrich syndrome
have receptors for IgE. Mast cells are
abundant in the skin and the tissues Decreased in:
lining the respiratory and alimentary • Advanced carcinoma
tracts. When IgE antibody becomes • Agammaglobulinemia
cross-linked with antigen/allergen,
• Ataxia-telangiectasia
the release of histamine, heparin, and
other chemicals from the granules in • IgE deficiency
the cells is triggered. A sequence of
events follows activation of IgE that CRITICAL VALUES: N/A
affects smooth muscle contraction,
vascular permeability, and inflamma- INTERFERING FACTORS:
• Drugs that may cause a decrease in IgE
tory reactions. The inflammatory
levels include phenytoin and trypto-
response allows proteins from phan.
the bloodstream to enter the
tissues. Helminths (worm parasites) • Penicillin G has been associated with
are especially susceptible to increased IgE levels in some patients
with drug-induced acute interstitial
immunoglobulin-mediated cytotoxic
nephritis.
chemicals. The inflammatory reaction
proteins attract macrophages from the • Normal IgE levels do not eliminate
circulatory system and granulocytes, allergic disorders as a possible dia-
such as eosinophils, from circulation gnosis.
and bone marrow. Eosinophils also
contain enzymes effective against the
parasitic invaders. ■ Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
INDICATIONS: Assist in the evaluation of Pretest:

allergy and parasitic infection
RESULT allergens.
Increased in: mune and respiratory systems, as
• Asthma well as results of previously per-
• Alcoholism formed tests and procedures. For
• Allergy and respiratory system tables.
➤ Obtain a list of the medications the follow the general guidelines in

patient is taking, including herbs, Appendix A. Perform a venipuncture,
nutritional supplements, and neutra- and collect the specimen in a 5-mL
ceuticals. The requesting health care red- or tiger-top tube.
when reviewing results. Post-test:
➤ Review the procedure with the pa- ➤ Consideration should be given
tient. to diet if the patient has food aller-
➤ Inform the patient that specimen gies.
collection takes approximately 5 to ➤ Evaluate test results in relation to
10 minutes. the patient’s symptoms and other
tests performed. Related labora-
Intratest: tory tests include allergen-specific
IgE, alveolar/arterial gradient and
➤ Direct the patient to breathe nor- arterial/alveolar oxygen ratio, blood
mally and to avoid unnecessary gases, complete blood count,
movement. eosinophil count, hypersensitivity
➤ Observe standard precautions and pneumonitis, and theophylline.
IMMUNOGLOBULINS A, D, G, AND M
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: IgA, IgD, IgG, and IgM.


Immunoglobulin A
1–9 mo 2–80 mg/dL 20–800 mg/L
10–12 mo 15–90 mg/dL 150–900 mg/L
2–3 y 18–150 mg/dL 180–1500 mg/L
4–5 y 25–160 mg/dL 250–1600 mg/L
6–8 y 35–200 mg/dL 350–2000 mg/L
9–12 y 45–250 mg/dL 450–2500 mg/L
Older than 12 y 40–350 mg/dL 400–3500 mg/L
Immunoglobulins A, D, G, and M 617
Immunoglobulin D
Newborn Greater than 2 mg/dL Greater than 20 mg/L
Adult Less than 15 mg/dL Less than 150 mg/L
Immunoglobulin G
Newborn 650–1600 mg/dL 6.5–16 g/L
1–9 mo 250–900 mg/dL 2.5–9 g/L
10–12 mo 290–1070 mg/dL 2.9–10.7 g/L
2–3 y 420–1200 mg/dL 4.2–12 g/L
4–6 y 460–1240 mg/dL 4.6–12.4 g/L
Greater than 6 y 650–1600 mg/dL 6.5–16 g/L
Immunoglobulin M
Newborn Less than 25 mg/dL Less than 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
DESCRIPTION: Immunoglobulins A, stimulus. IgM also forms natural anti-

D, E, G, and M are made by plasma bodies, such as ABO blood group an-
cells in response to foreign particles. tibodies. The presence of IgM in cord
Immunoglobulins neutralize toxic blood is an indication of congenital
substances, support phagocytosis, and infection. ■
destroy invading microorganisms.
They are made up of heavy and light INDICATIONS:
chains. Immunoglobulins produced • Assist in the diagnosis of multiple
by the proliferation of a single plasma myeloma
cell (clone) are called monoclonal. • Evaluate humoral immunity status
Polyclonal increases result when mul-
• Monitor therapy for multiple myeloma
tiple cell lines produce antibody. IgA
is found mainly in secretions such as • IgA: Evaluate anaphylaxis associated
tears, saliva, and breast milk. It is be- with the transfusion of blood and
lieved to protect mucous membranes blood products (anti-IgA antibodies
may develop in patients with low
from viruses and bacteria. The func-
levels of IgA, possibly resulting in
tion of IgD is not well understood. anaphylaxis when donated blood is
For details on IgE, see monograph ti- transfused)
tled “Immunoglobulin E.” IgG is the
predominant serum immunoglobulin RESULT
and is important in long-term defense
against disease. It is the only antibody Increases in:
that crosses the placenta. IgM is the
largest immunoglobulin, and it is the IgA:
first antibody to react to an antigenic • Polyclonal:
Chronic infections, especially Viral infection (hepatitis or

gastrointestinal (GI) and mononucleosis)
respiratory tracts
• Monoclonal:
Chronic liver disease
Cold agglutinin hemolysis disease
Immunodeficiency states, such as
Wiskott-Aldrich syndrome Malignant lymphoma
Inflammatory bowel disease Neoplasms (especially GI tract)
Lower GI cancer Reticulosis
Rheumatoid arthritis Waldenström’s macroglobulinemia
• Monoclonal: Decreases in:

IgA-type multiple myeloma
IgA:
IgD: • Ataxia-telangiectasia
• Polyclonal: • Chronic sinopulmonary disease
Chronic infections • Genetic IgA deficiency
Certain liver diseases
Connective tissue disorders IgD:
• Monoclonal: • Genetic IgD deficiency
IgD-type multiple myeloma • Malignant melanoma of the skin
• Preeclampsia
IgG:
• Polyclonal: IgG:
Autoimmune diseases, such as • Burns
systemic lupus erythematosus,
rheumatoid arthritis, and
• Genetic IgG deficiency
Sjögren’s syndrome • Nephrotic syndrome
Chronic liver disease • Pregnancy
Chronic or recurrent infections
Intrauterine devices IgM:
Sarcoidosis • Burns
• Monoclonal: • Secondary IgM deficiency associated
IgG-type multiple myeloma with IgG or IgA gammopathies
Leukemias
Lymphomas
IgM: • Drugs that may increase immunoglob-
• Polyclonal: ulin levels include asparaginase, cimeti-
Active sarcoidosis dine, and narcotics.
Chronic hepatocellular disease • Drugs that may decrease immunoglob-
Collagen vascular disease ulin levels include dextran, oral
Early response to bacterial or contraceptives, phenytoin, and methyl-
parasitic infection prednisolone (high doses).
Hyper-IgM dysgammaglobulinemia • Chemotherapy, immunosuppressive
Rheumatoid arthritis therapy, and radiation treatments
Variable in nephrotic syndrome decrease immunoglobulin levels.
Immunosuppressants: Cyclosporine, Methotrexate 619
• Specimens with macroglobulins, cryo- tion restrictions unless by medical

globulins, or cold agglutinins tested at direction.
cold temperatures may give falsely low ➤ Review the procedure with the
values. patient.
10 minutes.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
➤ Obtain a history of the patient’s movement.
GI, hematopoietic, immune, and and collect the specimen in a 5-mL
musculoskeletal systems, as well as red-top tube.
results of previously performed ➤ Label the specimen, and promptly
tests and procedures. For related transport it to the laboratory.
tests, refer to the gastrointestinal,
hematopoietic, immune, and muscu- Post-test:
loskeletal system tables.
➤ Obtain a list of medications the ing or hematoma formation. Apply
patient is taking, including herbs, pressure bandage.
ceuticals. The requesting health care ➤ Evaluate test results in relation to
practitioner and laboratory should be the patient’s symptoms and other
advised if the patient regularly uses tests performed. Related labora-
these products so that their effects tory tests include bone marrow
can be taken into consideration biopsy, complete blood count with
when reviewing results. evaluation of peripheral smear,
immunofixation electrophoresis,
➤ Note any recent procedures that can urine immunofixation electrophore-
interfere with test results. sis, protein, urine protein, protein
➤ There are no food, fluid, or medica- electrophoresis, and urinalysis.
IMMUNOSUPPRESSANTS:
CYCLOSPORINE, METHOTREXATE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Cyclosporine (Sandimmune), methotrexate (MTX,

amethopterin, Folex, Rheumatrex), methotrexate sodium (Mexate).
SPECIMEN: Whole blood (1 mL) collected in lavender-top tube for

cyclosporine. Serum (1 mL) collected in a red-top tube for methotrexate.
Immunosuppressant Administration Collection Time
Cyclosporine Oral 12 hours after dose
Methotrexate Oral Varies according to dosing
protocol
Intramuscular Varies according to dosing
protocol
Therapeutic Half- Volume of Protein Excre-

Dose Life Distribution Binding tion
Conven- SI Units
tional (Conver-
Units sion
Factor
0.832)
Cyclo- 100–400 83–333 8–24 h 4–6 L/kg 90% Renal
sporine ng/mL nmol/L
Renal
transplant
100–300 83–250 8–24 h 4–6 L/kg 90% Renal
ng/mL nmol/L
Cardiac
transplant
100–250 83–208 8–24 h 4–6 L/kg 90% Renal
ng/mL nmol/L
Bone
marrow
transplant
Metho- Dependent 8–15 h 0.4–1.0 50–70% Renal
trexate on thera- L/kg
peutic
approach
DESCRIPTION: Cyclosporine is an therapeutic drugs, including patient

immunosuppressive drug used in the age, weight, interacting medications,
management of organ rejection, espe- electrolyte balance, protein levels, wa-
cially rejection of the heart, liver, and ter balance, and conditions that affect
kidney. Its most serious side effect is absorption and excretion; as well as
renal impairment or renal failure. foods, herbals, vitamins, and minerals
Methotrexate is a highly toxic drug that can either potentiate or inhibit
that causes cell death by disrupting the intended target concentration.
DNA synthesis. Collection times should be docu-
Many factors must be considered mented carefully in relation to the
in effective dosing and monitoring of time of medication administration. It
Immunosuppressants: Cyclosporine, Methotrexate 621
is essential that this information be stomatitis, vomiting, anorexia, hyperten-

communicated clearly and accurately sion, infection, fluid retention, hyper-
to avoid misunderstanding of the calcemic metabolic acidosis, tremor,
dose time in relation to the collection seizures, headache, and flushing. Possible
time. Miscommunication between interventions include close monitoring
of blood levels to make dosing adjust-
the individual administering the
ments, inducing emesis (if orally in-
medication and the individual col- gested), performing gastric lavage (if
lecting the specimen is the most fre- orally ingested), withholding the drug,
quent cause of subtherapeutic levels, and initiating alternative therapy for a
toxic levels, and misleading informa- short time until the patient is stabilized.
tion used in calculation of future Methotrexate: Low-dose therapy,
doses. ■ greater than 9.1 ng/mL; high-
dose therapy, greater than 454
INDICATIONS ng/mL
Signs and symptoms of methotrexate
Cyclosporine: toxicity include increased severity of ex-
• Assist in the management of treat- pected side effects, which include nausea,
ments to prevent organ rejection stomatitis, vomiting, anorexia, bleeding,
infection, bone marrow depression, and
• Monitor for toxicity over a prolonged period of use, hepato-
toxicity. The effect of methotrexate on
Methotrexate: normal cells can be reversed by adminis-
• Monitor effectiveness of treatment of tration of 5-formyltetrahydrofolate
cancer and some autoimmune disor- (citrovorum or leucovorin).
ders 5-Formyltetrahydrofolate allows higher
• Monitor for toxicity doses of methotrexate to be given.
RESULT INTERFERING FACTORS:

• Numerous drugs interact with and ei-
ther increase cyclosporine levels or in-
crease the risk of toxicity. These drugs
effect
include acyclovir, aminoglycosides,
Toxic levels Adjust dose
amiodarone, amphotericin B, anabolic
as indicated
steroids, cephalosporins, cimetidine,
Cyclosporine Renal
danazol, erythromycin, furosemide,
impairment
ketoconazole, melphalan, methylpred-
Methotrexate Renal
nisolone, miconazole, nonsteroidal
impairment
anti-inflammatory drugs (NSAIDs),
oral contraceptives, and trimethoprim-
CRITICAL VALUES: It is important sulfamethoxazole.
to note the adverse effects of subthera- • Drugs that may decrease cyclosporine
peutic levels. Care should be taken to levels include carbamazepine, etho-
investigate signs and symptoms of too toin, mephenytoin, phenobarbital,
little and too much medication. phenytoin, primidone, and rifampin.
Cyclosporine: Greater than 400
ng/mL • Drugs that may increase methotrexate
Signs and symptoms of cyclosporine levels or increase the risk of toxicity
toxicity include increased severity of ex- include NSAIDs, probenecid, salicy-
pected side effects, which include nausea, late, and sulfonamides.
• Antibiotics may decrease the absorp- normally and to avoid unnecessary

tion of methotrexate. movement.
pendix A. Consider recommended
Nursing Implications and collection time around dosing sched-
Procedure ● ● ● ● ● ● ● ● ● ● ● ule. Perform a venipuncture, and col-
lect the specimen in a lavender-top
Pretest: tube for cyclosporine and a red-top
tube for methotrexate.
allergens.
➤ Obtain a history of the patient’s gen- Post-test:
itourinary system as well as results
of previously performed tests and ➤ Observe venipuncture site for bleed-
to the genitourinary system and pressure bandage.
therapeutic/toxicology table. ➤ Explain to the patient the impor-
➤ Obtain a list of the medications the tance of following the medication
patient is taking, including herbs, nu- regimen and instructions regarding
tritional supplements, and nutraceu- food and drug interactions.
ticals. The requesting health care ➤ Instruct the patient to be prepared to
practitioner and laboratory should be list to the pharmacist the other med-
advised if the patient regularly uses ications he or she already is taking in
these products so that their effects the event that the requesting health
can be taken into consideration care practitioner prescribes a med-
when reviewing results. For related ication.
tests, refer to the therapeutic/toxi-
cology table. ➤ Recognize anxiety related to test re-
sults and offer support. Patients re-
➤ There are no food, fluid, or medica- ceiving these drugs usually have
tion restrictions unless by medical conditions that can be intermittently
direction. moderate to severely debilitating
➤ Review the procedure with the and resulting in significant lifestyle
patient. changes. Educate the patient regard-
➤ Inform the patient that specimen ing access to counseling services,
collection takes approximately 5 to as appropriate.
10 minutes. ➤ Evaluate test results in relation to
Intratest: tests performed. Related laboratory
tests include creatinine and blood
➤ Direct the patient to breathe urea nitrogen (BUN).
INFECTIOUS MONONUCLEOSIS SCREEN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Monospot, heterophil antibody test, IM serology.

Infectious Mononucleosis Screen 623

REFERENCE VALUE: (Method: Agglutination) Negative.
DESCRIPTION: Infectious mononu- • A false-negative result may occur if

cleosis is caused by the Epstein-Barr treatment was begun before antibodies
virus (EBV). The incubation period is developed or if the test was done less
10 to 50 days, and the symptoms last than 6 days after exposure to the virus.
1 to 4 weeks after the infection has
fully developed. The hallmark of EBV
infection is the presence of heterophil Nursing Implications and
antibodies, also called Paul-Bunnell- Procedure ● ● ● ● ● ● ● ● ● ● ●
Davidsohn antibodies, which are im- Pretest:

munoglobulin M (IgM) antibodies
that agglutinate sheep or horse red ➤ Obtain a history of the patient’s
blood cells. The disease induces for- allergens. Obtain a history of expo-
mation of abnormal lymphocytes in sure.
the lymph nodes; stimulates increased ➤ Obtain a history of the patient’s
formation of heterophil antibodies; hepatobiliary and immune systems,
and is characterized by fever, cervical as well as results of previously
lymphadenopathy, tonsillopharyngi- performed tests and procedures.
tis, and hepatosplenomegaly. EBV is hepatobiliary and immune system
also thought to play a role in Burkitt’s tables.
lymphoma, nasopharyngeal carci- ➤ Obtain a list of medications the pa-
noma, and chronic fatigue syndrome. tient is taking, including herbs, nutri-
If the results of the heterophil anti- tional supplements, and nutraceuti-
body screening test are negative and cals. The requesting health care
infectious mononucleosis is highly advised if the patient regularly uses
suspected, EBV-specific serology these products so that their effects
should be requested. ■ can be taken into consideration
INDICATIONS: Assist in confirming infec- ➤ Note any recent therapies that can
tious mononucleosis interfere with test results.
RESULT direction.
Positive findings in: Infectious ➤ Review the procedure with the
mononucleosis patient. Inform the patient that spec-
imen collection takes approximately
5 to 10 minutes.
Intratest:
• False-positive results may occur in normally and to avoid unnecessary
the presence of narcotic addiction, movement.
serum sickness, lymphomas, hepatitis, ➤ Observe standard precautions and
leukemia, cancer of the pancreas, and follow the general guidelines in
phenytoin therapy. Appendix A. Perform a venipuncture,
and collect the specimen in a 5-mL false-negative or false-positive. In-

red-top tube. form the patient that signs and
➤ Label the specimen, and promptly symptoms of infection include fever,
transport it to the laboratory. chills, sore throat, enlarged lymph
nodes and fatigue. Self-care while
Post-test: the disease runs its course includes
adequate fluid and nutritional intake
➤ Observe venipuncture site for bleed- along with sufficient rest. Activities
ing or hematoma formation. Apply that cause fatigue or stress should
pressure bandage. be avoided.
➤ Advise the patient to refrain from ➤ Evaluate test results in relation to
direct contact with others because the patient’s symptoms and other
the disease is transmitted through tests performed. Related laboratory
saliva. tests include complete blood count
➤ Inform the patient that approxi- with peripheral blood smear evalua-
mately 10 percent of all results are tion.
INSULIN AND INSULIN RESPONSE

TO GLUCOSE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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
1h 18–276 mIU/L 125–1917 pmol/L Less than 200

mg/dL
2h 16–166 mIU/L 111–1153 pmol/L Less than 140
mg/dL
3h Less than 25 Less than 174 65–120 mg/dL
mIU/L pmol/L
mIU/L pmol/L
mIU/L pmol/L
Insulin and Insulin Response to Glucose 625
DESCRIPTION: Insulin is secreted in • Excessive administration of insulin

response to elevated blood glucose, • Insulin- and proinsulin-secreting
and its overall effect is to promote tumors (insulinomas)
glucose use and energy storage. The
• Obesity
insulin response test measures the rate
of insulin secreted by the beta cells of • Reactive hypoglycemia in developing
the islets of Langerhans in the diabetes
pancreas; it may be performed simul- • Severe liver disease
taneously with a 5-hour glucose toler-
ance test for hypoglycemia. ■ Decreased in:
• Beta cell failure
INDICATIONS:
• Assist in the diagnosis of early or devel- CRITICAL VALUES:
oping non–insulin-dependent (type 2) Greater than 35 mIU/L
diabetes, as indicated by excessive Symptoms of elevated insulin levels
production of insulin in relation to include dizziness, diaphoresis, faintness,
blood glucose levels (best shown with pallor, weakness, stupor, and seizures.
glucose tolerance tests or 2-hour post- Possible interventions include adminis-
prandial tests) tering 50% dextrose in water (D5W)
solution, administering glucagon, and
• Assist in the diagnosis of insulinoma,
monitoring blood glucose level hourly.
as indicated by sustained high levels
of insulin and absence of blood INTERFERING FACTORS:
glucose–related variations • Drugs and substances that may increase
• Confirm functional hypoglycemia, as insulin levels include acetohexamide,
indicated by circulating insulin levels alanine, albuterol, amino acids, beclo-
appropriate to changing blood glucose methasone, betamethasone, broxaterol,
levels calcium gluconate, cannabis, chlor-
propamide, cyclic AMP, glibornuride,
• Differentiate between insulin-resistant glipizide, glisoxepide, glucagon,
diabetes, in which insulin levels are glyburide, ibopamine, insulin, insulin-
high, and non–insulin-resistant dia- like growth factor–I, oral contracep-
betes, in which insulin levels are low tives, pancreozymin, prednisolone,
• Evaluate fasting hypoglycemia of prednisone, rifampin, salbutamol,
unknown cause terbutaline, tolazamide, tolbutamide,
trichlormethiazide, and verapamil.
• Evaluate postprandial hypoglycemia of
unknown cause • Drugs that may decrease insulin levels
include acarbose, asparaginase, calci-
• Evaluate uncontrolled insulin- tonin, cimetidine, clofibrate, dexfen-
dependent (type 1) diabetes fluramine, diltiazem, doxazosin,
enalapril, enprostil, ether, hydrox-
RESULT ypropyl methylcellulose, insulin-like
growth factor–I, metformin, niacin,
Increased in: nifedipine, nitrendipine, octreotide,
• Acromegaly phenytoin, propranolol, and psyllium.
• Alcohol use • Administration of insulin or oral
hypoglycemic agents within 8 hours of
• Cushing’s syndrome
the test can lead to falsely elevated
• Diabetes levels.
• Hemodialysis destroys insulin and collection takes approximately 5 to

affects test results. 10 minutes.
• Recent radioactive scans or radiation Intratest:

can interfere with test results when
radioimmunoassay is the test method. ➤ Ensure that the patient has complied
Procedure ● ● ● ● ● ● ● ● ● ● ● movement.
complaints, including a list of known red-top tube.
allergens.
previously performed tests and Post-test:
to the endocrine system table. ➤ Observe venipuncture site for bleed-
➤ Obtain a list of the medications the ing or hematoma formation. Apply
patient is taking, including herbs, nu- pressure bandage.
tritional supplements and nutraceuti- ➤ Instruct the patient to resume usual
cals. The requesting health care diet and medication as directed by
practitioner and laboratory should be the requesting health care practi-
advised if the patient regularly uses tioner.
these products so their effects can ➤ Increased insulin levels may be as-
be taken into consideration when re- sociated with diabetes. Instruct the
viewing results. diabetic patient, as appropriate, in
➤ Note any recent procedures that can nutritional management of the dis-
interfere with test results. ease. Patients who adhere to dietary
➤ There are no fluid restrictions unless recommendations report a better
by medical direction. general feeling of health, better
weight management, greater control
➤ If a single sample is to be collected, of glucose and lipid values, and im-
the patient should have fasted and proved use of insulin. There is no “di-
refrained, with medical direction, abetic” diet; however, there are
from taking insulin or other oral many meal-planning approaches
hypoglycemic agents for at least 8 with nutritional goals endorsed by
hours before specimen collection. the American Dietetic Association.
➤ Hypoglycemia: Serial specimens for The nutritional needs of each dia-
insulin levels are collected in betic patient must be determined in-
conjunction with glucose levels after dividually with the appropriate health
administration of a 100-g dose of care professionals, particularly pro-
glucola. The patient should be fessionals trained in nutrition.
prepared as for a standard oral ➤ Instruct the patient and caregiver
glucose tolerance test over a 5-hour to report signs and symptoms of
period. hypoglycemia (weakness, confu-
➤ Review the procedure with the sion, diaphoresis, rapid pulse) or
patient. Inform the patient that hyperglycemia (thirst, polyuria,
multiple specimens may be hunger, and lethargy).
required. ➤ Recognize anxiety related to test
➤ Inform the patient that specimen results and provide support. Provide
Insulin Antibodies 627
teaching and information regarding ➤ Evaluate test results in relation

the clinical implications of the test to the patient’s symptoms and
results, as appropriate. other tests performed. Related
➤ Emphasize, as appropriate, that laboratory tests include C-peptide,
good glycemic control delays the fructosamine, glucose, glycated
onset and slows the progression of hemoglobin, insulin antibodies, and
diabetic retinopathy, nephropathy, microalbumin.
and neuropathy.
INSULIN ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
REFERENCE VALUE: (Method: Radioimmunoassay) Less than 3 percent;
includes binding of human, beef, and pork insulin to antibodies in patient’s
serum.
DESCRIPTION: The most common RESULT

anti-insulin antibody is immunoglob-
ulin G (IgG), but IgA, IgM, IgD, and Increased in:
IgE antibodies also have anti-insulin • Insulin allergy or resistance
properties. These antibodies usually
do not cause clinical problems, but • Factitious hypoglycemia
they may complicate insulin assay • Polyendocrine autoimmune syndromes
testing. IgM is thought to participate
in insulin resistance and IgE in • Steroid-induced diabetes (a side effect
insulin allergy. Improvements in the of treatment for systemic lupus
purity of animal insulin and increased erythematosus)
use of human insulin have resulted in
Decreased in: N/A
a significant decrease in the incidence
of insulin antibody formation. ■
INDICATIONS:
• Assist in confirming insulin resistance
• Assist in determining if hypoglycemia
INTERFERING FACTORS: Recent radioac-
tive scans or radiation can interfere with
is caused by insulin abuse
test results when radioimmunoassay is
• Assist in determining insulin allergy the test method.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Direct the patient to breathe
Pretest: movement.
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.
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).
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.
collection takes approximately 5 to tests include C-peptide, glucose,
10 minutes. and insulin.
INTRAVENOUS PYELOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Excretory urography (EUG), intravenous urogra-

phy (IVU, IUG), IVP.
AREA OF APPLICATION: Kidneys, ureters, bladder, and renal pelvis.

CONTRAST: Intravenous radiopaque iodine-based contrast medium.
Intravenous Pyelography 629
DESCRIPTION: Intravenous pyelogra- RESULT

phy (IVP) is the most commonly
performed test to determine urinary Normal Findings:
tract dysfunction or renal disease. IVP • Normal size and shape of kidneys,
uses IV radiopaque contrast medium ureters, and bladder
to visualize the kidneys, ureters, blad- • Normal bladder and absence of masses
der, and renal pelvis. The contrast or renal calculi, with prompt visualiza-
medium concentrates in the blood tion of contrast medium through the
and is filtered out by the glomeruli; it urinary system
passes out through the renal tubules
and is concentrated in the urine. Abnormal Findings:
Renal function is reflected by the • Absence of a kidney (congenital
length of time it takes the contrast malformation)
medium to appear and to be excreted • Benign and malignant kidney tumors
by each kidney. A series of x-rays is • Bladder tumors
performed during a 30-minute period
to view passage of the medium • Congenital renal or urinary tract
through the kidneys and ureters abnormalities
into the bladder. A final film is taken • Glomerulonephritis
after the patient empties the bladder • Hydronephrosis
(postvoiding film). Computed tomo-
graphy (CT) may be employed • Prostatic enlargement
during the examination to permit the • Pyelonephritis
examination of an individual layer or
• Renal cysts
plane of the organ that may be
obscured by surrounding overlying • Renal hematomas
structures. ■ • Renal or ureteral calculi
• Soft-tissue masses
INDICATIONS:
• Evaluate known or suspected ureteral • Tumors of the collecting system
obstruction
• Evaluate function of the kidneys,
ureters, and bladder INTERFERING FACTORS:
• Evaluate the presence of renal, ureter,
or bladder calculi This procedure is contraindicated
for:
• Evaluate the cause of blood in the urine • Patients with allergies to shellfish or
• Aid in the diagnosis of renovascular iodinated dye. The contrast
hypertension medium used may cause a life-
• Evaluate space-occupying lesions or with a known hypersensitivity to the
congenital anomalies of the urinary contrast medium may benefit from
system premedication with corticosteroids or
• Evaluate the effects of urinary system
trauma • Patients with bleeding disorders.
• Patients who are pregnant or suspected • Retained barium from a previous radi-
of being pregnant, unless the potential ologic procedure
• Elderly and other patients who are failure to restrict food intake before the
chronically dehydrated before study
• End-stage renal disease, which may
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
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
• 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-
Factors that may impair clear badges that reveal their level of expo-
imaging: sure to radiation.
mental status Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
overexposure or underexposure and a ➤ Inform the patient that the proce-
poor-quality study dure assesses the kidneys, ureters,
and bladder.
exceed the weight limit for the equip- ➤ Inform the patient that the proce-
dure is performed in a radiology
ment department by a technologist and a
• Incorrect positioning of the patient, physician and takes approximately
which may produce poor visualization 30 minutes.
of the area to be examined, especially ➤ Ask the patient to lie still during the
for oblique and decubitus views and procedure because movement pro-
for films done by portable equipment duces unclear images; the patient
may be asked to hold his or her
• Metallic objects within the examina- breath for short periods.
tion field (e.g., jewelry or body rings), ➤ Obtain a history of allergies or sensi-
which may inhibit organ visualization tivities to contrast medium or shell-
and can produce unclear images fish.
Intravenous Pyelography 631
➤ Obtain a history of the patient’s ➤ A kidney, ureter, and bladder (KUB)

complaints. or plain film is taken to ensure that
➤ Obtain a history of the patient’s gen- no barium or stool obscures visuali-
itourinary and abdominal systems, zation of the urinary system.
as well as results of previously per- ➤ Insert an IV line, if one is not already
formed tests and procedures. For rein place, and inject the contrast
lated tests, refer to the genitourinary medium.
system table. ➤ X-ray exposures are made at 1-,
➤ Determine date of last menstrual 5-, 10-, 15-, 20-, and 30-minute inter-
period and the possibility of preg- vals to follow the course of the
nancy in perimenopausal women. contrast medium through the urinary
➤ Patients receiving metformin system. Instruct the patient to exhale
(Glucophage) for non–insulin- deeply and to hold his or her breath
dependent (type 2) diabetes should while the x-ray is taken, and then to
discontinue the drug on the day of breathe after the film is taken.
the test and continue to withhold it ➤ Ask the patient to void; a postvoiding
for 48 hours after the test. Failure to exposure is done to visualize the
do so may result in lactic acidosis. empty bladder.
intake the day before the test but to Post-test:
withhold food and fluids for 8 hours
before the test. ➤ Direct the patient to resume usual
➤ Schedule gastrointestinal or any diet, activity, and medication, if with-
barium studies after this study. held and as directed by the physi-
cian. Renal function should be
Intratest: assessed before metformin is
restarted.
➤ Give the patient a laxative or a ➤ Inform the patient that the contrast
cathartic, as ordered, on the evening medium may cause a temporary
before the examination. flushing of the face, a feeling of
➤ Give the patient an enema or warmth, or nausea.
suppository on the morning of the ➤ Inform the patient that further
test, as ordered. examinations may be necessary to
➤ Have the patient put on a hospital evaluate progression of the disease
gown, but instruct the patient not to process or to determine the need for
void until after the test is performed. a change in therapy.
➤ Administer sedative to a child or to ➤ Maintain the patient on adequate
an uncooperative adult, as ordered. hydration after the procedure.
➤ Ask the patient to lie still during the ➤ Monitor urinary output after the
procedure because movement pro- procedure. Decreased urine output
duces unclear images. Make sure may indicate impending renal failure.
jewelry, watches, chains, belts, and ➤ Determine if the patient or family
any other metallic objects have been members have any further ques-
removed from the abdominal area. tions or concerns.
➤ Remove any wires connected to ➤ A physician specializing in this branch
electrodes, if allowed. of medicine sends a written report to
➤ Place the patient on the table in the the ordering provider, who discusses
supine position with hands over the the results with the patient.
head or relaxed at the patient’s side. ➤ Evaluate test results in relation to
➤ For male patients, place lead protec- the patient’s symptoms and other
tion over the testicles to prevent tests performed. Related diagnostic
their irradiation but remove it for tests include renogram, renal ultra-
bladder exposures. sound, and CT scan of the kidneys.
INTRINSIC FACTOR ANTIBODIES

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: IF antibodies.
collected in a lavender-top (ethylenediaminetetra-acetic acid) tube is also
acceptable.
REFERENCE VALUE: (Method: Radioimmunoassay) None detected.
DESCRIPTION: Intrinsic factor (IF) is • Some patients with hyperthyroidism

produced by the parietal cells of the
gastric mucosa and is required for Decreased in: N/A
the normal absorption of vitamin B12.
In some diseases, antibodies are CRITICAL VALUES: N/A
produced that bind the cobalamin-IF
complex, prevent the complex from
• Recent treatment with methotrexate
binding to ileum receptors, and or another folic acid antagonist can
prevent vitamin B12 absorption. interfere with test results.
There are two types of antibodies:
type 1, the more commonly present • Vitamin B12 injected or ingested
within 48 hours of the test invalidates
blocking antibody; and type 2, the
results.
binding antibody. The blocking anti-
body inhibits uptake of vitamin B12 at • Recent radioactive scans or radia-
the binding site of IF. Binding anti- tion can interfere with test results
body combines with either free or when radioimmunoassay is the test
method.
complexed IF. ■
INDICATIONS:
• Assist in the diagnosis of pernicious Nursing Implications and
anemia Procedure ● ● ● ● ● ● ● ● ● ● ●
• Evaluate patients with decreased vita- Pretest:

min B12 levels
allergens.
hematopoietic and gastrointestinal
• Megaloblastic anemia systems, as well as results of previ-
• Pernicious anemia ously performed tests and proce-
• Some patients with insulin-dependent hematopoietic and gastrointestinal
(type 1) diabetes system tables.
Iron 633
➤ Obtain a list of the medications Intratest:

herbs, nutritional supplements, and ➤ Direct the patient to breathe
nutraceuticals. The requesting health normally and to avoid unnecessary
care practitioner and laboratory movement.
should be advised if the patient is ➤ Observe standard precautions and
regularly using these products so follow the general guidelines in
that their effects can be taken into Appendix A. Perform a venipuncture,
consideration when reviewing and collect the specimen in a 5-mL
results. red-top tube.
➤ Note any recent procedures that can ➤ Label the specimen, and promptly
interfere with test results. transport it to the laboratory.
➤ There are no food or fluid restric-
tions unless by medical direction. Post-test:
Administration of vitamin B12 should ➤ Observe venipuncture site for bleed-
be withheld within 48 hours before ing or hematoma formation. Apply
testing. pressure bandage.
collection takes approximately 5 to tests include complete blood count,
10 minutes. folic acid, and vitamin B12.
IRON
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Fe.
SI Units
Newborn 100–250 g/dL 17.9–44.8 mol/L
Infant–9 y 20–105 g/dL 3.6–18.8 mol/L
10–14 y 20–145 g/dL 3.6–26.0 mol/L
Adult
Male 65–175 g/dL 11.6–31.3 mol/L
Female 50–170 g/dL 9–30.4 mol/L
DESCRIPTION: Iron plays a principal • Evaluate iron overload in dialysis

role in erythropoiesis. Iron is neces- patients or patients with transfusion-
sary for the proliferation and matura- dependent anemias
tion of red blood cells and is required • Evaluate thalassemia and sideroblastic
for hemoglobin synthesis. Of the anemia
body’s normal 4 g of iron, approxi- • Monitor hematologic responses during
mately 65 percent of iron resides in pregnancy, when serum iron is usually
hemoglobin and 3 percent in myoglo- decreased
bin. A small amount is also found in
• Monitor response to treatment for
cellular enzymes that catalyze the
anemia
oxidation and reduction of iron. The
remainder of iron is stored in the liver,
bone marrow, and spleen as ferritin or RESULT
hemosiderin. Any iron present in the
Increased in:
serum is in transit among the alimen-
tary tract, the bone marrow, and avail- • Acute iron poisoning (children)
able iron storage forms. Iron travels in • Acute leukemia
the bloodstream bound to transferrin, • Acute liver disease
a protein manufactured by the liver.
Normally, iron enters the body by • Aplastic anemia
oral ingestion; only 10 percent is • Excessive iron therapy
absorbed, but 20 percent can be
• Hemochromatosis
absorbed in patients with iron-
deficiency anemia. Unbound iron is • Hemolytic anemias
highly toxic, but there is generally an • Lead toxicity
excess of transferrin available to
• Nephritis
prevent the buildup of unbound iron
in circulation. Iron overload is as clin- • Pernicious anemias
ically significant as iron deficiency, • Sideroblastic anemias
especially in the accidental poisoning
of children caused by excessive intake • Thalassemia
of iron-containing multivitamins. ■ • Transfusions (repeated)
• Vitamin B6 deficiency
INDICATIONS:
• Assist in the diagnosis of blood loss,
indicated by decreased serum iron Decreased in:
• Assist in the diagnosis of hemochro- • Acute and chronic infection
matosis or other disorders of iron • Carcinoma
metabolism and storage
• Chronic blood loss (gastrointestinal,
• Determine the presence of disorders uterine)
that involve diminished protein
synthesis or defects in iron absorption • Hypothyroidism
• Determine the differential diagnosis of • Iron-deficiency anemia

anemia • Nephrosis
• Evaluate accidental iron poisoning • Postoperative state
Iron 635
• Protein malnutrition (kwashiorkor) ➤ There are no fluid restrictions unless

by medical direction.
• Remission of pernicious anemia
➤ Instruct the patient to fast for at
least 12 hours before testing, and
CRITICAL VALUES: Ingestion of with medical direction, to refrain
30 mg/kg of elemental iron by a child from taking iron-containing medi-
may be sufficient to induce toxicity. cines before specimen collection.
Greater than 400 g/dL is indicative of ➤ Specimen collection should be
possible toxicity. Intervention may delayed for several days after blood
include chelation therapy by administra- transfusion.
tion of deferoxamine mesylate (Desferal). ➤ Gross hemolysis can interfere with
test results.
• Drugs that may increase iron levels inpatient.
clude blood transfusions, chemother-
apy, iron (intramuscular), iron dextran, collection takes approximately 5 to
iron-protein-succinylate, methimazole, 10 minutes.
methotrexate, oral contraceptives, and
rifampin. Intratest:
• Drugs that may decrease iron levels ➤ Ensure that the patient has complied
include allopurinol, acetylsalicylic acid, with dietary preparations and other
cholestyramine, corticotropin, corti- pretesting restrictions.
sone, deferoxamine, and metformin. ➤ Direct the patient to breathe
• Failure to withhold iron-containing movement.
medications 24 hours before the test
may falsely increase values. follow the general guidelines in
Nursing Implications and red- or tiger-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Label the specimen, and promptly
Pretest:
Post-test:
hematopoietic system and results of ➤ Instruct the patient to resume usual
previously performed tests and diet as directed by the requesting
procedures. For related tests, refer health care practitioner.
to the hematopoietic system table. ➤ Educate the patient with abnormally
➤ Obtain a list of medications the pa- elevated iron values, as appropriate,
tient is taking, including herbs, nutri- on the importance of reading food
tional supplements, and nutraceuti- labels either to avoid or to ingest
cals. The requesting health care foods containing iron. Foods high in
practitioner and laboratory should be iron include meats, eggs, grains, and
advised if the patient regularly uses vegetables. It is also important to
these products so that their effects explain that iron levels in foods can
can be taken into consideration be increased if foods are cooked in
when reviewing results. cookware containing iron.
➤ Note any recent therapies that can ➤ Educate the patient with abnormal
interfere with test results. iron values that numerous factors
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.
IRON-BINDING CAPACITY (TOTAL),

TRANSFERRIN, AND IRON
SATURATION
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: TIBC, Fe Sat.

REFERENCE VALUE: (Method: Spectrophotometry for TIBC and nephelom-
etry for transferrin)
Test Conventional Units SI Unit

TIBC 250–350 g/dL 45–63 mol/L
Transferrin 200–380 mg/dL 2–3.8 g/L
Iron saturation 20–50%
TIBC total iron-binding capacity.
DESCRIPTION: Iron plays a principal synthesis. Of the body’s normal 4 g of

role in erythropoiesis. It is necessary iron (less in women), about 65
for proliferation and maturation of percent is present in hemoglobin and
red blood cells and for hemoglobin about 3 percent in myoglobin. A
Iron-Binding Capacity (Total), Transferrin, and Iron Saturation 637
small amount is also found in cellular Decreased in:

enzymes that catalyze the oxidation • Chronic infections
and reduction of iron. The remainder • Cirrhosis
of iron is stored in the liver, bone
marrow, and spleen as ferritin or • Hemochromatosis
hemosiderin. Any iron present in the • Hemolytic anemias
serum is in transit among the alimen-
• Protein depletion
tary tract, the bone marrow, and avail-
able iron storage forms. Iron travels in • Neoplastic diseases
the bloodstream bound to transport • Renal disease
proteins. Transferrin is the major
• Sideroblastic anemias
iron-transport protein, carrying 60 to
70 percent of the body’s iron. For this • Thalassemia
reason, total iron-binding capacity
(TIBC) and transferrin are sometimes CRITICAL VALUES: N/A
referred to interchangeably, even
though other proteins carry iron and • Drugs that may increase TIBC levels
contribute to the TIBC. Unbound include mestranol and oral contracep-
iron is highly toxic, but there is gener- tives.
ally an excess of transferrin available
• Drugs that may decrease TIBC levels
to prevent the buildup of unbound include asparaginase, chlorampheni-
iron in circulation. The percentage of col, corticotropin, cortisone, and
iron saturation is calculated by divid- testosterone.
ing the serum iron value by the TIBC
value and multiplying by 100. ■
• Assist in the diagnosis of iron-

deficiency anemia Pretest:
• Differentiate between iron-deficiency ➤ Obtain a history of the patient’s
anemia and anemia secondary to complaints, including a list of known
chronic disease allergens.
• Monitor hematologic response to ther- ➤ Obtain a history of the patient’s
hematopoietic system and results of
apy during pregnancy and iron- previously performed tests and
deficiency anemias procedures. For related tests, refer
• Provide support for diagnosis of to the hematopoietic system table.
hemochromatosis or diseases of iron ➤ Obtain a list of the medications the
metabolism and storage patient is taking, including herbs,
RESULT ceuticals. The requesting health care
practitioner and laboratory should
be advised if the patient is regularly
Increased in: using these products so that their
• Acute liver disease effects can be taken into considera-
• Hypochromic (iron-deficiency)
anemias ➤ There are no food, fluid, or medica-
• Late pregnancy direction.
10 minutes. Post-test:
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.
KETONES, BLOOD AND URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Ketone bodies, acetoacetate, acetone.

SPECIMEN: Serum (1 mL) collected from red- or tiger-top tube. Urine (5
mL), random or timed specimen, collected in a clean plastic collection
container.
REFERENCE VALUE: (Method: Colorimetric nitroprusside reaction) Negative.
DESCRIPTION: Ketone bodies refer excessive fat metabolism, ketones are

to the three intermediate products found in blood and urine. Excessive
of metabolism: acetone, acetoacetic fat metabolism may occur if the pa-
acid, and -hydroxybutyrate. Even tient has impaired ability to metabo-
though -hydroxybutyrate is not a lize carbohydrates, inadequate carbo-
ketone, it is usually listed with the ke- hydrate intake, inadequate insulin
tone bodies. In healthy individuals, levels, excessive carbohydrate loss, or
ketones are produced and completely increased carbohydrate demand. A
metabolized by the liver so that meas- strongly positive acetone result with-
urable amounts are not normally out severe acidosis, accompanied by
present in serum. Ketones appear in normal glucose, electrolyte, and bi-
the urine before a significant serum carbonate levels, is strongly suggestive
level is detectable. If the patient has of isopropyl alcohol poisoning. A
Ketones, Blood and Urine 639
low-carbohydrate or low-fat diet may • Isopropyl alcohol ingestion

cause a positive acetone test. Ketosis
• Methylmalonic aciduria
in diabetics is usually accompanied by
increased glucose and decreased bicar- • Postanesthesia period
bonate and pH. Extremely elevated
levels of ketone bodies can result in • Propionyl coenzyme A carboxylase
deficiency
coma. This situation is particularly
life-threatening in children younger
Decreased in: N/A
than 10 years old. ■
INDICATIONS: CRITICAL VALUES: An elevated

• Assist in the diagnosis of starvation, level of ketone bodies is evidenced
stress, alcoholism, suspected isopropyl by fruity-smelling breath, acidosis,
alcohol ingestion, glycogen storage ketonuria, and decreased level of
disease, and other metabolic disorders consciousness. Administration of insulin
and frequent blood-glucose measurement
• Detect and monitor treatment of may be indicated.
diabetic ketoacidosis
• Monitor the control for diabetes INTERFERING FACTORS:
• Drugs that may cause an increase in
• Screen for ketonuria to assist in the
serum ketone levels include acetylsali-
assessment of inborn errors of metabo-
cylic acid (if therapy results in acidosis,
lism
especially in children),albuterol, fen-
• Screen for ketonuria to assist in the fluramine, levodopa, nifedipine, and
diagnosis of suspected isopropyl alco- paraldehyde.
hol poisoning
• Drugs that may cause a decrease in
• Screen for ketonuria due to acute serum ketone levels include acetylsali-
illness or stress in nondiabetic patients cylic acid and valproic acid. Increases
have been shown in hyperthyroid
RESULT patients receiving propranolol and
propylthiouracil.
Increased in:
• Acidosis • Drugs that may increase urine ketone
levels include acetylsalicylic acid (if
• Branched-chain ketonuria therapy results in acidosis, especially in
• Carbohydrate deficiency children), captopril, dimercaprol,
ether, ifosfamide, insulin, levodopa,
• Eclampsia mesna, metformin, methyldopa,
• Fasting or starvation N-acetylcysteine, niacin, paraldehyde,
penicillamine, phenazopyridine,
• Gestational diabetes phenolphthalein, phenolsulfonph-
• Glycogen storage diseases thalein, pyrazinamide, streptozocin,
sulfobromophthalein, and valproic
• Hyperglycemia acid.
• High-fat or high-protein diet • Drugs that may decrease urine ketone
• Ketoacidosis of alcoholism and levels include acetylsalicylic acid and
diabetes phenazopyridine.
• Illnesses with marked vomiting and • Urine should be checked within 60
diarrhea minutes of collection.
• Bacterial contamination of urine can Blood:

cause false-negative results. ➤ Direct the patient to breathe
• Failure to keep reagent strip tightly normally and to avoid unnecessary
closed can cause false-negative results. movement.
Light and moisture affect the ability of ➤ Perform a venipuncture, and collect
the chemicals in the strip to perform as the specimen in a 5-mL red- or tiger-
expected. top tube. Alternatively, a finger- or
heel-stick method of specimen
• False-negative or weakly false-positive collection can be used.
test results can be obtained when -
Urine:
hydroxybutyrate is the predominating
ketone body in cases of lactic acidosis. ➤ Review the procedure with the pa-
tient. Explain to the patient how to
collect a second-voided midstream
specimen: (1) void, then drink a
Nursing Implications and glass of water; and (2) wait 30 min-
Procedure ● ● ● ● ● ● ● ● ● ● ●
utes, and then try to void again.
➤ Instruct the patient to avoid exces-
Pretest: sive exercise and stress before
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
endocrine 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.
➤ Obtain a list of the medications the thoroughly wash her hands; (2)
patient is taking, including herbs, nu- cleanse the labia from front to back;
tritional supplements, and nutraceu- (3) while keeping the labia sepa-
ticals. The requesting health care rated, void a small amount into the
practitioner and laboratory should be toilet; and (4) without interrupting
advised if the patient regularly uses the urine stream, void directly into
these products so that their effects the specimen container.
when reviewing results. Blood or urine:
➤ There are no food, fluid, or medica- ➤ Label the specimen, and promptly
tion restrictions unless by medical transport it to the laboratory.
direction.
patient.
➤ Inform the patient that blood speci- ing or hematoma formation. Apply
men collection takes approximately pressure bandage.
5 to 10 minutes. The amount of time
required to collect a urine specimen ➤ Increased levels of ketone bodies
depends on the level of cooperation may be associated with diabetes. In-
from the patient. struct the diabetic patient, as appro-
priate, in nutritional management of
Intratest: the disease. Patients who adhere to
dietary recommendations report a
➤ Observe standard precautions and better general feeling of health, bet-
follow the general guidelines in ter weight management, greater
Appendix A. control of glucose and lipid values,
Kidney, Ureter, and Bladder Study 641
and improved use of insulin. There is glycemia (thirst, polyuria, hunger,

no “diabetic” diet; however, there and lethargy). Emphasize, as appro-
are many meal-planning approaches priate, that good glycemic control
with nutritional goals endorsed by delays the onset and slows the
the American Dietetic Association. progression of diabetic retinopathy,
The nutritional needs of each dia- nephropathy, and neuropathy.
betic patient must be determined in- ➤ Evaluate test results in relation to the
dividually with the appropriate health patient’s symptoms and other tests
care professionals, particularly pro- performed. Related laboratory tests
fessionals trained in nutrition. include anion gap, blood gases, elec-
➤ Instruct the patient and caregiver to trolytes, glucose, glycated hemoglo-
report signs and symptoms of hypo- bin, urine ketones, lactic acid,
glycemia (weakness, confusion, osmolality, urine osmolality, phos-
diaphoresis, rapid pulse) or hyper- phorus, and routine urinalysis.
KIDNEY, URETER, AND BLADDER

STUDY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Flat plate of the abdomen, plain film of the

abdomen, scout film, KUB.
AREA OF APPLICATION: Kidneys, ureters, bladder, and abdomen.

CONTRAST: None.
DESCRIPTION: 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
• 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-
RESULT which may inhibit organ visualization
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
Abnormal Findings: exceed the weight limit for the equip-
• Abnormal accumulation of bowel gas ment
• Ascites • Incorrect positioning of the patient,
• 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
• Intestinal obstruction ologic procedure
• Organomegaly • Gas or feces in the gastrointestinal tract
• Renal hematomas resulting from inadequate cleansing or
• 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
CRITICAL VALUES: N/A tion safety concerns regarding infants
INTERFERING FACTORS: • Risks associated with radiographic
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
Kidney, Ureter, and Bladder Study 643
examination is being done. Personnel the procedure because movement

working in the area where the exami- produces unclear images. Make
nation is being done should wear sure jewelry, watches, chains, belts,
badges that reveal their level of expo- and any other metallic objects have
been removed from the abdominal
sure to radiation. area.
➤ Remove any wires connected to
electrodes, if allowed.
➤ Place the patient on the table in a
Procedure ● ● ● ● ● ● ● ● ● ● ●
supine position with hands over the
head or relaxed at the side.
Pretest:
➤ For portable examinations, lower the
➤ Inform the patient about the head of the bed such that the patient
purpose of the procedure, various is lying as flat as he or she can toler-
positions to assume, and the need ate.
to hold his or her breath. ➤ For male patients, place lead protec-
➤ Inform the patient that the proce- tion over the testicles to prevent
dure is performed in a radiology their irradiation.
department by a technologist and ➤ Instruct the patient to inhale deeply
takes approximately 10 minutes. and to hold his or her breath while
➤ Obtain a history of the patient’s the x-ray is taken, and then to exhale
complaints. after the film is taken.
genitourinary and abdominal sys- Post-test:
tems, as well as results of previously
performed tests and procedures. For ➤ Inform the patient that further exam-
related tests, refer to the genitouri- inations may be necessary to evalu-
nary and gastrointestinal system ate progression of the disease
tables. process or to determine the need for
a change in therapy.
period and possibility of pregnancy ➤ Determine if the patient or family
in perimenopausal women. members have any further ques-
➤ Inform the patient that there are no tions or concerns.
food or fluid restrictions and that no ➤ A physician specializing in this
pain is associated with the study. branch of medicine sends a written
➤ Schedule intravenous pyelography report to the ordering provider, who
(IVP) or gastrointestinal studies after discusses the results with the
this study. patient.
➤ Have the patient put on a hospital tests include IVP as well as ultra-
gown. sound and computed tomography of
➤ Ask the patient to lie still during the abdomen.
KLEIHAUER-BETKE TEST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Fetal hemoglobin, hemoglobin F, acid elution slide

test.

aminetetra-acetic acid [EDTA]) tube. Freshly prepared blood smears are also
acceptable. Cord blood may be requested for use as a positive control.
REFERENCE VALUE: (Method: Microscopic examination of treated and

stained peripheral blood smear) Less than 1 percent.
DESCRIPTION: The Kleihauer-Betke CRITICAL VALUES: N/A

test is used to determine the degree of
fetal-maternal hemorrhage and to help INTERFERING FACTORS: Specimens must
calculate the dosage of RhoGAM to be be obtained before transfusion.
given in some cases of Rh-negative
mothers. The test can also be used to
distinguish some forms of thalassemia Nursing Implications and
from the hereditary persistence of fetal Procedure ● ● ● ● ● ● ● ● ● ● ●
hemoglobin, but hemoglobin elec-

trophoresis and flow-cytometry meth- Pretest:
ods are more commonly used for this ➤ Obtain a history of the patient’s
purpose. ■ complaints, including a list of known
allergens.
• Assist in the diagnosis of certain types hematopoietic and reproductive
of anemia. systems, as well as results of previ-
• Calculating dosage of RhoGAM
• Screening postpartum maternal blood hematopoietic and reproductive
for the presence of fetal-maternal system tables.
hemorrhage ➤ Obtain a list of medications the pa-
RESULT tional supplements, and nutraceuti-
Positive in: practitioner and laboratory should be
• Fetal-maternal hemorrhage advised if the patient regularly uses
• Hereditary persistence of fetal hemo- can be taken into consideration
globin when reviewing results.
Negative in: N/A interfere with test results.
Lactate Dehydrogenase and Isoenzymes 645
➤ There are no food, fluid, or medica- Appendix A. Perform a venipuncture,

tion restrictions unless by medical and collect the specimen in a 5-mL
direction. lavender-top tube.
patient. transport it to the laboratory. Sample
➤ Inform the patient that specimen must be less than 6 hours old.
10 minutes. Post-test:
Intratest: ➤ Observe venipuncture site for bleed-

follow the general guidelines in tests include blood group and type.
LACTATE DEHYDROGENASE
AND ISOENZYMES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: LDH and isos, LD and isos.

REFERENCE VALUE: (Method: Enzymatic analysis for lactate dehydrogenase,
electrophoretic analysis for isoenzymes) Reference ranges are method
dependent and may vary from laboratory to laboratory.
Lactate Dehydrogenase
SI Units
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
LDH Fraction % of Total Fraction of Total

LDH1 14–26 0.14–0.26
LDH2 29–39 0.29–0.39
LDH3 20–26 0.20–0.26
LDH4 8–16 0.08–0.16
LDH5 6–16 0.06–0.16
DESCRIPTION: Lactate dehydroge- elevated LDH1 and LDH2, from

nase (LDH) is an enzyme that pulmonary infarction and liver prob-
catalyzes the reversible conversion of lems, which elevate LDH4 and LDH5
lactate to pyruvate within cells. • Evaluate the degree of muscle wasting
Because many tissues contain LDH, in muscular dystrophy (LDH levels rise
elevated total LDH is considered a early in this disorder and approach
nonspecific indicator of cellular normal as muscle mass is reduced by
damage unless other clinical data atrophy)
make the tissue origin obvious. • Evaluate the effectiveness of cancer
Determining tissue origin is aided by chemotherapy (LDH levels should fall
electrophoretic analysis of the five with successful treatment)
isoenzymes specific to certain tissues. • Evaluate red cell hemolysis or renal
The heart and erythrocytes are rich infarction, especially as indicated by
sources of LDH1, LDH2, and LDH3; reversal of the LDH1:LDH2 ratio
the kidneys contain large amounts of
• Investigate acute MI or extension
LDH3 and LDH4; and the liver and thereof, as indicated by elevation
skeletal muscles are high in LDH4 (usually) of total LDH, elevation of
and LDH5. Certain glands (e.g., LDH1 and LDH2, and reversal of the
thyroid, adrenal, thymus), the LDH1:LDH2 ratio within 48 hours of
pancreas, spleen, lungs, lymph nodes, the infarction
and white blood cells contain LDH3, • Investigate chronicity of liver, lung,
whereas the ilium is an additional and kidney disorders, as evidenced by
source of LDH5. There have been LDH levels that remain persistently
documented reports of a sixth isoen- high
zyme of LDH. It is seen in patients
with severe liver disease and is an RESULT
indicator of a very poor prognosis.
LDH is found in every tissue of the Total LDH increased in:
body. It is of no use as a specific diag- • Carcinoma of the liver
nostic marker. Testing for the pres-
• Chronic alcoholism
ence of LDH and isoenzymes is rarely
used anymore to confirm acute • Cirrhosis
myocardial infarction (MI), having • Congestive heart failure
been replaced by more sensitive and
specific creatine kinase (CK-MB) and • Hemolytic anemias
troponin assays. ■ • Hypoxia
• Leukemias
INDICATIONS:
• Differentiate acute MI, evidenced by • MI or pulmonary infarction
Lactate Dehydrogenase and Isoenzymes 647
• Megaloblastic and pernicious anemia because LDH1 fraction is of red blood

cell origin.
• Musculoskeletal disease
• Some isoenzymes are temperature
• Obstructive jaundice
sensitive; therefore prolonged storage
• Pancreatitis at refrigerated temperatures may cause
false decreases.
• Renal disease (severe)
• Shock
• Viral hepatitis Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
Total LDH decreased in: N/A

Pretest:
LDH Isoenzymes: ➤ Obtain a history of the patient’s
• LDH1 fraction increased over LDH2 complaints, including a list of known
can be seen in acute MI, anemias allergens.
(pernicious, hemolytic, acute sickle ➤ Obtain a history of the patient’s car-
cell, megaloblastic, hemolytic), and diovascular, hematopoietic, hepato-
acute renal cortical injury due to any biliary, and musculoskeletal sys-
cause. The LDH1 fraction in particular tems, as well as results of previously
is elevated in cases of germ cell tumors. performed tests and procedures.
For related tests, refer to the cardio-
• Increases in the middle fractions are vascular, hematopoietic, hepatobil-
associated with conditions in which iary, and musculoskeletal system
massive platelet destruction has tables.
occurred (e.g., pulmonary embolism, ➤ Obtain a list of the medications the
post-transfusion period), and in patient is taking, including herbs, nu-
lymphatic system disorders (e.g., infec- tritional supplements, and nutraceu-
tious mononucleosis, lymphomas, ticals. The requesting health care
lymphocytic leukemias).
• An increase in LDH5 occurs with these products so that their effects
musculoskeletal damage and many can be taken into consideration
types of liver damage (e.g., cirrhosis, when reviewing results.
cancer, hepatitis). ➤ There are no food, fluid, or medica-
CRITICAL VALUES: N/A direction.
INTERFERING FACTORS: patient.
• Drugs that may increase total LDH ➤ Inform the patient that specimen
levels include amiodarone, etretinate, collection takes approximately 5 to
fluosol-DA, methotrexate, oxacillin, 10 minutes.
plicamycin, propoxyphene and strep-
tokinase. Intratest:
• Drugs that may decrease total LDH ➤ Direct the patient to breathe
levels include ascorbic acid, cefo- normally and to avoid unnecessary
taxime, enalapril, fluorides, naltrexone, movement.
and oxylate. ➤ Observe standard precautions and
• Hemolysis will cause significant false Appendix A. Perform a venipuncture,
elevations in total LDH and a false and collect the specimen in a 5-mL
“flip” pattern of the isoenzymes red- or tiger-top tube.
➤ 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.
REFERENCE VALUE: (Method: Spectrophotometry/enzymatic analysis)

3–23 mg/dL 0.3–2.6 mmol/L
DESCRIPTION: Lactic acid (present metabolize lactate sufficiently, lactate

in blood as lactate) is a byproduct of levels become elevated. The lactic
carbohydrate metabolism. Normally acid test can be performed in
metabolized in the liver, lactate conjunction with pyruvic acid testing
concentration is based on the rate of to monitor tissue oxygenation. Lactic
production and metabolism. Levels acidosis can be differentiated from
increase during strenuous exercise, ketoacidosis by the absence of ketosis
which results in insufficient oxygen and grossly elevated glucose levels. ■
delivery to the tissues. Pyruvate, the
normal end product of glucose INDICATIONS:
metabolism, is converted to lactate in • Assess tissue oxygenation
emergency situations when energy is • Evaluate acidosis
needed but there is insufficient
oxygen in the system to favor the RESULT
aerobic and customary energy cycle.
Increased in:
When hypoxia or circulatory collapse
increases production of lactate, or • Cardiac failure
when the hepatic system doesn’t • Diabetes
Lactic Acid 649
• Hemorrhage • Delay in transport of the specimen to

the laboratory must be avoided.
• Hepatic coma
Specimens not processed by centrifuga-
• Ingestion of large doses of ethanol or tion in a tightly stoppered collection
acetaminophen container within 15 minutes of collec-
tion should be rejected for analysis. It is
• Lactic acidosis
preferable to transport specimens to
• Pulmonary embolism the laboratory in an ice slurry to
further retard cellular metabolism that
• Pulmonary failure
might shift lactate levels in the sample
• Reye’s syndrome before analysis.
• Shock
• Strenuous exercise
Decreased in: N/A
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
CRITICAL VALUES:
Greater than or equal to 45 mg/dL
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
INTERFERING FACTORS: to the cardiovascular, endocrine,
• Drugs that may increase lactate levels hepatobiliary, musculoskeletal, and
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
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
because this enzyme reacts with the results.
available lactate substrate.
• 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
collection takes approximately 5 to gray-top (sodium fluoride) or green-

10 minutes. top (lithium heparin) tube.
➤ Prepare an ice slurry in a cup or plas- ➤ Label the specimen, and promptly
tic bag to have on hand for immedi- transport it to the laboratory. The
ate transport of the specimen to the tightly capped sample should be
laboratory. placed in an ice slurry immediately
Intratest: specimen label can be protected
from water in the ice slurry if the
➤ Ensure that the patient has complied specimen is first placed in a protec-
with dietary preparations and other tive plastic bag.
Post-test:
normally and to avoid unnecessary ➤ Observe venipuncture site for bleed-
movement. Instruct the patient not ing or hematoma formation. Apply
to clench and unclench fist immedi- pressure bandage.
ately before or during specimen ➤ Evaluate test results in relation to
collection. Do not use a tourniquet. the patient’s symptoms and other
follow the general guidelines in tests include arterial/alveolar oxygen
Appendix A. Perform a venipuncture, ratio, anion gap, blood gases, and
and collect the specimen in a 5-mL electrolytes.
LACTOSE TOLERANCE TEST

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: LTT.
SPECIMEN: Plasma (1 mL) collected in gray-top (fluoride/oxalate) tube.
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.
DESCRIPTION: Lactose is a disaccha- galactose. When sufficient lactase is

ride found in dairy products. When not available, intestinal bacteria
ingested, lactose is broken down in metabolize the lactose, resulting in
the intestine, by the sugar-splitting abdominal bloating, pain, flatus, and
enzyme lactase, into glucose and diarrhea. The lactose tolerance test
Lactose Tolerance Test 651
screens for lactose intolerance by ➤ There are no medication restrictions

monitoring glucose levels after inges- unless by medical direction.
tion of a dose of lactose. ■ ➤ Inform the patient that fasting for at
least 12 hours before the test is
INDICATIONS: Evaluate patients for sus- required and that strenuous activity
should also be avoided for at least 12
pected lactose intolerance hours before the test.
RESULT patient. Inform the patient that the
test may produce symptoms such
Glucose levels increased in: N/A as cramps and diarrhea. Instruct the
patient not to smoke cigarettes or
Glucose levels decreased in: chew gum during the test.
Lactose intolerance ➤ Obtain the pediatric patient’s weight
to calculate dose of lactose to be
CRITICAL VALUES: N/A administered.
➤ Inform the patient that multiple
INTERFERING FACTORS: samples over a 90-minute interval
• Numerous medications may alter will be collected and that each spec-
imen collection takes approximately
glucose levels (see monograph titled
5 to 10 minutes.
“Glucose”).
• Failure to restrict diet and exercise may Intratest:
alter test results. ➤ Ensure that the patient has complied
• Delayed gastric emptying may decrease with dietary preparations and other
glucose levels.
➤ Administer 50 g of lactose dissolved
• Smoking may falsely increase glucose in a small amount of water to adults
levels. over a 5- to 10-minute period.
Pediatric dosage is based on weight:
0.6 to 1.3 g lactose per kilogram of
body weight for infants less than 12
Nursing Implications and months old; 1.7 g lactose per kilo-
Procedure ● ● ● ● ● ● ● ● ● ● ●
gram of body weight for children 1 to
12 years old. Record time of inges-
Pretest: tion. Encourage the patient to drink
one to two glasses of water.
complaints, including a list of known follow the general guidelines in Ap-
allergens. pendix A. Perform a venipuncture,
gastrointestinal system and results red-top tube or red pediatric Micro-
of previously performed tests and tainer. Samples should be collected
procedures. For related tests, refer at baseline, 30, 45, 60, and 90 min-
to the gastrointestinal system table. utes. Record any symptoms the pa-
➤ Obtain a list of the medications the tient reports throughout the course
patient is taking, including herbs, nu- of the test.
tritional supplements, and nutraceu- ➤ Glucose values change rapidly in an
ticals. The requesting health care unprocessed, unpreserved speci-
practitioner and laboratory should be men; therefore, if a Microtainer is
advised if the patient regularly uses used, each sample should be trans-
these products so that their effects ported immediately after collection.
can be taken into consideration Label the specimen, and promptly
when reviewing results. transport it to the laboratory.
Post-test: intolerance to avoid milk products

and to carefully read labels on
➤ Observe venipuncture site for bleed- prepared products. Yogurt, which
ing or hematoma formation. Apply contains inactive lactase enzyme,
pressure bandage. may be ingested. The lactase in
➤ Provide teaching and information yogurt is activated by the tempera-
regarding the clinical implications of ture and pH of the duodenum and
the test results, as appropriate. substitutes for the lack of endoge-
➤ Instruct the patient that resuming nous lactase. Advise the patient that
his or her usual diet may not be pos- products such as Lactaid tablets or
sible if lactose intolerance is identi- drops may allow ingestion of milk
fied. Educate patients on the impor- products without sequelae. Lactose-
tance of following the dietary advice free milk is also available.
of a nutritionist to ensure proper nu- ➤ Evaluate test results in relation to
tritional balance. Recognize anxiety the patient’s symptoms and other
caused by a perceived change in tests performed. Related laboratory
lifestyle, and offer support. tests include D-xylose absorption
➤ Instruct the patient with lactose and fecal analysis.
LAPAROSCOPY, ABDOMINAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Abdominal peritoneoscopy.

CONTRAST: Carbon dioxide (CO2).
DESCRIPTION: Abdominal or gastro- abdominal wall so that the instru-

intestinal laparoscopy provides direct ments can be inserted safely. Advan-
visualization of the liver, gallbladder, tages of this procedure compared to
spleen, and stomach after insufflation an open laparotomy include reduced
of carbon dioxide (CO2). In this pain, reduced length of stay at the
procedure, a rigid laparoscope is hospital or surgical center, and
introduced into the body cavity reduced time off from work. ■
through a 1- to 2-cm abdominal inci-
sion. The endoscope has a micro- INDICATIONS:
scope to allow visualization of the • Evaluate abdominal pain or abdominal
organs, and it can be used to insert mass of unknown origin
instruments for performing certain • Obtain biopsy specimens of benign or
procedures, such as biopsy and tumor cancerous tumors
resection. Under general anesthesia,
the peritoneal cavity is inflated with 2 • Evaluate jaundice of unknown origin
to 3 L of CO2. The gas distends the • Evaluate and treat appendicitis
Laparoscopy, Abdominal 653
• 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
• Evaluate abdominal trauma in an visualization:
emergency • Inability of the patient to cooperate or
RESULT because of age, significant pain, or
mental status
Normal Findings:
• Normal appearance of the liver, spleen, exceed the weight limit for the equip-
gallbladder, pancreas, and other ment
abdominal contents
Abnormal Findings: which may produce poor visualization
• Abdominal adhesions of the area to be examined
• Appendicitis • A history of peritonitis or multiple

abdominal operations causing dense
• Ascites adhesions
• Cancer of any of the organs
• Cirrhosis of the liver • Failure to follow dietary restrictions
• Gangrenous gallbladder before the procedure may cause the
• Intra-abdominal bleeding
• Patients who are in a hypoxemic or
• Portal hypertension hypercapnic state will require continu-
• Splenomegaly ous oxygen administration.
• Patients with acute infection or
CRITICAL VALUES: N/A advanced malignancy involving the
abdominal wall are at increased risk
INTERFERING FACTORS: because organisms may be introduced
into the normally sterile peritoneal
This procedure is contraindicated cavity.
for:
of being pregnant, unless the potential Nursing Implications and
benefits of the procedure far outweigh Procedure ● ● ● ● ● ● ● ● ● ● ●
the risk of radiation exposure to the

fetus Pretest:
• Patients with bleeding disorders, espe- ➤ Inform the patient that the proce-
dure assesses the abdominal ➤ Insert an intravenous line or venous

organs. access device at a low “keep open”
➤ Inform the patient that the proce- rate.
dure is generally performed in an ➤ Administer medications, as ordered,
operating room by a physician while to reduce discomfort and to
the patient is under general anesthe- promote relaxation and sedation.
sia, but that it may be done under
➤ Place the patient on the laparoscopy
local anesthesia. Inform the patient
table. General anesthesia is adminis-
that the procedure takes approxi-
tered. Then place the patient in a
mately 15 to 30 minutes.
modified lithotomy position with the
➤ Assess whether the patient is aller- head tilted downward. Cleanse the
gic to latex. abdomen with an antiseptic solu-
➤ Determine date of last menstrual tion, and drape and catheterize the
period and the possibility of preg- patient, if ordered.
nancy in perimenopausal women. ➤ The physician identifies the site
➤ Obtain a history of the patient’s for the scope insertion and adminis-
reproductive system and previously ters local anesthesia. After deeper
performed laboratory tests (espe- layers are anesthetized, a pneu-
cially complete blood count, moperitoneum needle is placed
prothrombin time, partial thrombo- between the visceral and parietal
plastin time, clotting and bleeding peritoneum.
times), surgeries, therapies, and ➤ Cleanse the abdomen with antisep-
procedures. For related tests, refer tic solution and drape with sterile
to the gastrointestinal system table. drapes. CO2 is insufflated through
➤ Obtain a history of the patient’s the pneumoperitoneum needle to
complaints, including a list of known separate the abdominal wall from
allergens and sensitivities to anes- the viscera and to aid in visualization
thetics and analgesics. of the abdominal structures. The
➤ Obtain a list of the medications the pneumoperitoneum needle is re-
patient is taking. moved, and the trocar and laparo-
scope are inserted through the
➤ Restrict food or fluids for at least 8
incision.
hours before the procedure.
➤ Obtain a written, informed consent ➤ After the examination, collection of
before administering any medica- tissue samples, and performance of
tions prior to the procedure. therapeutic procedures, the scope is
withdrawn. All possible CO2 is evac-
➤ Wear gloves and gowns throughout uated via the trocar, which is then
the procedure. removed. The skin incision is closed
➤ Obtain and record baseline vital with sutures, clips, or sterile strips,
signs. and a small dressing or adhesive
strip is applied.
Intratest:
➤ Administer a cleansing enema 4 Post-test:
hours before the procedure. ➤ Inform the patient to resume usual
➤ Ask the patient to void before the diet when the vital signs return to
procedure. Have the patient put on a baseline levels, usually within 2
hospital gown. hours after the procedure, but
➤ Ask the patient to lie still during the instruct the patient to restrict activity
procedure because movement for 2 to 7 days after the procedure.
impairs clear visualization. Make ➤ Inform the patient that further exam-
sure jewelry, watches, chains, belts, inations may be necessary to evalu-
and any other metallic objects have ate progression of the disease
been removed from the abdominal process or to determine the need for
area. a change in therapy.
Laparoscopy, Gynecologic 655
➤ Inform the patient that shoulder ➤ Determine whether the patient or

discomfort may be experienced for 1 family members have any further
or 2 days after the procedure as a questions or concerns.
result abdominal distention caused
by insufflation of CO2 into the
abdomen, and that mild analgesics
and cold compresses, as ordered,
can be used to relieve the discom-
patient.
fort.
➤ Emphasize that any persistent shoul- ➤ Evaluate test results in relation to
der pain, abdominal pain, vaginal the patient’s symptoms and other
bleeding, fever, redness, or swelling tests performed. Related diagnostic
of the incisional area must be re- tests include abdominal ultrasound
ported to the physician immediately. and pelvic ultrasound.
LAPAROSCOPY, GYNECOLOGIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gynecologic pelviscopy, gynecologic laparoscopy,

pelvic endoscopy, peritoneoscopy.

CONTRAST: Carbon dioxide (CO2).
DESCRIPTION: Gynecologic anesthesia, the peritoneal cavity is

laparoscopy provides direct visualiza- inflated with 2 to 3 L of CO2. The
tion of the internal pelvic contents gas distends the abdominal wall so
including the ovaries, fallopian tubes, that the instruments can be inserted
and uterus after insufflation of safely. Advantages of this procedure
carbon dioxide (CO2). It is done to compared to an open laparotomy
diagnose and treat pelvic organ disor- include reduced pain, reduced length
ders, as well as to perform surgical of stay at the hospital or surgical
procedures on the organs. In this center, and reduced time off from
procedure, a rigid laparoscope is work. ■
introduced into the body cavity
through a 1- to 2-cm periumbilical INDICATIONS:
• Evaluate amenorrhea and infertility
incision. The endoscope has a micro-
scope to allow visualization of the • Evaluate fallopian tubes and anatomic
organs, and it can be used to insert defects to determine the cause of infer-
instruments for performing certain tility
procedures, such as biopsy and tumor • Evaluate reproductive organs after
resection. Under general or local therapy for infertility
• Evaluate pelvic pain or masses of CRITICAL VALUES: N/A

unknown cause
• Evaluate known or suspected INTERFERING FACTORS:
endometriosis, salpingitis, and hydros-
alpinx This procedure is contraindicated
for:
• Detect ectopic pregnancy and deter- • Patients who are pregnant or suspected
mine the need for surgery of being pregnant, unless the potential
• Detect pelvic inflammatory disease or benefits of the procedure far outweigh
abscess the risks to the fetus and mother
• Detect uterine fibroids, ovarian cysts, • Patients with bleeding disorders, espe-
and uterine malformations (ovarian cially those associated with uremia and
cysts may be aspirated during the cytotoxic chemotherapy
procedure) • Patients with cardiac conditions or
• Obtain biopsy specimens to confirm dysrhythmias
suspected pelvic malignancies or • Patients with advanced respiratory or
metastasis cardiovascular disease
• Treat endometriosis through electro- • Patients with intestinal obstruction,
cautery or laser vaporization abdominal mass, abdominal hernia, or
• Remove adhesions or foreign bodies suspected intra-abdominal hemorrhage
such as intrauterine devices (IUDs)
• Perform vaginal hysterectomy visualization:
• Perform tubal sterilization and ovarian • Inability of the patient to cooperate or
biopsy remain still during the procedure
mental status
RESULT
Normal Findings: exceed the weight limit for the equip-
ment
• Normal appearance of uterus, ovaries,
fallopian tubes, and other pelvic • Incorrect positioning of the patient,
contents which may produce poor visualization
Abnormal Findings: • A history of peritonitis or multiple
• Ectopic pregnancy abdominal operations causing dense
adhesions
• Endometriosis
• Ovarian cyst Other considerations:
• Ovarian tumor
• Pelvic adhesions procedure to be canceled or repeated.
• Pelvic inflammatory disease • Patients who are in a hypoxemic or
hypercapnic state will require continu-
• Pelvic tumor
ous oxygen administration.
• Salpingitis
• Patients with acute infection or
• Uterine fibroids advanced malignancy involving the
Laparoscopy, Gynecologic 657
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
➤ 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.
➤ 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, procan 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
dressing or adhesive strip is applied. gesics and cold compresses, as

After the perineum is cleansed, the ordered, can be used to relieve the
uterine manipulator is removed and discomfort.
a sterile pad applied. ➤ Emphasize that any persistent shoul-
der pain, abdominal pain, vaginal
Post-test: bleeding, fever, redness, or swelling
➤ Inform the patient to resume usual of the incisional area must be
diet when the vital signs return to reported to the physician immedi-
baseline levels, usually within 2 ately.
hours after the procedure, but ➤ Determine whether the patient or
instruct the patient to restrict activity family members have any further
for 2 to 7 days after the procedure. questions or concerns.
➤ Inform the patient that further exam- ➤ A physician specializing in this
inations may be necessary to evalu- branch of medicine sends a written
ate progression of the disease report to the ordering provider, who
process or to determine the need for discusses the results with the
a change in therapy. patient.
➤ Inform the patient that shoulder ➤ Evaluate test results in relation to
discomfort may be experienced for 1 the patient’s symptoms and other
or 2 days after the procedure as a tests performed. Related diagnostic
result of abdominal distention tests include ultrasound or com-
caused by insufflation of CO2 into puted tomography of the pelvis as
the abdomen, and that mild anal- well as ultrasound the abdomen.
LATEX ALLERGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
DESCRIPTION: Latex is found in gloves. It is estimated that 8 to 17

numerous medical supplies, such as percent of health care workers have
gloves, catheters, and bandages. Some become allergic to latex. There are
individuals who are routinely exposed two types of allergic reactions. Type
to latex products, particularly as part IV allergic contact dermatitis is
of their occupation, have become caused by chemicals used in the
highly allergic to latex. Health care process of manufacturing latex. It is a
workers are classified as high risk, delayed reaction occurring within 6
especially since the 1987 mandate of to 48 hours of direct-skin or mucous-
standard/universal precautions that membrane contact with latex prod-
resulted in increased use of latex ucts. The type I allergic reaction
Latex Allergy 659
occurs in response to proteins in the nutritional supplements, and nutra-

natural latex products by direct-skin ceuticals. The requesting health care
or mucous-membrane contact or by advised if the patient regularly uses
inhaling aerosolized powder from a these products so that their effects
latex glove. Other high-risk individu- can be taken into consideration
als include people with spina bifida, when reviewing results.
spinal cord injury, myelodysplasia, ➤ There are no food, fluid, or medica-
atopic dermatitis, eczema, history tion restrictions unless by medical
direction.
of allergies (personal or family),
history of chronic illness, or multiple ➤ Review the procedure with the
patient.
surgeries. ■
INDICATIONS: Suspected latex allergy 10 minutes.
RESULT Intratest:
Positive findings in: Latex allergy normally and to avoid unnecessary
movement.
Negative findings in: N/A ➤ Observe standard precautions and
CRITICAL VALUES: N/A Appendix A. Perform a venipuncture,
red-top tube.
INTERFERING FACTORS: N/A ➤ Label the specimen, and promptly
Procedure ● ● ● ● ● ● ● ● ● ● ●

pressure bandage.
➤ Obtain a history of the patient’s ➤ Assist the patient, as appropriate, in
complaints, including a list of known identifying sources of exposure in
allergens. order for the patient to eliminate or
➤ Obtain a history of the patient’s reduce the opportunity for continued
immune system, a history of latex exposure.
exposure, and results of previously ➤ Evaluate test results in relation to
performed tests and procedures. For the patient’s symptoms, history of
related tests, refer to the immune exposure, and other tests per-
system table. formed. Related laboratory tests in-
➤ Obtain a list of the medications the clude complete blood count and im-
patient is taking, including herbs, munoglobulin E.
LEAD
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Pb.
SPECIMEN: Whole blood (1 mL) collected in a special lead-free royal blue–
or tan-top tube. Plasma (1 mL) collected in lavender-top (ethylenedi-
aminetetra-acetic acid [EDTA]) tube is also acceptable.
SI Units
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.
DESCRIPTION: Lead is a heavy metal INDICATIONS: Assist in the diagnosis

and trace element. It is absorbed and treatment of lead poisoning
through the respiratory and gastroin-
testinal systems. It can also be
RESULT
transported from mother to fetus Increased in:
through the placenta. When there • Anemia of lead intoxication
is frequent exposure to lead-
• Lead encephalopathy
containing items (e.g., paint, batter-
ies, gasoline, pottery, bullets, printing • Metal poisoning
materials) or occupations (mining, Decreased in: N/A
automobile, printing, and welding
industries), many organs of the body CRITICAL VALUES: N/A
are affected. Lead poisoning can
cause severe behavioral and neuro- INTERFERING FACTORS: Contamination
of the collection site and/or specimen
logic effects. The blood test is consid-
with lead in dust can be avoided by
ered the best indicator of lead taking special care to have the surfaces
poisoning, and confirmation is made surrounding the collection location
by the lead mobilization test cleaned. Extra care should also be used to
performed on a 24-hour urine speci- avoid contamination during the actual
men. ■ venipuncture.
Lecithin/Sphingomyelin Ratio 661

Nursing Implications and patient.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: 10 minutes.
allergens. ➤ Direct the patient to breathe
movement.
previously performed tests and ➤ Observe standard precautions and
procedures. For related tests, refer follow the general guidelines in
to the hematopoietic system and Appendix A. Perform a venipuncture,
therapeutic/toxicology tables. and collect the specimen in a 5-mL
royal blue– or tan-top tube.
exposure to lead. ➤ Label the specimen, and promptly
the patient is taking, including Post-test:
nutraceuticals. The requesting health ➤ Observe venipuncture site for bleed-
care practitioner and laboratory ing or hematoma formation. Apply
should be advised if the patient pressure bandage.
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 labora-
results. tory tests include complete blood
➤ There are no food, fluid, or medica- count, -aminolevulinic acid, erythro-
tion restrictions unless by medical cyte protoporphyrin, and urine
direction. porphyrins.
LECITHIN/SPHINGOMYELIN RATIO
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: L/S ratio.

SPECIMEN: Amniotic fluid (10 mL) collected in a sterile, brown glass or
plastic tube or bottle protected from light.
REFERENCE VALUE: (Method: Thin-layer chromatography)

Mature (nondiabetic): Greater than 2:1 in the presence of phosphatidyl
glycerol
Borderline: 1.5 to 1.9:1
Immature: Less than 1.5:1
DESCRIPTION: Respiratory distress tic accuracy. Production of phospho-

syndrome (RDS) is the most lipid surfactant is delayed in diabetic
common problem encountered in the mothers. Therefore, caution must be
care of premature infants. RDS, also used when interpreting the results
called hyaline membrane disease, obtained from a diabetic patient, and
results from a deficiency of phospho- a higher ratio is expected to predict
lipid lung surfactants. The phospho- maturity. ■
lipids in surfactant are produced by
specialized alveolar cells and stored in INDICATIONS:
granular lamellar bodies in the lung. • Assist in the evaluation of fetal lung
maturity
In normally developed lungs, surfac-
tant coats the surface of the alveoli. • Determine the optimal time for obstet-
Surfactant reduces the surface tension ric intervention in cases of threatened
of the alveolar wall during breathing. fetal survival caused by stresses related
When there is an insufficient quantity to maternal diabetes, toxemia, he-
molytic diseases of the newborn, or
of surfactant, the alveoli are unable to
postmaturity
expand normally and gas exchange is
inhibited. Amniocentesis is a proce- • Identify fetuses at risk of developing
dure by which fluid is removed from respiratory distress syndrome (RDS)
the amniotic sac to assess fetal lung
maturity. RESULT
Lecithin is the primary surfactant
Increased in:
phospholipid, and it is a stabilizing
• Hypertension
factor for the alveoli. It is produced at
a low but constant rate until the • Intrauterine growth retardation
35th week of gestation, after which • Malnutrition
its production sharply increases.
• Maternal diabetes
Sphingomyelin, another phospho-
lipid component of surfactant, is also • Placenta previa
produced at a constant rate after the • Placental infarction
26th week of gestation. Before the
35th week, the lecithin/sphin- • Premature rupture of the membranes
gomyelin (L/S) ratio is usually less
Decreased in:
than 1.6:1. The ratio increases to 2.0
• Immature fetal lungs
or greater when the rate of lecithin
production increases after the 35th • Advanced maternal age
week of gestation. Other phospho- • Polyhydramnios
lipids, such as phosphatidyl glycerol
(PG) and phosphatidyl inositol (PI), • Multiple gestation
increase over time in amniotic fluid as
CRITICAL VALUES: An L/S ratio less
well. The presence of PG indicates than 1.5:1 is predictive of RDS at the
that the fetus is within 2 to 6 weeks of time of delivery. Infants known to be at
lung maturity (i.e., at full term). risk for RDS can be treated with surfac-
Simultaneous measurement of PG tant by intratracheal administration at
with the L/S ratio improves diagnos- birth.
Lecithin/Sphingomyelin Ratio 663
INTERFERING FACTORS: void before the test, because an

• Fetal blood falsely elevates L/S ratio. empty bladder is less likely to be
accidentally punctured during speci-
• Exposing the specimen to light may men collection.
cause falsely decreased values. ➤ Review the amniocentesis proce-
dure with the patient.
• There is some risk to having an amnio-
centesis performed, and this should be ➤ Assess whether the patient has an
weighed against the need to obtain the allergy to local anesthetics, and
inform the health care practitioner
desired diagnostic information. A small
accordingly.
percentage (0.5%) of patients have
experienced complications including ➤ Obtain written and informed
premature rupture of the membranes,
premature labor, spontaneous abor-
tion, and stillbirth. ➤ Inform the patient that specimen
collection usually takes 20 to 30
minutes.

Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Record maternal and fetal baseline
vital signs. Monitor for uterine
Pretest: contractions.
➤ Obtain a history of the patient’s ➤ Ultrasound is used to locate the
complaints, including a list of known fetus, placenta, and amniotic fluid.
allergens. ➤ Observe standard precautions and
reproductive and respiratory system Appendix A.
and results of previously performed ➤ Assemble the necessary equip-
tests and procedures. For related ment, including an amniocentesis
tests, refer to the reproductive and tray with solution for skin prepara-
respiratory system tables. tion, local anesthetic, 10- or 20-mL
➤ Obtain a list of the medications the syringe, needles of various sizes
patient is taking, including herbs, nu- (including a 22-gauge, 5-inch spinal
tritional supplements, and nutraceu- needle), sterile drapes, sterile
ticals. The requesting health care gloves, and foil-covered or amber
practitioner and laboratory should be specimen collection containers.
advised if the patient regularly uses ➤ Ensure that the patient has a
these products so that their effects full bladder before the procedure
can be taken into consideration if gestation is 20 weeks or less;
when reviewing results. have patient void before the proce-
➤ There are no food, fluid, or medica- dure if gestation is 21 weeks or
tion restrictions unless by medical more.
direction. ➤ Assist the patient to a supine posi-
➤ If the patient is less than 20 weeks’ tion. Raise her head or legs slightly
gestation, instruct her to drink extra to promote comfort and to relax
fluids 1 hour before the test and to abdominal muscles. If the uterus is
refrain from urination. The full blad- large, place a pillow or rolled blanket
der assists in raising the uterus up under the patient’s right side to
and out of the way to provide better prevent hypertension caused by
visualization during the ultrasound great-vessel compression.
procedure. Patients who are at 20 ➤ Note fetal position and pocket of
weeks’ gestation or beyond do not amniotic fluid as determined by
need to drink extra fluids and should ultrasound and palpation.
➤ Cleanse suprapubic area with an ➤ A Kleihauer-Betke test should be

antiseptic solution and protect with performed on maternal blood after
sterile drapes. A local anesthetic is amniocentesis of an Rh-negative
injected. Explain that this may cause patient to determine if fetal-maternal
a stinging sensation. hemorrhage has occurred. Adminis-
➤ A 22-gauge, 5-inch spinal needle is tration of Rh immune globulin is
inserted through the abdominal and recommended if the results are
uterine walls. Explain that a sensa- increased. Some protocols may
tion of pressure may be experienced recommend automatically adminis-
when the needle is inserted. Explain tering Rh immune globulin after
to the patient how to use focusing amniocentesis of an Rh-negative
and controlled breathing for relax- patient and ignoring Kleihauer-Betke
ation during the procedure. testing.
➤ After the fluid is collected and the ➤ Recognize anxiety related to test
needle withdrawn, apply slight pres- results and offer support. Provide
sure to the site. If there is no teaching and information regarding
evidence of bleeding or other the clinical implications of the test
drainage, apply a sterile adhesive results, as appropriate. Encourage
bandage to the site. the family to seek counseling if
concerned with pregnancy termina-
tion or to seek genetic counseling
Post-test: if a chromosomal abnormality is
determined. Provide teaching and
➤ Fetal heart rate and maternal life
information regarding the clinical
signs (i.e., heart rate, blood
implications of the test results, as
pressure, pulse, and respira-
appropriate. Decisions regarding
tion) must be compared to baseline
elective abortion should take place
values and closely monitored every
in the presence of both parents.
15 minutes for 30 to 60 minutes
Provide a nonjudgmental, nonthreat-
after the amniocentesis procedure.
ening atmosphere for discussing the
➤ Observe the patient after the proce- risks and difficulties of delivering and
dure for symptoms of discomfort, raising an abnormal infant, as well as
such as nausea, faintness, or cramp- exploring other options (termination
ing. Instruct the patient to lie on her of pregnancy or adoption). It is also
right side if symptoms are present. important to discuss feelings the
➤ Instruct the patient to rest until all mother and father may experience
symptoms have disappeared before (e.g., guilt, depression, anger) if fetal
resuming normal levels of activity. abnormalities are detected.
➤ Instruct the patient to immediately ➤ Evaluate test results in relation to
report any symptoms of itching at the patient’s symptoms and other
the collection site, fever, leakage of tests performed. Related laboratory
fluid, severe abdominal pain, or tests include 1-fetoprotein, amni-
change in fetal activity (either otic fluid analysis, Kleihauer-Betke
increased or decreased). test, and chromosomal analysis.
LEUKOCYTE ALKALINE PHOSPHATASE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: LAP, LAP score, LAP smear.

Leukocyte Alkaline Phosphatase 665

REFERENCE VALUE: (Method: Microscopic evaluation of specially stained

blood smears) 32 to 182 (score based on 0 to 4 rating of 100
neutrophils).
DESCRIPTION: Alkaline phosphatase • Multiple myeloma

is an enzyme important for intracellu- • Polycythemia vera
lar metabolic processes. It is present in
the cytoplasm of neutrophilic granu- • Pregnancy
locytes from the metamyelocyte to • Stress
the segmented stage. Leukocyte alka- • Thrombocytopenia
line phosphatase (LAP) concentra-
tions may be altered by the presence Decreased in:
of infection, stress, chronic inflamma- • Chronic myelogenous leukemia
tory diseases, Hodgkin’s disease, and
hematologic disorders. Levels are low • Hereditary hypophosphatemia
in leukemic leukocytes and high in • Idiopathic thrombocytopenia purpura
normal white blood cells (WBCs), • Nephrotic syndrome
making this test useful as a supportive
test in the differential diagnosis of • Paroxysmal nocturnal hemoglobinuria
leukemia. It should be noted that test • Sickle cell anemia
results must be correlated with the
• Sideroblastic anemia
patient’s condition because LAP levels
increase toward normal in response to
therapy. ■
INDICATIONS: INTERFERING FACTORS: Drugs that may

increase the LAP score include steroids.
• Differentiate chronic myelocytic
leukemia from other disorders that
increase the WBC count
• Monitor response of Hodgkin’s disease
to therapy Procedure ● ● ● ● ● ● ● ● ● ● ●
RESULT Pretest:

• Aplastic leukemia allergens.
• Chronic inflammation ➤ Obtain a history of the patient’s
hematopoietic and immune sys-
• Down syndrome tems, as well as results of previously
• Hodgkin’s disease performed tests and procedures. For
related tests, refer to the hematopoi-
• Hairy cell leukemia etic and immune system tables.
• Leukemia (acute and chronic ➤ Obtain a list of the medications the
lymphoblastic) patient is taking, including herbs, nu-
• Myelofibrosis with myeloid metaplasia ticals. The requesting health care
practitioner and laboratory should be follow the general guidelines in

advised if the patient regularly uses Appendix A. Perform a venipuncture,
these products so that their effects and collect the specimen in a 5-mL
can be taken into consideration lavender-top tube.
when reviewing results. ➤ Label the specimen, and promptly
patient.
10 minutes. ➤ Instruct the patient to avoid expo-
sure to infection if WBC count is
Intratest: decreased.
movement. tests include bone marrow biopsy
➤ Observe standard precautions and and WBC count.
LIPASE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Triacylglycerol acylhydrolase.

REFERENCE VALUE: (Method: Spectrophotometry) Plasma values may be 15

percent lower than serum values.

40–375 U/L 0.68–6.38 Kat/L
DESCRIPTION: Lipases are digestive stream when damage occurs to the

enzymes secreted by the pancreas into pancreatic acinar cells. Its presence in
the duodenum. Different lipolytic the blood indicates pancreatic disease
enzymes have specific substrates, but because it is the only organ that se-
overall activity is collectively de- cretes this enzyme. ■
scribed as lipase. Lipase participates
in fat digestion by breaking down INDICATIONS:
triglycerides into fatty acids and glyc- • Assist in the diagnosis of acute and
erol. Lipase is released into the blood- chronic pancreatitis
Lipase 667
• Assist in the diagnosis of pancreatic gastrointestinal and hepatobiliary

carcinoma systems, as well as results of previ-
RESULT gastrointestinal and hepatobiliary
system tables.
Increased in:
• Acute cholecystitis patient is taking, including herbs, nu-
• Obstruction of the pancreatic duct
• Pancreatic cyst or pseudocyst practitioner and laboratory should be
• Pancreatic carcinoma (early) these products so that their effects
• Pancreatic inflammation
• Pancreatitis (acute and chronic) ➤ Note any recent procedures that can
• Renal failure (early)
Decreased in: N/A tion restrictions unless by medical
direction.
CRITICAL VALUES: N/A patient.
INTERFERING FACTORS: collection takes approximately 5 to
• Drugs that may increase lipase levels 10 minutes.
include asparaginase, azathioprine,
cholinergics, codeine, deoxycholate, Intratest:
didanosine, glycocholate, indo-
methacin, methacholine, methylpred- ➤ Direct the patient to breathe
nisolone, morphine, narcotics, normally and to avoid unnecessary
movement.
pancreozymin, pentazocine, and
taurocholate. ➤ Observe standard precautions and
• Drugs that may decrease lipase levels Appendix A. Perform a venipuncture,
include protamine and saline (intra- and collect the specimen in a 5-mL
venous infusions). red- or tiger-top tube.
• Endoscopic retrograde cholangiopan-
creatography may increase lipase levels.
• Serum lipase levels increase with Post-test:
hemodialysis. Therefore, predialysis ➤ Observe venipuncture site for bleed-
specimens should be collected for ing or hematoma formation. Apply
lipase analysis. pressure bandage.
➤ Increased lipase levels may be asso-
ciated with pancreatic disorders.
Nursing Implications and ➤ Instruct the patient to ingest small,
Procedure ● ● ● ● ● ● ● ● ● ● ● frequent meals if he or she has a
gastrointestinal disorder; advise the
Pretest: patient to consider other dietary al-
terations as well. After acute symp-
➤ Obtain a history of the patient’s toms subside and bowel sounds re-
complaints, including a list of known turn, patients are usually prescribed
allergens. a clear liquid diet, progressing to a
➤ Obtain a history of the patient’s low-fat, high-carbohydrate diet.
➤ Administer vitamin B12, as ordered, the patient’s symptoms and other

to the patient with decreased lipase tests performed. Related labora-
levels, especially if his or her disease tory tests include alanine amino-
prevents adequate absorption of the transferase, alkaline phosphatase,
vitamin. amylase, fluid amylase, aspartate
aminotransferase, bilirubin, CA 19-9,
➤ Encourage the alcoholic patient to
calcium, fecal fat, -glutamyl trans-
avoid alcohol and to seek appropri-
peptidase, magnesium, mumps
ate counseling for substance abuse.
serology, triglycerides, and white
➤ Evaluate test results in relation to blood cell count.
LIPOPROTEIN ELECTROPHORESIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Lipid fractionation; lipoprotein phenotyping; 1-

lipoprotein cholesterol, high-density lipoprotein (HDL); -lipoprotein
cholesterol, low-density lipoprotein (LDL); pre--lipoprotein cholesterol,
very-low-density lipoprotein (VLDL).

REFERENCE VALUE: (Method: Electrophoresis and 4 C test for specimen
appearance) There is no quantitative interpretation of this test. The speci-
men appearance and electrophoretic pattern is visually interpreted.
Hyperlipoproteinemia: Specimen Electrophoretic

Fredrickson Type Appearance Pattern
Type I Clear with creamy top Heavy chylomicron
layer band
Type IIa Clear Heavy band
Type IIb Clear or faintly turbid Heavy and pre-
band
Type III Slightly to moderately Heavy band
turbid
Type IV Slightly to moderately Heavy pre- band
turbid
Type V Slightly to moderately Intense chylomicron
turbid with creamy band and heavy
top layer pre- band
DESCRIPTION: Lipoprotein elec- tant risk factor in the development of

trophoresis measures lipoprotein frac- coronary artery disease (CAD). The
tions to determine abnormal lipoprotein fractions in order of
distribution and concentration of increasing density are (1) chylomi-
lipoproteins in the serum, an impor- crons, (2) very-low-density lipopro-
Lipoprotein Electrophoresis 669
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
• 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
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
monographs titled “Cholesterol, Total” follow the general guidelines in

and “Triglycerides”). Appendix A. Perform a venipuncture,
Procedure ● ● ● ● ● ● ● ● ● ● ●
Post-test:
Pretest:
allergens.
➤ 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.
pretesting restrictions. ➤ Evaluate test results in relation to
➤ 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.
Liver and Spleen Scan 671
LIVER AND SPLEEN SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Liver and spleen scintigraphy, liver-spleen scan,

radionuclide liver scan, spleen scan.

CONTRAST: Intravenous radioactive technetium-99m sulfur colloid.
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
• Detect infiltrative processes that affect INTERFERING FACTORS:

the liver, such as sarcoidosis and
amyloidosis This procedure is contraindicated
• Evaluate palpable abdominal masses for:
• Differentiate between splenomegaly of being pregnant, unless the potential
and hepatomegaly benefits of the procedure far outweigh
• Determine superior vena cava obstruc- the risks to the fetus and mother
tion or Budd-Chiari syndrome
• Evaluate liver and spleen damage imaging:
caused by radiation therapy or toxic • Inability of the patient to cooperate or
drug therapy remain still during the procedure
• Evaluate jaundice because of age, significant pain, or
mental status
RESULT • Metallic objects within the examina-
Normal Findings:
• Normal size, contour, position, and and can produce unclear images
function of the liver and spleen
• Abscesses ment
• Cirrhosis • Incorrect positioning of the patient,

• Cysts of the area to be examined, especially
• Inflammation of the diaphragmatic for oblique and decubitus views
area • Other nuclear scans done within the
• Hemangiomas preceding 24 to 48 hours
• Hematoma Other considerations:

• Hepatitis • The scan may fail to detect focal
lesions smaller than 2 cm in diameter.
• Infection
may allow the tracer to seep deep into
• Infarction the muscle tissue, producing erroneous
hot spots.
• Infiltrate process (amyloidosis and
sarcoidosis) • Consultation with a physician should
• Metastatic tumors
• Nodular hyperplasia of patients who are lactating.
• Portal hypertension • Risks associated with radiologic overex-
posure can result from frequent x-ray
• Primary benign or malignant tumors
procedures. Personnel in the room
• Traumatic lesions with the patient should wear a protec-
tive lead apron, stand behind a shield,
CRITICAL VALUES: N/A or leave the area while the examination
Liver and Spleen Scan 673
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
➤ Determine date of last menstrual after the procedure.
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
➤ Administer sedative to a child or to patient.
➤ 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.
LUNG PERFUSION SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Radioactive perfusion scan, lung scintiscan, lung

perfusion scintigraphy, perfusion-ventilation scan, pulmonary scan, radionu-
clide perfusion lung scan, V/Q scan.

CONTRAST: Intravenous radioactive material, usually macroaggregated albu-
min (MAA).
DESCRIPTION: The lung perfusion angiography, and arterial blood gases.

scan is a nuclear medicine study A recent chest x-ray is essential for
performed to evaluate a patient for accurate interpretation of the lung
pulmonary embolus (PE) or other perfusion scan. An area of nonperfu-
pulmonary disorders. Technetium sion seen in the same area as a
(Tc-99m) is injected intravenously pulmonary parenchymal abnormality
and distributed throughout the on the chest x-ray indicates that a PE
pulmonary vasculature because of the is not present; the defect may repre-
gravitational effect on perfusion. The sent some other pathologic condi-
scan, which produces a visual image tion, such as pneumonia. ■
of pulmonary blood flow, is useful in
diagnosing or confirming pulmonary INDICATIONS:
• Aid in the diagnosis of PE in a patient
vascular obstruction. The diameter of
with a normal chest x-ray
the intravenously injected macroag-
gregated albumin (MAA) is larger • Differentiate between PE and other
than that of the pulmonary capillar- pulmonary diseases, such as pneumo-
nia, pulmonary effusion, atelectasis,
ies; therefore the MAA temporarily
asthma, bronchitis, emphysema, and
becomes lodged in the pulmonary tumors
vasculature. A gamma camera detects
• Evaluate perfusion changes associated
the radiation emitted from the
with congestive heart failure and
injected radioactive material, and a pulmonary hypertension
representative image of the lung is
obtained. This procedure is often • Detect malignant tumor
done in conjunction with the ventila- • Evaluate pulmonary function preoper-
tion scan to obtain clinical informa- atively in a patient with pulmonary
tion that assists in differentiating disease
among the many possible pathologic RESULT
conditions revealed by the procedure.
The results are correlated with other Normal Findings:
diagnostic studies, such as pulmonary • Diffuse and homogeneous uptake of
function, chest x-ray, pulmonary the radioactive material by the lungs
Lung Perfusion Scan 675
Abnormal Findings: of the area to be examined, especially

• Asthma for oblique and decubitus views and
for films done by portable equipment
• Atelectasis
• Other nuclear scans done on the same
• Bronchitis day
• Emphysema
• Left atrial or pulmonary hypertension may allow the tracer to seep deep into
• Lung displacement by fluid or chest the muscle tissue, producing erroneous
masses hot spots.
• Pneumonia • Consultation with a physician should

• Pneumonitis tion safety concerns regarding infants
• Pulmonary embolism of patients who are lactating.
• Tuberculosis • Risks associated with radiologic overex-

posure can result from frequent x-ray
CRITICAL VALUES: N/A procedures. Personnel in the room
with the patient should wear a protec-
INTERFERING FACTORS: tive lead apron, stand behind a shield,
or leave the area while the examination
is being done. Personnel working in
for: the area where the examination is being
done should wear badges that reveal
their level of exposure to radiation.
• Patients with atrial and ventricular Procedure ● ● ● ● ● ● ● ● ● ● ●
septal defects, because the MAA parti-

cles will not reach the lungs Pretest:
• Patients with pulmonary hypertension ➤ Inform the patient that the procedure
assesses blood flow to the lungs.
Factors that may impair clear ➤ Inform the patient that the proce-
imaging: dure is performed in a special
• Inability of the patient to cooperate or department by a technologist and is
remain still during the procedure usually done in conjunction with a
because of age, significant pain, or ventilation test; the combined proce-
mental status dures take approximately 60
minutes.
• Metallic objects within the examina- ➤ Obtain pertinent history, pulmonary
tion field (e.g., jewelry or body rings), findings, and chest x-ray results on
which may inhibit organ visualization the same day as the ventilation
and can produce unclear images examination. For related tests, refer
ment allergens.
• Incorrect positioning of the patient, ➤ Obtain a list of the medications the
which may produce poor visualization patient is taking.
➤ Determine date of last menstrual amounts of fluids for 24 to 48 hours

period and possibility of pregnancy to eliminate the radionuclide from
in perimenopausal women. the body, unless contraindicated. Tell
➤ Do not restrict food and fluids, the patient that radionuclide is elimi-
unless otherwise indicated. nated from the body within 6 to 24
hours.
Intratest: ➤ The presence of conditions that
affect perfusion or ventilation (e.g.,
➤ Ask the patient to void before the tumors that obstruct the pulmonary
procedure. Have the patient put on a artery, vasculitis, pulmonary edema,
hospital gown. sickle cell disease, parasitic disease,
➤ Administer sedative to a child or to emphysema, effusion, infection) can
an uncooperative adult, as ordered. simulate a perfusion defect similar
➤ Make sure jewelry, chains, and any to PE.
other metallic objects have been ➤ Observe the patient for up to 60
removed from the chest area. minutes after the study for a possi-
➤ Place the patient in a supine position ble anaphylactic reaction to the
on a flat table with foam wedges, radionuclide, such as rash, tighten-
which help maintain position and im- ing of throat, or difficulty breathing.
mobilization. Ask the patient to lie ➤ Inform the patient to flush the toilet
still during the procedure because immediately after each voiding
movement produces unclear im- following the procedure and to wash
ages. The radionuclide is adminis- hands meticulously with soap and
tered intravenously after the syringe water after each voiding for 24 hours
is shaken to resuspend the particles. after the procedure.
Images of the lungs are obtained in ➤ Tell all caregivers to wear gloves
the anterior, posterior, both lateral, when discarding urine for 24 hours
and both oblique views. after the procedure. Wash gloved
➤ Wear gloves during the radionuclide hands with soap and water before
administration and while handling removing gloves. Then wash hands
the patient’s urine. after the gloves are removed.
Post-test: branch of medicine sends a written
➤ Evaluate the patient’s vital signs. discusses the results with the
Monitor vital signs every 15 to 30 patient.
minutes and compare with baseline
readings until the patient is stable. ➤ Evaluate test results in relation to
➤ Instruct the patient to resume tests performed. Related diagnostic
normal activity, medications, and tests include x-ray, computed
diet, unless otherwise indicated. tomography, and magnetic reso-
➤ Advise the patient to drink increased nance imaging of the chest.
Lung Ventilation Scan 677
LUNG VENTILATION SCAN

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SYNONYMS/ACRONYM: Radioactive ventilation scan, VQ lung scan,

aerosol lung scan, ventilation scan, xenon lung scan.

CONTRAST: Done with inhaled radioactive material (xenon gas or
technetium-DTPA).
DESCRIPTION: The lung ventilation responsible for perfusion abnormali-

scan is a nuclear medicine study ties will produce abnormal wash-in
performed to evaluate a patient for and wash-out phases. This test can be
pulmonary embolus (PE) or other used to quantify regional ventilation
pulmonary disorders. It can evaluate in patients with pulmonary disease. ■
respiratory function (i.e., demon-
strating areas of the lung that are INDICATIONS:
patent and capable of ventilation) • Aid in the diagnosis of PE
and dysfunction (e.g., parenchymal • Differentiate between PE and other
abnormalities affecting ventilation, pulmonary diseases, such as pneumo-
such as pneumonia). The procedure nia, pulmonary effusion, atelectasis,
is performed after the patient inhales asthma, bronchitis, emphysema, and
air mixed with a radioactive gas tumors
through a face mask and mouthpiece. • Evaluate regional respiratory function
The radioactive gas delineates areas of
• Identify areas of the lung that are
the lung during ventilation. The capable of ventilation
distribution of the gas throughout the
lung is measured in three phases: • Locate hypoventilation (regional),
Wash-in phase: Phase during which can result from chronic obstruc-
buildup of the radioactive gas tive pulmonary disease (COPD) or
excessive smoking
Equilibrium phase: Phase after the
patient rebreathes from a
closed delivery system RESULT
Wash-out phase: Phase after the
radioactive gas has been Normal Findings:
removed • Equal distribution of radioactive gas
This procedure is usually throughout both lungs and a normal
performed along with a lung perfu- wash-out phase
sion scan. When PE is present, venti-
Abnormal Findings:
lation scans display a normal wash-in
and wash-out of radioactivity from • Atelectasis
the lung areas. Parenchymal disease • Bronchogenic carcinoma
• Bronchitis • Risks associated with radiographic

• COPD
• Emphysema room with the patient should wear a
• Pneumonia
• PE examination is being done. Personnel
• Regional hypoventilation
• Sarcoidosis badges that reveal their level of expo-
sure to radiation.
• Tuberculosis
• Tumor

for:
• Patients who are pregnant or suspected ➤ Inform the patient that the proce-
of being pregnant, unless the potential dure assesses airflow to the lungs.
benefits of the procedure far outweigh ➤ Inform the patient that the proce-
the risks to the fetus and mother dure is performed in a special
Factors that may impair clear usually is done in conjunction with a
imaging: lung perfusion scan; the combined
tests take approximately 60
• Inability of the patient to cooperate or minutes.
➤ Obtain pertinent history, pulmonary
because of age, significant pain, or findings, and chest x-ray results on
mental status the same day as the ventilation
• Metallic objects within the examina- examination. For related tests, refer
which may inhibit organ visualization ➤ Determine date of last menstrual
and can produce unclear images period and possibility of pregnancy
• Patients who are very obese, who may ➤ Do not restrict food and fluids,
exceed the weight limit for the equip- unless otherwise indicated.
ment
Intratest:
which may produce poor visualization ➤ Ask the patient to void before the
of the area to be examined, especially procedure. Have the patient put on a
for oblique and decubitus views and hospital gown.
for films done by portable equipment ➤ Administer sedative to a child or to
• Other nuclear scans done within the
➤ Make sure jewelry, chains, and any
preceding 24 to 48 hours other metallic objects have been
removed from the chest area.
• Consultation with a physician should on a flat table with foam wedges,
occur before the procedure for radia- which help maintain position and
tion safety concerns regarding infants immobilization. Ask the patient to lie
of patients who are lactating. still during the procedure because
Lupus Anticoagulant Antibodies 679
movement produces unclear artery, vasculitis, pulmonary edema,

images. The radionuclide is adminis- sickle cell disease, parasitic disease,
tered through a mask, which is emphysema, effusion, infection) can
placed over the patient’s nose and simulate a perfusion defect similar
mouth. The patient is asked to hold to PE.
his or her breath for a short period of ➤ Observe patient for up to 60
time while the scan is taken. The minutes after the study for a possi-
distribution of the radioactive gas is ble anaphylactic reaction to the
monitored and measured on a radionuclide, such as rash, tighten-
nuclear scanner. The patient’s chest ing of throat, or difficulty breathing.
is imaged while the gas is in the
lungs. Images of the lungs are ➤ Inform the patient to flush the toilet
obtained in the posterior and, when immediately after each voiding
possible, both oblique views. following the procedure and to wash
➤ Wear gloves during the radionuclide water after each voiding for 24 hours
administration and while handling after the procedure.
the patient’s urine.
Post-test: when discarding urine for 24 hours
after the procedure. Wash gloved
➤ Evaluate the patient’s vital signs. hands with soap and water before
Monitor vital signs every 15 to 30 removing gloves. Then wash hands
minutes and compare with baseline after the gloves are removed.
readings until the patient is stable. ➤ A physician specializing in this
➤ Advise patient to drink increased branch of medicine sends a written
amounts of fluids for 24 to 48 hours report to the ordering provider, who
to eliminate the radionuclide from discusses the results with the
the body, unless contraindicated. Tell patient.
the patient that radionuclide is elimi- ➤ Evaluate test results in relation to
nated from the body within 6 to 24 the patient’s symptoms and other
hours. tests performed. Related diagnostic
➤ The presence of conditions that tests include lung perfusion scan as
affect perfusion or ventilation (e.g., well as x-ray and computed tomog-
tumors that obstruct the pulmonary raphy of the chest.
LUPUS ANTICOAGULANT ANTIBODIES

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SYNONYMS/ACRONYM: Lupus inhibitor phospholipid type, lupus

antiphospholipid antibodies.

REFERENCE VALUE: (Method: Dilute Russell venom viper test time) Negative.
DESCRIPTION: Lupus anticoagulant activate platelets and coagulation

antibodies are immunoglobulins, factors, causing erroneous results.
usually of the IgG class. They are also • Hemolyzed specimens must be rejected
referred to as lupus antiphospholipid because hemolysis is an indication of
antibodies because they interfere with platelet and coagulation factor activa-
phospholipid-dependent coagulation tion.
tests such as activated partial throm- • Incompletely filled tubes contaminated
boplastin time (APTT) by reacting with heparin or clotted specimens
with the phospholipids in the test must be rejected.
system. They are not associated with a
bleeding disorder unless thrombocy- with optical testing methods, produc-
topenia or antiprothrombin antibod- ing erroneous results.
ies are already present. They are
associated with an increased risk of
thrombosis. ■
• Evaluate prolonged activated partial

thromboplastin times Pretest:
• Investigate reasons for fetal death
allergens.
RESULT
Positive in: hematopoietic, immune, muscu-
loskeletal, and reproductive sys-
• Fetal loss tems, as well as results of previously
• Raynaud’s syndrome performed tests and procedures. For
related tests, refer to the hematopoi-
• Rheumatoid arthritis etic, immune, musculoskeletal, and
• Systemic lupus erythematosus
• Thromboembolism patient is taking, including herbs, nu-
Negative in: N/A ticals. The requesting health care
CRITICAL VALUES: N/A advised if the patient regularly uses
INTERFERING FACTORS: can be taken into consideration
• Drugs that may cause a positive lupus when reviewing results.
anticoagulant test result include chlor- ➤ There are no food or fluid restrictions
promazine and heparin. unless by medical direction.
• Placement of tourniquet for longer ➤ Heparin therapy should be discontin-
than 1 minute can result in venous ued 2 days before specimen collec-
tion, with medical direction.
stasis and changes in the concentration Coumarin therapy should be discon-
of plasma proteins to be measured. tinued 2 weeks before specimen
Platelet activation may also occur collection, with medical direction.
under these conditions, causing erro- ➤ Review the procedure with the
neous results. patient.
• Vascular injury during phlebotomy can ➤ Inform the patient that specimen
Luteinizing Hormone 681
collection takes approximately 5 to ➤ When multiple specimens are

10 minutes. drawn, the blue-top tube should be
Intratest: culture) and red-top tubes. When
➤ Ensure that the patient has complied coagulation testing is the only test to
with pretesting restrictions. be done, an extra red-top tube
should be collected before the blue-
➤ Direct the patient to breathe top tube to avoid contaminating the
normally and to avoid unnecessary specimen with tissue thromboplas-
movement. tin, which can falsely decrease
➤ Observe standard precautions and values.
The NCCLS recommendation for
blue-top tube. Important note: Two
processed and unprocessed sam-
ples stored in unopened tubes is
citrate preservative are currently
that testing should be completed
added to blue-top tubes for coagula-
within 1 to 4 hours of collection.
Laboratory Standards (NCCLS) Post-test:
guideline for sodium citrate is 3.2%.
Laboratories establish reference ➤ Observe venipuncture site for bleed-
ranges for coagulation testing based ing or hematoma formation. Apply
on numerous factors, including pressure bandage.
sodium citrate concentration, test ➤ Evaluate test results in relation to
equipment, and test reagents. It is the patient’s symptoms and other
important to inquire from the labora- tests performed. Related laboratory
tory which concentration it recom- tests include anticardiolipin antibody,
mends, because each concentration antinuclear antibody, activated
will have its own specific reference partial thromboplastin time, and
range. protein S.
LUTEINIZING HORMONE
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SYNONYMS/ACRONYMS: LH, luteotropin, interstitial cell–stimulating

hormone (ICSH).


Concentration by
Sex and by Phase Conventional SI Units
(in Women) Units (Conversion Factor 1)
Male
Less than 2 y 0.5–1.9 mIU/mL 0.5–1.9 IU/L
2–10 y Less than 0.5 mIU/mL Less than 0.5 IU/L
11–20 y 0.5–5.3 mIU/mL 0.5–5.3 IU/L
Adult 1.2–7.8 mIU/mL 1.2–7.8 IU/L
Female
Less than 2–10 y Less than 0.5 mIU/mL Less than 0.5 IU/L
11–20 y 0.5–9.0 mIU/mL 0.5–9.0 IU/L
Phase in Women
Follicular 1.7–15.0 mIU/mL 1.7–15.0 IU/L
Ovulatory 21.9–56.6 mIU/mL 21.9–56.6 IU/L
Luteal 0.6–16.3 mIU/mL 0.6–16.3 IU/L
Postmenopausal 14.2–52.3 mIU/mL 14.2–52.3 IU/L
DESCRIPTION: Luteinizing hormone INDICATIONS:

(LH) is secreted by the anterior pitu- • Distinguish between primary and
itary gland in response to stimulation secondary causes of gonadal failure
by gonadotropin-releasing hormone, • Evaluate children with precocious
the same hypothalamic releasing fac- puberty
tor that stimulates follicle-stimulating
• Evaluate male and female infertility, as
hormone release. LH affects gonadal indicated by decreased LH levels
function in both men and women. In
women, a surge of LH normally oc- • Evaluate response to therapy to induce
curs at the midpoint of the menstrual ovulation
cycle (ovulatory phase); this surge is • Support diagnosis of infertility caused
believed to be induced by high estro- by anovulation, as evidenced by lack of
gen levels. LH causes the ovum to be LH surge at the midpoint of the
expelled from the ovary and stimu- menstrual cycle
lates development of the corpus lu-
teum and progesterone production. RESULT
As progesterone levels rise, LH pro-
Increased in:
duction decreases. In males, LH stim-
ulates the interstitial cells of Leydig, • Anorchia
located in the testes, to produce • Gonadal failure
testosterone. For this reason, in refer- • Menopause
ence to males, LH is sometimes called
interstitial cell stimulating hormone. • Primary gonadal dysfunction
Secretion of LH is pulsatile and fol-
Decreased in:
lows a circadian rhythm in response
to the normal intermittent secretion • Anorexia nervosa
of gonadotropin-releasing hormone. ■ • Kallmann’s syndrome
Luteinizing Hormone 683
• Malnutrition ➤ Obtain a list of the medications the

• Pituitary or hypothalamic dysfunction tritional supplements, and nutraceu-
• Severe stress ticals. The requesting health care
INTERFERING FACTORS: when reviewing results.
• Drugs and hormones that may increase ➤ There are no food, fluid, or medica-
LH levels include clomiphene, tion restrictions unless by medical
gonadotropin-releasing hormone, direction.
goserelin, ketoconazole, mestranol, ➤ Review the procedure with the
nafarelin, naloxone, nilutamide, spiro- patient.
nolactone, and tamoxifen. ➤ If the test is being performed to
• Drugs and hormones that may de- detect ovulation, inform the patient
crease LH levels include anabolic that it may be necessary to obtain a
steroids, anticonvulsants, conjugated series of samples over a period of
estrogens, danazol, digoxin, D-Trp-6- several days to detect peak LH
LHRH, estrogen/progestin therapy, levels.
goserelin, megestrol, norethindrone, ➤ Inform the patient that specimen
octreotide, oral contraceptives, phe- collection takes approximately 5 to
nothiazine, pimozide, pravastatin, 10 minutes.
progesterone, stanozolol, and tamox-
ifen. Intratest:
• In menstruating women, values vary in ➤ Direct the patient to breathe
relation to the phase of the menstrual normally and to avoid unnecessary
movement.
cycle.
• LH secretion follows a circadian follow the general guidelines in
rhythm, higher levels occurring during Appendix A. Perform a venipuncture,
sleep. and collect the specimen in a 5-mL
Nursing Implications and transport it to the laboratory. Provide
Procedure ● ● ● ● ● ● ● ● ● ● ● date of last menstrual period.
Pretest: Post-test:
➤ 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.
LYME ANTIBODY
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REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative.
DESCRIPTION: Borrelia burgdorferi, a INTERFERING FACTORS:

deer tick–borne spirochete, is the • High rheumatoid-factor titers as well
organism that causes Lyme disease. as cross-reactivity with Epstein-Barr
Lyme disease affects multiple systems virus and other spirochetes (e.g.,
and is characterized by fever, arthral- Rickettsia, Treponema) may cause false-
positive results.
gia, and arthritis. The circular, red
rash characterizing erythema migrans • Positive test results should be
can appear 3 to 30 days after the tick confirmed by the Western Blot
bite. About one-half of patients in the method.
early stage of Lyme disease (stage 1)
and generally all of those in the
advanced stage (stage 2)—with Nursing Implications and
cardiac, neurologic, and rheumatoid Procedure ● ● ● ● ● ● ● ● ● ● ●
manifestations—will have a positive Pretest:

test result. Patients in remission will
also have a positive test response. The ➤ Obtain a history of the patient’s
presence of immunoglobulin M allergens.
(IgM) antibodies indicates acute
infection. The presence of IgG immune and musculoskeletal
antibodies indicates current or past systems, as well as results of previ-
infection. ■ ously performed tests and proce-
dures and history of exposure. For
INDICATIONS: Assist in establishing a and musculoskeletal system tables.
diagnosis of Lyme disease
RESULT nutritional supplements, and nu-
traceuticals. The requesting health
Positive findings in: Lyme disease care practitioner and laboratory
should be advised if the patient reg-
ularly uses these products so that
Negative findings in: N/A their effects can be taken into con-
sideration when reviewing results.
Lymphangiography 685

➤ Review the procedure with the ➤ Warn the patient that false-positive
patient. Inform the patient that test results can occur and that false-
several tests may be necessary to negative test results frequently
confirm diagnosis. occur.
➤ Inform the patient that each speci- ➤ Recognize anxiety related to test
men collection takes approximately results and offer support. Provide
5 to 10 minutes. teaching and information regarding
Intratest: results, as appropriate. Educate the
➤ Direct the patient to breathe ing services if results are positive,
normally and to avoid unnecessary because Lyme disease can be debil-
movement. itating and can result in significant
➤ Observe standard precautions and changes in lifestyle.
follow the general guidelines in ➤ Advise the patient to wear light-
Appendix A. Perform a venipuncture, colored clothing that covers extrem-
and collect the specimen in a 5-mL ities when in areas infested by
red-top tube. deer ticks, and to check body for
➤ Label the specimen, and promptly ticks after returning from infested
transport it to the laboratory. area.
tests performed. A related test is
➤ Observe venipuncture site for bleed- synovial fluid analysis.
LYMPHANGIOGRAPHY
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SYNONYM/ACRONYM: Lymphangiogram.
AREA OF APPLICATION: Lymphatic system.
DESCRIPTION: Lymphangiography cause cancer (lymphomas and

involves visualization of the lym- Hodgkin’s disease) often spreads via
phatic system after the injection of an the lymphatic system. When the lym-
iodinated oil–based contrast medium phatic system becomes obstructed,
into a lymphatic vessel in the hand or painful edema of the extremities usu-
foot. The lymphatic system consists ally results. The procedure is usually
of lymph vessels and nodes. Assess- performed for cancer staging in pa-
ment of this system is important be- tients with an established diagnosis of
lymphoma or metastatic tumor. In- • Nodal lymphoma

jection into the hand allows visualiza- • Retroperitoneal lymphomas associated
tion of the axillary and supraclavicu- with Hodgkin’s disease
lar nodes. Injection into the foot
allows visualization of the lymphatics CRITICAL VALUES: N/A
of the leg, inguinal and iliac regions,
and retroperitoneum up to the tho- INTERFERING FACTORS:
racic duct. Less commonly, injection
into the foot can be used to visualize This procedure is contraindicated
for:
the cervical region (retroauricular
• Patients with pulmonary insufficien-
area). This procedure can assess pro-
cies, cardiac diseases, or severe renal or
gression of the disease, assist in plan- hepatic disease.
ning surgery, and monitor the effec-
tiveness of chemotherapy or radiation • Patients with allergies to shellfish
treatment. ■ or iodinated dye. The contrast
INDICATIONS: with a known hypersensitivity to the
• Determine lymphatic cancer staging
• Evaluate effects of chemotherapy or premedication with corticosteroids or
radiation therapy the use of nonionic contrast medium.
• Evaluate edema of an extremity with- • Patients who are pregnant or suspected
out known cause of being pregnant, unless the potential
• Determine the extent of adenopathy
• Distinguish primary from secondary
lymphedema
• Plan surgical treatment or evaluate the test, because of their risk of
effectiveness of chemotherapy or radia- contrast-induced renal failure.
tion therapy in controlling malignant
tumors
RESULT younger), unless the benefits of the x-
Normal Findings: exposure to high levels of radiation.
• Normal lymphatic vessels and nodes
that fill completely with contrast Factors that may impair clear
medium on the initial films. On the imaging:
24-hour films, the lymph nodes are • Inability of the patient to cooperate or
fully opacified and well circumscribed. remain still during the procedure
The lymphatic channels are emptied a because of age, significant pain, or
few hours after injection of the contrast mental status
medium.
Abnormal Findings: tion field (e.g., jewelry or body rings),
• Abnormal lymphatic vessels
• Metastatic tumor involving the lymph graphic equipment to accommodate
glands obese or thin patients, which can cause
Lymphangiography 687
overexposure or underexposure and a ➤ Inform the patient that the proce-

poor-quality study dure is performed by a physician and
takes 1 to 2 hours. Inform the
• Patients who are very obese, who may patient that he or she may have to
exceed the weight limit for the equip- return the next day, but that this set
ment of images will take only 30 minutes.
• Incorrect positioning of the patient, ➤ Obtain a history of allergies or sensi-
which may produce poor visualization tivities to contrast medium or
shellfish.
• Gas or feces in the gastrointestinal tract complaints, including a list of known
resulting from inadequate cleansing or allergens.
failure to restrict food intake before the ➤ Obtain a history of the patient’s
study lymphatic system and previously
• Retained barium from a previous radi- performed tests, treatments, and
ologic procedure
to the endocrine and immunologic
• Inability to cannulate the lymphatic system tables.
vessels ➤ Ascertain recent coagulation times
and other laboratory tests, as
Other considerations: ordered, especially blood urea nitro-
• Be aware of risks associated with the gen (BUN) and creatinine.
contrast medium. The oil-based ➤ Inform the patient that the proce-
contrast medium may embolize dure may be painful and that there
into the lungs and will temporarily may be moments of discomfort.
diminish pulmonary function. This ➤ Inform the patient that he or she
can produce lipid pneumonia, which is may feel some discomfort when the
a life-threatening complication. contrast medium and anesthesia are
injected.
• Consultation with a physician should ➤ Obtain a written and informed
occur before the procedure for radia- consent before administering any
tion safety concerns regarding infants medications prior to the procedure.
of patients who are lactating. ➤ Instruct the patient on the impor-
• Risks associated with radiographic tance of lying motionless throughout
overexposure can result from frequent the procedure.
x-ray procedures. Personnel in the ➤ Instruct patient to withhold anticoag-
room with the patient should wear a ulant medication or to reduce
protective lead apron, stand behind a dosage before the procedure, as
shield, or leave the area while the ordered.
examination is being done. Personnel ➤ Determine date of last menstrual
working in the area where the exami- period and possibility of pregnancy
badges that reveal their level of expo- ➤ Do not restrict food and fluids,
sure to radiation. unless otherwise indicated.
➤ Obtain and record baseline vital
signs, and assess neurologic status.
Procedure ● ● ● ● ● ● ● ● ● ● ● Intratest:
➤ Have emergency equipment readily
Pretest: accessible.
➤ Inform the patient that the proce- ➤ Administer an antihistamine or
dure assesses the lymphatic sys- steroid, as ordered by a physician,
tem. for patients with a known significant
allergic reaction to the IV contrast normal activity, diet, and previous

medium. medication use, unless otherwise
➤ Ask the patient to void before the indicated.
procedure. Have the patient put on a ➤ Instruct patient to maintain bedrest
hospital gown. up to 24 hours to reduce extremity
➤ Administer a mild sedative, as swelling after the procedure, or as
ordered. ordered.
➤ Place the patient in a supine position ➤ Advise patient to drink increased
on an x-ray table. Cleanse the amounts of fluids for 24 to 48 hours
selected vein and cover with a ster- to eliminate the radionuclide from
ile drape. the body, unless contraindicated. Tell
➤ A local anesthetic is injected at
the site, and a small incision is
hours.
made or a needle inserted. The
contrast medium is injected intrader- ➤ Advise the patient to immediately
mally into the area between the report symptoms such as fast
toes or fingers. The lymphatic heart rate, difficulty breathing, skin
vessels are identified as the contrast rash, itching, nausea, vomiting, or
medium moves. A local anesthetic decreased urinary output.
is then injected into the dorsum of ➤ Observe the cannula insertion site
each foot or hand, and a small for bleeding, inflammation, or
incision is made and cannulated hematoma formation.
for injection of the contrast medium.
➤ Instruct the patient to apply cold
➤ The contrast medium is then compresses to the cannulated site,
injected, and the flow of the contrast as needed, to reduce discomfort or
medium is followed by fluoroscopy. edema.
When the contrast medium reaches
the upper lumbar level, the infusion ➤ Monitor for signs of infection, such
of contrast medium is discontinued. as pain, fever, increased pulse rate,
X-ray images are taken of the chest, and muscle aches.
abdomen, and pelvis to determine ➤ Assess neurologic status and vital
the extent of filling of the lymphatic signs as directed.
vessels. ➤ Observe for a delayed allergic
➤ Twenty-four–hour delayed images reaction to contrast medium or
may be taken to examine the pulmonary embolus, which may
lymphatic system after a period of include shortness of breath,
time has elapsed and to monitor the increased heart rate, pleuritic pain,
progress of delayed flow. hypotension, low-grade fever, and
➤ Monitor the patient for complica- cyanosis.
tions related to the contrast medium ➤ A physician specializing in this
(e.g., allergic reaction, anaphylaxis, branch of medicine sends a written
bronchospasm). report to the ordering provider, who
➤ When the procedure is complete, discusses the results with the
the cannula is removed and the inci- patient.
sion sutured. ➤ Evaluate test results in relation to
Post-test: tests performed. Related diagnostic
tests include computed tomography
➤ Instruct the patient to resume of the abdomen and pelvis.
Magnesium, Serum 689
MAGNESIUM, SERUM
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SYNONYM/ACRONYM: Serum Mg.

Alternative Units SI Units

Conventional (Conversion (Conversion
Age Units Factor 0.8229) Factor 0.4114)
Newborn 1.5–2.2 mg/dL 1.23–1.81 mEq/L 0.62–0.91 mmol/L
Child 1.7–2.1 mg/dL 1.40–1.73 mEq/L 0.70–0.86 mmol/L
Adult 1.6–2.6 mg/dL 1.32–2.14 mEq/L 0.66–1.07 mmol/L
DESCRIPTION: Magnesium is re- arrhythmias can exist despite normal

quired as a cofactor in numerous serum magnesium levels. ■
crucial enzymatic processes, such
as protein synthesis, nucleic acid INDICATIONS:
synthesis, and muscle contraction. • Determine electrolyte balance in renal
failure and chronic alcoholism
Magnesium is also required for the
use of adenosine diphosphate as a • Evaluate cardiac arrhythmias
source of energy. It is the fourth (decreased magnesium levels can lead
most abundant cation and the to excessive ventricular irritability)
second most abundant intracellular • Evaluate known or suspected disorders
ion. Magnesium is needed for the associated with altered magnesium
transmission of nerve impulses and levels
muscle relaxation. It controls absorp- • Monitor the effects of various drugs on
tion of sodium, potassium, calcium, magnesium levels
and phosphorus; utilization of carbo-
hydrate, lipid, and protein; and RESULT
activation of enzyme systems that Increased in:
enable the B vitamins to function. • Addison’s disease
Magnesium is also essential for oxida-
tive phosphorylation, nucleic acid • Adrenocortical insufficiency
synthesis, and blood clotting. Urine • Dehydration
magnesium levels reflect magnesium • Diabetic acidosis (severe)
deficiency before serum levels.
Magnesium deficiency severe enough • Hypothyroidism
to cause hypocalcemia and cardiac • Systemic lupus erythematosus
• Multiple myeloma P-R and Q-T intervals, and bradycardia

• Overuse of antacids may be seen. Toxic levels of magnesium
may be reversed with the administration
• Renal insufficiency of calcium, dialysis treatments, and
• Tissue trauma removal of the source of excessive intake.
Decreased in: INTERFERING FACTORS:

• Alcoholism • Drugs that may increase magnesium
levels include acetylsalicylic acid and
• Diabetic acidosis progesterone.
• Glomerulonephritis (chronic) • Drugs that may decrease magnesium
• Hemodialysis levels include albuterol, aminoglyco-
sides, amphotericin B, bendroflume-
• Hyperaldosteronism thiazide, chlorthalidone, citrates,
• Hypercalcemia cyclosporines, cisplatin, digoxin,
• Hypoparathyroidism gentamicin, glucagon, and oral contra-
ceptives.
• Inadequate intake
• Hemolysis results in a false elevation in
• Inappropriate secretion of antidiuretic values; such specimens should be
hormone rejected for analysis.
• Long-term hyperalimentation • Specimens should never be collected
• Malabsorption above an IV line because of the poten-
tial for dilution when the specimen
• Pancreatitis and the IV solution combine in the
• Pregnancy collection container, falsely decreasing
• Severe loss of body fluids (diarrhea, the result. There is also the potential of
lactation, sweating, laxative abuse) contaminating the sample with the
substance of interest, contained in the
CRITICAL VALUES: IV solution, falsely increasing the
Less than 1.2 mg/dL result.
Greater than 6.1 mg/dL
Symptoms such as tetany, weakness, Nursing Implications and
dizziness, tremors, hyperactivity, nausea, Procedure ● ● ● ● ● ● ● ● ● ● ●
vomiting, and convulsions occur at
decreased (less than 1.2 mg/dL) concen- Pretest:
trations. Electrocardiographic (ECG)
changes (prolonged P-R and Q-T inter- ➤ Obtain a history of the patient’s
vals, broad flat T waves, and ventricular complaints, including a list of known
allergens.
tachycardia) may also occur. Treatment
may include administration of magne- ➤ Obtain a history of the patient’s
sium salts, monitoring for respiratory cardiovascular, endocrine, gastroin-
testinal, genitourinary, and reproduc-
depression and areflexia (intravenous
[IV] administration of magnesium salts), previously performed tests and
and monitoring for diarrhea and meta- procedures. For related tests, refer
bolic alkalosis (oral administration to to the cardiovascular, endocrine,
replace magnesium). gastrointestinal, genitourinary, and
Respiratory paralysis, decreased reproductive system tables.
reflexes, and cardiac arrest occur at ➤ Obtain a list of medications the
grossly elevated (greater than 15 mg/dL) patient is taking, including herbs,
levels. ECG changes, such as prolonged nutritional supplements, and
Magnesium, Urine 691
nutraceuticals. The requesting health Post-test:

should be advised if the patient ➤ Observe venipuncture site for bleed-
regularly uses these products so ing or hematoma formation. Apply
that their effects can be taken into pressure bandage.
consideration when reviewing ➤ Educate the magnesium-deficient
results. patient regarding good dietary
➤ There are no food, fluid, or medica- sources of magnesium, such as
tion restrictions unless by medical green vegetables, seeds, legumes,
direction. shrimp, and some bran cereals.
Advise the patient that high intake of
➤ Review the procedure with the substances such as phosphorus,
patient. calcium, fat, and protein interferes
➤ Inform the patient that specimen with the absorption of magnesium.
collection takes approximately 5 to ➤ Instruct the patient to report any
10 minutes. signs or symptoms of electrolyte
imbalance, such as dehydration, diar-
Intratest: rhea, vomiting, or prolonged
anorexia.
➤ Observe standard precautions and tests include aspartate aminotrans-
follow the general guidelines in ferase, C-reactive protein, calcium,
Appendix A. Perform a venipuncture, creatine kinase and isoenzymes,
and collect the specimen in a 5-mL lactate dehydrogenase and isoen-
red- or tiger-top tube. zymes, kidney stone analysis, urine
➤ Label the specimen, and promptly magnesium, myoglobin, potassium,
transport it to the laboratory. troponin, and vitamin D.
MAGNESIUM, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

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.
Alternative Units SI Units

Conventional (Conversion (Conversion
Units Factor 0.8229) Factor 0.4114)
7.3–12.2 mg/24 h 6.0–10.0 mEq/24 h 3.0–5.0 mmol/24 h
DESCRIPTION: Magnesium is re- • Evaluate known or suspected

quired as a cofactor in numerous endocrine disorder
crucial enzymatic processes, such • Evaluate known or suspected renal
as protein synthesis, nucleic acid disease
synthesis, and muscle contraction.
• Evaluate magnesium imbalance
Magnesium is also required for the
use of adenosine diphosphate as a • Evaluate a malabsorption problem
source of energy. It is the fourth
most abundant cation and the RESULT
second most abundant intracellular
Increased in:
ion. Magnesium is needed for the
transmission of nerve impulses and • Alcoholism
muscle relaxation. It controls absorp- • Bartter’s syndrome
tion of sodium, potassium, calcium, • Transplant recipients on cyclosporine
and phosphorus; utilization of carbo- and prednisone
hydrate, lipid, and protein; and
activation of enzyme systems that • Use of diuretics
enable the B vitamins to function. • Use of corticosteroids
Magnesium is also essential for oxida-
tive phosphorylation, nucleic acid Decreased in:
synthesis, and blood clotting. Urine • Abnormal renal function
magnesium levels reflect magnesium • Crohn’s disease
deficiency before serum levels.
Magnesium deficiency severe enough • Inappropriate secretion of antidiuretic
to cause hypocalcemia and cardiac hormone
arrhythmias can exist despite normal • Salt-losing conditions
serum magnesium levels.
Regulating electrolyte balance is CRITICAL VALUES: N/A
one of the major functions of the
kidneys. In normally functioning INTERFERING FACTORS:
kidneys, urine levels increase when • Drugs that may increase urine magne-
sium levels include cisplatin, cy-
serum levels are high and decrease
closporine, ethacrynic acid, furo-
when serum levels are low to maintain semide, mercaptomerin, mercurial
homeostasis. Analyzing these urinary diuretics, and thiazides.
levels can provide important clues as
to the functioning of the kidneys and • Drugs that may decrease urine magne-
sium levels include amiloride, an-
other major organs. Tests for elec-
giotensin, oral contraceptives, parathy-
trolytes, such as magnesium, in urine roid extract, phosphates.
usually involve timed urine collec-
tions over a 12- or 24-hour period. • Magnesium levels follow a circadian
Measurement of random specimens rhythm, and for this reason 24-hour
collections are recommended.
may also be requested. ■
• All urine voided for the timed collec-
INDICATIONS: tion period must be included in the
• Determine the potential cause of renal collection, or else falsely decreased
calculi values may be obtained. Compare
Magnesium, Urine 693
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
collection device for a health care
Nursing Implications and staff member to add to the labora-
Procedure ● ● ● ● ● ● ● ● ● ● ●
Intratest:
Pretest:
Appendix A.
allergens.
➤ Obtain a history of the patient’s Random specimen (collect in
endocrine, gastrointestinal, and early morning):
genitourinary systems, as well as
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.
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
a.m., if possible. Collect first voiding transport it to the laboratory. Include

and discard. Record the time the on the label the amount of urine,
specimen was discarded as the test start and stop times, and inges-
beginning of the timed collection tion of any foods or medications that
period. The next morning, ask the can affect test results.
patient to void at the same time the
collection was started and add this Post-test:
last voiding to the container.
➤ If an indwelling catheter is in place, ➤ Educate the magnesium-deficient
replace the tubing and container patient regarding good dietary
system at the start of the collection sources of magnesium, such as
time. Keep the container system on green vegetables, seeds, legumes,
ice during the collection period, or shrimp, and some bran cereals.
empty the urine into a larger Advise the patient that high intake of
container periodically during the substances such as phosphorus,
collection period; monitor to ensure calcium, fat, and protein interferes
continued drainage, and conclude with the absorption of magnesium.
the test the next morning at the ➤ Instruct the patient to report any
same hour the collection was signs or symptoms of electrolyte
begun. imbalance, such as dehydration, diar-
➤ At the conclusion of the test, rhea, vomiting, or prolonged
compare the quantity of urine with anorexia.
the urinary output record for the ➤ Evaluate test results in relation to
collection; if the specimen contains the patient’s symptoms and other
less than what was recorded as tests performed. Related laboratory
output, some urine may have been tests include calcium, kidney stone
discarded, invalidating the test. analysis, magnesium, phosphorus,
➤ Label the specimen, and promptly potassium, and vitamin D.
MAGNETIC RESONANCE IMAGING,

ABDOMEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Abdominal MRI.

AREA OF APPLICATION: Liver/abdominal area.
CONTRAST: Can be done with or without contrast medium (gadolinium).
DESCRIPTION: Magnetic resonance produces images primarily based on

imaging (MRI) uses a magnet and water content of tissue. The magnetic
radio waves to produce an energy field causes the hydrogen atoms in
field that can be displayed as an tissue to line up, and when radio
image. Use of magnetic fields with waves are directed toward the
the aid of radiofrequency energy magnetic field, the atoms absorb the
Magnetic Resonance Imaging, Abdomen 695
radio waves and change their posi- pancreatitis, venous thrombosis, or

tion. When the radio waves are pseudoaneurysm
turned off, the atoms go back to their • Differentiate liver tumors from liver
original position; this change in the abnormalities, such as cysts, cavernous
energy field is sensed by the equip- hemangiomas, and hepatic amebic
ment, and an image is generated by abscesses
the attached computer system. • Detect renal vein thrombosis
Abdominal MRI produces cross-
sectional images of the abdomen in • Evaluate postoperative angioplasty sites
multiple planes without the use of and bypass grafts
ionizing radiation or the interference • Detect soft tissue abnormalities
of bone. • Determine and monitor tissue damage
Abdominal MRI is performed to in renal transplant patients
assist in diagnosing abnormalities of
abdominal and hepatic structures. • Differentiate aortic aneurysms from
tumors near the aorta
Contrast-enhanced imaging is effec-
tive for distinguishing peritoneal • Determine the presence of blood clots,
metastases from primary tumors of cysts, fluid or fat accumulation in
the gastrointestinal tract. Primary tissues, hemorrhage, and infarctions
tumors of the stomach, pancreas, • Monitor and evaluate the effectiveness
colon, and appendix often spread by of medical or surgical interventions
intraperitoneal tumor shedding and and the course of the disease
subsequent peritoneal carcinomatosis.
MRI uses the noniodinated contrast RESULT
medium gadopentetate dimeglumine Normal Findings:
(Magnevist), which is administered
• Normal anatomic structures, soft tissue
intravenously to enhance contrast density, and biochemical constituents
differences between normal and of body tissues, including blood flow
abnormal tissues.
Magnetic resonance angiography Abnormal Findings:
(MRA) is an application of MRI that • Acute tubular necrosis
provides images of blood flow and • Glomerulonephritis
diseased and normal blood vessels. In
patients who are allergic to iodinated • Hydronephrosis
contrast medium, MRA is used • Masses, lesions, infections, or inflam-
in place of angiography (see mono- mations
graph titled “Angiography, Magnetic • Renal vein thrombosis
Resonance”). ■
• Vena cava obstruction
• Detect abdominal aortic diseases
• Detect and stage cancer (primary or INTERFERING FACTORS:
metastatic tumors of liver, pancreas,
prostate, uterus, and bladder) This procedure is contraindicated
for:
• Detect chronic pancreatitis
• Patients with certain ferrous metal
• Determine vascular complications of prostheses, valves, aneurysm clips,
inner ear prostheses, or other metallic department by a technologist and a

objects physician and takes approximately
30 to 60 minutes.
• Patients with metal in their body, such
as shrapnel or ferrous metal in the eye tivities to contrast medium.
• Patients with cardiac pacemakers, ➤ Obtain a list of medications the
because the pacemaker can be patient is taking.
deactivated by MRI ➤ Obtain a history of the patient’s
• Patients who are claustrophobic hepatic and abdominal systems, as
• 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
remain still during the procedure gastrointestinal system table.
because of age, significant pain, or ➤ Determine previous laboratory
mental status abnormalities, especially blood urea
• Patients with extreme cases of claustro- contrast medium is to be used.
the study tests are obtained and recorded
• Patients who are very obese, who may before the procedure.
exceed the weight limit for the equip- ➤ Obtain occupational history to deter-
ment mine the presence of metal in the
body, such as shrapnel or flecks of
• Incorrect positioning of the patient, ferrous metal in the eye (which can
which may produce poor visualization cause retinal hemorrhage).
of the area to be examined ➤ Determine date of last menstrual
• Metallic objects within the examina- period and possibility of pregnancy in
tion field (e.g., jewelry, body rings), perimenopausal women.
which may inhibit organ visualization ➤ Ensure that the patient and staff
and can produce unclear images have removed all external metallic
objects from the patient before he or
Other considerations: she enters the scanning room.
• If contrast medium is allowed to seep ➤ Inform the patient that the technolo-
deep into the muscle tissue, vascular gist will place him or her in a supine
visualization will be impossible. position on a flat table in a large,
cylindrical scanner.
➤ Tell the patient to expect to hear loud
Nursing Implications and banging from the scanner and possi-
bly to see magnetophosphenes
Procedure ● ● ● ● ● ● ● ● ● ● ●
(flickering lights in the visual field);
these will stop when the procedure
Pretest: is over.
➤ Inform the patient that the proce- ➤ Instruct the patient to take slow,
dure assesses the abdomen. deep breaths if nausea occurs
➤ Inform the patient that the proce- during the procedure.
dure is performed in a special ➤ Do not restrict food and fluids.
Magnetic Resonance Imaging, Brain 697
Intratest: ➤ The table is moved into the scanner.

Instruct the patient to remain still.
➤ Ask the patient to remove jewelry, The scanner makes noises as it
including watches, hairpins, and acquires images of the body. The
other metallic objects, and credit patient may be asked to hold his or
cards. her breath to facilitate visualization.
➤ Ask the patient to void before the A number of images are taken.
procedure. These images are reconstructed by
➤ Administer a sedative to a child or to a computer and reviewed.
an uncooperative adult, as ordered. ➤ Administer the contrast medium, if
➤ Administer an antianxiety agent, as ordered. A second series of images
ordered, if the patient has claustro- is obtained.
phobia.
Post-test:
on a flat table; use foam wedges to ➤ Instruct the patient to resume
help maintain position and immobi- medications, normal activity, and
lization. Ask the patient to lie still diet, unless otherwise indicated.
during the procedure because move- ➤ Observe for delayed allergic reac-
ment produces unclear images, thus tions, such as urticaria, hives, nau-
affecting the results and making sea, or vomiting, if contrast medium
interpretation difficult. was used.
➤ Supply earplugs to the patient to ➤ A physician specializing in this
block out the loud, banging sounds branch of medicine sends a written
that occur during the test. report to the ordering provider, who
➤ If an electrocardiogram or respira- discusses the results with the
tory gating is to be performed in patient.
conjunction with the scan, apply ➤ Evaluate test results in relation to
MRI-safe electrodes to the appropri- the patient’s symptoms and other
ate sites. tests performed. Related diagnostic
➤ The patient can communicate with tests include ultrasound, angiogram,
the technologist doing the examina- and computed tomography of the
tion via a microphone within the abdomen; and kidney, ureter, and
machine. bladder (KUB) film.

BRAIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Brain MRI.

AREA OF APPLICATION: Brain area.
DESCRIPTION: Magnetic resonance Magnetic resonance angiography

imaging (MRI) uses a magnet and (MRA) is an application of MRI that
radio waves to produce an energy provides images of blood flow and
field that can be displayed as an diseased and normal blood vessels. In
image. Use of magnetic fields with the patients who are allergic to iodinated
aid of radiofrequency energy produces contrast medium, MRA is used
images primarily based on water in place of angiography (see mono-
content of tissue. The magnetic field graph titled “Angiography, Magnetic
causes the hydrogen atoms in tissue to Resonance”). ■
line up, and when radio waves are
directed toward the magnetic field, INDICATIONS:
• Detect and locate brain tumors
the atoms absorb the radio waves and
change their position. When the radio • Detect cause of cerebrovascular acci-
waves are turned off, the atoms go dent, cerebral infarct, or hemorrhage
back to their original position, this • Evaluate vascularity of the brain and
change in the energy field is sensed by evaluate vascular integrity
the equipment, and an image is • Evaluate the solid, cystic, and hemor-
generated by the attached computer rhagic components of lesions
system. MRI produces cross-sectional
• Detect cranial bone, face, throat, and
images of the pathologic lesions in
neck soft tissue lesions
multiple planes without the use of
ionizing radiation or the interference • Evaluate the potential causes of
of bone or surrounding tissue. headache, visual loss, and vomiting
Brain MRI can distinguish solid, • Evaluate intracranial infections
cystic, and hemorrhagic components • Evaluate the cause of seizures, such as
of lesions. This procedure is done to intracranial infection, edema, or
aid in the diagnosis of intracranial ab- increased intracranial pressure
normalities, including tumors, is-
• Evaluate demyelinating disorders
chemia, infection, and multiple scle-
rosis, and assessment of brain • Evaluate cerebral changes associated
maturation in pediatric patients. with dementia
Rapidly flowing blood on spin-echo • Evaluate shunt placement and function
MRI appears as an absence of signal in patients with hydrocephalus
or a void in the vessel’s lumen. Blood • Monitor and evaluate the effectiveness
flow can be evaluated in the cav- of medical or surgical interventions,
ernous and carotid arteries. chemotherapy, and radiation therapy
Aneurysms may be diagnosed without and the course of disease
traditional iodine contrast–based an-
giography, and old clotted blood in RESULT
the walls of the aneurysms appears Normal Findings:
white. MRI uses the noniodinated
• Normal anatomic structures, soft tissue
contrast medium gadopentetate density, blood flow rate, face,
dimeglumine (Magnevist), which is nasopharynx, neck, tongue, and brain
administered intravenously to en-
hance contrast differences between Abnormal Findings:
normal and abnormal tissues. • Abscess
Magnetic Resonance Imaging, Brain 699
• Acoustic neuroma remain still during the procedure

• Aneurysm
mental status
• Arteriovenous malformation
• Benign meningioma phobia, unless sedation is given before
the study.
• Cerebral aneurysm
• Cerebral infarction
• Craniopharyngioma or meningioma which may inhibit organ visualization
• Granuloma
• Intraparenchymal hematoma or
hemorrhage
ment
• Lipoma
• Metastasis which may produce poor visualization
• Multiple sclerosis
• Optic nerve tumor Other considerations:
• Pituitary microadenoma • If contrast medium is allowed to seep
deep into the muscle tissue, vascular
• Subdural empyema visualization will be impossible.
• Ventriculitis
CRITICAL VALUES: N/A Nursing Implications and

Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
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
• 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,
performed tests, treatments, surger-
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
endocrine and musculoskeletal on a flat table; use foam wedges to

system tables. help maintain position and immobi-
➤ Determine previous laboratory lization. Ask the patient to lie still
abnormalities, especially blood urea during the procedure because move-
nitrogen (BUN) and creatinine, if ment produces unclear images, thus
contrast medium is to be used. affecting the results and making
interpretation difficult.
tests are obtained and recorded ➤ Supply earplugs to the patient to
before the procedure. block out the loud, banging sounds
that occur during the test.
➤ Obtain occupational history to deter-
mine the presence of metal in the ➤ If an electrocardiogram or respira-
body, such as shrapnel or flecks of tory gating is to be performed in
ferrous metal in the eye (which can conjunction with the scan, apply
cause retinal hemorrhage). MRI-safe electrodes to the appropri-
ate sites.
period and possibility of pregnancy ➤ The patient can communicate with
in perimenopausal women. the technologist doing the examina-
tion via a microphone within the
➤ Ensure that the patient and staff machine.
have removed all external metallic
objects from the patient before he or ➤ The table is moved into the scanner.
she enters the scanning room. Instruct the patient to remain still.
➤ Inform the patient that the technolo- acquires images of the body. The
gist will place him or her in a supine patient may be asked to hold his or
position on a flat table in a large, her breath to facilitate visualization.
cylindrical scanner. A number of images are taken.
➤ Tell the patient to expect to hear These images are reconstructed by
loud banging from the scanner a computer and reviewed.
and possibly to see magneto- ➤ Administer the contrast medium, if
phosphenes (flickering lights in the ordered. A second series of images
visual field); these will stop when is obtained.
the procedure is over.
➤ Instruct the patient to take slow, Post-test:
during the procedure. ➤ Instruct the patient to resume
medications, normal activity, and
➤ Do not restrict food and fluids. diet, unless otherwise indicated.
➤ Observe for delayed allergic reac-
Intratest: tions, such as urticaria, hives,
➤ Ask the patient to remove jewelry, nausea, or vomiting, if contrast
including watches, hairpins, and medium was used.
other metallic objects, and credit ➤ A physician specializing in this
cards. branch of medicine sends a written
➤ Ask the patient to void before the report to the ordering provider, who
procedure. discusses the results with the
patient.
➤ Administer a sedative to a child or to
an uncooperative adult, as ordered. ➤ Evaluate test results in relation to
➤ Administer an antianxiety agent, as tests performed. Related diagnostic
ordered, if the patient has claustro- tests include computed tomography
phobia. of the brain and electroencephalog-
➤ Place the patient in a supine position raphy.
Magnetic Resonance Imaging, Chest 701

CHEST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Chest MRI.

DESCRIPTION: Magnetic resonance spin-echo sequence, used to diagnose

imaging (MRI) uses a magnet and anatomical abnormalities of the heart
radio waves to produce an energy and aorta, and the other is the ECG-
field that can be displayed as an referenced gradient refocused se-
image. Use of magnetic fields with quence, used to diagnose heart func-
the aid of radiofrequency energy tion and analyze blood flow patterns.
produces images primarily based on Magnetic resonance angiography
water content of tissue. The magnetic (MRA) is an application of MRI that
field causes the hydrogen atoms in provides images of blood flow and
tissue to line up, and when radio diseased and normal blood vessels. In
waves are directed toward the patients who are allergic to iodinated
magnetic field, the atoms absorb the contrast medium, MRA is used in
radio waves and change their posi- place of angiography (see mono-
tion. When the radio waves are graph titled “Angiography, Magnetic
turned off, the atoms go back to their Resonance”). ■
original position, this change in the
energy field is sensed by the equip- INDICATIONS:
ment, and an image is generated by • Detect thoracic aortic diseases
the attached computer system. MRI • Confirm diagnosis of cardiac and peri-
produces cross-sectional images of the cardiac masses
pathologic lesions in multiple planes
• Identify congenital heart diseases
without the use of ionizing radiation
or the interference of bone or • Determine cardiac ventricular func-
surrounding tissue. tion
Chest MRI scanning is performed • Detect myocardial infarction and
to assist in diagnosing abnormalities cardiac muscle ischemia
of cardiovascular and pulmonary • Detect pleural effusion
structures. Two special techniques are
available for evaluation of cardiovas- • Evaluate postoperative angioplasty
cular structures. One is the electro- sites and bypass grafts
cardiograph (ECG)–gated multislice • Detect pericardial abnormalities
• Detect aortic aneurysms because the pacemaker can be

deactivated by MRI
tumors near the aorta • Patients who are claustrophobic
• Determine blood, fluid, or fat accumu- • Patients who are pregnant or suspected
lation in tissues, pleuritic space, or of being pregnant, unless the potential
vessels benefits of the procedure far outweigh
• Evaluate cardiac chambers and
pulmonary vessels
• Monitor and evaluate the effectiveness imaging:
of medical or surgical therapeutic regi- • Inability of the patient to cooperate or
men remain still during the procedure
RESULT mental status
Normal Findings:
• Normal heart and lung structures, soft the study
tissue, and function, including blood
flow rate • Patients who are very obese, who may
Abnormal Findings: ment
• Aortic dissection • Incorrect positioning of the patient,
• Congenital heart diseases, including which may produce poor visualization
pulmonary atresia, aortic coarctation, of the area to be examined
agenesis of the pulmonary artery, and • Metallic objects within the examina-
transposition of the great vessels tion field (e.g., jewelry or body rings),
• Constrictive pericarditis which may inhibit organ visualization
• Intramural and periaortic hematoma
• Myocardial infarction Other considerations:
• If contrast medium is allowed to seep
• Pericardial hematoma or effusion deep into the muscle tissue, vascular
• Pleural effusion visualization will be impossible.


• Patients with certain ferrous metal dure assesses the chest.
objects department by a technologist and a
as shrapnel or ferrous metal in the eye
• Patients with cardiac pacemakers tivities to contrast medium.
Magnetic Resonance Imaging, Chest 703
➤ Obtain a list of medications the including watches, hairpins, and

patient is taking. other metallic objects, and credit
➤ Obtain a history of the patient’s cards.
cardiac and pulmonary findings, as ➤ Ask the patient to void before the
well as results of previously procedure.
performed tests, treatments, surger- ➤ Administer a sedative to a child or to
ies, and procedures. Determine if an uncooperative adult, as ordered.
the patient has ever had any device ➤ Administer an antianxiety agent, as
implanted into the body, including ordered, if the patient has claustro-
copper intrauterine devices, pace- phobia.
makers, ear implants, and heart
valves. ➤ Place the patient in a supine position
on a flat table; use foam wedges to
➤ For related tests, refer to the respi- help maintain position and immobi-
ratory system table. lization. Ask the patient to lie still
➤ Determine previous laboratory during the procedure because move-
abnormalities, especially blood urea ment produces unclear images, thus
nitrogen (BUN) and creatinine, if affecting the results and making
contrast medium is to be used. interpretation difficult.
➤ Ensure that the results of blood ➤ Supply earplugs to the patient to
tests are obtained and recorded block out the loud, banging sounds
before the procedure. that occur during the test.
➤ If an electrocardiogram or respira-
tory gating is to be performed in
mine the presence of metal in the
conjunction with the scan, apply
MRI-safe electrodes to the appropri-
ferrous metal in the eye (which can
ate sites.
cause retinal hemorrhage).
➤ The patient can communicate with
➤ Determine date of last menstrual the technologist doing the examina-
period and possibility of pregnancy tion via a microphone within the
in perimenopausal women. machine.
➤ Ensure that the patient and staff ➤ The table is moved into the scanner.
have removed all external metallic Instruct the patient to remain still.
objects from the patient before he or The scanner makes noises as it
she enters the scanning room. acquires images of the body. The
➤ Inform the patient that the technolo- patient may be asked to hold his or
gist will place him or her in a supine her breath to facilitate visualization.
position on a flat table in a large, A number of images are taken.
cylindrical scanner. These images are reconstructed by
a computer and reviewed.
➤ Tell the patient to expect to hear loud
banging from the scanner and possi- ➤ Administer the contrast medium, if
bly to see magnetophosphenes ordered. A second series of images
(flickering lights in the visual field); is obtained.
these will stop when the procedure
is over. Post-test:
➤ Instruct the patient to take slow, ➤ Instruct the patient to resume
deep breaths if nausea occurs medications, normal activity, and
during the procedure. diet, unless otherwise indicated.
➤ Do not restrict food and fluids. ➤ Observe for delayed allergic reac-
tions, such as urticaria, hives,
nausea, or vomiting, if contrast
Intratest: medium was used.
➤ Ask the patient to remove jewelry, ➤ A physician specializing in this
branch of medicine sends a written the patient’s symptoms and other

report to the ordering provider, who tests performed. Related tests
discusses the results with the include computed tomography and
patient. x-ray of the chest, echocardiogram,
➤ Evaluate test results in relation to and myocardial scan.

MUSCULOSKELETAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Musculoskeletal (knee, shoulder, hand, wrist, foot,

elbow, hip) MRI.
AREA OF APPLICATION: Bones, joints, soft tissues.

DESCRIPTION: Magnetic resonance Musculoskeletal MRI is performed

imaging (MRI) uses a magnet and to assist in diagnosing abnormalities
radio waves to produce an energy of bones and joints and surrounding
field that can be displayed as an soft tissue structures, including carti-
image. Use of magnetic fields with lage, synovium, ligaments, and
the aid of radiofrequency energy tendons. MRI eliminates the risks
produces images primarily based on associated with exposure to x-rays
water content of tissue. The magnetic and causes no harm to cells.
field causes the hydrogen atoms in Contrast-enhanced imaging is effec-
tissue to line up, and when radio tive for evaluating scarring from
waves are directed toward the previous surgery, vascular abnorma-
magnetic field, the atoms absorb the lities, and differentiation of metas-
radio waves and change their posi- tases from primary tumors. MRI
tion. When the radio waves are uses the noniodinated contrast
turned off, the atoms go back to their medium gadopentetate dimeglumine
original position, this change in the (Magnevist), which is administered
energy field is sensed by the equip- intravenously to enhance contrast
ment, and an image is generated by differences between normal and
the attached computer system. MRI abnormal tissues.
produces cross-sectional images of Magnetic resonance angiography
bones and joints in multiple planes (MRA) is an application of MRI that
without the use of ionizing radiation provides images of blood flow and
or the interference of bone or diseased and normal blood vessels.
surrounding tissue. In patients who are allergic to iodi-
Magnetic Resonance Imaging, Musculoskeletal 705
nated contrast medium, MRA is used • Fibrosarcoma

in place of angiography (see mono- • Hemangioma (muscular or osseous)
graph titled “Angiography, Magnetic
Resonance”). ■ • Herniated disk
• Infection
INDICATIONS:
• Detect benign and cancerous tumors • Meniscal tears or degeneration
and cysts of the bone or soft tissue • Rotator cuff tears
• Determine cause of low back pain, • Osteochondroma
including herniated disk and spinal
degenerative disease • Osteogenic sarcoma
• Detect avascular necrosis of the • Osteomyelitis
femoral head or knee
• Spinal stenosis
• Detect bone infarcts in the epiphyseal
• Stress fracture
or diaphyseal sites
• Confirm diagnosis of osteomyelitis • Synovitis
• Differentiate between primary and • Tumor

secondary malignant processes of the
bone marrow CRITICAL VALUES: N/A
• Detect changes in bone marrow INTERFERING FACTORS:
• Detect tears or degeneration of liga-
ments, tendons, and meniscus result- This procedure is contraindicated
ing from trauma or pathology for:
• Differentiate between a stress fracture • Patients with cardiac pacemakers
and a tumor because the pacemaker can be
deactivated by MRI
• Evaluate meniscal detachment of the
temporomandibular joint • Patients with certain ferrous metal
prostheses, valves, aneurysm clips,
RESULT inner ear prostheses, or other metallic
objects
Normal Findings:
• Patients with metal in their body, such
• Normal bones, joints, and surrounding as shrapnel or ferrous metal in the eye
tissue structures; no articular disease,
bone marrow disorders, tumors, infec- • Patients who are claustrophobic
tions, or trauma to the bones, joints, or
muscles • Patients who are pregnant or suspected
Abnormal Findings:
• Avascular necrosis of femoral head or
knee, as found in Legg-Calvé-Perthes Factors that may impair clear
disease imaging:
• Bone marrow disease, such as • Inability of the patient to cooperate or
Gaucher’s disease, aplastic anemia, remain still during the procedure
sickle cell disease, or polycythemia because of age, significant pain, or
mental status
• Degenerative spinal disease, such as
spondylosis or arthritis • Patients with extreme cases of claustro-
phobia unless sedation is given before nitrogen (BUN) and creatinine, if

the study contrast medium is to be used.
• Patients who are very obese, who may tests are obtained and recorded
exceed the weight limit for the equip- before the procedure.
ment
• Incorrect positioning of the patient, mine the presence of metal in the
which may produce poor visualization body, such as shrapnel or flecks of
of the area to be examined ferrous metal in the eye (which can
cause retinal hemorrhage).
tion field (e.g., jewelry or body rings), period and possibility of pregnancy
which may inhibit organ visualization in perimenopausal women.
➤ Ensure that the patient and staff
Other considerations: have removed all external metallic
objects from the patient before he or
• If contrast medium is allowed to seep she enters the scanning room.
deep into the muscle tissue, vascular
visualization will be impossible.
gist will place him or her in a supine
position on a flat table in a large,
cylindrical scanner.
➤ Tell the patient to expect to hear
Procedure ● ● ● ● ● ● ● ● ● ● ●
loud banging from the scanner
Pretest: phosphenes (flickering lights in the
visual field); these will stop when
➤ Inform the patient that the proce- the procedure is over.
dure assesses the bones and joints.
➤ Instruct the patient to take slow,
➤ Inform the patient that the proce- deep breaths if nausea occurs
dure is performed in a special during the procedure.
department by a technologist and a
physician and takes approximately ➤ Do not restrict food and fluids.
30 to 60 minutes.
➤ Obtain a history of allergies or sensi- Intratest:
➤ Obtain a list of medications the ➤ Ask the patient to remove jewelry,
patient is taking. including watches, hairpins, and
other metallic objects, and credit
➤ Obtain a history of the patient’s cards.
trauma or disease process of the
bones and joints, as well as results ➤ Ask the patient to void before the
of previously performed tests, treat- procedure.
ments, surgeries, and procedures. ➤ Administer a sedative to a child or to
Determine if the patient has ever an uncooperative adult, as ordered.
had any device implanted into the ➤ Administer an antianxiety agent, as
body, including copper intrauterine ordered, if the patient has claustro-
devices, pacemakers, ear implants, phobia.
and heart valves.
➤ For related tests, refer to the muscu- on a flat table; use foam wedges to
loskeletal system table. help maintain position and immobi-
➤ Determine previous laboratory lization. Ask the patient to lie still
abnormalities, especially blood urea during the procedure because move-
Magnetic Resonance Imaging, Pancreas 707
ment produces unclear images, thus ➤ Administer the contrast medium, if

affecting the results and making ordered. A second series of images
interpretation difficult. is obtained.
➤ Supply earplugs to the patient to
block out the loud, banging sounds Post-test:
that occur during the test. ➤ Instruct the patient to resume
➤ If an electrocardiogram or respiratory medications, normal activity, and
gating is to be performed in conjunc- diet, unless otherwise indicated.
tion with the scan, apply MRI-safe ➤ Observe for delayed allergic reac-
electrodes to the appropriate sites. tions, such as urticaria, hives, nau-
➤ The patient can communicate with sea, or vomiting, if contrast medium
the technologist doing the examina- was used.
tion via a microphone within the ➤ A physician specializing in this
machine. branch of medicine sends a written
➤ The table is moved into the scanner. report to the ordering provider, who
Instruct the patient to remain still. discusses the results with the
The scanner makes noises as it patient.
acquires images of the body. The ➤ Evaluate test results in relation
patient may be asked to hold his or to the patient’s symptoms and
her breath to facilitate visualization. other tests performed. Related diag-
A number of images are taken. nostic tests include bone x-rays,
These images are reconstructed by arthroscopy, and bone mineral
a computer and reviewed. density.

PANCREAS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Pancreatic MRI.

AREA OF APPLICATION: Pancreatic/upper abdominal area.
DESCRIPTION: Magnetic resonance tissue to line up, and when radio

imaging (MRI) uses a magnet and waves are directed toward the
radio waves to produce an energy magnetic field, the atoms absorb the
field that can be displayed as an radio waves and change their posi-
image. Use of magnetic fields with tion. When the radio waves are
the aid of radiofrequency energy turned off, the atoms go back to their
produces images primarily based on original position, this change in the
water content of tissue. The magnetic energy field is sensed by the equip-
field causes the hydrogen atoms in ment, and an image is generated by
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
Magnetic Resonance Imaging, Pancreas 709
• Pancreatic duct obstruction or calculi


This procedure is contraindicated dure assesses the pancreas.
for:
• Patients with certain ferrous metal dure is performed in a special
prostheses, valves, aneurysm clips, department by a technologist and a
inner ear prostheses, or other metallic physician and takes approximately
objects 30 to 60 minutes.
• Patients with metal in their body, such ➤ Obtain a history of allergies or sensi-
• Patients with cardiac pacemakers ➤ Obtain a list of medications the
patient is taking.
because the pacemaker can be
hepatic and pancreatic findings, as
• Patients who are claustrophobic well as results of previously
the patient has ever had any device
benefits of the procedure far outweigh implanted into the body, including
the risks to the fetus and mother copper intrauterine devices, pace-
Factors that may impair clear valves.
imaging:
➤ For related tests, refer to the hepa-
• Inability of the patient to cooperate or tobiliary system table.
➤ Determine previous laboratory
mental status nitrogen (BUN) and creatinine, if
• Patients with extreme cases of claustro- contrast medium is to be used.
phobia, unless sedation is given before ➤ Ensure that the results of blood
the study tests are obtained and recorded
mine the presence of metal in the
ment body, such as shrapnel or flecks of
• Incorrect positioning of the patient, ferrous metal in the eye (which can
which may produce poor visualization cause retinal hemorrhage).
of the area to be examined ➤ Determine date of last menstrual
• Metallic objects within the examina- in perimenopausal women.
tion field (e.g., jewelry or body rings), ➤ Ensure that the patient and staff
which may inhibit organ visualization have removed all external metallic
and can produce unclear images objects from the patient before he or
she enters the scanning room.
• If contrast medium is allowed to seep gist will place him or her in a supine
deep into the muscle tissue, vascular position on a flat table in a large,
visualization will be impossible. cylindrical scanner.
➤ Tell the patient to expect to hear MRI-safe electrodes to the appropri-

loud banging from the scanner ate sites.
and possibly to see magneto- ➤ The patient can communicate with
phosphenes (flickering lights in the the technologist doing the examina-
visual field); these will stop when tion via a microphone within the
the procedure is over. machine.
➤ Instruct the patient to take slow, ➤ The table is moved into the scanner.
deep breaths if nausea occurs Instruct the patient to remain still.
during the procedure. The scanner makes noises as it
➤ Do not restrict food and fluids. acquires images of the body. The
patient may be asked to hold his or
Intratest: A number of images are taken.
➤ Ask the patient to remove jewelry, These images are reconstructed by
including watches, hairpins, and a computer and reviewed.
other metallic objects, and credit ➤ Administer the contrast medium, if
cards. ordered. A second series of images
➤ Ask the patient to void before the is obtained.
procedure.
Post-test:
➤ Administer a sedative to a child or to
an uncooperative adult, as ordered. ➤ Instruct the patient to resume
medications, normal activity, and
➤ Administer an antianxiety agent, as diet, unless otherwise indicated.
ordered, if the patient has claustro-
phobia.
➤ Place the patient in a supine position nausea, or vomiting, if contrast
on a flat table; use foam wedges to medium was used.
help maintain position and immobi- ➤ A physician specializing in this
lization. Ask the patient to lie still branch of medicine sends a written
during the procedure because move- report to the ordering provider, who
ment produces unclear images, thus discusses the results with the
affecting the results and making patient.
interpretation difficult.
➤ Supply earplugs to the patient to the patient’s symptoms and other
block out the loud, banging sounds tests performed. Related diagnostic
that occur during the test. tests include computed tomography,
➤ If an electrocardiogram or respira- ultrasound, and angiogram of the
tory gating is to be performed in abdomen; hepatobiliary scan; and
conjunction with the scan, apply ultrasound of the biliary ducts.

PELVIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Pelvic MRI.

Magnetic Resonance Imaging, Pelvis 711
AREA OF APPLICATION: Pelvic area.

CONTRAST: Can be done with or without contrast (gadolinium).
DESCRIPTION: Magnetic resonance Magnetic resonance angiography

imaging (MRI) uses a magnet and (MRA) is an application of MRI that
radio waves to produce an energy provides images of blood flow and
field that can be displayed as an diseased and normal blood vessels.
image. Use of magnetic fields with the In patients who are allergic to iodi-
aid of radiofrequency energy produces nated contrast medium, MRA is used
images primarily based on water in place of angiography (see mono-
content of tissue. The magnetic field graph titled “Angiography, Magnetic
causes the hydrogen atoms in tissue to Resonance”). When the Food
line up, and when radio waves are and Drug Administration approves
directed toward the magnetic field, gastrointestinal contrast agents, these
the atoms absorb the radio waves and agents would assist in identifying
change their position. When the radio areas of bowel wall thickening, stric-
waves are turned off, the atoms go ture, and intraluminal abnormalities,
back to their original position, this such as tumors, sites of perforation,
change in the energy field is sensed by and fistula. ■
the equipment, and an image is
generated by the attached computer INDICATIONS:
• Detect pelvic vascular diseases
system. MRI produces cross-sectional
images of the pelvic area in multiple • Detect cancer (primary or metastatic
planes without the use of ionizing tumors of ovary, prostate, uterus, and
radiation or the interference of bone bladder) and provide cancer staging
or surrounding tissue. • Detect peritonitis
Pelvic MRI is performed to assist in
• Differentiate tumors from tissue
diagnosing abnormalities of the pelvis abnormalities, such as cysts, cavernous
and associated structures. Contrast- hemangiomas, and abscesses
enhanced MRI is effective for evaluat-
ing metastases from primary tumors. • Detect soft tissue abnormalities
MRI is highly effective for depicting • Determine blood clots, cysts, fluid or
small-volume peritoneal tumors, fat accumulation in tissues, hemor-
carcinomatosis, and peritonitis and rhage, and infarctions
for determining the response to • Monitor and evaluate the effectiveness
surgical and chemical therapies. of medical or surgical interventions
MRI uses the noniodinated contrast and course of the disease
medium gadopentetate dimeglumine
(Magnevist), which is administered RESULT
intravenously to enhance contrast
Normal Findings:
differences between normal and
• Normal pelvic structures and soft tissue
abnormal tissues. Oral and rectal density and biochemical constituents
contrast administration may be used of pelvic tissues, including blood flow
to isolate the bowel from adjacent
pelvic organs and improve organ visu- Abnormal Findings:
alization. • Ascites
• Masses, lesions, infections, or inflam- Other considerations:

mations • If contrast medium is allowed to seep
• Peritonitis deep into the muscle tissue, vascular
• Peritoneal tumor or carcinomatosis
• Pseudomyxoma peritonei

This procedure is contraindicated ➤ Inform the patient that the proce-
for: dure assesses the pelvis.
• Patients with certain ferrous metal ➤ Inform the patient that the proce-
prostheses, valves, aneurysm clips, dure is performed in a special
inner ear prostheses, or other metallic department by a technologist and a
objects physician and takes approximately
30 to 60 minutes.
• Patients with metal in their body, such ➤ Obtain a history of allergies or sensi-
• Patients with cardiac pacemakers, ➤ Obtain a list of medications the
because the pacemaker can be patient is taking.
pelvic and reproductive systems, as
• Patients who are claustrophobic well as results of previously
ies, and procedures. Determine if
the patient has ever had any device
benefits of the procedure far outweigh implanted into the body, including
the risks to the fetus and mother copper intrauterine devices, pace-
Factors that may impair clear valves.
imaging:
➤ For related tests, refer to the repro-
• Inability of the patient to cooperate or ductive and gastrointestinal system
remain still during the procedure table.
because of age, significant pain, or ➤ Determine previous laboratory
mental status abnormalities, especially blood urea
• Patients with extreme cases of claustro- nitrogen (BUN) and creatinine, if
the study ➤ Ensure that the results of blood
• Patients who are very obese, who may before the procedure.
exceed the weight limit for the equip- ➤ Obtain occupational history to deter-
ment mine the presence of metal in the
ferrous metal in the eye (which can
tion field (e.g., jewelry or body rings), cause retinal hemorrhage).
• Incorrect positioning of the patient, in perimenopausal women.
which may produce poor visualization ➤ Ensure that the patient and staff
of the area to be examined have removed all external metallic
Magnetic Resonance Imaging, Pelvis 713
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
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.
procedure. ➤ Observe for delayed allergic reac-
➤ 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.
MAGNETIC RESONANCE
IMAGING, PITUITARY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Pituitary MRI, MRI of the perisellar region.

AREA OF APPLICATION: Brain/pituitary area.
DESCRIPTION: Magnetic resonance as an absence of signal or a void

imaging (MRI) uses a magnet and in the vessel’s lumen. Blood flow
radio waves to produce an energy can be evaluated in the cavernous
field that can be displayed as an and carotid arteries. Suprasellar
image. Use of magnetic fields with aneurysms may be diagnosed without
the aid of radiofrequency energy angiography, and old clotted blood in
produces images primarily based on the walls of the aneurysms appears
water content of tissue. The magnetic white. MRI uses the noniodinated
field causes the hydrogen atoms in contrast medium gadopentetate
tissue to line up, and when radio dimeglumine (Magnevist), which
waves are directed toward the is administered intravenously to
magnetic field, the atoms absorb the enhance contrast differences between
radio waves and change their posi- normal and abnormal tissues.
tion. When the radio waves are Magnetic resonance angiography
turned off, the atoms go back to their (MRA) is an application of MRI that
original position, this change in the provides images of blood flow and
energy field is sensed by the equip- diseased and normal blood vessels.
ment, and an image is generated by In patients who are allergic to iodi-
the attached computer system. MRI nated contrast medium, MRA is used
produces cross-sectional images of the in place of angiography (see mono-
pituitary and perisellar region in graph titled “Angiography, Magnetic
multiple planes without the use of Resonance”). ■
ionizing radiation or the interference
of bone or surrounding tissue. INDICATIONS:
Pituitary MRI shows the relation- • Detect microadenoma or macroade-
ship of pituitary lesions to the optic noma of the pituitary
chiasm and cavernous sinuses. MRI • Detect tumors of the pituitary
has the capability of distinguishing
the solid, cystic, and hemorrhagic • Evaluate vascularity of the pituitary
components of lesions. Rapidly flow- • Evaluate the solid, cystic, and hemor-
ing blood on spin-echo MRI appears rhagic components of lesions
Magnetic Resonance Imaging, Pituitary 715
• Detect perisellar abnormalities of being pregnant, unless the potential

• Evaluate potential cause of headache,
visual loss, and vomiting
• Monitor and evaluate the effectiveness Factors that may impair clear
of medical or surgical interventions imaging:
and course of disease • Inability of the patient to cooperate or
mental status
Normal Findings:
• Normal anatomic structures, density, phobia, unless sedation is given before
and biochemical constituents of the the study
pituitary, including blood flow
• Abscess ment
• Aneurysm • Incorrect positioning of the patient,
• Choristoma of the area to be examined
• Craniopharyngioma or meningioma • Metallic objects within the examina-
• Granuloma tion field (e.g., jewelry or rings), which
may inhibit organ visualization and
• Infarct or hemorrhage can produce unclear images
• Empty sella
• Macroadenoma or microadenoma • If contrast medium is allowed to seep
• Metastasis deep into the muscle tissue, vascular
• Parasitic infection
CRITICAL VALUES: N/A Nursing Implications and


• Patients with certain ferrous metal dure assesses the pituitary.
objects department by a technologist and a
as shrapnel or ferrous metal in the eye
• Patients with cardiac pacemakers, tivities to contrast medium.
because the pacemaker can be ➤ Obtain a list of medications the
deactivated by MRI patient is taking.
• Patients who are claustrophobic ➤ Obtain a history of the patient’s pitu-
itary, endocrine, and cranial findings,
• Patients who are pregnant or suspected as well as results of previously
performed tests, treatments, surger- ordered, if the patient has claustro-

ies, and procedures. Determine if phobia.
the patient has ever had any device ➤ Place the patient in a supine position
implanted into the body, including on a flat table; use foam wedges to
copper intrauterine devices, pace- help maintain position and immobi-
makers, ear implants, and heart lization. Ask the patient to lie still
valves. during the procedure because move-
➤ For related tests, refer to the ment produces unclear images, thus
endocrine system table. affecting the results and making
➤ Determine previous laboratory interpretation difficult.
abnormalities, especially blood urea ➤ Supply earplugs to the patient to
nitrogen (BUN) and creatinine, if block out the loud, banging sounds
contrast medium is to be used. that occur during the test.
➤ Ensure that the results of blood ➤ If an electrocardiogram or respira-
tests are obtained and recorded tory gating is to be performed in
before the procedure. conjunction with the scan, apply
➤ Obtain occupational history to deter- MRI-safe electrodes to the appropri-
mine the presence of metal in the ate sites.
body, such as shrapnel or flecks of ➤ The patient can communicate with
ferrous metal in the eye (which can the technologist doing the examina-
cause retinal hemorrhage). tion via a microphone within the
➤ Determine date of last menstrual machine.
period and possibility of pregnancy ➤ The table is moved into the scanner.
in perimenopausal women. Instruct the patient to remain still.
➤ Ensure that the patient and staff The scanner makes noises as it
have removed all external metallic acquires images of the body. The
objects from the patient before he or patient may be asked to hold his or
she enters the scanning room. her breath to facilitate visualization.
➤ Inform the patient that the technolo- A number of images are taken.
gist will place him or her in a supine These images are reconstructed by
position on a flat table in a large, a computer and reviewed.
cylindrical scanner. ➤ Administer the contrast medium, if
➤ Tell the patient to expect to hear ordered. A second series of images
loud banging from the scanner is obtained.
phosphenes (flickering lights in the Post-test:
visual field); these will stop when ➤ Instruct the patient to resume
the procedure is over. medications, normal activity, and
➤ Instruct the patient to take slow, diet, unless otherwise indicated.
➤ Do not restrict food and fluids. nausea, or vomiting, if contrast
medium was used.
Intratest: ➤ A physician specializing in this
➤ Ask the patient to remove jewelry, branch of medicine sends a written
including watches, hairpins, and report to the ordering provider, who
other metallic objects, and credit discusses the results with the
cards. patient.
➤ Ask the patient to void before the ➤ Evaluate test results in relation to
procedure. the patient’s symptoms and other
➤ Administer a sedative to a child or to tests include electroencephalogra-
an uncooperative adult, as ordered. phy, as well as MRI and computed
➤ Administer an antianxiety agent, as tomography of the brain.
Mammography 717
MAMMOGRAPHY
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SYNONYMS/ACRONYM: Mammogram, breast x-ray.

AREA OF APPLICATION: Breast.
CONTRAST: None.
DESCRIPTION: Mammography, an x- of the mammogram before the physi-

ray examination of the breast, is most cian interprets the findings.
commonly used to detect breast can- When a mass is detected, additional
cer; however, it can also be used to studies are performed to help differen-
detect and evaluate symptomatic tiate the nature of the mass, as follows:
changes associated with other breast Magnification views of the area
diseases, including mastitis, abscess, in question
cystic changes, cysts, benign tumors, Focal or “spot” views of the area
masses, and lymph nodes. Mammog- in question, done with a
raphy is usually performed with tradi- specialized paddle-style
compression device
tional x-ray film, but totally elec-
Ultrasound images of the area in
tronic image recording is becoming
question, which help
commonplace. This type of radio- differentiate between a fluid-
logic procedure reduces the amount filled cystic lesion and a solid
or radiation exposure to the patient lesion indicative of cancer
and produces detailed images with The American Cancer Society rec-
excellent contrast. Two views of each ommends that all women follow a
breast are usually taken. Benign cysts personal breast-care plan according to
appear as clearly defined, regular, age:
clear spots that are bilateral; cancer Women aged 20 to 39: Clinical
appears as irregular, poorly defined, breast examination performed
unilateral opaque areas or clusters of by a health care professional
calcifications. Mammography can be every 3 years and a monthly
breast self-examination
used to locate a nonpalpable lesion
Women aged 40 and older:
for biopsy. Mammography cannot
Annual mammogram, clinical
detect breast cancer with 100 percent breast examination every year
accuracy: In approximately 15 per- by a health care professional
cent of breast cancer cases, the cancer (near time of the mammo-
is not detected with mammography. gram), and monthly breast self-
To assist in early detection of nonpal- examination. ■
pable breast lesions, computer-
assisted diagnosis is currently being INDICATIONS:
used. With this technique, a com- • Evaluate known or suspected breast
puter performs automated scanning cancer
• 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
• 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-
• Mastitis of patients who are lactating.
• Soft-tissue masses • Risks associated with radiographic
• Vascular calcification overexposure can result from frequent
CRITICAL VALUES: N/A room with the patient should wear a
INTERFERING FACTORS: shield, or leave the area while the
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.
• Patients younger than age 25, because Nursing Implications and
the density of the breast tissue is such Procedure ● ● ● ● ● ● ● ● ● ● ●
that diagnostic x-rays are of limited

value Pretest:
Factors that may impair clear purpose of the procedure, various
imaging: positions to assume, and the need
• Inability of the patient to cooperate or to hold her breath during x-ray expo-
remain still during the procedure sures.
because of age, significant pain, or ➤ Obtain a history of the patient’s
mental status complaints, if any.
Meckel’s Diverticulum Scan 719
➤ Obtain a history of known or ➤ Make sure jewelry, chains, and any

suspected breast disease, family other metallic objects have been
history of breast disease, and removed from the chest area.
results of previously performed ➤ Assist the patient to a standing or
tests, treatments, therapies, surger- sitting position in front of the x-ray
ies, biopsies, and other procedures. machine, which is adjusted to the
➤ For related tests, refer to the repro- level of the breasts. Position the
ductive system table. patient’s arms out of the range of
➤ Inform the patient not to apply the area to be filmed.
deodorant, body creams, or ➤ Place breasts, one at a time,
powders on the day of the proce- between the compression appara-
dure. tus. Usually two views or exposures
➤ Inform the patient there may be are taken of each breast. Ask the
discomfort associated with the patient to hold her breath during
study, while the breast is being exposures.
compressed. The compression
allows for better visualization of the Post-test:
breast tissue.
➤ Inform the patient that further exam-
➤ Determine date of last menstrual inations may be necessary to further
period and possibility of pregnancy evaluate questionable areas of the
in perimenopausal women. breast, evaluate progression of the
➤ Inform the patient the best time to disease process, or determine the
schedule the examination is 1 week need for a change in therapy.
after menses, when breast tender- ➤ Determine if patient or family
ness is decreased. members have any further ques-
➤ Explain to the patient that the radia- tions or concerns.
tion dose will be kept to an absolute
➤ Educate the patient regarding
minimum.
the techniques for breast self-
➤ Do not restrict food and fluids, examination.
unless otherwise indicated.
➤ Inform the patient that the proce- branch of medicine sends a written
dure lasts 15 to 30 minutes. report to the ordering provider, who
Intratest: patient.
procedure. Have the patient put on a the patient’s symptoms and any
hospital gown. related tests performed.
MECKEL’S DIVERTICULUM SCAN

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SYNONYMS/ACRONYM: Meckel’s scan, Meckel’s scintigraphy, ectopic

gastric mucosa scan.

CONTRAST: Intravenous radioactive technetium-99m pertechnetate.
DESCRIPTION: Meckel’s diverticu- INTERFERING FACTORS:

lum scan is a nuclear medicine study
performed to assist in diagnosing the This procedure is contraindicated
cause of abdominal pain or occult for:
gastrointestinal (GI) bleeding, and • Patients who are pregnant or suspected
to assess the presence and size of of being pregnant, unless the potential
a congenital anomaly of the GI
tract. After intravenous injection
of technetium-99m pertechnetate, Factors that may impair clear
immediate and delayed imaging is imaging:
performed, with various views of the • Inability of the patient to cooperate or
abdomen obtained. The radionuclide remain still during the procedure
is taken up and concentrated by pari- because of age, significant pain, or
etal cells of the gastric mucosa, mental status
whether located in the stomach or in • Metallic objects within the examina-
a Meckel’s diverticulum. Up to 25 tion field (e.g., jewelry or body rings),
percent of Meckel’s diverticulum is which may inhibit organ visualization
lined internally with ectopic gastric and can produce unclear images
mucosal tissue. This tissue is usually • Patients who are very obese, who may
located in the ileum and right lower exceed the weight limit for the equip-
quadrant of the abdomen; it secretes ment
acid that causes ulceration of intes- • Incorrect positioning of the patient,
tinal tissue, which results in abdomi- which may produce poor visualization
nal pain and occult blood in stools. ■ of the area to be examined
INDICATIONS: ologic procedure
• Aid in the diagnosis of unexplained
abdominal pain and GI bleeding • Other nuclear scans done within
caused by hydrochloric acid and pepsin preceding 24 hours
secreted by ectopic gastric mucosa,
which ulcerates nearby mucosa
• False-positive results may come from
• Detect sites of ectopic gastric mucosa nondiverticular bleeding, intussuscep-
tion, duplication cysts, inflammatory
RESULT bowel disease, hemangioma of the
bowel, and other organ infections.
Normal Findings:
• Inadequate amount of gastric mucosa
• Normal distribution of radionuclide by within Meckel’s diverticulum can affect
gastric mucosa at normal sites the ability to visualize abnormalities.
Abnormal Findings: • Inaccurate timing for imaging after the

radionuclide injection can affect the
• Meckel’s diverticulum, evidenced by
results.
focally increased radioactive uptake in
areas other than normal structures • Failure to follow dietary restrictions
CRITICAL VALUES: N/A procedure to be canceled or repeated.
Meckel’s Diverticulum Scan 721
• Improper injection of the radionuclide before the study to block GI secre-

that allows the tracer to seep deep into tion, as appropriate.
the muscle tissue produces erroneous ➤ Occasionally, gastrin is given to
hot spots. increase the uptake of the radionu-
clide by the ectopic gastric mucosa.
• Consultation with a physician should ➤ Obtain and record baseline vital
occur before the procedure for radia- signs.
➤ Ensure that the patient has fasted
of patients who are lactating. for 6 to 8 hours before the scan,
• Risks associated with radiographic unless otherwise indicated.
Intratest:
room with the patient should wear a ➤ Ask the patient to void before the
protective lead apron, stand behind a procedure. Have the patient put on a
shield, or leave the area while the hospital gown.
examination is being done. Personnel ➤ Administer sedative to a child or to
working in the area where the exami- an uncooperative adult, as ordered.
nation is being done should wear ➤ Make sure jewelry, watches, chains,
badges that reveal their level of expo- belts, and any other metallic objects
sure to radiation. have been removed from the
abdominal area.
Nursing Implications and on a flat table with foam wedges,
which help maintain position and im-
Procedure ● ● ● ● ● ● ● ● ● ● ●
mobilization. Ask the patient to lie
still during the procedure because
Pretest: movement produces unclear im-
➤ Inform the patient that the proce- ages. The radionuclide is adminis-
dure assesses GI bleeding. tered intravenously, and the ab-
domen is scanned immediately for 1
➤ Inform the patient that the proce- minute to screen for vascular lesions
dure is performed in a special that cause bleeding. Then images
nuclear medicine department by a are taken every 5 minutes for the
technologist and usually takes next 60 minutes in the anterior,
approximately 60 minutes. oblique, lateral, and postvoid anterior
➤ Obtain a history of allergies or sensi- views.
tivities to contrast medium. ➤ Wear gloves during the radionuclide
➤ Obtain a list of medications the injection and while handling the
patient is taking. patient’s urine.
toms of Meckel’s diverticulum, such
Post-test:
as bleeding, pain, intussusception, ➤ Instruct the patient to resume
volvulus, or diverticulitis, as well as normal activity, medications, and
results of previously performed diet, unless otherwise indicated.
tests and surgical procedures. For ➤ Evaluate the patient’s vital signs.
related tests, refer to the cardiovas- Monitor vital signs every 15 to
cular and gastrointestinal system 30 minutes and compare with base-
tables. line readings until the patient is
➤ Determine date of last menstrual stable.
period and possibility of pregnancy ➤ Advise patient to drink increased
in perimenopausal women. amounts of fluids for 24 to 48 hours
➤ Ensure that a histamine blocker is to eliminate the radionuclide from
administered, as ordered, 2 days the body, unless contraindicated. Tell
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.
D ESCRIPTION : Mediastinoscopy into the mediastinum for the deter-

provides direct visualization of the mination of treatment planning in
structures that lie beneath the medi- cancer patients. ■
astinum, which is the area behind the
sternum and between the lungs. The INDICATIONS:
test is performed under general anes- • Confirm radiologic or cytologic
thesia by means of a mediastinoscope evidence of carcinoma or sarcoidosis
inserted through a surgical incision at • Confirm radiologic evidence of a
the suprasternal notch. Structures thoracic infectious process of an inde-
that can be viewed include the terminate nature, coccidioidomycosis,
trachea, the esophagus, the heart and or histoplasmosis
its major vessels, the thymus gland, • Detect Hodgkin’s disease
and the lymph nodes that receive
drainage from the lungs. The proce- • Determine stage of known bron-
dure is performed primarily to visual- chogenic carcinoma, as indicated by
the extent of mediastinal lymph node
ize and obtain biopsy specimens of
involvement
the mediastinal lymph nodes, and to
determine the extent of metastasis • Detect metastasis into the anterior
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
• Hodgkin’s disease respiratory problems as well as
• 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-
tion. General anesthesia is adminis-
of being pregnant, unless the potential tered via an endotracheal tube.
➤ 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
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
patient.
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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SPECIMEN: Urine (25 mL) from a timed specimen collected in a clean
amber, plastic collection container with 6N hydrochloride as a preservative.

Metanephrines 725

Normetanephrines

0–3 mo 47–156 g/24 h 257–852 nmol/24 h
4–6 mo 31–111 g/24 h 171–607 nmol/24 h
7–9 mo 42–109 g/24 h 230–595 nmol/24 h
10–12 mo 23–103 g/24 h 127–562 nmol/24 h
1–2 y 32–118 g/24 h 175–647 nmol/24 h
2–6 y 50–111 g/24 h 274–604 nmol/24 h
6–10 y 47–176 g/24 h 255–964 nmol/24 h
10–16 y 53–290 g/24 h 289–1586 nmol/24 h
Adult 82–500 g/24 h 448–2730 nmol/24 h
Metanephrines

0–3 mo 5.9–37 g/24 h 30–188 nmol/24 h
4–6 mo 6.1–42 g/24 h 31–213 nmol/24 h
7–9 mo 12–41 g/24 h 61–210 nmol/24 h
10–12 mo 8.5–101 g/24 h 43–510 nmol/24 h
1–2 y 6.7–52 g/24 h 34–264 nmol/24 h
2–6 y 11–99 g/24 h 56–501 nmol/24 h
6–10 y 54–138 g/24 h 275–701 nmol/24 h
10–16 y 39–243 g/24 h 200–1231 nmol/24 h
Adult 45–290 g/24 h 228–1470 nmol/24 h
DESCRIPTION: Metanephrines are • Assist in identifying the cause of

the inactive metabolites of epineph- hypertension
rine and norepinephrine. Meta- • Verify suspected tumors associated
nephrines are either excreted or with excessive catecholamine secretion
further metabolized into vanillylman-
delic acid. Release of metanephrines RESULT
in the urine is indicative of disorders
associated with excessive cate- Increased in:
cholamine production, particularly • Ganglioneuroma
pheochromocytoma. Vanillylman- • Neuroblastoma
delic acid and catecholamines are
normally measured with urinary • Pheochromocytoma
metanephrines. Creatinine is usually • Severe stress
measured simultaneously to ensure
adequate collection and to calculate Decreased in: N/A
an excretion ratio of metabolite to
creatinine. ■ CRITICAL VALUES: N/A
• Assist in the diagnosis of suspected • Drugs that may increase metanephrine
pheochromocytoma levels include labetalol, monoamine
oxidase inhibitors, oxprenolol, oxytet- of the collection device to prevent

racycline, and prochlorperazine. contamination of the specimen.
Place a sign in the bathroom to
• Methylglucamine in x-ray contrast remind the patient to save all urine.
medium may cause false-negative ➤ Instruct the patient to void all urine
results. into the collection device and then to
pour the urine into the laboratory
Nursing Implications and collection device for a health care
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
➤ Obtain a history of the patient’s Appendix A.
previously performed tests and Timed specimen:
procedures. For related tests, refer ➤ Obtain a clean 3-L urine specimen
to the endocrine system table. container, toilet-mounted collection
➤ Obtain a list of the medications device, and plastic bag (for transport
the patient is taking, including of the specimen container). The
herbs, nutritional supplements, and specimen must be refrigerated or
nutraceuticals. The requesting health kept on ice throughout the entire
care practitioner and laboratory collection period. If an indwelling
should be advised if the patient urinary catheter is in place, the
regularly uses these products so drainage bag must be kept on ice.
that their effects can be taken into ➤ Begin the test between 6 and 8
consideration when reviewing a.m., if possible. Collect first voiding
results. and discard. Record the time the
➤ Note any recent procedures that can specimen was discarded as the
interfere with test results. beginning of the timed collection
period. The next morning, ask the
patient to void at the same time the
collection was started and add this
direction.
➤ If an indwelling catheter is in place,
sive exercise and stress during the
replace the tubing and container
24-hour collection of urine.
system at the start of the collection
➤ Review the procedure with the time. Keep the container system on
patient. Provide a nonmetallic urinal, ice during the collection period, or
bedpan, or toilet-mounted collection empty the urine into a larger
device. container periodically during the
➤ Usually a 24-hour time frame for collection period; monitor to ensure
urine collection is ordered. Inform continued drainage, and conclude
the patient that all urine must be the test the next morning at the
saved during that 24-hour period. same hour the collection was
Instruct the patient not to void begun.
directly into the laboratory collection ➤ At the conclusion of the test,
container. Instruct the patient to compare the quantity of urine with
avoid defecating in the collection the urinary output record for the
device and to keep toilet tissue out collection; if the specimen contains
Methemoglobin 727
less than what was recorded as Post-test:

discarded, invalidating the test. ➤ Evaluate test results in relation to
transport it to the laboratory. Include tests include catecholamines, homo-
on the label the amount of urine and vanillic acid, and vanillylmandelic
test start and stop times. acid.
METHEMOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Hemoglobin, hemoglobin M, MetHb, Hgb M.

SPECIMEN: Whole blood (1 mL) collected in green-top (heparin) tube.

0.06–0.24 g/dL* 9.3–37.2 mol/L*
* Percentage of total hemoglobin 0.41–1.15 percent.
Note: The conversion factor of 155 is based on the molecular weight of hemoglobin of
64,500 daltons (d) or 64.5 kd.
DESCRIPTION: Methemoglobin is a adenine dinucleotide (NADH)-

structural hemoglobin variant formed methemoglobin reductase or presence
when the heme portion of the deoxy- of methemoglobin.
genated hemoglobin is oxidized to a • Evaluate cyanosis in the presence of
ferric state that renders it incapable of normal blood gases
combining with and transporting
oxygen to tissues. Visible cyanosis can RESULT
result as levels approach 10 to 15
percent of total hemoglobin. ■ Increased in:
• Acquired methemoglobinemia (drugs,
INDICATIONS: tobacco smoking, or ionizing radia-
• Assist in the detection of acquired tion)
methemoglobinemia caused by the
toxic effects of chemicals and drugs • Carbon monoxide poisoning
• Assist in the detection of congenital • Hereditary methemoglobinemia (defi-
methemoglobinemia, indicated by de- ciency of NADH-methemoglobin
ficiency of red blood cell nicotinamide reductase or hemoglobinopathy)
Decreased in: N/A ion, causing nitrite toxicity and

increased methemoglobin.
CRITICAL VALUES: • Prompt and proper specimen process-
Cyanosis can occur at levels ing, storage, and analysis are important
greater than 10 percent. to achieve accurate results. Methemo-
Dizziness, fatigue, headache, and globin is unstable and should be trans-
tachycardia can occur at levels ported on ice within a few hours of col-
greater than 30 percent. lection, or else the specimen should be
Signs of central nervous system rejected.
depression can occur at levels
greater than 45 percent.
Death may occur at levels greater Procedure ● ● ● ● ● ● ● ● ● ● ●
than 70 percent.
Possible interventions include airway Pretest:
protection, administration of oxygen,
monitoring neurologic status every hour, ➤ Obtain a history of the patient’s
continuous pulse oximetry, hyperbaric
allergens.
oxygen therapy, and exchange transfu-
sion. Administration of activated char- ➤ Obtain a history of the patient’s
coal or gastric lavage may be effective if previously performed tests and
performed soon after the toxic agent is procedures. For related tests, refer
ingested. Emesis should never be induced to the hematopoietic system table.
in patients with no gag reflex because of ➤ Obtain a list of medications the pa-
the risk of aspiration. Methylene blue tient is taking, including herbs, nutri-
may be used to reverse the process of tional supplements, and nutraceuti-
methemoglobin formation, but it should cals. The requesting health care
be used cautiously when methemoglobin practitioner and laboratory should be
levels are greater than 30 percent. Use of advised if the patient regularly uses
methylene blue is contraindicated in the these products so that their effects
presence of glucose-6-phosphate dehy- can be taken into consideration
drogenase deficiency.
• Drugs that may increase methemoglo-
bin levels include acetanilid, amyl patient.
nitrate, aniline derivatives, benzo-
caine, chlorates, chloroquine, dapsone, collection takes approximately 5 to
glucosulfone, isoniazid, lidocaine, 10 minutes.
phenacetin, phenytoin, primaquine,
➤ Prepare an ice slurry in a cup or plas-
nitroglycerin, resorcinol, sulfonamides, tic bag to have on hand for immedi-
and thiazolsulfone. ate transport of the specimen to the
laboratory.
• Well water containing nitrate is the
most common cause of methemoglo- Intratest:
binemia in infants.
• Breastfeeding infants are capable of normally and to avoid unnecessary
converting inorganic nitrate from movement.
common topical anesthetic applica- ➤ Observe standard precautions and
tions containing nitrate to the nitrite follow the general guidelines in
Microalbumin 729
Appendix A. Perform a venipuncture, Post-test:

green-top tube. ➤ Observe venipuncture site for bleed-
➤ Label the specimen, and promptly ing or hematoma formation. Apply
transport it to the laboratory. The pressure bandage.
tightly stoppered specimen should ➤ Evaluate test results in relation to
be placed in an ice slurry immedi- the patient’s symptoms and other
ately after collection. Information on tests performed. Related laboratory
the specimen label can be protected tests include arterial/alveolar oxygen
from water in the ice slurry if the ratio, blood gases, carboxyhemoglo-
specimen is first placed in a protec- bin, and hemoglobin electrophore-
tive plastic bag. sis.
MICROALBUMIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Albumin, urine.

a clean plastic collection container.
REFERENCE VALUE: (Method: Nephelometry immunoassay)

Test Units Factor 0.001)
Random
microalbumin 0–30 g/mL 0–0.03 g/L
24-h microalbumin Greater than 40 g/24 h Greater than 0.04 g/24 h
Simultaneous measurement of urine creatinine or creatinine clearance may be
requested. Normal ratio of microalbumin to creatinine is less than 15.
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
RESULT nutritional supplements, and

Increased in:
• Cardiomyopathy regularly uses these products so
• Diabetic nephropathy that their effects can be taken into
• Exercise results.
• Hypertension (uncontrolled) ➤ There are no food, fluid, or medica-
• Preeclampsia direction.
• Renal disease ➤ Instruct the patient to avoid exces-
sive exercise and stress during the
• Urinary tract infections 24-hour collection of urine.
Decreased in: N/A patient. Provide a nonmetallic urinal,
CRITICAL VALUES: N/A device.
➤ Usually a 24-hour time frame for
INTERFERING FACTORS: urine collection is ordered. Inform
• Drugs that may decrease microalbu- the patient that all urine must be
min levels include captopril, dipyri-
Instruct the patient not to void
damole, enalapril, furosemide, inda- directly into the laboratory collection
pamide, perindopril, quinapril, container. Instruct the patient to
ramipril, tolrestat, and triflusal. avoid defecating in the collection
device and to keep toilet tissue out
tion period must be included in the contamination of the specimen.
collection or else falsely decreased Place a sign in the bathroom to
values may be obtained. Compare remind the patient to save all urine.
output records with volume collected ➤ Instruct the patient to void all urine
to verify that all voids were included in into the collection device and then to
the collection. pour the urine into the laboratory
Nursing Implications and staff member to add to the labora-
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: Intratest:
allergens. Appendix A.
endocrine and genitourinary Random specimen (collect in
systems as well as results of previ- early morning):
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
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.
Indwelling catheter: Post-test:

➤ Put on gloves. Empty drainage tube ➤ Instruct the patient, as appropriate,
of urine. It may be necessary to in nutritional management of
clamp off the catheter for 15 to 30 diabetes. Patients who adhere to
minutes before specimen collection. dietary recommendations report a
Cleanse specimen port with antisep- better general feeling of health,
tic swab, and then aspirate 5 mL of better weight management, greater
urine with a 21- to 25-gauge needle control of glucose and lipid values,
and syringe. Transfer urine to a ster- and improved use of insulin. There is
ile container. no “diabetic diet”; however, there
are many meal-planning approaches
Timed specimen: with nutritional goals endorsed by
➤ Obtain a clean 3-L urine specimen the American Dietetic Association.
container, toilet-mounted collection The nutritional needs of each
device, and plastic bag (for transport diabetic patient need to be deter-
of the specimen container). The mined individually with the appropri-
specimen must be refrigerated or ate health care professionals,
kept on ice throughout the entire particularly professionals trained in
collection period. If an indwelling nutrition.
urinary catheter is in place, the ➤ Instruct the patient and caregiver to
drainage bag must be kept on ice. report signs and symptoms of hypo-
➤ Begin the test between 6 and 8 glycemia or hyperglycemia.
a.m., if possible. Collect first voiding ➤ Recognize anxiety related to test
and discard. Record the time the results and offer support. Provide
specimen was discarded as the teaching and information regarding
beginning of the timed collection the clinical implications of the test
period. The next morning, ask the results, as appropriate. Emphasize, if
patient to void at the same time the indicated, that good glycemic control
collection was started and add this delays the onset and slows the
last voiding to the container. progression of diabetic retinopathy,
➤ If an indwelling catheter is in place, nephropathy, and neuropathy.
replace the tubing and container Educate the patient regarding
system at the start of the collection access to counseling services, as
time. Keep the container system on appropriate.
ice during the collection period, or ➤ Evaluate test results in relation to
empty the urine into a larger the patient’s symptoms and other
container periodically during the tests performed. Related laboratory
collection period; monitor to ensure tests include cortisol, urine creati-
continued drainage, and conclude nine, creatinine clearance, glucose,
the test the next morning at the glycated hemoglobin, glucose toler-
same hour the collection was ance test, insulin, insulin antibodies,
begun. urine protein and fractions, and
➤ At the conclusion of the test, urinalysis.
2-MICROGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: 2-M.
SPECIMEN: Serum (1 mL) collected in a red-top tube or 5 mL urine from a
timed collection in a clean, plastic container with 1N NaOH as a preserva-
tive.
REFERENCE VALUE: (Method: Immunoassay for serum sample, radioim-

munoassay for urine sample)
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
DESCRIPTION: 2-Microglobulin is • Detect chronic lymphocytic leukemia,

an amino acid peptide component of multiple myeloma, lung cancer,
human leukocyte antigen (HLA) hepatoma, or breast cancer
complexes. 2-Microglobulin in- • Detect HIV infection (note: levels do
creases in inflammatory conditions not correlate with stages of infection)
and when lymphocyte turnover
• Evaluate renal disease to differentiate
increases, such as in lymphocytic glomerular from tubular dysfunction
leukemia or when T-lymphocyte
helper (OKT4) cells are attacked by • Monitor antiretroviral therapy
human immunodeficiency virus
(HIV). Serum 2-microglobulin
RESULT
becomes elevated with malfunction- Increased in:
ing glomeruli, but decreases with
• Acquired immune deficiency syn-
malfunctioning tubules because it is drome (AIDS)
metabolized by the renal tubules.
Conversely, urine 2-microglobulin • Aminoglycoside toxicity
decreases with malfunctioning • Amyloidosis
glomeruli, but becomes elevated with
• Autoimmune disorders
malfunctioning tubules. ■
• Breast cancer
INDICATIONS: • Crohn’s disease
• Detect aminoglycoside toxicity
(becomes elevated before creatinine) • Felty’s syndrome
2-Microglobulin 733
• Hepatitis • Urinary 2-microglobulin is unstable

• Hepatoma at pH less than 5.5.
• Hyperthyroidism • Recent radioactive scans or radiation

• Inflammation of all types fere with test results when radioim-
• Leukemia (chronic lymphocytic) munoassay is the test method.
• Lung cancer
• Lymphoma Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• 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,
• 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-
Decreased in: practitioner and laboratory should be
• Renal disease (glomerular): urine only advised if the patient regularly uses
• Renal disease (tubular): serum only be taken into consideration when
reviewing results.
• Response to zidovudine (AZT)
CRITICAL VALUES: N/A interfere with test results.
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,
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
saved; instruct the patient to avoid continued drainage, and conclude

defecating in the collection device the test the next morning at the
and to keep toilet tissue out of the same hour the collection started.
collection device to prevent contam- ➤ At the conclusion of the test,
ination of the specimen. Place a sign compare the quantity of urine with
in the bathroom as a reminder to the urinary output record for the
save all urine. collection. If the specimen contains
➤ Instruct the patient to void all urine less than what was recorded as
into the collection device and then output, some urine may have been
pour the urine into the laboratory discarded, thus invalidating the test.
collection container. Alternatively, ➤ Observe standard precautions and
the specimen can be left in the follow the general guidelines in
collection device for a health care Appendix A. Label the specimen,
staff member to add to the labora- and promptly transport it to the labo-
tory collection container. ratory. Include on the label the
amount of urine and ingestion of any
Intratest: medications that can affect test
results.
Blood:
➤ Direct the patient to breathe Post-test:
movement. ➤ Observe venipuncture site for bleed-
➤ Observe standard precautions and pressure bandage.
Appendix A. Perform a venipuncture, ➤ Educate the patient regarding the
and collect the specimen in a 5-mL risk of infection related to immuno-
red-top tube. suppressed inflammatory response
and fatigue related to decreased
Urine: energy production.
➤ Obtain a clean 3-L urine specimen ➤ Stress the importance of good nutri-
container, toilet-mounted collection tion, and suggest that the patient
device, and plastic bag (for transport meet with a nutritional specialist.
of the specimen container). The Also, stress the importance of
specimen must be refrigerated or following the care plan for medica-
kept on ice throughout the entire tions and follow-up visits.
collection period. If an indwelling ➤ Recognize anxiety related to test
urinary catheter is in place, the results and offer support. Provide
drainage bag must be kept on ice. teaching and disease information, as
➤ If possible, begin the test between 6 appropriate. Educate the patient
and 8 a.m. Collect first voiding and regarding access to counseling serv-
discard. Record the time the speci- ices.
men was discarded as the beginning ➤ Evaluate test results in relation to
of the timed collection period. At the the patient’s symptoms and other
same time the next morning, ask the tests performed. Related laboratory
patient to void and add this last void- tests include biopsy of the suspect
ing to the container. tissue; CD4/CD8 enumeration;
➤ If an indwelling catheter is in place, complete blood count; creatinine;
replace the tubing and container erythrocyte sedimentation rate;
system at the start of the collection gentamicin; hepatitis serology;
time. Keep the container system on HIV-1/HIV-2 serology; immuno-
ice during the collection period, or fixation electrophoresis; immuno-
empty the urine into a larger globulins A, G, and M; protein
container periodically during the electrophoresis; total protein;
collection period; monitor to ensure tobramycin; and urinalysis.
Mumps Serology 735
MUMPS SEROLOGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: N/A.
REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative or
DESCRIPTION: Mumps serology is RESULT

done to determine the presence of
Positive findings in: Past or current
mumps antibody, indicating exposure mumps infection.
to or active presence of mumps.
Mumps, also known as parotitis, is an
infectious viral disease of the parotid CRITICAL VALUES: N/A
glands caused by a myxovirus that is
transmitted by direct contact with or INTERFERING FACTORS: N/A
droplets spread from the saliva of
an infected person. The incubation
period averages 3 weeks. Virus can be Nursing Implications and
shed in saliva for 2 weeks after infec- Procedure ● ● ● ● ● ● ● ● ● ● ●
tion and in urine for 2 weeks after the

onset of symptoms. Complications of Pretest:
infection include aseptic meningitis, ➤ Obtain a history of the patient’s
encephalitis, and inflammation of the complaints, including a list of known
allergens. Obtain a history of expo-
testes, ovaries, and pancreas. The
sure.
presence of immunoglobulin M
(IgM) antibodies indicates acute immune system as well as results
infection. The presence of IgG anti- of previously performed tests and
bodies indicates current or past infec- procedures. For related tests, refer
tion. ■ to the immune system table.
INDICATIONS: patient is taking, including herbs,
• Determine resistance to or protection nutritional supplements, and nutra-
against the mumps virus by a positive
practitioner and laboratory should
reaction, or susceptibility to mumps by be advised if the patient regularly
a negative reaction uses these products so that their
• Document immunity effects can be taken into considera-
• Evaluate mumpslike diseases and ➤ There are no food, fluid, or medica-
differentiate between these and actual tion restrictions unless by medical
mumps direction.
➤ 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.
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
sample taken in 7 to 14 days.
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.
MYOCARDIAL INFARCT SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: PYP cardiac scan, infarct scan, pyrophosphate

cardiac scan, acute myocardial infarction scan.
AREA OF APPLICATION: Heart, chest/thorax.

CONTRAST: Intravenous contrast medium.
D ESCRIPTION : Technetium-99m influx of calcium through damaged

stannous pyrophosphate (PYP) scan- cell membranes, which accompanies
ning, also known as myocardial infarct myocardial necrosis; that is, the
imaging, reveals the presence of radionuclide may be binding to
myocardial perfusion and the extent calcium phosphates or to hydroxyap-
of myocardial infarction (MI). This atite. The PYP in these damaged cells
procedure can distinguish new from can be viewed as spots of increased
old infarct when a patient has had radionuclide uptake that appear in 12
abnormal electrocardiograms (ECGs) hours at the earliest.
and cardiac enzymes have returned to PYP uptake usually takes place 24
normal. PYP uptake by acutely to 72 hours after MI, and the
infarcted tissue may be related to the radionuclide remains detectable for
Myocardial Infarct Scan 737
approximately 10 to 14 days after the uptake is present, it is graded in rela-

MI. PYP uptake is proportional to the tion to adjacent rib activity)
blood flow to the affected area; with
large areas of necrosis, PYP uptake Abnormal Findings:
may be maximal around the periph- • MI, indicated by increased PYP uptake
ery of a necrotic area, with little in the myocardium
uptake being detectable in the poorly
perfused center. Most of the PYP is
concentrated in regions that have 20 INTERFERING FACTORS:
to 40 percent of the normal blood
flow. This procedure is contraindicated
Single-photon emission computed for:
tomography (SPECT) can be used to • Patients who are pregnant or suspected
visualize the heart from multiple of being pregnant, unless the potential
angles and planes, enabling areas of benefits of the procedure far outweigh
MI to be viewed with greater accuracy
fetus
and resolution. This technique
removes overlying structures that may • Patients with hypersensitivity to the
confuse interpretation of the results. radionuclide.
With the availability of assays of
troponins, myocardial infarct imaging imaging:
has become less important in the
diagnosis of acute MI. ■ remain still during the procedure
INDICATIONS: mental status
• Aid in the diagnosis of (or confirm and
locate) acute MI when ECG and • Conditions such as chest wall trauma,
enzyme testing do not provide a diag- cardiac trauma, or recent cardioversion
nosis procedure
• Evaluate possible reinfarction or exten- • Myocarditis
sion of the infarct • Pericarditis
• Obtain baseline information about • Left ventricular aneurysm
infarction before cardiac surgery
• Metastasis
• Aid in the diagnosis of perioperative
MI • Valvular and coronary artery calcifica-
tions
• Differentiate between a new and old
infarction • Cardiac neoplasms
• Aneurysms
RESULT
Normal Findings: Nursing Implications and
• Normal coronary blood flow and tissue Procedure ● ● ● ● ● ● ● ● ● ● ●
perfusion, with no PYP localization in
the myocardium Pretest:
• No uptake above background activity ➤ Inform the patient that the procedure
in the myocardium (note: when PYP assesses blood flow to the heart.
➤ Inform the patient that the proce- Post-test:

department by a technologist and ➤ Instruct the patient to resume
takes approximately 30 to 60 normal activity and diet, unless
minutes for each set of images; the otherwise indicated.
patient may be imaged several ➤ If the patient must return for addi-
times, hours apart. tional imaging, advise the patient
➤ Obtain a history of allergies or sensi- to rest in the interim and restrict diet
tivities to contrast medium. to liquids before redistribution
studies.
patient is taking. ➤ Observe the injection site for
redness, swelling, or hematoma.
➤ Obtain a history of cardiac tests,
other diagnostic procedure results, ➤ Advise patient to drink increased
laboratory test results, present amounts of fluids for 24 to 48 hours
cardiac conditions or abnormalities, to eliminate the radionuclide from
and therapy received for cardiac the body, unless contraindicated. Tell
conditions. For related tests, refer to the patient that radionuclide is elimi-
the cardiovascular system table. nated from the body within 6 to 24
➤ Determine date of last menstrual hours.
period and possibility of pregnancy ➤ Observe patient for up to 60
in perimenopausal women. minutes after the study for a
➤ Reassure the patient that the possible anaphylactic reaction to
radioactive material poses no the radionuclide, such as rash,
radioactive hazard and rarely tightening of throat, or difficulty
produces side effects. breathing.
➤ Restrict food for 4 hours, nicotine for ➤ Instruct the patient to flush the toilet
4 to 6 hours, and medications for 24 immediately after each voiding
hours before the procedure. following the procedure and to wash
Intratest: water after each voiding for 24 hours
➤ Ensure that emergency equipment
is readily available during the proce-
when discarding urine for 24
dure.
hours after the procedure. Wash
➤ Ask the patient to void before the gloved hands with soap and
procedure. Have the patient put on a water before removing gloves. Then
hospital gown. wash hands after the gloves are
➤ Inform the patient that movement removed.
during the procedure affects the ➤ A physician specializing in this
results and makes interpretation branch of medicine sends a written
difficult. report to the ordering provider, who
➤ Images of the patient’s heart begin 2 discusses the results with the
to 4 hours after injection of the patient.
radionuclide. ➤ Evaluate test results in relation to
➤ Images of the heart are taken from a the patient’s symptoms and other
minimum of three angles: anterior, tests performed. Related diagnostic
left anterior oblique, and left lateral. tests include electrocardiogram,
In most circumstances, however, echocardiogram, myocardial perfu-
SPECT is done so that the heart can sion scan, and computed tomogra-
be viewed from multiple angles and phy and magnetic resonance
planes. imaging of the chest.
Myocardial Perfusion Heart Scan 739
MYOCARDIAL PERFUSION HEART SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Thallium scan, sestamibi scan, stress thallium.

AREA OF APPLICATION: Heart, chest/thorax.
CONTRAST: Intravenous contrast medium.
DESCRIPTION: Cardiac scanning is a tribution (delayed images) enables

nuclear medicine study that reveals differentiation between normally
clinical information about coronary perfused, healthy myocardium (which
blood flow, ventricular size, and is normal at rest but ischemic on
cardiac function. Thallium-201 chlo- stress) and infarcted myocardium.
ride rest or stress studies are used to Technetium-99m agents such as
evaluate myocardial blood flow to sestamibi (2-methoxyisobutylisoni-
assist in diagnosing or determining trile) are delivered similarly to
the risk for ischemic cardiac disease, thallium-201 during myocardial
coronary artery disease (CAD), and perfusion imaging, but they are
myocardial infarction (MI). This extracted to a lesser degree on the first
procedure is an alternative to angiog- pass through the heart and are taken
raphy or cardiac catheterization in up by the mitochondria. Over a short
cases where these procedures may period, the radionuclide concentrates
pose a risk to the patient. Thallium- in the heart to the same degree as
201 is a potassium analogue and is thallium-201. The advantage to
taken up by myocardial cells propor- technetium-99m agents is that imme-
tional to blood flow to the cell and diate imaging is unnecessary because
cell viability. During stress studies, the the radionuclide remains fixed to the
radionuclide is injected at peak exer- heart muscle for several hours. The
cise, after which the patient continues examination requires two separate
to exercise for several minutes. injections, one for the rest portion
During exercise, areas of heart muscle and one for the stress portion of the
supplied by normal arteries increase procedure. These injections can take
their blood supply, as well as the place on the same day or preferably
supply of thallium-201 delivery to the over a 2-day period. Examination
heart muscle, to a greater extent than quality is improved if the patient is
regions of the heart muscle supplied given a light, fatty meal after the
by stenosed coronary arteries. This radionuclide is injected to facilitate
discrepancy in blood flow becomes hepatobiliary clearance of the radioac-
apparent and quantifiable in subse- tivity. If stress testing cannot be
quent imaging. Comparison of early performed by exercising, dipyri-
stress images with 3 to 4 hours’ redis- damole (Persantine) or adenosine, a
vasodilator, can be administered RESULT

orally or intravenously. A coronary
vasodilator is administered before the Normal Findings:
thallium-201, or other radionuclide, • Normal wall motion, coronary blood
and the scanning procedure is then flow, tissue perfusion, and ventricular
performed. Vasodilators increase size and function
blood flow in normal coronary arter- Abnormal Findings:
ies twofold to threefold without exer- • Abnormal stress images with normal
cise, and they reveal perfusion defects resting images, indicating transient
when blood flow is compromised ischemia
by vessel pathology. Vasodilator-
• Abnormal stress and resting images,
mediated myocardial perfusion scan- indicating previous MI
ning is reserved for patients who are
unable to participate in treadmill, • Cardiac hypertrophy, indicated by
bicycle, or handgrip exercises for increased radionuclide uptake in the
myocardium
stress testing because of lung disease,
neurologic disorders (e.g., multiple • Enlarged left ventricle
sclerosis, spinal cord injury), morbid • Heart chamber disorder
obesity, and orthopedic disorders
(e.g., arthritis, limb amputation). • Ventricular septal defects
Single photon emission computed CRITICAL VALUES: N/A
tomography (SPECT) can be used to
visualize the heart from multiple INTERFERING FACTORS:
angles and planes, enabling areas of
MI to be viewed with greater accuracy This procedure is contraindicated
for:
and resolution. This technique
removes overlying structures that may
confuse interpretation of the results. ■ benefits of the procedure far outweigh
INDICATIONS: fetus
• Aid in the diagnosis of or risk for CAD
• Patients with hypersensitivity to the
• Evaluate the extent of CAD and deter- radionuclide
mine cardiac function
• Patients with left ventricular hypertro-
• Assess the function of collateral coro- phy, right and left bundle-branch
nary arteries block, or hypokalemia, and patients
• Evaluate bypass graft patency and receiving cardiotonic therapy
general cardiac status after surgery • Patients with anginal pain at rest
• Evaluate the site of an old MI to deter- or patients with severe atherosclerotic
mine obstruction to cardiac muscle coronary vessels, in whom dipyri-
perfusion damole testing cannot be performed
• Determine rest defects and reperfusion • Patients with asthma, because chemical
with delayed imaging in unstable stress with vasodilators can cause bron-
angina chospasms
• Evaluate the effectiveness of medica- Factors that may impair clear

tion regimen and balloon angioplasty imaging:
procedure on narrow coronary arteries • Inability of the patient to cooperate or
Myocardial Perfusion Heart Scan 741
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
• 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
• 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.
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
before administering any medica- normal activity, medications, and

tions prior to the procedure. diet, unless otherwise indicated. If
➤ Tell the patient to wear walking the patient must return for further
shoes for treadmill exercise, and thallium-201 imaging, advise the
emphasize the importance of the patient to rest in the interim and to
patient reporting fatigue, pain, or restrict diet to liquids before redistri-
shortness of breath. bution studies.
➤ Restrict food for 4 hours, nicotine for ➤ Evaluate the patient’s vital signs.
4 to 6 hours, and medications for 24 Observe the patient for 60 minutes
hours before the test. after the procedure for possible
reaction to the radionuclide or for
➤ Establish an intravenous access complications from the exercise.
➤ Monitor ECG tracings and compare
➤ Obtain and record baseline vital with baseline readings until stable.
signs and electrocardiographic (ECG)
tracings. ➤ Observe the injection site for
redness, swelling, or hematoma.
Intratest: ➤ Advise patient to drink increased
amounts of fluids for 24 to 48 hours
➤ Ensure that emergency equipment to eliminate the radionuclide from
is readily available during the proce- the body, unless contraindicated. Tell
dure. the patient that radionuclide is elimi-
➤ Ask the patient to void before the nated from the body within 6 to 24
procedure. Have the patient put on a hours.
hospital gown. ➤ Instruct the patient to flush the toilet
➤ Make sure jewelry, chains, and any immediately after each voiding
other metallic objects have been following the procedure and to wash
removed from the chest area. hands meticulously with soap and
➤ Expose the chest, and attach the water after each voiding for 24 hours
ECG leads for simultaneous trac- after the procedure.
ings; apply a blood pressure cuff. ➤ Tell all caregivers to wear gloves
➤ Assist the patient onto the treadmill when discarding urine for 24 hours
or bicycle ergometer and ask the after the procedure. Wash gloved
patient to exercise to a calculated 80 hands with soap and water before
to 85 percent of the maximum heart removing gloves. Then wash hands
rate, as determined by the protocol after the gloves are removed.
selected. ➤ A physician specializing in this
➤ Thallium-201 is injected 60 to 90 branch of medicine sends a written
seconds before exercise is termi- report to the ordering provider, who
nated, and imaging is done immedi- discusses the results with the
ately in the supine position and patient.
repeated in 4 hours. ➤ Inform the patient that abnormalities
➤ Patients who cannot exercise are found of the heart scan may indicate
given dipyridamole 4 minutes before the need for further procedures,
thallium-201 is injected. including cardiac catheterization.
➤ Inform the patient that movement ➤ Evaluate test results in relation
during the procedure affects the to the patient’s symptoms and
results and makes interpretation other tests performed. Related
difficult. diagnostic tests include echocardio-
gram, computed tomography and
Post-test: magnetic resonance imaging of
the chest, ECG, and Holter monitor-
➤ Instruct the patient to resume ing.
Myoglobin 743
MYOGLOBIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: MB.

5–70 g/dL 5–70 g/dL
DESCRIPTION: Myoglobin is an • Rhabdomyolysis

oxygen-binding muscle protein • Shock
normally found in skeletal and
cardiac muscle. It is released into the • Thrombolytic therapy
bloodstream after muscle damage
Decreased in:
from ischemia, trauma, or inflamma-
• Myasthenia gravis
tion. Although myoglobin testing is
more sensitive than creatinine kinase • Presence of antibodies to myoglobin as
and isoenzymes, it does not indicate seen in patients with polymyositis
the specific site involved. ■ • Rheumatoid arthritis
• Assist in predicting a flare-up of
polymyositis INTERFERING FACTORS: N/A
• Estimate damage from skeletal muscle
injury or myocardial infarction
RESULT Procedure ● ● ● ● ● ● ● ● ● ● ●
Increased in: Pretest:

• Cardiac surgery ➤ Obtain a history of the patient’s
• Cocaine use complaints, including a list of known
allergens.
• Exercise
• Malignant hyperthermia cardiovascular and musculoskeletal
system as well as results of previ-
• Myocardial infarction ously performed tests and proce-
• Progressive muscular dystrophy dures. For related tests, refer to the
cardiovascular and musculoskeletal
• Renal failure system tables.
➤ Obtain a list of medications the follow the general guidelines in

patient is taking, including herbs, Appendix A. Perform a venipuncture,
nutritional supplements, and nutra- and collect the specimen in a 5-mL
ceuticals. The requesting health care red- or tiger-top tube.
can be taken into consideration Post-test:
➤ Inform the patient that specimen tests include apolipoprotein A and
collection takes approximately 5 to B; muscle biopsy; C-reactive
10 minutes. protein; high-density, low-density,
and very-low-density lipoprotein
Intratest: cholesterol; chylomicrons; triglyc-
erides; creatine kinase and isoen-
➤ Direct the patient to breathe zymes; homocysteine, lactate
normally and to avoid unnecessary dehydrogenase and isoenzymes;
movement. lipoprotein electrophoresis; magne-
➤ Observe standard precautions and sium; and troponin.
OSMOLALITY, SERUM AND URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Osmo.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube; urine (5
mL) from an unpreserved random specimen collected in a clean, plastic
REFERENCE VALUE: (Method: Freezing point depression)
SI Units
Serum 275–295 mOsm/kg 275–295 mmol/kg
Urine
Newborn 75–300 mOsm/kg 75–300 mmol/kg
Children 250–900 mOsm/kg 250–900 mmol/kg
and adults
Osmolality, Serum and Urine 745
DESCRIPTION: Osmolality refers to • Assist in rapid screening for toxic

the number of particles in solution; it substances, such as ethylene glycol,
is independent of particle size, shape, ethanol, isopropanol, and methanol
and charge. Measurement of osmotic • Evaluate electrolyte and acid-base
concentration in serum provides clin- balance
ically useful information about water • Evaluate state of hydration
and dissolved-particle transport across
fluid compartment membranes. Urine:
Osmolality is used to assist in the • Evaluate concentrating ability of the
diagnosis of metabolic, renal, and kidneys
endocrine disorders. The simultane- • Evaluate diabetes insipidus
ous determination of serum and urine
osmolality provides the opportunity • Evaluate neonatal patients with protein
to compare values between the two or glucose in the urine
fluids. A normal urine-to-serum ratio • Perform workup for renal disease
is approximately 0.2 to 4.7 for
random samples and greater than 3.0 RESULT
for first-morning samples (dehydra-
Increased in:
tion normally occurs overnight). The
• Serum:
major dissolved particles that
Azotemia
contribute to osmolality are sodium,
Dehydration
chloride, bicarbonate, urea, and
glucose. Some of these substances are Diabetes insipidus
used in the following calculated esti- Diabetic ketoacidosis
mate: Hypercalcemia
Hypernatremia
Serum osmolality {[2 (Na+)]+
[glucose/18] + [BUN/2.8]} • Urine:
Amyloidosis
Measured osmolality is higher than
Azotemia
the estimated value. The osmolal gap
Congestive heart failure
is the difference between the meas-
Dehydration
ured and calculated values and is
normally 5 to 10 mOsm/kg. If the Hyponatremia
difference is greater than 15 Syndrome of inappropriate
antidiuretic hormone production
mOsm/kg, consider ethylene glycol,
(SIADH)
isopropanol, methanol, or ethanol
toxicity. These substances behave like Decreased in:
antifreeze, lowering the freezing point • Serum:
in the blood, and provide mislead- Adrenocorticoid insufficiency
ingly high results. ■ Hyponatremia
SIADH
INDICATIONS Water intoxication
Serum: • Urine:
• Assist in the evaluation of antidiuretic Diabetes insipidus
hormone (ADH) function Hypokalemia
Hypernatremia lality include captopril, demeclocy-

Primary polydipsia cline, glyburide, lithium, methoxyflu-
rane, octreotide, tolazamide, and
CRITICAL VALUES: Serum: verapamil.
Less than 265 mOsm/kg
Greater than 320 mOsm/kg
Serious clinical conditions may be Nursing Implications and
associated with elevated or decreased Procedure ● ● ● ● ● ● ● ● ● ● ●
serum osmolality. The following condi-

tions are associated with elevated serum Pretest:
osmolality: ➤ Obtain a history of the patient’s
Respiratory arrest: 360 mOsm/kg complaints, including a list of known
Stupor of hyperglycemia: 385 allergens.
mOsm/kg ➤ Obtain a history of the patient’s en-
Grand mal seizures: 420 mOsm/kg docrine and genitourinary systems,
Death: greater than 420mOsm/kg formed tests and procedures. For re-
Symptoms of critically high levels lated tests, refer to the endocrine
include poor skin turgor, listlessness, and genitourinary system tables.
acidosis (decreased pH), shock, seizures, ➤ Obtain a list of the medications the
coma, and cardiopulmonary arrest. patient is taking, including herbs, nu-
Intervention may include close monitor- tritional supplements, and nutraceu-
ing of electrolytes, administering intra- ticals. The requesting health care
venous fluids with the appropriate practitioner and laboratory should be
composition to shift water either in or advised if the patient regularly uses
out of the intravascular space as needed, these products so that their effects
monitoring cardiac signs, continuing
neurologic checks, and taking seizure
precautions. ➤ There are no food, fluid, or medica-
direction.
• Drugs that may increase serum osmo- ➤ Review the procedure with the
patient.
lality include citrates (as an anticoagu-
lant), corticosteroids, ethylene glycol, ➤ Inform the patient that specimen
glycerin, inulin, ioxithalamic acid, collection takes approximately 5 to
10 minutes.
mannitol, and methoxyflurane.
• Drugs that may decrease serum osmo- Intratest:
lality include bendroflumethiazide, ➤ Direct the patient to breathe nor-
carbamazepine, chlorpromazine, mally and to avoid unnecessary
chlorthalidone, cyclophosphamide, cy- movement. Observe standard pre-
clothiazide, hydrochlorothiazide, lor- cautions and follow the general
cainide, methyclothiazide, and polythi- guidelines in Appendix A.
azide.
Blood:
• Drugs that may increase urine osmolal-
ity include anesthetic agents, chlor-
the specimen in a 5-mL red-top
propamide, cyclophosphamide, furo- tube.
semide, mannitol, metolazone,
octreotide, phloridzin, and vincristine. Urine:
• Drugs that may decrease urine osmo- ➤ Review the procedure with the
Osmolality, Serum and Urine 747
patient. Provide a nonmetallic urinal, clamp off the catheter for 15 to 30

bedpan, or toilet-mounted collection minutes before specimen collection.
device. Cleanse specimen port with antisep-
➤ Either a random specimen or a tic swab, and then aspirate 5 mL of
timed collection may be requested. urine with a 21- to 25-gauge needle
For timed specimens, a 12- or 24- and syringe. Transfer urine to a ster-
hour time frame for urine collection ile container.
may be ordered. Inform the patient
that all urine must be saved during Blood or urine:
that 24-hour period. Instruct the pa- ➤ Label the specimen, and promptly
tient not to void directly into the lab- transport it to the laboratory.
oratory collection container. Instruct
the patient to avoid defecating in the Post-test:
collection device and to keep toilet
tissue out of the collection device to ➤ Observe venipuncture site for bleed-
prevent contamination of the speci- ing or hematoma formation. Apply
men. Place a sign in the bathroom to pressure bandage.
remind the patient to save all urine.
➤ Decreased osmolality may be asso-
➤ Instruct the patient to void all urine ciated with overhydration. Observe
into the collection device and then to the patient for signs and symptoms
pour the urine into the laboratory of fluid-volume excess related to
collection container. Alternatively excess electrolyte intake, fluid-
the specimen can be left in the volume deficit related to active
collection device for a health care loss, or risk of injury related to
staff member to add to the labora- an alteration in body chemistry.
tory collection container. (For electrolyte-specific dietary
references, see monographs titled
“Chloride,” “Potassium,” and
➤ Instruct the male patient to (1) thor- “Sodium.”)
oughly wash his hands, (2) cleanse ➤ Increased osmolality may be associ-
the meatus, (3) void a small amount ated with dehydration. Evaluate the
into the toilet, and (4) void directly patient for signs and symptoms of
into the specimen container. dehydration. Dehydration is a signifi-
➤ Instruct the female patient to (1) cant and common finding in geriatric
thoroughly wash her hands; (2) and other patients in whom renal
cleanse the labia from front to back; function has deteriorated.
(3) while keeping the labia sepa- ➤ Evaluate test results in relation to
rated, void a small amount into the the patient’s symptoms and other
toilet; and (4) without interrupting tests performed. Related laboratory
the urine stream, void directly into tests include ADH, ammonia, serum
the specimen container. and urine creatinine, serum and
Indwelling catheter: urine electrolytes, ethanol, ketones,
urine ketones, glucose, blood urea
➤ Put on gloves. Empty drainage tube nitrogen (BUN), and urine urea nitro-
of urine. It may be necessary to gen.
OSMOTIC FRAGILITY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Red blood cell osmotic fragility, OF.

SPECIMEN: Whole blood (1 mL) collected in a green-top (heparin) tube
and two peripheral blood smears.
REFERENCE VALUE: (Method: Spectrophotometry) Hemolysis begins at 0.5

w/v sodium chloride (NaCl) solution and is complete at 0.3 w/v NaCl solu-
tion. Results are compared to a normal curve.
DESCRIPTION: Osmotic fragility • Liver disease

(OF) is an indication of the ability of • Reticulocytosis
red blood cells (RBCs) to take on
water without lysing. In this test, • Thalassemias
RBCs are placed in graded dilutions
of sodium chloride. Swelling of the
cells occurs at lower concentrations of INTERFERING FACTORS:
NaCl as they take on water in the • Drugs that may increase osmotic
hypotonic solution. Thicker cells, fragility include dapsone.
such as spherocytes, have an increased • Parasitic infestations, such as malaria,
OF; thinner cells have a decreased may independently cause cell hemoly-
OF. ■ sis.
INDICATIONS: Evaluate hemolytic • Specimens should be submitted for
anemia. analysis immediately after collection.
RESULT
Increased in: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Acquired immune hemolytic anemias Pretest:

• Hemolytic disease of the newborn ➤ Obtain a history of the patient’s
• Hereditary spherocytosis complaints, including a list of known
allergens.
• Malaria ➤ Obtain a history of the patient’s
• Pyruvate kinase deficiency hematopoietic system and results
Decreased in: to the hematopoietic system table.
• Asplenia ➤ Obtain a list of the medications
• Hemoglobinopathies the patient is taking, including
• Iron deficiency anemia nutraceuticals. The requesting
Osteocalcin 749
health care practitioner and labora- ➤ Observe standard precautions and

tory should be advised if the patient follow the general guidelines in
regularly uses these products so Appendix A. Perform a venipuncture,
that their effects can be taken into and collect the specimen in a 5-mL
consideration when reviewing green-top tube.
results. ➤ Label the specimen, and promptly
patient.
➤ Direct the patient to breathe glucose-6-phosphate dehydroge-
normally and to avoid unnecessary nase, Ham’s test, and pyruvate
movement. kinase.
OSTEOCALCIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Bone GLA protein, BGP.

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
DESCRIPTION: Osteocalcin is an during the matrix mineralization

important bone cell matrix protein phase of bone formation and is the
and sensitive marker in bone metabo- most abundant noncollagenous bone
lism. It is produced by osteoblasts cell protein. Synthesis of osteocalcin
is dependent on vitamin K. levels include anticonvulsants,

Osteocalcin levels parallel alkaline calcitriol, and estrogens.
phosphatase levels. Osteocalcin levels • Drugs that may decrease calcitonin
are affected by a number of factors, levels include glucocorticoids.
including the hormone estrogen.
Assessment of osteocalcin levels
within 1 week before the serum osteo-
permits indirect measurement of calcin test can interfere with test results
osteoblast activity and bone forma- when radioimmunoassay is the test
tion. Because it is released into the method.
bloodstream during bone resorption,
there is some question as to whether
osteocalcin might also be considered a Nursing Implications and
marker for bone matrix degradation Procedure ● ● ● ● ● ● ● ● ● ● ●
and turnover. ■
Pretest:
INDICATIONS:
• Assist in the diagnosis of bone cancer ➤ Obtain a history of the patient’s
• 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.
Increased in: the patient is taking, including
• Adolescents undergoing a growth spurt nutraceuticals. The requesting health
• Chronic renal failure care practitioner and laboratory
• Hyperthyroidism (primary and regularly uses these products so
secondary) that their effects can be taken
• Metastatic skeletal disease results.
• Paget’s disease ➤ Note any recent procedures that can
• Renal osteodystrophy
• Some patients with osteoporosis tion restrictions unless by medical
direction.
Decreased in: ➤ Review the procedure with the
• Growth hormone deficiency patient.
• Pregnancy collection takes approximately 5 to
• Primary biliary cirrhosis 10 minutes.

• Drugs that may increase calcitonin movement.
Ova and Parasites, Stool 751
➤ 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.
OVA AND PARASITES, STOOL

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: O & P.
SPECIMEN: Stool collected in a clean plastic, tightly capped container.
No presence of parasites, ova, or larvae.
DESCRIPTION: This test evaluates sites are nonpathogenic; others, such

stool for the presence of intestinal as protozoa and worms, can cause
parasites and their eggs. Some para- serious illness. ■
INDICATIONS: Assist in the diagnosis of • Medications such as antacids, antibi-

parasitic infestation otics, bismuth, castor oil, antidiarrheal
compounds, iron, magnesia, or psyl-
RESULT lium fiber (Metamucil) may interfere
with analysis.
• Amebiasis—Entamoeba histolytica
infection Nursing Implications and
• Ascariasis—Ascaris lumbricoides infec- Procedure ● ● ● ● ● ● ● ● ● ● ●
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-
• 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
• 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
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-
Oxalate, Urine 753
men directly into the container. If the Post-test:

patient is bedridden, use a clean
bedpan and transfer the specimen ➤ Recognize anxiety related to test
into the container using a tongue results and offer support. Educate
depressor. the patient with positive findings on
the transmission of the parasite, as
➤ Specimens to be examined for the
indicated. Provide teaching and infor-
presence of pinworms are collected
mation regarding the clinical implica-
by the “Scotch tape” method in the
tions of the test results, as
morning before bathing or defeca-
appropriate.
tion. A small paddle with a piece of
cellophane tape (sticky side facing ➤ Warn the patient that one negative
out) is pressed against the perianal result does not rule out parasitic
area. The tape is placed in a collec- infestation and that additional speci-
tion container and submitted to de- mens may be required.
termine if ova are present. Some- ➤ Evaluate test results in relation to
times adult worms are observed the patient’s symptoms and other
protruding from the rectum. tests performed. Related laboratory
➤ Label the specimen, and promptly tests include immunoglobulin E,
transport it to the laboratory. stool culture, and fecal analysis.
OXALATE, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SPECIMEN: Urine (25 mL) from a timed specimen collected in a clean,
plastic collection container with hydrogen chloride (HCl) as a preservative.

0–40 mg/24 h 0–456 mol/24 h
DESCRIPTION: Oxalate is derived doses of vitamin C (ascorbic acid).

from the metabolism of oxalic acid, Hyperoxaluria is also associated with
glycine, and ascorbic acid. Some ethylene glycol poisoning (oxalic
individuals with malabsorption acid is used in cleaning and bleaching
disorders absorb and excrete abnor- agents). Patients who absorb and
mally high amounts of oxalate, result- excrete large amounts of oxalate
ing in hyperoxaluria. Hyperoxaluria may form calcium oxalate kidney
may be seen in patients who consume stones. Simultaneous measurement
large amounts of animal protein, of serum and urine calcium is often
certain fruits and vegetables, or mega- requested. ■
INDICATIONS: Nursing Implications and

• Assist in the evaluation of patients with
ethylene glycol poisoning Procedure ● ● ● ● ● ● ● ● ● ● ●
• Assist in the evaluation of patients with Pretest:

malabsorption syndromes or patients ➤ Obtain a history of the patient’s
who have had jejunoileal bypass complaints, including a list of known
surgery allergens.
• Assist in the evaluation of patients with
gastrointestinal and genitourinary
a history of kidney stones systems, as well as results of previ-
RESULT dures. For related tests, refer to the
gastrointestinal and genitourinary
Increased in: system tables.
• Bacterial overgrowth ➤ Obtain a list of the medications the
• Biliary tract disease tritional supplements and nutraceuti-
• Bowel disease practitioner and laboratory should be
• Celiac disease advised if the patient regularly uses
• Cirrhosis can be taken into consideration
• Diabetes by medical direction.
➤ Calcium supplements, gelatin,
• Ethylene glycol poisoning rhubarb, spinach, strawberries,
• Ileal resection tomatoes, and vitamin C should be
restricted for at least 24 hours be-
• Jejunal shunt fore the test. High-protein meals
should also be avoided 24 hours be-
• Pancreatic disease fore specimen collection.
• Primary hereditary hyperoxaluria (rare) ➤ Review the procedure with the
patient. Provide a nonmetallic urinal,
• Pyridoxine (vitamin B6) deficiency bedpan, or toilet-mounted collection
device.
• Sarcoidosis
Decreased in: the patient that all urine must be
• Hypercalciuria saved during that 24-hour period.
• Renal failure directly into the laboratory collection
container. Instruct the patient to
CRITICAL VALUES: N/A avoid defecating in the collection
device and to keep toilet tissue out
INTERFERING FACTORS: of the collection device to prevent
• Drugs and vitamins that may increase contamination of the specimen.
oxalate levels include methoxyflurane, Place a sign in the bathroom to
remind the patient to save all urine.
ascorbic acid, and calcium.
• Drugs that may decrease oxalate levels into the collection device and then to
include nifedipine and pyridoxine. pour the urine into the laboratory
Oxalate, Urine 755
collection container. Alternatively collection was started and add this

the specimen can be left in the last voiding to the container.
collection device for a health care ➤ If an indwelling catheter is in place,
staff member to add to the labora- replace the tubing and container
tory collection container. system at the start of the collection
time. Keep the container system on
Intratest: ice during the collection period, or
➤ Ensure that the patient has complied empty the urine into a larger
with dietary preparations and other container periodically during the
pretesting restrictions. collection period; monitor to ensure
continued drainage, and conclude
➤ Observe standard precautions and the test the next morning at the
follow the general guidelines in same hour the collection was
Appendix A. begun.
Random specimen (collect in ➤ At the conclusion of the test,
early morning):
the urinary output record for the
Clean-catch specimen: less than what was recorded as
the meatus, (3) void a small amount ➤ Label the specimen, and promptly
into the toilet, and (4) void directly transport it to the laboratory. Include
into the specimen container. on the label the amount of urine,
test start and stop times, and inges-
tion of any foods or medications that
can affect test results.
rated, void a small amount into the Post-test:
toilet; and (4) without interrupting ➤ Instruct the patient to resume usual
the urine stream, void directly into diet and medication as directed by
the specimen container. the requesting health care practi-
tioner. Consideration may be given
Timed specimen:
to lessen dietary intake of oxalate if
➤ Obtain a clean 3-L urine specimen urine levels are increased. Encour-
container, toilet-mounted collection age patients with abnormal results
device, and plastic bag (for transport to seek advice regarding dietary
of the specimen container). The modifications from a trained nutri-
specimen must be refrigerated or tionist. Magnesium supplementa-
kept on ice throughout the entire tion may be recommended for pa-
collection period. If an indwelling tients with gastrointestinal disease
urinary catheter is in place, the to prevent the development of cal-
drainage bag must be kept on ice. cium oxalate kidney stones.
➤ Begin the test between 6 and 8 ➤ Evaluate test results in relation to
a.m., if possible. Collect first voiding the patient’s symptoms and other
and discard. Record the time the tests performed. Related laboratory
specimen was discarded as the tests include serum and urine cal-
beginning of the timed collection cium, kidney stone analysis, serum
period. The next morning, ask the and urine magnesium, urine uric
patient to void at the same time the acid, urinalysis, and vitamin C.
PAPANICOLAOU SMEAR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Pap smear, cervical smear.

SPECIMEN: Cervical and endocervical cells.
REFERENCE VALUE: (Method: Microscopic examination of fixed and stained
smear) Reporting of Pap smear findings may follow one of several formats
and may vary from laboratory to laboratory. Simplified content of the two
most common formats for interpretation are listed.
Traditional Method Description

Class I Normal cells only
Class II Atypical cells but not malignant or
inflammatory
Class III Atypical cells suspicious of malignancy/mild
cervical dysplasia
Class IV Atypical cells suggestive of malignancy/severe
cervical dysplasia
Class V Cancerous cells conclusive for malignancy
Bethesda System Description

Adequacy of the specimen Satisfactory
Satisfactory but limited by lack of required
patient information, contamination, or poor
technique, which prevents evaluation of
50–70% of the cells
Unsatisfactory—should be rejected and
recollected
General interpretation Within normal limits
Benign cellular changes
Cellular abnormality
Descriptive diagnoses
Benign cellular changes Infection or reactive changes
Epithelial cell Graded squamous and glandular cell
abnormalities description
Description of other malignant neoplasms
Hormonal evaluation (vaginal smears only)
Papanicolaou Smear 757
DESCRIPTION: The Papanicolaou RESULT

(Pap) smear is primarily used for the
early detection of cervical cancer. The Positive findings in: (See table
[Bethesda system], listed earlier under
interpretation of Pap smears is as “Reference value”)
heavily dependent on the collection
and fixation technique as it is on the Decreased in: N/A
completeness and accuracy of the
clinical information provided with CRITICAL VALUES: N/A
the specimen. The patient’s age, date
of last menstrual period, parity, surgi- INTERFERING FACTORS:
cal status, postmenopausal status, • The smear should not be allowed to air
hormone therapy (including use of dry before fixation.
oral contraceptives), history of radia- • Lubricating jelly should not be used on
tion or chemotherapy, abnormal vagi- the speculum.
nal bleeding, and history of previous
• Improper collection site may result in
Pap smears are essential for proper specimen rejection. Samples for cancer
interpretation. screening are obtained from the poste-
Improvements in specimen prepa- rior vaginal fornix and from the cervix.
ration have added to the increased Samples for hormonal evaluation are
quality of screening procedures. The obtained from the vagina.
Cytyc ThinPrep PapTest (Cytyc • Contamination with blood from
Corporation, Boxborough, MA), samples collected during the patient’s
approved by the U.S. Food and Drug menstrual period may be cause for
Administration in 1996, is a tech- specimen rejection.
nique that provides a uniform mono-
layer of cells free of debris such as
blood and mucus. Computerized Nursing Implications and
scanning systems are also being used Procedure ● ● ● ● ● ● ● ● ● ● ●
to reduce the number of smears that

require manual review by a cytotech- Pretest:
nologist or pathologist. ■ ➤ Obtain a history of the patient’s
INDICATIONS: allergens.
• Assist in the diagnosis of cervical ➤ Obtain a history of the patient’s
dysplasia immune and reproductive systems,
• Assist in the diagnosis of endometrio- as well as results of previously
sis, condyloma, and vaginal adenosis performed tests and procedures. For
• Assist in the diagnosis of genital and reproductive system table.
infections (herpes, Candida spp.,
Trichomonas vaginalis, cytomegalo- patient is taking, including herbs, nu-
virus, Chlamydia, lymphogranuloma tritional supplements, and nutraceu-
venereum, human papillomavirus, and ticals. The requesting health care
Actinomyces spp. practitioner and laboratory should be
• Assist in the diagnosis of primary and advised if the patient regularly uses
metastatic neoplasms
• Evaluate hormonal function when reviewing results.
➤ There are no food or fluid restrictions ThinPrep collection:

➤ The specimen is obtained using a
➤ If the patient is taking vaginal antibi- special broomlike device. The central
otic medication, testing should be bristles of the device are inserted
delayed for 1 month after the treat- deep enough into the endocervical
ment has been completed. canal to allow the bristles to contact
➤ Review the procedure with the the ectocervix. The device is rotated
patient. Sensitivity to cultural and five times in a clockwise direction,
social issues, as well as concern for and then removed and rinsed in a
modesty, is important in providing special solution vial. The device is
psychological support. pushed against the bottom of the
➤ Instruct the patient to avoid douch- solution vial 10 times and then vigor-
ing or sexual intercourse for 24 ously swirled to detach the cells
hours before specimen collection. brushed from the patient’s tissue.
Verify that the patient is not men-
struating.
General:
➤ Instruct the patient to void before ➤ Label the specimen, and promptly
specimen collection. transport it to the laboratory.
➤ Inform the patient that specimen Post-test:
10 minutes. ➤ Cleanse or allow the patient to clean
secretions or excess lubricant (if a
Intratest: pelvic and/or rectal examination is
also performed) from the perineal
➤ Position the patient on the gyneco- area. Provide a sanitary pad if cervi-
logic examination table with the feet cal bleeding occurs.
in stirrups. Drape the patient’s legs
➤ Inform the patient, as appropriate,
to provide privacy and reduce chill-
that repeat testing may be re-
ing.
quested in the event of specimen re-
➤ Direct the patient to breathe jection or abnormal findings.
normally and to avoid unnecessary ➤ Recognize anxiety related to test
movement. results and offer support. Provide
➤ Observe standard precautions and teaching and information regarding
follow the general guidelines in the clinical implications of the test
Appendix A. results, as appropriate. Educate the
Conventional collection: ing services.
➤ The speculum may be dipped in ➤ Inform the patient that women aged
warm water to aid in comfortable 20 to 40 should have a Pap smear at
insertion. After the speculum is least every 3 years; women older
properly positioned, the specimen is than 40 should have a Pap smear
obtained (using a wooden spatula, annually. Women at risk (e.g., with a
cotton-tipped applicator, or synthetic positive family history of cervical
fiber brush) and smeared onto cancer) may need to have more
slides. The speculum is removed, frequent Pap smears.
and the slides are immediately fixed ➤ Evaluate test results in relation to
with a liquid or spray containing 95% the patient’s symptoms and other
ethanol. A pelvic and/or rectal exam- tests performed. Related laboratory
ination may be performed, if neces- tests include Chlamydia, related
sary, after specimen collection. cultures, and cervical biopsy.
Parathyroid Hormone: Intact, C-Terminal, and N-Terminal 759
PARATHYROID HORMONE: INTACT,

C-TERMINAL, AND N-TERMINAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Parathormone, PTH.

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube is recom-
mended for C-terminal and N-terminal. Plasma (1 mL) collected in laven-
der-top (EDTA) tube is recommended for intact PTH. Specimen should be
transported tightly capped and in an ice slurry.
SI Units
C-terminal
1–16 y 51–217 pg/mL 51–217 ng/L
Adults 50–330 pg/mL 50–330 ng/L
N-terminal
2–13 y 14–21 pg/mL 14–21 ng/L
Intact
Cord blood Less than 3 pg/mL Less than 3 ng/L
2–20 y 9–52 pg/mL 9–52 ng/L
DESCRIPTION: Parathyroid hormone metabolites, causing increased

(PTH) is secreted by the parathyroid calcium absorption in the small intes-
glands in response to decreased levels tine. The net result of PTH action is
of circulating calcium. PTH assists in maintenance of adequate serum
the mobilization of calcium from calcium levels. In normal individuals,
bone into the bloodstream, promot- intact PTH has a circulating half-life
ing renal tubular reabsorption of of about 5 minutes. N-terminal PTH
calcium and depression of phosphate has a circulating half-life of about 2
reabsorption, thereby reducing minutes and is found in very small
calcium excretion and increasing quantities. Intact and N-terminal
phosphate excretion by the kidneys. PTH are the only biologically active
PTH also decreases the renal secre- forms of the hormone. Ninety
tion of hydrogen ions, which leads to percent of circulating PTH is
increased renal excretion of bicarbon- composed of inactive C-terminal and
ate and chloride. PTH enhances renal midregion fragments. PTH is cleared
production of active vitamin D from the body by the kidneys. ■
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:
• Fluorosis
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Primary, secondary, or tertiary hyper-

parathyroidism Pretest:
• Pseudogout ➤ Obtain a history of the patient’s
• Pseudohypoparathyroidism allergens.
• Spinal cord trauma ➤ Obtain a history of the patient’s
• Zollinger-Ellison syndrome previously performed tests and
Decreased in: to the endocrine system table.
• Autoimmune destruction of the ➤ Obtain a list of the medications
parathyroids the patient is taking, including
• DiGeorge syndrome nutraceuticals. The requesting health
• Hyperthyroidism should be advised if the patient
• Hypomagnesemia regularly uses these products so
• Nonparathyroid hypercalcemia (in the consideration when reviewing
absence of renal failure) results.
Parathyroid Scan 761
➤ 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
➤ 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.
patient. Post-test:
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.”)
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Parathyroid scintiscan.

AREA OF APPLICATION: Parathyroid.
CONTRAST: Intravenous technetium-99m (Tc-99m) pertechnetate, Tc-99m
sestamibi, oral iodine-123, and thallium.
DESCRIPTION: Parathyroid scanning adenomas in clinically proven

is performed to assist in the preoper- primary hyperparathyroidism; it is
ative localization of parathyroid useful for distinguishing between
intrinsic and extrinsic parathyroid Factors that may impair clear

adenomas. It is also performed after imaging:
surgery to verify the presence of the • Inability of the patient to cooperate or
parathyroid gland in children, and it remain still during the procedure
is done after thyroidectomy as well. because of age, significant pain, or
mental status
The radionuclide is administered
10 to 20 minutes before the imaging • Ingestion of foods containing iodine
is performed. The thyroid and (e.g., iodized salt) and medications
surrounding tissues should be care- containing iodine (e.g., cough syrup,
potassium iodide, vitamins, Lugol’s
fully palpated.
solution, thyroid replacement medica-
Fine-needle aspiration biopsy tions), which can decrease uptake of
guided by ultrasound is occasionally the radionuclide
necessary to differentiate thyroid
• Recent use of iodinated contrast
pathology, as well as pathology of
medium for radiographic studies or
other tissues, from parathyroid recently performed nuclear medicine
neoplasia. ■ procedures, which can affect the
uptake of the radionuclide
INDICATIONS:
• Aid in the diagnosis of hyperparathy- • Patients who are very obese, who may
roidism exceed the weight limit for the equip-
ment
• Differentiate between extrinsic and
intrinsic parathyroid adenoma, but not • Incorrect positioning of the patient,
between benign and malignant condi- which may produce poor visualization
tions of the area to be examined
• Evaluate the parathyroid in patients tion field (e.g., jewelry or body rings),
with severe hypercalcemia or in which may inhibit organ visualization
patients before parathyroidectomy and can produce unclear images
RESULT Other considerations:
Normal Findings:
that allows the tracer to seep deep into
• No areas of increased perfusion or the muscle tissue produces erroneous
uptake in the thyroid or parathyroid hot spots.
Abnormal Findings: • Consultation with a physician should
• Intrinsic and extrinsic parathyroid occur before the procedure for radia-
adenomas tion safety concerns regarding infants
CRITICAL VALUES: N/A • Risks associated with radiographic
INTERFERING FACTORS: x-ray procedures. Personnel in the
room with the patient should stand
This procedure is contraindicated behind a shield or leave the area while
for: the examination is being done.
• Patients who are pregnant or suspected Personnel working in the area where
of being pregnant, unless the potential the examination is being done should
benefits of the procedure far outweigh wear badges that reveal their level of
the risks to the fetus and mother exposure to radiation.
Parathyroid Scan 763
other metallic objects have been

Nursing Implications and removed from the neck area.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Administer technetium-99m (Tc-
99m) pertechnetate intravenously
Pretest: before scanning.
➤ Inform the patient that the proce- ➤ To scan the parathyroid gland, the
dure assesses the parathyroid patient is placed in a supine position
glands. under a radionuclide gamma camera
➤ Inform the patient that the proce- 15 minutes after the radionuclide
dure is performed in a special injection. Imaging is performed over
nuclear medicine department by a the anterior neck area.
technologist and takes 30 to 60 ➤ Ask the patient to lie still during the
minutes. procedure because movement
➤ Obtain a history of the patient’s produces unclear images.
complaints, including a list of known ➤ The images are recorded on film or
allergens. stored electronically for recall and
➤ Obtain a history of the patient’s future analysis and interpretation by
parathyroid and thyroid, as well as a physician.
results of previously performed labo- ➤ With the patient in the same posi-
ratory tests, surgical procedures, tion, Tc-99m sestamibi is injected,
other radiology procedures, and and after 10 minutes a second image
parathyroid therapy. For related is obtained and stored in the
tests, refer to the endocrine system computer. The computer subtracts
table. the technetium-visualized thyroid
➤ Obtain a list of the medications the structures from the thallium accu-
patient is taking. mulation in a parathyroid adenoma.
➤ Determine whether the patient has ➤ Iodine-123 may be administered
had any recent intake of iodine. orally in place of Tc-99m pertechne-
tate; the imaging sequence, as
➤ Make sure all blood tests are
described above, is performed 24
obtained before the test is
hours later.
performed.
➤ Determine date of last menstrual ➤ Wear gloves during the radionuclide
period and possibility of pregnancy injection and while handling the
in perimenopausal women. patient’s urine.
➤ Do not restrict food or fluids unless Post-test:
otherwise indicated.
➤ All radiographic procedures done ➤ Assess injection site for redness or
with iodinated contrast medium swelling. Apply warm soaks to
should be done after this procedure promote comfort if a hematoma
is completed. develops.
➤ Ensure that the patient has not been ➤ Advise patient to drink increased
scheduled for more than one amounts of fluids for 24 to 48 hours
radionuclide scan on the same day. to eliminate the radionuclide from
Multiple procedures on the same the body, unless contraindicated. Tell
day may interfere with interpretation the patient that radionuclide is elimi-
of results. nated from the body within 6 to 24
hours.
Intratest: ➤ Instruct the patient to flush the toilet
➤ Ask the patient to void before the following the procedure and to wash
procedure. Have the patient put on a hands meticulously with soap and
hospital gown. water after each voiding for 24 hours
➤ Make sure jewelry, chains, and any after the procedure.
➤ 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.
REFERENCE VALUE: (Method: Clot detection) 25 to 39 seconds, usually

compared 10 seconds to a normal control. Reference ranges vary with
respect to the equipment and reagents used to perform the assay.
DESCRIPTION: The activated partial 30 to 40 percent deficiency in one of

thromboplastin time (APTT) coagu- the factors required, or when factor
lation test evaluates the function of inhibitors (e.g., antithrombin III,
the intrinsic (factors XII, XI, IX, and protein C, or protein S) are present.
VIII) and common (factors V, X, II, The APTT has additional activators,
and I) pathways of the coagulation such as kaolin, Celite, or elegiac acid,
sequence, specifically the intrinsic that more rapidly activate factor XII,
thromboplastin system. It represents making this test faster and more reli-
the time required for a firm fibrin clot ably reproducible than the partial
to form after tissue thromboplastin or thromboplastin time (PTT). A
phospholipid reagents similar to comparison between the results of
thromboplastin and calcium are APTT and prothrombin time (PT)
added to the specimen. The APTT is tests can allow some inferences to be
abnormal in 90 percent of patients made that a factor deficiency exists. A
with coagulation disorders and is normal APTT with a prolonged PT
useful in monitoring the inactivation can only occur with factor VII defi-
of factor II effect of heparin therapy. ciency. A prolonged APTT with a
The test is prolonged when there is a normal PT could indicate a defi-
Partial Thromboplastin Time, Activated 765
ciency in factors XII, XI, IX, VIII, • Disseminated intravascular coagula-

and VIII:C (von Willebrand factor). tion
Factor deficiencies can also be identi- • Factor deficiencies
fied by correction or substitution
studies using normal serum. These • Hemodialysis patients
studies are easy to perform and are • Polycythemia
accomplished by adding plasma from • Severe liver disease
a normal patient to a sample from
a patient suspected to be factor- • Vitamin K deficiency
deficient. When the APTT is • Von Willebrand’s disease
repeated and is corrected, or within
the reference range, it can be assumed CRITICAL VALUES: Greater than 70
that the prolonged APTT is caused by seconds. Important signs to note are
a factor deficiency. The administra- prolonged bleeding, hematoma at the
tion of prophylactic low-dose heparin puncture site, hemorrhage, blood in
stool, bleeding gums, and shock.
does not require serial monitoring of
Monitoring vital signs and neurologic
APTT. (For more information on changes until values are within normal
factor deficiencies, see monograph range is indicated. Administration of
titled “Fibrinogen.”) ■ protamine sulfate may be requested.
The requesting health care practitioner
INDICATIONS: should also be notified if the APTT is less
• Detect congenital deficiencies in clot- than 53 seconds in a patient receiving
ting factors, as seen in diseases such as heparin therapy. Low values indicate that
hemophilia A (factor VIII) and hemo- the therapy is providing inadequate anti-
philia B (factor IX) coagulation.
• Evaluate response to anticoagulant
therapy with heparin or coumarin INTERFERING FACTORS:
derivatives • Drugs and vitamins such as anistre-
plase, antihistamines, chlorpromazine,
• Identify individuals who may be prone salicylates, and ascorbic acid may cause
to bleeding during surgical, obstetric, prolonged APTT.
dental, or invasive diagnostic proce-
dures • Anticoagulant therapy with heparin
will prolong the APTT.
• Identify the possible cause of abnormal
bleeding, such as epistaxis, hematoma, • Copper is a component of factor V,
gingival bleeding, hematuria, and and severe copper deficiencies may
menorrhagia result in prolonged APTT values.
• Monitor the hemostatic effects of • Traumatic venipunctures can activate
conditions such as liver disease, protein the coagulation sequence by contami-
deficiency, and fat malabsorption nation of the sample with tissue
thromboplastin and can produce
RESULT falsely shortened results.
• Failure to fill the tube sufficiently to
Prolonged in: yield a proper blood-to-anticoagulant
• Afibrinogenemia ratio invalidates the results and is
reason for specimen rejection.
• Circulating products of fibrin and
fibrinogen degradation • Excessive agitation that causes sample
hemolysis can falsely shorten the receiving anticoagulant therapy, note

APTT because the hemolyzed cells the time and amount of the last
activate plasma-clotting factors. dose.
• Inadequate mixing of the tube can tion restrictions unless by medical
produce erroneous results. direction.
• Specimens left unprocessed for longer ➤ Review the procedure with the
than 4 hours should be rejected for patient.
analysis. ➤ Inform the patient that specimen
• High platelet count or inadequate collection takes approximately 5 to
centrifugation will result in decreased 10 minutes.
values. Intratest:
• Hematocrit greater than 55 percent
may cause falsely prolonged results normally and to avoid unnecessary
because of anticoagulant excess. The movement.
excess anticoagulant chelates the
calcium reagent in the test system, follow the general guidelines in
making it unavailable to react properly Appendix A. Perform a venipuncture,
with the patient sample. and collect the specimen in a
5-mL blue-top tube. Fill the tube
Nursing Implications and different concentrations of sodium
Procedure ● ● ● ● ● ● ● ● ● ● ●
added to blue-top tubes for coagula-
Pretest:
➤ Obtain a history of the patient’s Laboratory Standards (NCCLS)
complaints, including a list of known guideline for sodium citrate is 3.2%.
allergens. Laboratories establish reference
➤ Obtain a history of the patient’s ranges for coagulation testing based
hematopoietic and hepatobiliary on numerous factors, including
systems, history of any bleeding sodium citrate concentration, test
disorders, and results of previously equipment, and test reagents. It is
performed tests and procedures, important to inquire from the labora-
especially bleeding time, clotting tory which concentration it recom-
time, complete blood count, PTT, mends, because each concentration
platelets, and prothrombin time. For will have its own specific reference
related tests, refer to the hematopoi- range.
etic and hepatobiliary system tables. ➤ When multiple specimens are
➤ Obtain a list of the medications the drawn, the blue-top tube should be
patient is taking, including anticoag- collected after sterile (i.e., blood
ulant therapy, acetylsalicylic acid, culture) and red-top tubes. When
herbs, and nutraceuticals known to coagulation testing is the only work
affect coagulation. It is recom- to be done, an extra red-top tube
mended that use of these products should be collected before the blue-
be discontinued 14 days before top tube to avoid contaminating the
dental or surgical procedures. The specimen with tissue thromboplas-
requesting health care practitioner tin.
and laboratory should be advised if ➤ Label the specimen, and promptly
the patient regularly uses these transport it to the laboratory. The
products so that their effects can be NCCLS recommendation for
taken into consideration when processed and unprocessed speci-
reviewing results. If the patient is mens stored in unopened tubes is
Parvovirus B19 IgG and IgM Antibodies 767
that testing should be completed soft bristle toothbrush, use of an

within 1 to 4 hours of collection. electric razor, avoidance of constipa-
tion, avoidance of acetylsalicylic acid
Post-test: and similar products, and avoidance
of intramuscular injections.
➤ Inform the patient of the importance
of periodic laboratory testing while
pressure bandage.
taking an anticoagulant.
➤ Instruct the patient to report severe ➤ Evaluate test results in relation to
bruising or bleeding from any areas the patient’s symptoms and other
of the skin or mucous membranes. tests performed. Related laboratory
➤ Inform the patient with prolonged tests include antithrombin III,
APTT values of the importance of specific factor assays, fibrin break-
taking precautions against bruising down products, platelet count,
and bleeding, including the use of a protein C, and protein S.
PARVOVIRUS B19 IMMUNOGLOBULIN G

AND IMMUNOGLOBULIN M
ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Negative Less than 0.8 or aplastic crisis in patients with

Equivocal 0.8–1.2 sickle cell anemia, spherocytosis, or
thalassemia. Fetal hydrops and spon-
taneous abortion may also occur as a
DESCRIPTION: Parvovirus B19, a result of infection during pregnancy.
single-stranded DNA virus transmit- The incubation period is approxi-
ted by respiratory secretions, is the mately 1 week after exposure. B19-
only parvovirus known to infect specific antibodies appear in the
humans. Its primary site of replica- serum approximately 3 days after the
tion is in red blood cell precursors in onset of symptoms. The presence of
the bone marrow. It is capable of immunoglobulin M (IgM) antibodies
causing disease along a wide spectrum indicates acute infection. The pres-
ranging from a self-limited erythema ence of IgG antibodies indicates past
(fifth disease) to bone marrow failure infection and is believed to confer
lifelong immunity. Parvovirus can care practitioner and laboratory

also be detected by DNA hybridiza- should be advised if the patient
tion using a polymerase chain reac- that their effects can be taken into
tion. ■ consideration when reviewing
results.
INDICATIONS: Assist in establishing a ➤ There are no food, fluid, or medica-
diagnosis of parvovirus B19 infection tion restrictions unless by medical
direction.
RESULT ➤ Review the procedure with the
patient. Inform the patient that a
Positive findings in: subsequent sample will be required
• Arthritis in 7 to 14 days.
• Erythema infectiosum (fifth disease)
• Erythrocyte aplasia 10 minutes.
• Hydrops fetalis Intratest:

Negative findings in: N/A ➤ Direct the patient to breathe
movement.
INTERFERING FACTORS: Immunocom- Appendix A. Perform a venipuncture,
promised patients may not develop suffi- and collect the specimen in a 5-mL
cient antibody to be detected. red-top tube.

complaints, including a list of known ➤ Emphasize the need for the patient
allergens. to return to have a convalescent
➤ Obtain a history of the patient’s blood sample taken in 7 to 14 days.
immune system and results of previ- ➤ Evaluate test results in relation
ously performed tests and proce- to the patient’s symptoms and
dures. For related tests, refer to the other tests performed. Related
immune system table. laboratory tests include complete
➤ Obtain a list of the medications blood count, bone marrow biopsy,
the patient is taking, including hemoglobin electrophoresis, red
herbs, nutritional supplements, and blood cell morphology, and sickle
nutraceuticals. The requesting health cell screen.
Pericardial Fluid Analysis 769
PERICARDIAL FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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.
REFERENCE VALUE: (Method: Spectrophotometry for glucose, automated or

manual cell count, macroscopic examination of cultured organisms, and
microscopic examination of specimen for microbiology and cytology; micro-
scopic examination of cultured microorganisms)
Pericardial Fluid Reference Value

Appearance Clear
Color Pale yellow
Glucose Parallel serum values
Red blood cell count None seen
White blood cell count Less than 1000/mm3
Culture No growth
Gram stain No organisms seen
DESCRIPTION: The heart is located distinguish a transudate from an

within a protective membrane called exudate. Transudates are effusions
the pericardium. The fluid between that form as a result of a systemic
the pericardial membranes is called disorder that disrupts the regulation
serous fluid. Normally only a small of fluid balance, such as a suspected
amount of fluid is present because perforation. Exudates are caused
the rates of fluid production and by conditions involving the tissue
absorption are about the same. of the membrane itself, such as
Many abnormal conditions can an infection or malignancy. Fluid
result in the buildup of fluid within is withdrawn from the pericardium
the pericardium. Specific tests are by needle aspiration and tested
usually ordered in addition to a as listed in the previous and following
common battery of tests used to tables. ■
Characteristic Transudate Exudate

Appearance Clear Cloudy or turbid
Specific gravity Less than 1.015 Greater than 1.015
Total protein Less than 2.5 g/dL Greater than 3.0 g/dL
Fluid-to-serum Less than 0.5 Greater than 0.5
protein ratio
LDH Parallels serum value Less than 200 U/L
LDH ratio
Fluid cholesterol Less than 55 mg/dL Greater than 55 mg/dL
White blood cell Less than 100/mm3 Greater than 1000/mm3
count
LDH lactate dehydrogenase.
INDICATIONS: Decreased in (condition/test

• Evaluate effusion of unknown etiology showing decreased result):
• Bacterial pericarditis (glucose)
• Investigate suspected hemorrhage,
immune disease, malignancy, or infec- • Malignancy (glucose)
tion • Rheumatoid disease or systemic lupus
erythematosus (glucose)
RESULT
Increased in (condition/test show-
ing increased result): INTERFERING FACTORS:
• Bloody fluid may be the result of a
• Bacterial pericarditis (red blood cell
traumatic tap.
[RBC] count, white blood cell [WBC]
count with a predominance of • Unknown hyperglycemia or hypo-
neutrophils) glycemia may be misleading in the
comparison of fluid and serum glucose
• Hemorrhagic pericarditis (RBC count,
levels. Therefore, it is advisable to
WBC count)
collect comparative serum samples a
• Malignancy (RBC count, abnormal few hours before performing pericar-
cytology) diocentesis.
• Postmyocardial infarction syndrome,
also called Dressler’s syndrome (RBC
count, WBC count with a predomi- Nursing Implications and
nance of neutrophils) Procedure ● ● ● ● ● ● ● ● ● ● ●
• Rheumatoid disease or systemic lupus Pretest:

erythematosus (RBC count, WBC
count)
• Tuberculous or fungal pericarditis allergens.
(RBC count, WBC count with a ➤ Obtain a history of the patient’s car-
predominance of lymphocytes) diovascular and immune systems,
• Viral pericarditis (RBC count, WBC formed tests and procedures. For re-
count with a predominance of lated tests refer to the cardiovascu-
neutrophils) lar and immune system tables.
Pericardial Fluid Analysis 771
➤ 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.
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:
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-
piratory and cardiac distress, such as
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
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.
PERITONEAL FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Ascites fluid analysis.

SPECIMEN: Peritoneal fluid (5 mL) collected in a red- or green-top
(heparin) tube for amylase, glucose, and alkaline phosphatase; lavender-top
(ethylenediaminetetra-acetic acid [EDTA]) tube for cell count; sterile
containers for microbiology specimens; 200 to 500 mL of fluid in a clear
container with anticoagulant for cytology.
REFERENCE VALUE: (Method: Spectrophotometry for glucose, amylase, and

alkaline phosphatase; automated or manual cell count, macroscopic exami-
nation of cultured organisms, and microscopic examination of specimen for
microbiology and cytology; microscopic examination of cultured microor-
ganisms)
Peritoneal Fluid Reference Value

Appearance Clear
Color Pale yellow
Amylase Parallel serum values
Alkaline phosphatase Parallel serum values
Red blood cell count Less than 100,000/mm3

Peritoneal Fluid Analysis 773
Peritoneal Fluid Reference Value

White blood cell count Less than 300/mm3
Culture No growth
Acid-fast stain No organisms seen
DESCRIPTION: The peritoneal cavity distinguish a transudate from an

and organs within it are lined with a exudate. Transudates are effusions
protective membrane. The fluid that form as a result of a systemic
between the membranes is called disorder that disrupts the regulation
serous fluid. Normally only a small of fluid balance, such as a suspected
amount of fluid is present because perforation. Exudates are caused
the rates of fluid production and by conditions involving the tissue
absorption are about the same. of the membrane itself, such as an
Many abnormal conditions can result infection or malignancy. Fluid is
in the buildup of fluid within the withdrawn from the peritoneal cavity
peritoneal cavity. Specific tests are by needle aspiration and tested as
usually ordered in addition to a listed in the previous and following
common battery of tests used to tables. ■

protein ratio
LDH ratio
White blood cell Less than 100/mm3 Greater than 1000/mm3
count
LDH lactate dehydrogenase.
INDICATIONS: [RBC] count, carcinoembryonic anti-

• Evaluate ascites of unknown cause gen, abnormal cytology)
• Investigate suspected peritoneal • Abdominal trauma (RBC count
rupture, perforation, malignancy, or greater than 100,000/mm3)
infection
• Ascites caused by cirrhosis (white
RESULT blood cell [WBC] count, neutrophils
greater than 25 percent but less than
Increased in (condition/test show-
50 percent, absolute granulocyte count
ing increased result): greater than 250/mm3)
• Abdominal malignancy (red blood cell • Bacterial peritonitis (WBC count,
neutrophils greater than 50 percent, ➤ Obtain a list of the medications the

absolute granulocyte count greater patient is taking, including herbs, nu-
than 250/mm3) tritional supplements, and nutraceu-
• Peritoneal effusion due to gastric stran- practitioner and laboratory should be
gulation, perforation, or necrosis advised if the patient regularly uses
(amylase, ammonia, alkaline phos- these products so that their effects
phatase) can be taken into consideration
• Peritoneal effusion due to pancreatitis,
pancreatic trauma, or pancreatic ➤ There are no food or fluid restrictions
pseudocyst (amylase)
➤ The requesting health care practi-
• Rupture or perforation of urinary blad- tioner may request that anticoagu-
der (ammonia, creatinine, urea) lants and aspirin be withheld.
• Tuberculous effusion (elevated ➤ If patient has ascites, obtain weight
lymphocyte count, positive acid-fast and measure abdominal girth.
bacillus smear and culture [25 to 50 ➤ Review the procedure with the
percent of cases]) patient. Explain the importance of
remaining still during the procedure.
Decreased in (condition/test ➤ Inform the patient that a local anes-
showing decreased result): thetic will be administered at the
• Abdominal malignancy (glucose) abdominal needle insertion site
immediately before the procedure to
• Tuberculous effusion (glucose)
reduce discomfort during aspiration.
Explain that the anesthetic injection
CRITICAL VALUES: N/A may cause a stinging sensation.
Explain that after the skin has been
INTERFERING FACTORS: anesthetized, a large needle will be
• Bloody fluids may result from a trau- inserted through the abdominal wall
matic tap. and a “popping” sensation may be
experienced as the needle pene-
• Unknown hyperglycemia or hypo- trates the peritoneum.
glycemia may be misleading in the
➤ Assess whether the patient has an
comparison of fluid and serum glucose
allergy to local anesthetics, and
levels. Therefore, it is advisable to inform the health care practitioner
collect comparative serum samples a accordingly.
few hours before performing paracen-
tesis. consent before administering any
➤ Have the patient void or catheterize
Nursing Implications and the patient to avoid accidental punc-
Procedure ● ● ● ● ● ● ● ● ● ● ●
ture of the bladder if he or she is
unable to void.
Pretest:
➤ Obtain a history of the patient’s collection takes approximately 30
complaints, including a list of known minutes.
allergens.
➤ Obtain a history of the patient’s gas- Intratest:
trointestinal and immune systems,
as well as results of previously per- ➤ Assist the patient to a seated posi-
formed tests and procedures. For re- tion with feet and back supported or
lated tests, refer to the gastrointesti- in high Fowler’s position.
nal and immune system tables. ➤ Direct the patient to breathe
Phosphorus, Serum 775
normally and to avoid unnecessary medication as directed by the

movement. requesting health care practitioner.
➤ Take and record baseline vital signs. ➤ Inform the patient that 1 hour or
➤ Observe standard precautions and more of bed rest is required after the
follow the general guidelines in procedure.
Appendix A. ➤ Take vital signs every 15 minutes for
➤ Cleanse the skin with an antiseptic the first hour, every 30 minutes for
solution, and protect the area with a the next 2 hours, every hour for the
sterile drape. The skin at the injec- next 4 hours and every 4 hours for
tion site is anesthetized. the next 24 hours. Take the patient’s
temperature every 4 hours for 24
➤ The paracentesis needle is inserted hours. Monitor intake and output for
1 to 2 inches below the umbilicus, 24 hours.
and fluid is removed. If lavage fluid is
required (helpful if malignancy is ➤ Assess the puncture site for bleed-
suspected), saline or Ringer’s lactate ing or drainage and signs of inflam-
can be infused via the needle over a mation each time vital signs are
15- to 20-minute period before the taken and daily thereafter for several
lavage fluid is removed. Monitor vital days.
signs every 15 minutes for signs of ➤ If a large amount of fluid was
hypovolemia or shock. removed, obtain weight and meas-
➤ No more than 1500 to 2000 mL ure abdominal girth.
should be removed at a time, even in ➤ Instruct the patient to immediately
the case of a therapeutic paracente- report severe abdominal pain (note:
sis, because of the risk of hypov- rigidity of abdominal muscles indi-
olemia and shock. cates developing peritonitis).
➤ The needle is withdrawn and slight ➤ Administer antibiotics, as ordered,
pressure applied to the site. If there and instruct the patient in the impor-
is no evidence of bleeding or tance of completing the entire
drainage, a sterile dressing is applied course of antibiotic therapy even if
to the site. no symptoms are present.
➤ Fill the appropriate collection con- ➤ Evaluate test results in relation to
tainers with fluid for analysis. the patient’s symptoms and other
➤ Label the specimens, and promptly tests performed. Related laboratory
transport them to the laboratory. tests include bacterial culture, CA
15-3, CA 19-9, CA 125, carcinoem-
Post-test: bryonic antigen, fungal culture,
mycobacterial culture, and viral
➤ Instruct the patient to resume usual culture.
PHOSPHORUS, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Inorganic phosphorus, phosphate, PO4.

SI Units
0–5 d 4.6–8.0 mg/dL 1.5–2.6 mmol/L
1–3 y 3.9–6.5 mg/dL 1.3–2.1 mmol/L
4–6 y 4.0–5.4 mg/dL 1.3–1.7 mmol/L
7–11 y 3.7–5.6 mg/dL 1.2–1.8 mmol/L
12–13 y 3.3–5.4 mg/dL 1.1–1.7 mmol/L
14–15 y 2.9–5.4 mg/dL 0.9–1.7 mmol/L
16–19 y 2.8–4.6 mg/dL 0.9–1.5 mmol/L
Adult 2.5–4.5 mg/dL 0.8–1.4 mmol/L
DESCRIPTION: Phosphorus, in the INDICATIONS:

form of phosphate, is distributed • Assist in establishing a diagnosis of
throughout the body. Approximately hyperparathyroidism
85 percent of the body’s phosphorus • Assist in the evaluation of renal failure
is stored in bones; the remainder is
found in cells and body fluids. It is RESULT
the major intracellular anion and
plays a crucial role in cellular metabo- Increased in:
lism, maintenance of cellular • Acromegaly
membranes, and formation of bones
• Bone metastases
and teeth. Phosphorus also indirectly
affects the release of oxygen from • Diabetic ketoacidosis
hemoglobin by affecting the forma- • Excessive levels of vitamin D
tion of 2,3-bisphosphoglycerate.
• Hyperthermia
Levels of phosphorus are dependent
on dietary intake. • Hypocalcemia
Phosphorus excretion is regulated • Hypoparathyroidism
by the kidneys. Calcium and phos-
phorus are interrelated with respect to • Lactic acidosis
absorption and metabolic function. • Milk alkali syndrome
They have an inverse relationship • Pulmonary embolism
with respect to concentration: serum
phosphorus is increased when serum • Pseudohypoparathyroidism
calcium is decreased. Hyperphos- • Renal failure
phatemia can result in an infant fed
• Respiratory acidosis
only cow’s milk during the first few
weeks of life because of the combina- Decreased in:
tion of a high phosphorus content • Acute gout
in cow’s milk and the inability of
infants’ kidneys to clear the excess • Alcohol withdrawal
phosphorus. ■ • Gram-negative bacterial septicemia
Phosphorus, Serum 777
• Growth hormone deficiency roid extract, phosphates, sodium

etidronate, tetracycline (occurs with
• Hyperalimentation therapy
nephrotoxicity), and vitamin D.
• Hypercalcemia • Drugs that may decrease phosphorus
levels include acetazolamide, albuterol,
• Hyperinsulinism
aluminum salts, amino acids (via IV
• Hyperparathyroidism hyperalimentation), anesthetic agents,
anticonvulsants, calcitonin, epineph-
• Hypokalemia
rine, fibrin hydrolysate, fructose, glu-
• Impaired renal absorption cocorticoids, glucose, insulin, manni-
tol, oral contraceptives, pamidronate,
• Malabsorption syndromes
phenothiazine, phytate, and pli-
• Malnutrition camycin.
• Serum phosphorus levels are subject
• Osteomalacia
to diurnal variation: They are highest
• Parathyroid hormone–producing in late morning and lowest in the
tumors evening; therefore serial samples
should be collected at the same time of
• Primary hyperparathyroidism
day for consistency in interpretation.
• Renal tubular acidosis • Hemolysis will falsely increase phos-
phorus values.
• Renal tubular defects
• Respiratory alkalosis above an IV because of the potential
for dilution when the specimen and
• Respiratory infections
the IV solution combine in the collec-
• Rickets tion container, thereby falsely decreas-
ing the result. There is also the poten-
• Salicylate poisoning
tial of contaminating the sample with
• Severe burns the substance of interest, contained in
the IV solution, thereby falsely increas-
• Severe vomiting and diarrhea
ing the result.
• Vitamin D deficiency
CRITICAL VALUES: Values less Nursing Implications and

than 1.0 mg/dL may have significant Procedure ● ● ● ● ● ● ● ● ● ● ●
effects on the neuromuscular, gastroin-

testinal, cardiopulmonary, and skeletal Pretest:
systems. Interventions including intra-
venous (IV) replacement therapy with ➤ Obtain a history of the patient’s
sodium or potassium phosphate may be complaints, including a list of known
allergens.
necessary. Close monitoring of both
phosphorus and calcium is important ➤ Obtain a history of the patient’s en-
during replacement therapy. docrine, gastrointestinal, genitouri-
nary, and musculoskeletal systems,
INTERFERING FACTORS: formed tests and procedures. For re-
• Drugs that may increase phosphorus lated tests, refer to the endocrine,
levels include anabolic steroids, - gastrointestinal, genitourinary, and
adrenergic blockers, ergocalciferol, musculoskeletal system tables.
furosemide, hydrochlorothiazide, ➤ Obtain a list of the medications the
methicillin (occurs with nephro- patient is taking, including herbs, nu-
toxicity), oral contraceptives, parathy- tritional supplements, and nutraceu-
ticals. The requesting health care Post-test:

advised if the patient regularly uses ➤ Observe venipuncture site for bleed-
these products so that their effects ing or hematoma formation. Apply
can be taken into consideration pressure bandage.
when reviewing results. ➤ Severe hypophosphatemia is
➤ There are no food, fluid, or medica- common in elderly patients or
tion restrictions unless by medical patients who have been hospitalized
direction. for long periods of time. Good
dietary sources of phosphorus
➤ Review the procedure with the include meat, dairy products, nuts,
patient. and legumes.
➤ Inform the patient that specimen ➤ To decrease phosphorus levels to
collection takes approximately 5 to normal in the patient with hyper-
10 minutes. phosphatemia, dietary restriction
may be recommended. Other inter-
Intratest: ventions may include the administra-
tion of phosphate binders or
➤ Direct the patient to breathe administration of calcitriol (the acti-
normally and to avoid unnecessary vated form of vitamin D).
movement.
Appendix A. Perform a venipuncture, tests include calcitonin, calcium,
and collect the specimen in a 5-mL collagen crosslinked N-telopeptides,
red- or tiger-top tube. growth hormone, kidney stone
➤ Label the specimen, and promptly analysis, osteocalcin, parathyroid
transport it to the laboratory. hormones, and vitamin D.
PHOSPHORUS, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Urine phosphate.

collected in a clean, plastic collection container.
REFERENCE VALUE: (Method: Spectrophotometry) Reference values are

dependent on phosphorus and calcium intake. Phosphate excretion exhibits
diurnal variation and is significantly higher at night.

0.4–1.3 g/24 h 12.9–42.0 g/24 h
Phosphorus, Urine 779
DESCRIPTION: Phosphorus, in the • Vitamin D deficiency

form of phosphate, is distributed
throughout the body. Approximately Decreased in:
85 percent of the body’s phosphorus • Hypoparathyroidism
is stored in bones; the remainder is • Pseudohypoparathyroidism
found in cells and body fluids. It is
• Vitamin D intoxication
the major intracellular anion and
plays a crucial role in cellular meta- CRITICAL VALUES: N/A
bolism, maintenance of cellular
membranes, and formation of bones INTERFERING FACTORS:
and teeth. Phosphorus also indirectly • Drugs and vitamins that can cause an
affects the release of oxygen from increase in urine phosphorus levels
hemoglobin by affecting the forma- include acetazolamide, acetylsalicylic
tion of 2,3-bisphosphoglycerate. acid, alanine, bismuth salts, calcitonin,
corticosteroids, dihydrotachysterol,
Levels of phosphorus are dependent
glycine, hydrochlorothiazide, metola-
on dietary intake. zone, parathyroid extract, parathyroid
Analyzing urinary phosphorus hormone, phosphates, tryptophan,
levels can provide important clues to valine, and vitamin D.
the functioning of the kidneys and
• Drugs that can cause a decrease in
other major organs. Tests for phos- urine phosphorus levels include
phorus in urine usually involve timed aluminum-containing antacids.
urine collections over a 12- or 24-
• Urine phosphorus levels are subject to
hour period. Measurement of random
diurnal variation: Output is highest in
specimens may also be requested. the afternoon, which is why 24-hour
Children with thalassemia may have urine collections are recommended.
normal phosphorus absorption but
increased excretion, which may result
tion period must be included in the
in a phosphorus deficiency. ■ collection or else falsely decreased
values may be obtained. Compare
INDICATIONS: output records with volume collected
• Assist in the diagnosis of hyperparathy-
to verify that all voids were included in
roidism
the collection.
• Assist in the evaluation of calcium and
phosphorus balance
• Assist in the evaluation of nephrolithi-
asis Procedure ● ● ● ● ● ● ● ● ● ● ●
• Assist in the evaluation of renal tubular Pretest:

disease
RESULT allergens.
Increased in: ➤ Obtain a history of the patient’s en-
docrine and genitourinary systems,
• Abuse of diuretics as well as results of previously per-
• Primary hyperparathyroidism formed tests and procedures. For re-
lated tests, refer to the endocrine
• Renal tubular acidosis and genitourinary system tables.
➤ 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.
➤ 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.
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
Intratest: the test the next morning at the
same hour the collection was
➤ Observe standard precautions and begun.
Appendix A. ➤ At the conclusion of the test,
Random specimen (collect in the urinary output record for the
early morning): collection; if the specimen contains
Clean-catch specimen: discarded, invalidating the test.
➤ Instruct the male patient to (1) thor- ➤ Label the specimen, and promptly
Plasminogen 781
transport it to the laboratory. Include patient, if appropriate, on the impor-

on the label the amount of urine, tance of drinking a sufficient amount
test start and stop times, and inges- of water when kidney stones are
tion of any foods or medications that suspected.
can affect test results. ➤ Evaluate test results in relation to
tests include calcitonin, kidney stone
➤ Increased urine phosphorus levels analysis, parathyroid hormone, phos-
may be associated with the forma- phorus, serum and urine calcium,
tion of kidney stones. Educate the and urinalysis.
PLASMINOGEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Profibrinolysin, PMG.

REFERENCE VALUE: (Method: Chromogenic substrate) 80 to 120 percent of
normal for plasma.
DESCRIPTION: Plasminogen is a RESULT

plasma glycoprotein. It is the circulat-
ing, inactive precursor to plasmin. Increased in:
Damaged tissues release a substance • Pregnancy (late)
called plasminogen activator that initi- Decreased in:
ates the conversion of plasminogen to
• DIC
plasmin. Plasmin participates in fibri-
nolysis and is capable of degrading • Fibrinolytic therapy with tissue plas-
minogen activators such as streptoki-
fibrin, factor I (fibrinogen), factor V,
nase or urokinase
and factor VIII. (For more informa-
tion on fibrin degradation, see mono- • Postsurgical period
graph titled “Fibrinogen.”) ■ • Hereditary deficiency
• Liver disease
INDICATIONS: Evaluate the level of
circulating plasminogen in patients with • Neonatal hyaline membrane disease
thrombosis or disseminated intravascular
coagulation (DIC) CRITICAL VALUES: N/A
INTERFERING FACTORS: Drugs that may blue-top tube. Important note:

decrease plasminogen levels include Two different concentrations of
sodium citrate preservative are cur-
streptokinase and urokinase.
rently added to blue-top tubes for
coagulation studies: 3.2% and
3.8%. The National Committee for
Nursing Implications and Clinical Laboratory Standards (NC-
Procedure ● ● ● ● ● ● ● ● ● ● ●
CLS) guideline for sodium citrate is
3.2%. Laboratories establish refer-
Pretest: ence ranges for coagulation testing
based on numerous factors, includ-
➤ Obtain a history of the patient’s ing sodium citrate concentration,
complaints, including a list of known test equipment, and test reagents. It
allergens. is important to inquire from the labo-
➤ Obtain a history of the patient’s ratory which concentration it recom-
hematopoietic system and results of mends, because each concentration
previously performed tests and will have its own specific reference
procedures. For related tests, refer range.
to the hematopoietic system table. ➤ When multiple specimens are
➤ Obtain a list of the medications the drawn, the blue-top tube should be
patient is taking, including herbs, nu- collected after sterile (i.e., blood
tritional supplements, and nutraceu- culture) and red-top tubes. When
ticals. The requesting health care coagulation testing is the only work
practitioner and laboratory should be to be done, an extra red-top tube
advised if the patient regularly uses should be collected before the blue-
these products so that their effects top tube to avoid contaminating the
can be taken into consideration specimen with tissue thromboplas-
when reviewing results. tin, which can falsely decrease
values.
tion restrictions unless by medical ➤ Label the specimen, and promptly
direction. transport it to the laboratory. The
NCCLS recommendation for pro-
➤ Review the procedure with the cessed and unprocessed specimens
patient. stored in unopened tubes is that
➤ Inform the patient that specimen testing should be completed within
collection takes approximately 5 to 1 to 4 hours of collection.
10 minutes.
Post-test:
Intratest:
➤ Direct the patient to breathe ing or hematoma formation. Apply
normally and to avoid unnecessary pressure bandage.
Appendix A. Perform a venipuncture, tests include factor assays, fibrino-
and collect the specimen in a 5-mL gen, and fibrin degradation products.
Platelet Antibodies 783
PLATELET ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Antiplatelet antibody, platelet-bound IgG/IgM

direct and indirect.
SPECIMEN: Serum (1 mL) collected in a red-top tube for indirect IgG anti-
body. Whole blood (7 mL) collected in lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube for direct antibody.
REFERENCE VALUE: (Method: Solid-phase hemagglutination and flow

cytometry) Negative.
DESCRIPTION: Platelet antibodies INDICATIONS:

can be formed by autoimmune re- • Assist in the detection of platelet
sponse, or they can be acquired in alloimmune disorders
reaction to transfusion products. • Determine platelet type for refractory
Platelet autoantibodies are im- patients
munoglobulins of autoimmune ori-
gin (i.e., immunoglobulin G), and RESULT
they are present in various autoim-
mune disorders, including thrombo- Increased in:
cytopenias. Platelet alloantibodies de- • Acquired immunodeficiency
velop in patients who become syndrome (AIDS)
sensitized to platelet antigens of • Acute myeloid leukemia
transfused blood. As a result, destruc-
• Idiopathic thrombocytopenia purpura
tion of both donor and native
platelets occurs along with a short- • Immune complex diseases
ened survival time of platelets in the • Multiple blood transfusions
transfusion recipient. The platelet an-
tibody detection test is also used for
platelet typing, which allows compat- • Neonatal immune thrombocytopenia
ible platelets to be transfused to pa- • Paroxysmal hemoglobinuria
tients with disorders such as aplastic
anemia and cancer. Platelet typing • Rheumatoid arthritis
decreases the alloimmunization risk • Systemic lupus erythematosus
resulting from repeated transfusions • Thrombocytopenias provoked by
from random donors. Platelet typing drugs (see monograph titled “Platelet
may also provide additional support Count”)
for a diagnosis of post-transfusional
purpura. ■ Decreased in: N/A

10 minutes.
INTERFERING FACTORS: Hemolyzed or
clotted specimens will affect results.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
movement.
complaints, including a list of known red-top and a 7-mL lavender-top
allergens. tube.
hematopoietic and immune sys- transport it to the laboratory.
tems, a history of any bleeding
disorders, and results of previously
performed tests and procedures, Post-test:
especially bleeding time, complete ➤ Observe venipuncture site for bleed-
blood count, clotting time, partial ing or hematoma formation. Apply
thromboplastin time, prothrombin pressure bandage.
time, and platelets. For related tests,
refer to the hematopoietic and ➤ Note the patient’s response to
immune system tables. platelet transfusions.
➤ Obtain a list of the medications the ➤ Instruct the patient to report severe
patient is taking to include anticoag- bruising or bleeding from any areas
ulant therapy, acetylsalicylic acid, of the skin or mucous membranes.
herbals, and nutraceuticals known to ➤ Inform the patient who has devel-
affect coagulation. It is recom- oped platelet antibodies of the
mended that use be discontinued 14 importance of taking precautions
days before dental or surgical proce- against bruising and bleeding,
dures. The requesting health care including the use of a soft bristle
practitioner and laboratory should be toothbrush, use of an electric razor,
advised if the patient regularly uses avoidance of constipation, avoidance
these products so that their effects of acetylsalicylic acid and similar
can be taken into consideration products, and avoidance of intra-
when reviewing results. muscular injections.
➤ There are no food, fluid, or medica- ➤ Evaluate test results in relation to
tion restrictions unless by medical the patient’s symptoms and other
direction. tests performed. Related laboratory
➤ Review the procedure with the tests include clot retraction and
patient. platelet count.
PLATELET COUNT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Thrombocytes.
Platelet Count 785

REFERENCE VALUE: (Method: Automated, computerized multichannel

analyzers that sort and size cells on the basis of either changes in electrical
impedance or light pulses as the cells pass in front of a laser)
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.
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-
pathic thrombocytopenic purpura. • Rheumatic fever (acute)

MPV is also increased in May- • Rheumatoid arthritis
Hegglin anomaly, Bernard-Soulier
syndrome, myeloproliferative dis- • Splenectomy (2 months postproce-
orders, hyperthyroidism, and dure)
preeclampsia. MPV is decreased • Surgery (2 weeks postprocedure)
in Wiskott-Aldrich syndrome, • Trauma
septic thrombocytopenia, and
hypersplenism. ■ • Tuberculosis
• Ulcerative colitis
INDICATIONS:
• Confirm a low platelet count (throm- Decreased in (as a result
bocytopenia), which can be associated of megakaryocytic
with bleeding hypoproliferation):
• Confirm an elevated platelet count • Alcohol toxicity
(thrombocytosis), which can cause • Aplastic anemia
increased clotting
• Congenital states (Fanconi’s, May-
• Identify the possible cause of abnormal Hegglin, Bernard-Soulier, Wiskott-
bleeding, such as epistaxis, hematoma, Aldrich, Gaucher’s, Chédiak-Higashi
gingival bleeding, hematuria, and syndromes)
menorrhagia
• Drug toxicity
• Provide screening as part of a complete
blood count in a general physical • Prolonged hypoxia
examination, especially upon admis-
sion to a health care facility or before Decreased in (as a result of
ineffective thrombopoiesis):
surgery
• Ethanol abuse without malnutrition
RESULT • Iron-deficiency anemia
Increased in: • Megaloblastic anemia (B12/folate defi-

ciency)
• Acute infections
• After exercise (transient) • Paroxysmal nocturnal hemoglobinuria
• Anemias (posthemorrhagic, hemolytic, • Thrombopoietin deficiency

iron-deficiency) • Viral infection
• Chronic heart disease
Decreased in (as a result of bone
• Cirrhosis marrow replacement):
• Essential thrombocythemia • Lymphoma
• Leukemias (chronic) • Granulomatous infections
• Malignancies (carcinoma, Hodgkin’s, • Metastatic carcinoma
lymphomas) • Myelofibrosis
• Pancreatitis (chronic)
Increased destruction in (as a
• Polycythemia vera result of increased loss/
• Rebound recovery from thrombocy- consumption):
topenia • Contact with foreign surfaces (dialysis
Platelet Count 787
membranes, artificial organs, grafts, INTERFERING FACTORS:

prosthetic devices) • Drugs that may decrease platelet
• Disseminated intravascular coagula- counts include acetohexamide, ace-
tion tophenazine, amphotericin B, antazo-
line, anticonvulsants, antimony com-
• Extensive transfusion pounds, apronalide, arsenicals,
• Severe hemorrhage azathioprine, barbiturates, benzene,
busulfan, butaperazine, chlordane,
• Thrombotic thrombocytopenic pur- chlorophenothane, chlortetracycline,
pura dactinomycin, dextromethorphan, di-
• Uremia ethylstilbestrol, ethinamate, ethoxzo-
lamide, floxuridine, hexachloroben-
zene, hydantoin derivatives,
result of immune reaction): hydroflumethiazide, hydroxychloro-
quine, iproniazid, mechlorethamine,
• Antibody/human leukocyte antigen
mefenamic acid, mepazine, micona-
reactions
zole, mitomycin, nitrofurantoin, novo-
• Hemolytic disease of the newborn biocin, nystatin, phenolphthalein, phe-
(target is platelets instead of RBCs) nothiazine, pipamazine, plicamycin,
procarbazine, pyrazolones, strepto-
• Idiopathic thrombocytopenic purpura
mycin, sulfonamides, tetracycline, thi-
• Refractory reaction to platelet transfu- abendazole, thiouracil, tolazamide, to-
sion lazoline, tolbutamide, trifluoperazine,
and urethane.
result of immune reaction second-
• Drugs that may increase platelet counts
ary to infection): include glucocorticoids.
• Bacterial infections • X-ray therapy may also decrease
• Burns platelet counts.
• Congenital infections (cytomegalo- • The results of blood counts may vary

virus, herpes, syphilis, toxoplasmosis) depending on the patient’s position.
Platelet counts can decrease when the
• Histoplasmosis patient is recumbent, as a result of
• Malaria hemodilution, and can increase when
the patient rises, as a result of hemo-
• Rocky Mountain spotted fever concentration.
Increased destruction in (as a • Platelet counts normally increase under

result of other causes): a variety of stressors, such as high alti-
• Radiation tudes or strenuous exercise.
• Splenomegaly caused by liver disease • Platelet counts are normally decreased

before menstruation and during preg-
nancy.
CRITICAL VALUES:
Less than 50,000 K/L or mm3 • Leaving the tourniquet in place for
longer than 60 seconds can affect the
Greater than 1,000,000 K/L or
results.
mm3
Possible interventions for decreased • Traumatic venipunctures may lead to
platelet count may include transfusion of erroneous results as a result of activa-
platelets. tion of the coagulation sequence.
• 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
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.
Plethysmography 789
➤ Evaluate test results in relation to retraction, complete blood count,

the patient’s symptoms and other RBC morphology and inclusions,
tests performed. Related laboratory platelet antibodies, and white blood
tests include bleeding time, clot cell count and differential.
PLETHYSMOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Impedance plethysmography, PVR.

AREA OF APPLICATION: Veins, arteries, and lungs.
DESCRIPTION: Plethysmography is a When the cuffs are applied to an

noninvasive diagnostic manometric extremity in patients with venous
study used to measure changes in the obstruction, no initial increase in leg
size of blood vessels by determining volume is recorded because the
volume changes in the blood vessels venous volume of the leg cannot
of the eye, extremities, and neck; or dissipate quickly.
gas volume changes in the lungs. Body plethysmography measures the
Arterial plethysmography assesses total amount (volume) of air within
arterial circulation in an upper or the thorax, whether or not the air is
lower limb; it is used to diagnose in ventilatory communication with
extremity arteriosclerotic disease and the lung; the elasticity (compliance)
to rule out occlusive disease. The test of the lungs; and the resistance to
requires a normal extremity for airflow in the respiratory tree. It is
comparison of results. The test is used in conjunction with pulmonary
performed by applying a series of stress testing and pulmonary function
three blood pressure cuffs to the testing.
extremity. The amplitude of each Impedance plethysmography is
pulse wave is then recorded. widely used to detect acute deep vein
Venous plethysmography, done with thrombosis (DVT) of the leg, but it
a series of cuffs, measures changes can also be used in the arm,
in venous capacity and outflow abdomen, neck, or thorax. Doppler
(volume and rate of outflow); it flow studies now are used to identify
is used to diagnose a thrombotic DVT, but ultrasound studies are less
condition that causes obstruction of accurate in examinations below the
the major veins of the extremity. knee. ■
INDICATIONS • Detect infectious pulmonary diseases,

such as pneumonia
Arterial Plethysmography: • Determine baseline pulmonary status
• Evaluate suspected arterial occlusive before pulmonary rehabilitation to
disease determine potential therapeutic benefit
• Determine changes in toe or finger
pressures when ankle pressures are Impedance Plethysmography:
elevated as a result of arterial calcifica- • Detect and evaluate DVT
tions • Act as a diagnostic screen for patients
• Determine the effect of trauma on the at risk for DVT
arteries in an extremity • Evaluate patients with suspected
• Determine peripheral small-artery pulmonary embolism (most
changes (ischemia) caused by diabetes, pulmonary emboli are complications
and differentiate these changes from of DVT in the leg)
neuropathy • Evaluate degree of resolution of DVT
• Detect vascular changes associated after treatment
with Raynaud’s phenomenon and
disease RESULT
• Locate and determine the degree of
Normal Findings:
arterial atherosclerotic obstruction and
vessel patency in peripheral atheroscle- • Arterial plethysmography:
rotic disease, as well as inflammatory Normal arterial pulse waves: steep
changes causing obliteration in the up-slope, more gradual down-
vessels in thromboangiitis obliterans slope with narrow pointed peaks
Normal pressure: less than 20 mm
• Confirm suspected acute arterial Hg systolic difference between
embolization the lower and upper extremities;
toe pressure greater than or
Venous Plethysmography: equal to 80 percent of ankle
• Detect partial or total venous throm- pressure, and finger pressure
botic obstruction greater than or equal to 80
percent of wrist pressure
• Determine valve competency in
conjunction with Doppler ultrasonog- • Venous plethysmography:
raphy in the diagnosis of varicose veins Normal venous blood flow in the
extremities
Body Plethysmography: Venous filling times greater than
• Detect or determine the status of 20 seconds
chronic obstructive pulmonary disease • Body plethysmography:
(COPD), such as emphysema, asthma,
Thoracic gas volume: 2400 mL
or chronic bronchitis
Compliance: 0.2 L/cm H2O
• Detect or determine the status of Airway resistance: 0.6 to 2.5 cm
restrictive pulmonary disease, such as H2O/L per second
fibrosis
• Impedance plethysmography:
• Differentiate between obstructive and
Sharp rise in volume with
restrictive pulmonary pathology temporary occlusion
• Detect acute pulmonary disorders, Rapid venous outflow with release
such as atelectasis of the occlusion
Plethysmography 791
Abnormal Findings: to the extremity to be examined, which

can affect blood flow to the limb
• DVT (arterial, venous, or impedance
plethysmography) Body Plethysmography:
• Incompetent valves, thrombosis, or
thrombotic obstruction in a major vein Factors that may impair results of
in an extremity the examination:
• Inability of the patient to follow
• COPD, restrictive lung disease, lung
breathing instructions during the
infection, or atelectasis (body plethys-
procedure
mography)
• Small-vessel diabetic changes Impedance Plethysmography:
• Vascular disease (Raynaud’s phenome-
Factors that may impair results of
non) the examination:
• Vascular trauma • Movement of the extremity during
electrical impedance recording, poor
CRITICAL VALUES: N/A electrode contact, or nonlinear electri-
cal output, which can cause false-
INTERFERING FACTORS positive impedance plethysmography
results
Arterial Plethysmography:
• Constricting clothing or bandages
Factors that may impair results of
the examination:
• Cigarette smoking 2 hours before the Nursing Implications and
study, which causes inaccurate results Procedure ● ● ● ● ● ● ● ● ● ● ●
because the nicotine constricts the

arteries Pretest:
• Alcohol consumption ➤ Explain to the patient the purpose
of the procedure and how it is
• Low cardiac output performed; assess for compliance
• Shock with directions given for rest, posi-
tioning, and activity before and
• Compression of pelvic veins (tumors or during the procedure. For body
external compression by dressings) plethysmography, explain that the
procedure measures the amount of
• Environmental temperatures (hot or air contained in the chest, the elas-
cold) ticity of the lungs, and the occur-
rence of restrictive breathing in the
• Arterial occlusion proximal to the bronchioles.
extremity to be examined, which can
➤ Explain that the procedure is gener-
prevent blood flow to the limb
ally performed in a specialized area
by a technologist or at bedside and
Venous Plethysmography: usually takes 30 to 60 minutes.
Factors that may impair results of ➤ Obtain a history of signs and symp-
the examination: toms of vascular disorders, known
or suspected peripheral vascular dis-
• Environmental temperature or cold ease (for arterial and vascular
extremity, which constricts the vessels plethysmography), known or sus-
• High anxiety level or muscle tenseness pected diseases of the pulmonary
system (for body plethysmography),
• Venous thrombotic occlusion proximal signs or symptoms of DVT or circu-
latory changes (for impedance measure the pulse waves of each

plethysmography), results of previ- cuff. When compared with a normal
ous diagnostic tests and proce- limb, these measurements deter-
dures, and medical regimens. For mine the presence of arterial occlu-
related tests, refer to the cardiovas- sive disease.
cular system table. ➤ Explain to the patient that it is essen-
➤ Obtain a list of the medications the tial to remain still during the proce-
patient is taking. dure.
➤ Obtain pertinent history of other Venous plethysmography:
diagnostic procedure results, labora-
tory test results, present cardiac ➤ Explain to the patient that cuffs are
conditions or vascular abnormalities, applied to the extremity to measure
surgeries, and therapy received. and compare blood flow.
➤ Determine date of last menstrual ➤ Place the patient in a semi-Fowler
period and possibility of pregnancy position on an examining table or in
in perimenopausal women. bed.
➤ Ensure that the patient has refrained ➤ Apply two cuffs to the extremity one
from smoking for 2 hours before the on the proximal part of the extremity
procedure. (occlusion cuff) and the other on the
➤ For body plethysmography, record distal part of the extremity (recorder
the patient’s weight, height, and cuff). Attach a third cuff to the pulse
gender. Determine whether the volume recorder.
patient is claustrophobic. ➤ Inflate the recorder cuff to 10 mm
➤ Explain that the procedure is pain- Hg, and evaluate the effects of respi-
less and carries no risks. ration on venous volume: Absence
of changes during respirations indi-
➤ Ask the patient to notify medical cates venous thrombotic occlusion.
personnel if he or she has ill effects
➤ Inflate the occlusion cuff to 50 mm
or unexpected symptoms during the
Hg, and record venous volume on
test.
the pulse monitor. Deflate the occlu-
➤ Do not restrict food, fluid, or medica- sion cuff after the highest volume is
tions. recorded in the recorder cuff. A
➤ Obtain and record baseline vital delay in the return to preocclusion
signs. volume indicates venous thrombotic
occlusion.
Intratest: ➤ Explain to the patient that it is essen-
tial to remain still during the proce-
dure.
hospital gown. Body plethysmography:
Arterial plethysmography: ➤ Place the patient in a sitting position
on a chair in the body box.
➤ Explain to the patient that cuffs are
➤ Position a nose clip to prevent
applied to the extremity to measure
breathing through the nose, and
and compare blood flow.
connect a mouthpiece to a measur-
➤ Place the patient in a semi-Fowler ing instrument.
position on the examining table or ➤ Ask the patient to breathe through
bed. the mouthpiece.
➤ Apply three blood pressure cuffs to ➤ Close the door to the box, and
the extremity and attach a pulse record the start time of the proce-
volume recorder (plethysmograph), dure. At the beginning of the study,
which records the amplitude of each ask the patient to pant rapidly and
pulse wave. shallowly, without allowing the glot-
➤ Inflate the cuffs to 65 mm Hg to tis to close.
Pleural Fluid Analysis 793
➤ For compliance testing, a double- Post-test:

lumen nasoesophageal catheter is
inserted, and the bag is inflated with ➤ Remove conductive gel and elec-
air. Intraesophageal pressure is trodes, as applied.
recorded during normal breathing. ➤ Instruct the patient to continue
normal activity and diet, unless
Impedance plethysmography: otherwise indicated.
➤ Place the patient on his or her back ➤ Note severe ischemia, ulcers, and
with the leg being tested above the pain of the extremity after arterial,
heart level. venous, or impedance plethysmog-
raphy, and handle the extremity
➤ Flex the patient’s knee slightly, and gently.
rotate the hips by shifting weight to
the same side as the leg being ➤ Note respiratory pattern after body
tested. plethysmography, and allow the
patient time to resume a normal
➤ Apply conductive gel and electrodes. breathing pattern.
➤ Inflate the pressure cuff attached to ➤ A physician specializing in this
the thigh temporarily to occlude branch of medicine sends a written
venous return without interfering report to the ordering provider, who
with arterial blood flow. Expect the discusses the results with the
blood volume in the other calf to patient.
increase. ➤ Inform the patient that further exam-
➤ A tracing of changes in electrical inations may be necessary to evalu-
impedance occurring during inflation ate progression of the disease
and for 15 seconds after cuff defla- process or to determine the need for
tion is recorded. a change in therapy.
➤ With DVT, blood volume increases ➤ Note test results in relation to the
less than expected because the patient’s symptoms and any related
veins are already at capacity. tests performed.
PLEURAL FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Thoracentesis fluid analysis.

SPECIMEN: Pleural fluid (5 mL) collected in a green-top (heparin) tube for
amylase, cholesterol, glucose, lactate dehydrogenase (LDH), pH, protein,
and triglycerides; lavender-top (ethylenediaminetetra-acetic acid [EDTA])
tube for cell count; sterile containers for microbiology specimens; equal
amounts of fixative and fluid in plastic containers for cytology.
REFERENCE VALUE: (Method: Spectrophotometry for amylase, cholesterol,

glucose, LDH, protein, and triglycerides; ion-selective electrode for pH;
automated or manual cell count; macroscopic and microscopic examination
of cultured microorganisms; microscopic examination of specimen for
microbiology and cytology.)
Pleural Fluid Reference Value

Appearance Clear
Color Pale yellow
Amylase Parallel serum values
Cholesterol Parallel serum values
LDH Less than 200 U/L
Fluid LDH–to–serum LDH ratio 0.6 or less
Protein 3.0 g/dL
Fluid protein–to–serum protein ratio 0.5 or less
Triglycerides Parallel serum values
pH 7.37–7.43
RBC count Less than 1000/mm3
WBC count Less than 1000/mm3
Culture No growth
LDH lactate dehydrogenase; RBC red blood cell; WBC white blood cell.
DESCRIPTION: The pleural cavity transudate from an exudate.

and organs within it are lined with a Transudates are effusions that form
protective membrane. The fluid as a result of a systemic disorder that
between the membranes is called disrupts the regulation of fluid
serous fluid. Normally only a small balance, such as a suspected perfora-
amount of fluid is present because tion. Exudates are caused by
the rates of fluid production and conditions involving the tissue of
absorption are about the same. Many the membrane itself, such as an infec-
abnormal conditions can result in tion or malignancy. Fluid is with-
the buildup of fluid within the pleu- drawn from the pleural cavity
ral cavity. Specific tests are usually by needle aspiration and tested as
ordered in addition to a common listed in the previous and following
battery of tests used to distinguish a tables. ■

Fluid protein–to–serum Less than 0.5 Greater than 0.5
protein ratio
Fluid LDH–to–serum Less than 0.6 Greater than 0.6
LDH ratio
WBC count Less than 100/mm3 Greater than 1000/mm3
LDH lactate dehydrogenase; WBC white blood cell.
Pleural Fluid Analysis 795
INDICATIONS: increased LDH-to-serum ratio,

• Differentiate transudates from increased amylase
exudates • Pulmonary infarction: RBC count
• Evaluate effusion of unknown cause 10,000 to 100,000/mm3, WBC count
5000 to 15,000/mm3 with a predomi-
• Investigate suspected rupture, immune nance of neutrophils, pH greater than
disease, malignancy, or infection 7.3, normal glucose, increased fluid
protein–to–serum protein ratio, and
RESULT: increased fluid LDH–to–serum LDH
• Bacterial or tuberculous empyema: Red ratio.
blood cell (RBC) count 5000/mm3,
white blood cell (WBC) count 25,000 • Pulmonary tuberculosis: RBC count
to 100,000/mm3 with a predominance 10,000/mm3, WBC count 5000 to
of neutrophils, increased protein-to- 10,000/mm3 with a predominance of
serum ratio, increased LDH-to-serum lymphocytes, positive acid-fast bacillus
ratio, decreased glucose, pH less than stain and culture, increased protein,
7.3 decreased glucose, pH less than 7.3
• Chylous pleural effusion: Marked • Rheumatoid disease: Normal RBC
increase in both triglycerides (two to count, WBC count 1000 to
three times serum level) and chylomi- 20,000/mm3 with a predominance of
crons either lymphocytes or neutrophils, pH
less than 7.3, decreased glucose,
• Effusion caused by pneumonia: RBC increased protein-to-serum ratio,
count 5000/mm3, WBC count 5000 increased LDH-to-serum ratio,
to 25,000/mm3 with a predominance increased immunoglobulins
of neutrophils and some eosinophils,
increased protein-to-serum ratio, • Systemic lupus erythematosus: Similar
increased LDH-to-serum ratio, pH less findings as with rheumatoid disease,
than 7.4 (and decreased glucose if except that glucose is usually not
bacterial pneumonia) decreased
• Esophageal rupture: Significantly CRITICAL VALUES: N/A
decreased pH (6.0) and elevated
amylase INTERFERING FACTORS:
• Hemothorax: Bloody appearance, • Bloody fluids may be the result of a
increased RBC count, elevated hemat- traumatic tap.
ocrit • Unknown hyperglycemia or hypo-
• Malignancy: RBC count 1000 to glycemia may be misleading in the
100,000/mm3, WBC count 5000 to comparison of fluid and serum glucose
10,000/mm3 with a predominance levels. It is advisable to collect compar-
of lymphocytes, abnormal cytology, ative serum samples a few hours before
increased protein-to-serum ratio, thoracentesis.
increased LDH-to-serum ratio,
deceased glucose, pH less than 7.3
• Pancreatitis: RBC count 1000 to Nursing Implications and
10,000/mm3, WBC count 5000 to Procedure ● ● ● ● ● ● ● ● ● ● ●
20,000/mm3 with a predominance of

Pretest:
neutrophils, pH greater than 7.3,
increased protein-to-serum ratio, ➤ Obtain a history of the patient’s
complaints, including a list of known normally and to avoid unnecessary

allergens. movement.
➤ Obtain a history of the patient’s ➤ Record baseline vital signs.
immune and respiratory systems, as ➤ Observe standard precautions and
well as results of previously follow the general guidelines in
performed tests and procedures. For Appendix A.
and respiratory system tables. ➤ Cleanse the skin with an antiseptic
solution, and protect area with ster-
➤ Obtain a list of medications the ile drape. The skin at the injection
patient is taking, including herbs, site is anesthetized.
nutraceuticals. The requesting health ➤ The thoracentesis needle is
care practitioner and laboratory inserted, and fluid is removed.
should be advised if the patient ➤ The needle is withdrawn, and slight
regularly uses these products so pressure is applied to the site. If
that their effects can be taken into there is no evidence of bleeding or
consideration when reviewing drainage, a sterile dressing is applied
results. to the site.
➤ There are no food or fluid restrictions ➤ Label the specimen, and promptly
unless by medical direction. transport it to the laboratory.
tioner may request that a cough Post-test:
suppressant be given before the ➤ Instruct the patient to resume usual
procedure. medications, as directed by the
➤ Anticoagulants and aspirin may be requesting health care practitioner.
withheld by medical direction. ➤ Inform the patient that 1 hour or
➤ Review the procedure with the more of bed rest (lying on the unaf-
patient. Explain the importance of fected side) is required after the
remaining still during the procedure. procedure. Elevate the patient’s
➤ Inform the patient that a local anes- head for comfort.
thetic will be administered at the ➤ Observe the patient for signs of
chest needle-insertion site immedi- respiratory distress or skin color
ately before the procedure. Explain changes.
that the anesthetic injection may ➤ Assess vital signs every 15 minutes
cause a stinging sensation. for the first hour, every 30 minutes
➤ Assess if the patient has an allergy for the next 2 hours, every hour for
to local anesthetics, and inform the the next 4 hours, and every 4 hours
health care practitioner accordingly. for the next 24 hours. Take tempera-
➤ Obtain written and informed ture every 4 hours for 24 hours.
consent before medication is admin- Monitor intake and output for 24
istered prior to the procedure. hours.
➤ Have the patient void before the ➤ Prepare the patient for a chest x-ray,
procedure. if ordered, to ensure that a pneu-
mothorax has not occurred as a
➤ Inform the patient that specimen result of the procedure.
minutes and is performed by a ➤ Assess the puncture site for bleed-
health care practitioner. ing or drainage and signs of inflam-
mation each time vital signs are
Intratest: assessed and daily for several days
thereafter.
➤ Assist the patient into a sitting or ➤ Administer antibiotics, as ordered,
side-lying position. and instruct the patient in the impor-
➤ Direct the patient to breathe tance of completing the entire
Porphyrins, Urine 797
course of antibiotic therapy even if tests include bacterial culture, CA

no symptoms are present. 15-3, CA 19-9, CA 125, carcinoem-
➤ Evaluate test results in relation to bryonic antigen, fungal culture,
the patient’s symptoms and other mycobacterial culture, and viral
tests performed. Related laboratory culture.
PORPHYRINS, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Coproporphyrin, porphobilinogen, urobilinogen,

and other porphyrins.

a clean, amber-colored, plastic collection container with sodium carbonate
as a preservative.
REFERENCE VALUE: (Method: Chromatography for uroporphyrins; spec-

trophotometry for -aminolevulinic acid, urobilinogen, and porphobilino-
gen)
Test Conventional Units SI Units

Total porphyrins Less than 320 g/24 h
Coproporphyrin
Tetracarboxylco-
proporphyrin
Male Less than 96 g/24 h Less than 147 nmol/24 h
Female Less than 60 g/24 h Less than 92 nmol/24 h
Uroporphyrins
Pentacarboxyl-
porphyrin
Hexacarboxyl-
porphyrin

Test Conventional Units SI Units

Heptacarboxyl-
porphyrin
Porphobilinogen Less than 2.0 mg/24 h Less than 8.8 mol/24 h
Urobilinogen 0.5–4.0 EU/24 h 0.5–4.0 EU/24 h
-Aminolevulinic 1.5–7.5 mg/24 h 11.4–57.2 mol/24 h
acid
DESCRIPTION: Porphyrins are pro- INDICATIONS:

duced during the synthesis of heme. • Assist in the diagnosis of congenital or
If heme synthesis is disturbed, these acquired porphyrias, characterized by
precursors accumulate and are ex- abdominal pain, tachycardia, emesis,
creted in the urine in excessive fever, leukocytosis, and neurologic
abnormalities
amounts. Conditions producing in-
creased levels of heme precursors are • Detect suspected lead poisoning, as
called porphyrias. The two main cate- indicated by elevated porphyrins
gories of genetically determined por-
phyrias are erythropoietic porphyrias, RESULT
in which major abnormalities occur
Increased in:
in red blood cell chemistry, and he-
• Acute hepatic porphyrias
patic porphyrias, in which heme pre-
cursors are found in urine and feces. • Congenital or acquired porphyrias
Erythropoietic and hepatic porphyr- • Heavy metal, benzene, or carbon tetra-
ias are rare. Acquired porphyrias are chloride toxicity
characterized by greater accumulation
• Variegated porphyrias
of precursors in urine and feces than
in red blood cells. Lead poisoning is Decreased in: N/A
the most common cause of acquired
porphyrias. Porphyrins are reddish CRITICAL VALUES: N/A
fluorescent compounds. Depending
on the type of porphyrin present, the INTERFERING FACTORS:
urine may be reddish, resembling • Drugs that may increase urine
port wine. Porphobilinogen is ex- porphyrin levels include acriflavine,
creted as a colorless compound. A aminopyrine, ethoxazene, griseofulvin,
color change may occur in an acidic hexachlorobenzene, oxytetracycline,
sample containing porphobilinogen and sulfonmethane.
if the sample is exposed to air for sev- • Numerous drugs are suspected as po-
eral hours. ■ tential initiators of acute attacks, but
Porphyrins, Urine 799
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
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
• Failure to collect all urine and store tory collection container.
specimen properly during the 24-hour
test period will interfere with results. Intratest:
Nursing Implications and Appendix A.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Random specimen (collect in
Pretest: early morning):
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:
results. ➤ Put on gloves. Empty drainage tube
of urine. It may be necessary to time. Keep the container system on

clamp off the catheter for 15 to 30 ice during the collection period, or
minutes before specimen collection. empty the urine into a larger
Cleanse specimen port with antisep- container periodically during the
tic swab, and then aspirate 5 mL of collection period; monitor to ensure
urine with a 21- to 25-gauge needle continued drainage, and conclude
and syringe. Transfer urine to a ster- the test the next morning at the
ile container. same hour the collection was
begun.
Timed specimen:
➤ Obtain a clean 3-L urine specimen compare the quantity of urine with
container, toilet-mounted collection the urinary output record for the
device, and plastic bag (for transport collection; if the specimen contains
of the specimen container). The less than what was recorded as
specimen must be refrigerated or output, some urine may have been
kept on ice throughout the entire discarded, invalidating the test.
collection period. If an indwelling
urinary catheter is in place, the ➤ Label the specimen, and promptly
drainage bag must be kept on ice. transport it to the laboratory. Include
on the label the amount of urine,
➤ Begin the test between 6 and 8 test start and stop times, and inges-
a.m., if possible. Collect first voiding tion of any foods or medications that
and discard. Record the time the can affect test results.
specimen was discarded as the
beginning of the timed collection
period. The next morning, ask the Post-test:
patient to void at the same time the ➤ Evaluate test results in relation to
collection was started and add this the patient’s symptoms and other
last voiding to the container. tests performed. Related laboratory
➤ If an indwelling catheter is in place, tests include -aminolevulinic acid,
replace the tubing and container erythrocyte protoporphyrin, and
system at the start of the collection lead.
POSITRON EMISSION TOMOGRAPHY,

BRAIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: PET scan of the brain.

DESCRIPTION: Positron emission computed tomography (CT). PET

tomography (PET) combines the uses positron emissions from specific
biochemical properties of nuclear radionuclides (oxygen, nitrogen,
medicine with the accuracy of carbon, and fluorine) to produce
Positron Emission Tomography, Brain 801
detailed functional images within the neurodegenerative diseases, inflam-

body. After the radionuclide becomes mation, cerebrovascular disease (indi-
concentrated in the brain, PET rectly), and brain tumors.
images of blood flow or metabolic The expense of the study and the
processes at the cellular level can be limited availability of radiopharma-
obtained. Fluorine-18, in the form of ceuticals limit the use of PET, even
fluorodeoxyglucose (FDG), is one of though it is more sensitive than tradi-
the more commonly used radionu- tional nuclear scanning and single
clides. FDG is a glucose analogue, photon emission computed tomogra-
and because every cell uses glucose, phy (SPECT). Changes in reimburse-
the metabolic activity occurring in ment and the advent of mobile
neurologic conditions can be meas- technology have increased the avail-
ured. There is little localization of ability of this procedure in the
FDG in normal tissue, allowing rapid community setting. ■
detection of abnormal disease states.
The brain uses oxygen and glucose INDICATIONS:
almost exclusively to meet its energy • Identify focal seizures, as evidenced by
needs, and therefore the brain’s decreased metabolism between seizures
metabolism has been studied widely • Evaluate Alzheimer’s disease and differ-
with PET. entiate it from other causes of demen-
The positron radiopharmaceuticals tia, as evidenced by decreased cerebral
generally have short half-lives, rang- flow and metabolism
ing from a few seconds to a few hours, • Identify cerebrovascular accident or
and therefore they must be produced aneurysm, as evidenced by decreased
in a cyclotron located near where the blood flow and oxygen use
test is being done. The PET scanner
• Detect Parkinson’s disease and
translates the emissions from the
Huntington’s disease, as evidenced by
radioactivity as the positron combines decreased metabolism
with the negative electrons from
the tissues and forms gamma rays that • Evaluate cranial tumors preoperatively
can be detected by the scanner. This and postoperatively and determine
stage and appropriate treatment or
information is transmitted to the
procedure
computer, which determines the loca-
tion and its distribution and translates • Determine physiologic changes in
the emissions as color-coded images psychosis and schizophrenia
for viewing, quantitative measure- • Determine the effectiveness of therapy,
ments, activity changes in relation as evidenced by biochemical activity of
to time, and three-dimensional normal and abnormal tissues
computer-aided analysis. Each radio-
• Differentiate between tumor recur-
nuclide tracer is designed to measure rence and radiation necrosis
a specific body process, such as
glucose metabolism, blood flow, or RESULT
brain tissue perfusion. The radionu-
clide can be administered intra- Normal Findings:
venously or inhaled as a gas. PET has • Normal patterns of tissue metabolism,
had the greatest clinical impact in blood flow, and radionuclide distribu-
patients with epilepsy, dementia, tion
Abnormal Findings: effects of these substances would make

• Alzheimer’s disease it difficult to evaluate the patient’s true
physiologic state (e.g., alcohol is a
• Cerebrovascular accident vasconstrictor and would decrease
• Cerebral metastases blood flow to the target organ)
• Creutzfeldt-Jakob disease • Metallic objects within the examina-
• Dementia which may inhibit organ visualization
• Head trauma and can produce unclear images
• Huntington’s disease
• Migraine • Improper injection of the radionuclide
• Parkinson’s disease that allows the tracer to seep deep into
the muscle tissue produces erroneous
• Schizophrenia hot spots.
• Seizure disorders • False-positive findings may occur as a
• Tumors result of normal gastrointestinal tract
uptake and uptake in areas of infection
CRITICAL VALUES: N/A or inflammation.
INTERFERING FACTORS occur before the procedure for radia-
This procedure is contraindicated of patients who are lactating.
for:
• Patients who are pregnant or suspected overexposure can result from frequent
of being pregnant, unless the potential x-ray procedures. Personnel in the
benefits of the procedure far outweigh room with the patient should stand
the risks to the fetus and mother behind a shield or leave the area while
the examination is being done.
Factors that may impair clear Personnel working in the area where
imaging:
the examination is being done should
• Inability of the patient to cooperate or wear badges that reveal their level of
remain still during the procedure exposure to radiation.
mental status
• Patients who are very obese, who may Nursing Implications and
exceed the weight limit for the equip- Procedure ● ● ● ● ● ● ● ● ● ● ●
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-
hypoglycemia can alter PET results
• 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-
Positron Emission Tomography, Brain 803
containing drinks for 24 hours before ➤ The radionuclide is injected, and

the study or as per physician order. imaging is started 30 minutes later.
➤ Instruct the insulin-dependent pa- ➤ If comparative studies are indicated,
tient to take insulin as usual on the additional injections may be needed.
day of the procedure, to have a meal
4 hours before the procedure, and ➤ The patient may be asked to perform
then to refrain from food or liquids. different cognitive activities (e.g.,
reading) to measure changes in brain
➤ Obtain a list of medications the activity during reasoning or remem-
patient is taking. bering.
➤ Obtain a history of neurologic tests,
other diagnostic procedure results, ➤ The patient may be blindfolded or
laboratory test results, present asked to use earplugs to decrease
neurologic conditions or abnormali- auditory and visual stimuli.
ties, and therapy received. For ➤ Wear gloves during the radionuclide
related tests, refer to the muscu- injection and while handling the
loskeletal system table. patient’s urine.
period and possibility of pregnancy Post-test:
➤ Reassure the patient that the ➤ Monitor electrocardiogram tracings
radionuclide poses minimal radioac- and blood pressures and compare
tive hazard because of its short half- with baseline readings until the
life and rarely produces side effects. patient is stable.
➤ Obtain a written, informed consent ➤ Observe the injection site for
for the procedure from the patient. redness, swelling, or hematoma.
➤ Sometimes fluorodeoxyglucose ➤ Observe the patient for 30 minutes
(FDG) examinations are done after after the procedure for possible
blood has been drawn to determine reaction to the radionuclide or other
circulating blood glucose levels. If procedure complications.
blood glucose levels are high, insulin
may be given. ➤ Instruct the patient to resume
➤ Obtain and record baseline electro- otherwise indicated.
cardiogram and vital signs.
➤ If the patient must return for further
Intratest: imaging, advise the patient to rest in
the interim and restrict diet to liquids
➤ Ensure that emergency equipment before further studies.
is readily available during the proce-
dure. ➤ Advise patient to drink increased
amounts of fluids for 24 hours to
➤ Ask the patient to void before the eliminate the radionuclide from the
procedure. body, unless contraindicated. Tell the
➤ Make sure jewelry and any other patient that radionuclide is elimi-
metallic objects have been removed nated from the body within 6 to 24
from the brain area. hours.
➤ Ask the patient to lie still during the ➤ Instruct the patient to flush the toilet
procedure because movement immediately after each voiding
produces unclear images. following the procedure and to wash
➤ Place the patient supine on the hands meticulously with soap and
imaging table with the head resting water after each voiding for 24 hours
in a supportive device to minimize after the procedure.
motion artifacts. ➤ Tell all caregivers to wear gloves
➤ An intravenous or arterial line may when discarding urine for 24 hours
be started. after the procedure. Wash gloved
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
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: PET scan of the heart.

AREA OF APPLICATION: Heart, chest/thorax, vascular system.
DESCRIPTION: Positron emission little localization of FDG in normal

tomography (PET) combines the tissue, allowing rapid detection of
biochemical properties of nuclear abnormal disease states.
medicine with the accuracy of The positron radiopharmaceuticals
computed tomography (CT). PET generally have short half-lives, rang-
uses positron emissions from specific ing from a few seconds to a few
radionuclides (oxygen, nitrogen, hours, and therefore they must be
carbon, and fluorine) to produce produced in a cyclotron located near
detailed functional images within the where the test is being done. The
body. After the radionuclide becomes PET scanner translates the emissions
concentrated in the heart, PET from the radioactivity as the positron
images of blood flow or metabolic combines with the negative electrons
processes at the cellular level can be from the tissues and forms gamma
obtained. Fluorine-18, in the form of rays that can be detected by the scan-
fluorodeoxyglucose (FDG), is one of ner. This information is transmitted
the more commonly used radionu- to the computer, which determines
clides. FDG is a glucose analogue, the location and its distribution and
and because every cell uses glucose, translates the emissions as color-
the metabolic activity occurring in coded images for viewing, quantita-
heart conditions such as myocardial tive measurements, activity changes
viability can be measured. There is in relation to time, and three-
Positron Emission Tomography, Heart 805
dimensional computer-aided analysis. glucose concentration, indicating

Each radionuclide tracer is designed necrotic, scarred tissue
to measure a specific body process, • Enlarged left ventricle
such as glucose metabolism, blood
flow, or tissue perfusion. The • Heart chamber disorder
radionuclide can be administered • Myocardial infarction, indicating
intravenously or inhaled as a gas. increased radionuclide uptake in the
The expense of the study and the myocardium
limited availability of radiopharma- • Pulmonary edema
ceuticals limit the use of PET, even
• Reduced blood flow but increased
though it is more sensitive than tradi-
glucose concentration, indicating
tional nuclear scanning and single ischemia
photon emission computed tomogra-
phy (SPECT). Changes in reimburse- CRITICAL VALUES: N/A
ment and the advent of mobile
technology have increased the avail- INTERFERING FACTORS:
ability of this procedure in the
community setting. ■ This procedure is contraindicated
for:
• Assess tissue permeability of being pregnant, unless the potential
• Determine the size of heart infarcts benefits of the procedure far outweigh
• Determine localization of areas of heart
metabolism Factors that may impair clear
• Determine the effects of therapeutic imaging:
drugs on malfunctioning or diseased • Inability of the patient to cooperate or
tissue remain still during the procedure
• Identify cerebrovascular accident or mental status
aneurysm, as evidenced by decreasing
blood flow and oxygen use • Patients who are very obese, who may
• Determine the presence of coronary ment
artery disease, as evidenced by meta-
bolic state during ischemia and after • Incorrect positioning of the patient,
angina which may produce poor visualization
RESULT • Drugs that alter glucose metabolism,
such as tranquilizers or insulin, because
Normal Findings: hypoglycemia can alter PET results
• Normal patterns of tissue metabolism,
blood flow, and radionuclide distribu- • The use of alcohol, tobacco, or
tion caffeine-containing drinks at least 24
hours before the study, because the
Abnormal Findings: effects of these substances would make
it difficult to evaluate the patient’s true
physiologic state (e.g., alcohol is a
(COPD)
vasconstrictor and would decrease
• Decreased blood flow and decreased blood flow to the target organ)
• Metallic objects within the examina- ➤ Obtain a list of medications the

tion field (e.g., jewelry or body rings), patient is taking.
which may inhibit organ visualization ➤ Obtain a history of cardiac tests,
and can produce unclear images other diagnostic procedure results,
laboratory test results, present
Other considerations: cardiac conditions or abnormalities,
and therapy received for cardiac
• Improper injection of the radionuclide conditions. For related tests, refer to
that allows the tracer to seep deep into the cardiovascular system table.
the muscle tissue produces erroneous ➤ Determine date of last menstrual
hot spots. period and possibility of pregnancy
• False-positive findings may occur as a in perimenopausal women.
result of normal gastrointestinal tract ➤ Reassure the patient that the
uptake and uptake in areas of infection radionuclide poses minimal radioac-
or inflammation. tive hazard because of its short half-
life and rarely produces side effects.
occur before the procedure for radia- for the procedure from the patient.
➤ Sometimes fluorodeoxyglucose
(FDG) examinations are done after
• Risks associated with radiographic blood has been drawn to determine
overexposure can result from frequent circulating blood glucose levels. If
x-ray procedures. Personnel in the blood glucose levels are high, insulin
room with the patient should stand may be given.
behind a shield or leave the area while
the examination is being done. Intratest:
Personnel working in the area where ➤ Ensure that emergency equipment
the examination is being done should is readily available during the proce-
wear badges that reveal their level of dure.
exposure to radiation. ➤ Ask the patient to void before the
hospital gown.
Nursing Implications and ➤ Make sure jewelry, chains, and any
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: ➤ Ask the patient to lie still during the
➤ Inform the patient that the procedure produces unclear images.
assesses blood flow to the heart.
➤ Expose the chest, and attach the
➤ Inform the patient that the procedure electrocardiogram leads for simulta-
is performed in a special depart- neous tracings. Apply a blood pres-
ment by a technologist and takes sure cuff.
➤ An intravenous or arterial line may
➤ Restrict alcohol, tobacco, or be started.
caffeine-containing drinks for 24
hours before the study or as per ➤ The radionuclide is injected; imaging
physician order. is done at periodic intervals, and
continuous scanning is done for 1
➤ Instruct the insulin-dependent hour.
patient to take insulin as usual on the
day of the procedure, to have a meal ➤ If comparative studies are indicated,
4 hours before the procedure, and additional injections may be needed.
then to refrain from food or liquids. ➤ Wear gloves during the radionuclide
Positron Emission Tomography, Pelvis 807
injection and while handling the immediately after each voiding

patient’s urine. following the procedure and to wash
Post-test: water after each voiding for 24 hours
➤ Monitor electrocardiogram tracings
and compare blood pressures with ➤ Tell all caregivers to wear gloves
baseline readings until the patient is when discarding urine for 24 hours
stable. after the procedure. Wash gloved
➤ Observe the injection site for hands with soap and water before
redness, swelling, or hematoma. removing gloves. Then wash hands
after the gloves are removed.
➤ Observe the patient for 60 minutes
after the procedure for possible ➤ Inform the patient that abnormalities
reaction to the radionuclide or other of the heart scan may indicate the
procedure complications. need for additional studies, including
➤ Instruct the patient to resume cardiac catheterization for cardiac
normal activity and diet, unless abnormalities.
otherwise indicated. ➤ A physician specializing in this
➤ If the patient must return for further branch of medicine sends a written
imaging, advise the patient to rest in report to the ordering provider, who
the interim and restrict diet to liquids discusses the results with the
before further studies. patient.
➤ Advise patient to drink increased ➤ Evaluate test results in relation to
amounts of fluids for 24 hours to the patient’s symptoms and other
eliminate the radionuclide from the tests performed.
body, unless contraindicated. Tell the ➤ Related diagnostic tests include
patient that radionuclide is elimi- echocardiogram, electrocardiogram,
nated from the body within 6 to 24 myocardial perfusion scan, and CT
hours. and magnetic resonance imaging of
➤ Instruct the patient to flush the toilet the chest.
POSITRON EMISSION TOMOGRAPHY,

PELVIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: PET scan of the pelvis.

DESCRIPTION: Positron emission medicine with the accuracy of

tomography (PET) combines the computed tomography (CT). PET
biochemical properties of nuclear uses positron emissions from specific
radionuclides (oxygen, nitrogen, The expense of the study and the

carbon, and fluorine) to produce limited availability of radiopharma-
detailed functional images within the ceuticals limit the use of PET, even
body. After the radionuclide becomes though it is more sensitive than tradi-
concentrated in the pelvis, PET tional nuclear scanning and single
images of blood flow or metabolic photon emission computed tomogra-
processes at the cellular level can be phy (SPECT). Changes in reimburse-
obtained. Colorectal tumor detection, ment and the advent of mobile
tumor staging, evaluation of the technology have increased the avail-
effects of therapy, detection of recur- ability of this procedure in the
rent disease, and detection of metas- community setting. ■
tases are the main reasons to do a
pelvic PET scan. Fluorine-18, in the INDICATIONS:
form of fluorodeoxyglucose (FDG), is • Determine the presence of colorectal
one of the more commonly used cancer
radionuclides. FDG is a glucose • Determine the recurrence of tumor or
analogue, and because every cell uses cancer
glucose, the metabolic activity occur- • Determine the presence of metastases
ring in pelvic conditions such as of a cancerous tumor
colorectal cancer can be measured.
• Determine the effects of therapy
There is little localization of FDG in
normal tissue, allowing rapid detec- • Identify the site for biopsy
tion of abnormal disease states.
The positron radiopharmaceuticals RESULT
generally have short half-lives, rang-
Normal Findings:
ing from a few seconds to a few hours,
and therefore they must be produced • Normal patterns of tissue metabolism,
blood flow, and radionuclide distribu-
in a cyclotron located near where the
tion
test is being done. The PET scanner
translates the emissions from the • No focal uptake of radionuclide
radioactivity as the positron combines
Abnormal Findings:
with the negative electrons from the
tissues and forms gamma rays that can • Focal uptake of the radionuclide in
pelvis
be detected by the scanner. This infor-
mation is transmitted to the • Focal uptake in abnormal lymph nodes
computer, which determines the loca- • Focal uptake in tumor
tion and its distribution and translates
the emissions as color-coded images • Focal uptake in metastases
for viewing, quantitative measure-
ments, activity changes in relation to
time, and three-dimensional
computer-aided analysis. Each
radionuclide tracer is designed to This procedure is contraindicated
measure a specific body process, such for:
as glucose metabolism, blood flow, or • Patients who are pregnant or suspected
tissue perfusion. of being pregnant, unless the potential
Positron Emission Tomography, Pelvis 809

the risks to the fetus and mother Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●

imaging: Pretest:
• Inability of the patient to cooperate or ➤ Inform the patient that the proce-
remain still during the procedure dure assesses the pelvis and its con-
because of age, significant pain, or tents for abnormal organ function.
mental status ➤ Inform the patient that the proce-
• Patients who are very obese, who may department by a technologist and
exceed the weight limit for the equip- takes approximately 30 to 50
ment minutes.
• Incorrect positioning of the patient, ➤ Restrict alcohol, tobacco, or
which may produce poor visualization caffeine-containing drinks for 24
of the area to be examined hours before the study or as per
physician order.
• Metallic objects within the examina- ➤ Instruct the insulin-dependent
tion field (e.g., jewelry or body rings), patient to take insulin as usual on the
which may inhibit organ visualization day of the procedure, to have a meal
and can produce unclear images 4 hours before the procedure, and
then to refrain from food or liquids.
• Drugs that alter glucose metabolism,
such as tranquilizers or insulin, because patient is taking.
hypoglycemia can alter PET results
➤ Obtain a history of pelvic tests,
other diagnostic procedure results,
laboratory test results, present
• Improper injection of the radionuclide conditions or abnormalities, surger-
that allows the tracer to seep deep into ies, and therapy received. For
the muscle tissue produces erroneous related tests, refer to the reproduc-
hot spots. tive and gastrointestinal system
tables.
• False-positive findings may occur as a
result of normal gastrointestinal tract period and possibility of pregnancy
uptake and uptake in areas of infection in perimenopausal women.
or inflammation.
➤ Reassure the patient that radioactive
• Consultation with a physician should material poses minimal radioactive
occur before the procedure for radia- hazard because of its short half-life
tion safety concerns regarding infants and rarely produces side effects.
of patients who are lactating. ➤ Obtain a written, informed consent
➤ Sometimes fluorodeoxyglucose
overexposure can result from frequent (FDG) examinations are done after
x-ray procedures. Personnel in the blood has been drawn to determine
room with the patient should wear a circulating blood glucose levels. If
protective lead apron, stand behind a blood glucose levels are high, insulin
shield, or leave the area while the may be given.
working in the area where the exami- Intratest:
nation is being done should wear ➤ Ensure that emergency equipment
badges that reveal their level of expo- is readily available during the proce-
sure to radiation. dure.
➤ 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
imaging is started after a 45-minute
delay. Continuous scanning may be
done for 1 hour after the patient is
placed in the supine position on a
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.
Post-test: branch of medicine sends a written
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Serum K.

Potassium, Serum 811

Serum SI Units (Conversion Factor 1)

Newborn 3.7–5.9 mmol/L or mEq/L
Infant 4.1–5.3 mmol/L or mEq/L
Child 3.4–4.7 mmol/L or mEq/L
Adult 3.5–5.0 mmol/L or mEq/L
Note : Serum values are 0.1 mmol/L higher than plasma values, and reference ranges
should be adjusted accordingly. It is important that serial measurements be collected
using the same type of collection container to reduce variability of results from collection
to collection.
DESCRIPTION: Electrolytes dissoci- Abnormal potassium can be caused

ate into electrically charged ions by a number of contributing factors,
when dissolved. Cations, including which can be categorized as follows:
potassium, carry a positive charge. Altered renal excretion: Normally,
Body fluids contain approximately 80 to 90 percent of the body’s
equal numbers of anions and cations, potassium is filtered out
through the kidneys each day
although the nature of the ions
(the remainder is excreted in
and their mobility differs between sweat and stool); renal disease
the intracellular and extracellular can result in abnormally high
compartments. Both types of ions potassium levels.
affect the electrical and osmolar func- Altered dietary intake: A severe
tions of the body. Electrolyte quanti- potassium deficiency can be
ties and the balance among them are caused by an inadequate
controlled by oxygen and carbon intake of dietary potassium.
dioxide exchange in the lungs; Altered cellular metabolism:
Damaged red blood cells
absorption, secretion, and excretion
(RBCs) release potassium into
of many substances by the kidneys; the circulating fluid, resulting in
and secretion of regulatory hormones increased potassium levels. ■
by the endocrine glands. Potassium is
the most abundant intracellular INDICATIONS:
cation. It is essential for the transmis- • Assess a known or suspected disorder
sion of electrical impulses in cardiac associated with renal disease, glucose
and skeletal muscle. It also functions metabolism, trauma, or burns
in enzyme reactions that transform • Assist in the evaluation of electrolyte
glucose into energy and amino acids imbalances; this test is especially indi-
into proteins. Potassium helps main- cated in elderly patients, patients
tain acid-base equilibrium, and it has receiving hyperalimentation supple-
a significant and inverse relationship ments, patients on hemodialysis, and
to pH: A decrease in pH of 0.1 patients with hypertension
increases the potassium level by 0.6 • Evaluate cardiac arrhythmia to deter-
mEq/L. mine whether altered potassium levels
are contributing to the problem, espe- • Prolonged periods of standing

cially during digitalis therapy, which
• Tissue trauma
leads to ventricular irritability
• Transfusion of old banked blood
• Evaluate the effects of drug therapy,
especially diuretics • Tubular unresponsiveness to aldos-
terone
• Evaluate the response to treatment for
abnormal potassium levels • Uremia
• Monitor known or suspected acidosis,
Decreased in:
because potassium moves from RBCs
into the extracellular fluid in acidotic • Alcoholism
states • Alkalosis
• Routine screen of electrolytes in acute • Anorexia nervosa
and chronic illness
• Bradycardia
RESULT • Chronic, excessive licorice ingestion
(from licorice root)
Increased in:
• Acidosis
• Acute renal failure
• Diet deficient in meat and vegetables
• Asthma
• Excess insulin
• Burns
• Familial periodic paralysis
• Chronic interstitial nephritis
• Gastrointestinal loss due to vomiting,
• Dehydration diarrhea, nasogastric suction, or intes-
• Dialysis tinal fistula
• Diet (excessive intake of salt substitutes • Hyperaldosteronism
or potassium salts of medications) • Hypertension
• Excessive theophylline administration • Hypomagnesemia
• Exercise • Intravenous (IV) therapy with inade-
• Hemolysis (massive) quate potassium supplementation
• Hyperventilation • Laxative abuse
• Hypoaldosteronism • Malabsorption
• Insulin deficiency • Pica (clay eating)
• Ketoacidosis • Renal tubular acidosis
• Leukocytosis • Stress
• Muscle necrosis • Sweating
• Near-drowning • Thyrotoxicosis
• Pregnancy • Toxic shock syndrome
Potassium, Serum 813
CRITICAL VALUES: tam (common when coadministered

with amikacin), large doses of any
Newborns: IV penicillin, phenolphthalein (with
Less than 2.5 mmol/L
chronic laxative abuse), phosphates, IV
theophylline, thiazides, and tri-
Greater than 7.0 mmol/L amterene. A number of these medica-
Adults: tions initially increase the serum potas-
sium level, but they also have a diuretic
Less than 2.5 mmol/L
effect, which promotes potassium loss
Greater than 6.5 mmol/L in the urine except in cases of renal in-
Note and report increased or decreased sufficiency.
values and symptoms of fluid imbalance
to the requesting health care practitioner. • Leukocytosis, as seen in leukemia,
Symptoms of hyperkalemia include irri- causes elevated potassium levels.
tability, diarrhea, cramps, oliguria, diffi- • False elevations can occur with vigor-
culty speaking, and cardiac arrhythmias ous pumping of the hand during
(peaked T waves and ventricular fibrilla- venipuncture. Hemolysis of the sample
tion). Continuous cardiac monitoring is and high platelet counts also increase
indicated. Administration of sodium potassium levels, as follows: (1)
bicarbonate or calcium chloride may be Because potassium is an intracellular
requested. If the patient is receiving an ion and concentrations are approxi-
IV supplement, verify that the patient is mately 150 times extracellular concen-
voiding. trations, even a slight amount of
Symptoms of hypokalemia include hemolysis can cause a significant
malaise, thirst, polyuria, anorexia, weak increase in levels. (2) Platelets release
pulse, low blood pressure, vomiting, potassium during the clotting process,
decreased reflexes, and electrocardio- and therefore serum samples collected
graphic changes (depressed T waves and from patients with elevated platelet
ventricular ectopy). Replacement therapy counts may produce spuriously high
is indicated. potassium levels. Plasma would be the
specimen of choice in patients known
INTERFERING FACTORS: to have elevated platelet counts.
• Drugs that can cause an increase in
potassium levels include dexametha- • False increases are seen in unprocessed
sone, enalapril, mannitol, methicillin, samples left at room temperature
metoprolol, nonsteroidal anti- because a significant amount of potas-
inflammatory drugs, some drugs with sium leaks out of the cells within a few
potassium salts, propranolol, spirono- hours. Plasma or serum should be sepa-
lactone, and succinylcholine. rated from cells within 4 hours of
• Drugs that can cause a decrease in collection.
potassium levels include acetazo- • Storage of unprocessed blood causes
lamide, alanine, albuterol, aldosterone, potassium levels to increase because
ammonium chloride, amphotericin a significant amount of potassium
B, acetylsalicylic acid, bicarbonate, leaks out of the cells within a few
bisacodyl, captopril, carbenicillin, hours. Plasma or serum should be
cathartics, cisplatin, clorexolone, des- separated from cells within 4 hours of
oxycorticosterone, dexamethasone, collection.
digoxin, diuretics, enalapril,
furosemide, hydrocortisone, hy- • Specimens should never be collected
droflumethiazide, laxatives, moxalac- above an IV line because of the poten-
tial for dilution when the specimen Appendix A. Perform a venipuncture,

and the IV solution combine in the and collect the specimen in a 5-mL
collection container, falsely decreasing red-, tiger-, or green-top (heparin)
the result. There is also the potential of tube.
contaminating the sample with the ➤ Label the specimen, and promptly
substance of interest, contained in the transport it to the laboratory.
IV solution, falsely increasing the
result. Post-test:
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ There are no recommended dietary
allowances established for potas-
Pretest: sium, but the estimated minimum
intake for adults is 200 mEq/d.
➤ Obtain a history of the patient’s Potassium is present in all plant and
complaints, and especially note animal cells, making dietary replace-
weakness and confusion. Obtain a ment simple to achieve in the
list of known allergens. potassium-deficient patient.
➤ Obtain a history of the patient’s ➤ Observe the patient for signs and
cardiovascular, endocrine, gastroin- symptoms of fluid-volume excess
testinal, genitourinary, immune, and related to excess potassium intake,
respiratory systems, as well as fluid-volume deficit related to active
results of previously performed loss, or risk of injury related to an al-
tests and procedures. For related teration in body chemistry. Symp-
tests, refer to the cardiovascular, toms include dehydration, diarrhea,
endocrine, gastrointestinal, geni- vomiting, or prolonged anorexia. In-
tourinary, immune, and respiratory struct the patient in electrolyte re-
system tables. placement therapy and changes in
➤ Obtain a list of medications the dietary intake that affect electrolyte
patient is taking. levels.
➤ There are no food, fluid, or medica- ➤ Increased potassium levels may be
tion restrictions unless by medical associated with dehydration. Evalu-
direction. ate the patient for signs and symp-
➤ Review the procedure with the toms of dehydration. Dehydration is
patient. a significant and common finding in
geriatric patients and other patients
➤ Inform the patient that specimen in whom renal function has deterio-
collection takes approximately 5 to rated.
10 minutes.
➤ Patients receiving digoxin or diuret-
Intratest: ics should have potassium levels
monitored carefully because cardiac
➤ Direct the patient to breathe arrhythmias can occur.
movement. Instruct patient not to the patient’s symptoms and other
clench and unclench the fist immedi- tests performed. Related laboratory
ately before or during specimen tests include aldosterone, arterial/
collection. alveolar oxygen ratio, anion gap,
➤ Observe standard precautions and blood gases, calcium, digoxin, elec-
follow the general guidelines in trolytes, and osmolality.
Potassium, Urine 815
POTASSIUM, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Urine K.

SI Units
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
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.
DESCRIPTION: Electrolytes dissoci- is essential for the transmission of

ate into electrically charged electrical impulses in cardiac and
ions when dissolved. Cations, includ- skeletal muscle. It also functions in
ing potassium, carry a positive enzyme reactions that transform
charge. Body fluids contain approxi- glucose into energy and amino acids
mately equal numbers of anions into proteins. Potassium helps main-
and cations, although the nature tain acid-base equilibrium, and it has
of the ions and their mobility differs a significant and inverse relationship
between the intracellular and to pH: A decrease in pH of 0.1
extracellular compartments. Both increases the potassium level by 0.6
types of ions affect the electrical mEq/L.
and osmolar functions of the Abnormal potassium can be caused
body. Electrolyte quantities and the by a number of contributing factors,
balance among them are controlled which can be categorized as follows:
by oxygen and carbon dioxide Altered renal excretion: Normally,
exchange in the lungs; absorption, 80 to 90 percent of the body’s
secretion, and excretion of many potassium is filtered out
through the kidneys each day
substances by the kidneys; and secre- (the remainder is excreted in
tion of regulatory hormones by the sweat and stool); renal disease
endocrine glands. Potassium is the can result in abnormally high
most abundant intracellular cation. It potassium levels.
Altered dietary intake: A severe • Diuretic therapy

potassium deficiency can be
caused by an inadequate intake • Starvation (onset)
of dietary potassium. • Vomiting
Altered cellular metabolism:
Damaged red blood cells
Decreased in:
(RBCs) release potassium into
the circulating fluid, resulting in • Addison’s disease
increased potassium levels. • Potassium deficiency (chronic)
Regulating electrolyte balance is
one of the major functions of the • Renal failure with decreased urine flow
kidneys. In normally functioning
kidneys, urine potassium levels CRITICAL VALUES: N/A
increase when serum levels are high
and decrease when serum levels are INTERFERING FACTORS:
low to maintain homeostasis. The • Drugs and substances that can cause an
kidneys respond to alkalosis by excret- increase in urine potassium levels in-
clude acetazolamide, acetylsalicylic
ing potassium to retain hydrogen ions
acid, ammonium chloride, ben-
and increase acidity. In acidosis, the droflumethiazide, carbenoxolone,
body excretes hydrogen ions and chlorthalidone, citrates, clopamide,
retains potassium. Analyzing these corticosteroids, cortisone, desoxycorti-
urinary levels can provide important costerone, dexamethasone, diuretics,
clues to the functioning of the dopamine, ethacrynic acid, glycyrrhiza,
kidneys and other major organs. intra-amniotic saline, mefruside, nia-
Urine potassium tests usually involve cinamide, some oral contraceptives,
timed urine collections over a 12- or thiazides, triflocin, and viomycin.
24-hour period. Measurement of • Drugs that can cause a decrease in
random specimens also may be urine potassium levels include alanine,
requested. ■ amiloride, anesthetic agents, cyclo-
sporine, felodipine, levarterenol, and
INDICATIONS: ramipril.
• Determine the potential cause of renal
• A dietary deficiency or excess of potas-
calculi
sium can lead to spurious results.
• Evaluate known or suspected endo-
• Diuretic therapy with excessive loss of
crine disorder
electrolytes into the urine may falsely
• Evaluate known or suspected renal elevate results.
disease
• Evaluate malabsorption disorders tion period must be included in the
collection or else falsely decreased
RESULT values may be obtained. Compare
output records with volume collected
Increased in: to verify that all voids were included in
• Albright-type renal disease the collection.
• Hyperaldosteronism • Potassium levels are subject to diurnal
variation (output being highest at
night), which is why 24-hour collec-
• Diabetic ketoacidosis tions are recommended.
Potassium, Urine 817
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: Appendix A.
➤ Obtain a history of the patient’s Random specimen (collect in

complaints, including a list of known early morning):
allergens.
➤ Obtain a history of the patient’s Clean-catch specimen:
genitourinary systems, as well as ➤ Instruct the male patient to (1) thor-
results of previously performed oughly wash his hands, (2) cleanse
tests and procedures. For related the meatus, (3) void a small amount
tests, refer to the endocrine, into the toilet, and (4) void directly
gastrointestinal, and genitourinary into the specimen container.
system tables. ➤ Instruct the female patient to (1)
➤ Obtain a list of the 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.
consideration when reviewing Indwelling catheter:
results.
➤ Put on gloves. Empty drainage tube
➤ There are no food, fluid, or medica- of urine. It may be necessary to
tion restrictions unless by medical clamp off the catheter for 15 to 30
direction. minutes before specimen collection.
➤ Review the procedure with the Cleanse specimen port with antisep-
patient. Provide a nonmetallic urinal, tic swab, and then aspirate 5 mL of
bedpan, or toilet-mounted collection urine with a 21- to 25-gauge needle
device. and syringe. Transfer urine to a ster-
➤ Usually a 24-hour time frame for ile container.
Timed specimen:
saved during that 24-hour period. ➤ Obtain a clean 3-L urine specimen
Instruct the patient not to void container, toilet-mounted collection
directly into the laboratory collection device, and plastic bag (for transport
container. Instruct the patient to of the specimen container). The
avoid defecating in the collection specimen must be refrigerated or
device and to keep toilet tissue out kept on ice throughout the entire
of the collection device to prevent collection period. If an indwelling
contamination of the specimen. urinary catheter is in place, the
Place a sign in the bathroom to drainage bag must be kept on ice.
remind the patient to save all urine. ➤ Begin the test between 6 and 8
➤ Instruct the patient to void all urine a.m., if possible. Collect first voiding
into the collection device and then to and discard. Record the time the
pour the urine into the laboratory specimen was discarded as the
collection container. Alternatively beginning of the timed collection
the specimen can be left in the period. The next morning, ask the
collection device for a health care patient to void at the same time the
staff member to add to the labora- collection was started and add this
tory collection container. last voiding to the container.
➤ If an indwelling catheter is in place, loss, or risk of injury related to an

replace the tubing and container alteration in body chemistry.
system at the start of the collection ➤ Increased potassium levels may
time. Keep the container system on be associated with dehydration.
ice during the collection period, or Evaluate the patient for signs
empty the urine into a larger and symptoms of dehydration.
container periodically during the Dehydration is a significant and
collection period; monitor to ensure common finding in geriatric patients
continued drainage, and conclude and other patients in whom renal
the test the next morning at the function has deteriorated.
begun. ➤ Patients receiving digoxin or diuret-
ics should have potassium levels
➤ At the conclusion of the test, monitored carefully because cardiac
compare the quantity of urine arrhythmias can occur.
with the urinary output record for
the collection; if the specimen ➤ Observe the patient for signs and
contains less than what was symptoms of fluid-volume excess
recorded as output, some urine may related to excess potassium intake,
have been discarded, invalidating the fluid-volume deficit related to active
test. loss, or risk of injury related to
an alteration in body chemistry.
➤ Label the specimen, and promptly Symptoms include dehydration,
transport it to the laboratory. Include diarrhea, vomiting, or prolonged
on the label the amount of urine, anorexia. Instruct the patient in elec-
test start and stop times, and inges- trolyte replacement therapy and
tion of any foods or medications that changes in dietary intake that affect
can affect test results. electrolyte levels.
Post-test: ➤ Increased urine potassium levels
may be associated with the forma-
➤ There are no recommended dietary tion of kidney stones. Educate the
allowances established for potas- patient, if appropriate, on the impor-
sium, but the estimated minimum tance of drinking a sufficient amount
intake for adults is 200 mEq/d. of water when kidney stones are
Potassium is present in all plant and suspected.
animal cells, making dietary re- ➤ Evaluate test results in relation to
placement simple to achieve in the the patient’s symptoms and other
potassium-deficient patient. tests performed. Related laboratory
➤ Observe the patient for signs and tests include aldosterone, kidney
symptoms of fluid-volume excess stone analysis, osmolality, serum
related to excess potassium intake, potassium, renin, and serum and
fluid-volume deficit related to active urine sodium.
PREALBUMIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Transthyretin.
Prealbumin 819

SI Units
Newborn–1 mo 7.0–39.0 mg/dL 70–390 mg/L
1–6 mo 8.3–34.0 mg/dL 83–340 mg/L
6 mo–4 y 2.0–36.0 mg/dL 20–360 mg/L
5–6 y 12.0–30.0 mg/dL 120–300 mg/L
6 y–adult 12.0–42.0 mg/dL 120–420 mg/L
DESCRIPTION: Prealbumin is a levels include anabolic steroids, anti-

protein primarily produced by the convulsants, danazol, oral contracep-
liver. It is the major transport protein tives, prednisolone, prednisone, and
for triiodothyronine and thyroxine. It propranolol.
is also important in the metabolism of • Drugs that may decrease prealbumin
retinol-binding protein, which is levels include amiodarone and diethyl-
needed for transporting vitamin A stilbestrol.
(retinol). Prealbumin has a short • Fasting 4 hours before specimen collec-
biological half-life of 2 days. This tion is highly recommended. Reference
makes it a good indicator of protein ranges are often based on fasting
status and an excellent marker for populations to provide some level of
malnutrition. Prealbumin is often standardization for comparison. The
measured simultaneously with trans- presence of lipids in the blood may also
ferrin and albumin. ■ interfere with the test method; fasting
eliminates this potential source of
INDICATIONS: Evaluate nutritional status error, especially if the patient has
elevated lipid levels.
RESULT
Increased in: Nursing Implications and
• Alcoholism Procedure ● ● ● ● ● ● ● ● ● ● ●
• Chronic renal failure Pretest:

• Patients receiving steroids ➤ Obtain a history of the patient’s
Decreased in: allergens.
• Acute-phase inflammatory response ➤ Obtain a history of the patient’s
• Diseases of the liver hepatobiliary systems, as well as
• Hepatic damage results of previously performed
• Malnutrition tests, refer to the endocrine,
gastrointestinal, and hepatobiliary
• Tissue necrosis system tables.
CRITICAL VALUES: N/A patient is taking, including herbs,
INTERFERING FACTORS: nutraceuticals. The requesting health
• Drugs that may increase prealbumin care practitioner and laboratory
should be advised if the patient and collect the specimen in a 5-mL

regularly uses these products so red- or tiger-top tube.
that their effects can be taken into ➤ Label the specimen, and promptly
consideration when reviewing transport it to the laboratory.
results.
➤ Instruct the patient to fast for 4 Post-test:
hours before specimen collection.
➤ There are no fluid or medication ing or hematoma formation. Apply
restrictions unless by medical direc- pressure bandage.
tion.
➤ Nutritional therapy may be indicated
➤ Review the procedure with the for patients with decreased prealbu-
patient. min levels. Educate the patient,
➤ Inform the patient that specimen as appropriate, that good dietary
collection takes approximately 5 to sources of complete protein
10 minutes. (containing all eight essential amino
acids) include meat, fish, eggs, and
Intratest: dairy products; and that good
sources of incomplete protein (lack-
➤ Direct the patient to breathe ing one or more of the eight essen-
normally and to avoid unnecessary tial amino acids) include grains, nuts,
movement. legumes, vegetables, and seeds.
➤ Ensure that the patient has complied ➤ Evaluate test results in relation to
with dietary preparations and other the patient’s symptoms and other
pretesting restrictions. tests performed. Related laboratory
➤ Observe standard precautions and tests include albumin, chloride,
follow the general guidelines in ferritin, iron/total iron-binding capac-
Appendix A. Perform a venipuncture, ity, potassium, protein, and sodium.
PROCTOSIGMOIDOSCOPY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Anoscopy (anal canal), proctoscopy (rectum),

sigmoidoscopy (sigmoid colon), flexible fiberoptic sigmoidoscopy, flexible
proctosigmoidoscopy.
AREA OF APPLICATION: Anus, rectum, colon.

CONTRAST: Air.
DESCRIPTION: Proctosigmoidoscopy procedure can be performed using a

allows direct visualization of the rigid or flexible fiberoptic endoscope,
mucosa of the anal canal (anoscopy), but the flexible instrument is gener-
rectum (proctoscopy), and distal ally preferred. The endoscope is a
sigmoid colon (sigmoidoscopy). The multichannel device allowing visuali-
Proctosigmoidoscopy 821
zation of the mucosal lining of the • Remove hemorrhoids by laser therapy

colon, instillation of air, removal of • Screen for colon cancer
fluid and foreign objects, obtaining of
tissue biopsy specimens, and use of a RESULT
laser for the destruction of tissue and
control of bleeding. The endoscope Normal Findings:
is advanced approximately 60 cm • Normal mucosa of the anal canal,
into the colon. This procedure is rectum, and sigmoid colon
commonly used in patients with
lower abdominal and perineal pain; Abnormal Findings:
changes in bowel habits; rectal • Anal fissure or fistula
prolapse during defecation; or passage • Anorectal abscess
of blood, mucus, or pus in the
• Bleeding sites
stool. Proctosigmoidoscopy can also
be a therapeutic procedure, allowing • Benign lesions
removal of polyps or hemorrhoids or • Bowel infection or inflammation
reduction of a volvulus. Biopsy speci-
mens of suspicious sites may be
obtained during the procedure. This • Diverticula
procedure is recommended for • Hypertrophic anal papillae
patients who are more than 50 years
old as part of a routine screening for • Internal and external hemorrhoids
colorectal cancer. ■ • Polyps
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
• 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
abdominal aortic or iliac aneurysm, ➤ Obtain a list of medications the

and coagulation abnormality patient is taking, including herbs,
nutraceuticals.
imaging: ➤ Obtain a history of GI disorders,
• Inability of the patient to cooperate or noting any information relating to
lower bowel, anal, rectal, or coagula-
remain still during the procedure tion disorders and use of drugs that
because of age, significant pain, or affect bleeding, such as aspirin and
mental status other salicylates. For related tests,
• Patients who are very obese, who may refer to the gastrointestinal system
table.
ment ➤ Obtain the results of laboratory tests
(particularly hematologic or coagula-
• Incorrect positioning of the patient, tion tests), treatments, surgeries,
which may produce poor visualization and procedures done to diagnose or
of the area to be examined treat disorders of the intestinal
system.
• Strictures or other abnormalities
preventing passage of the scope for the procedure from the patient.
• Barium swallow or upper gastrointesti- ➤ Determine date of last menstrual
nal (GI) series within the preceding 48 period and possibility of pregnancy
hours in perimenopausal women.
• Severe lower GI bleeding or the pres- ➤ Inform the patient that the urge to
ence of feces, barium, blood, or blood defecate may be experienced when
the scope is passed. Encourage
clots slow, deep breathing through the
mouth to help alleviate the feeling.
➤ Inform the patient that flatus may be
• Failure to follow dietary restrictions expelled during and after the proce-
before the procedure may cause the dure owing to air that is injected into
procedure to be canceled or repeated. the scope to improve visualization.
• Use of bowel preparations that include ➤ Note intake of oral iron preparations
laxatives or enemas should be avoided 1 week before the procedure
because these cause black, sticky
in pregnant patients or patients with feces that are difficult to remove
inflammatory bowel disease, unless with bowel preparation.
specifically directed by a physician.
barium because it can obscure the
area to be examined.
Nursing Implications and ➤ Inform the patient that it is important
Procedure ● ● ● ● ● ● ● ● ● ● ● the bowel be cleaned thoroughly so
that the physician can visualize the
Pretest: colon and that the patient will have
to take laxatives and receive enemas
➤ Explain to the patient the purpose of before the test. Ensure that ordered
the procedure and how it is laxative has been administered late
performed. in the afternoon of the day before
➤ Explain that the procedure is gener- the procedure.
ally performed in an endoscopy suite ➤ Restrict the diet to clear liquids for
by a physician and support staff and 48 hours before beginning oral
usually takes 15 to 30 minutes. bowel preparation.
Proctosigmoidoscopy 823
Intratest: ➤ Photographs are obtained for future

reference.
procedure. Have the patient put on a ➤ At the end of the procedure, the
hospital gown. scope is completely withdrawn, and
residual lubricant is cleansed from
➤ Two small-volume enemas are
the anal area.
administered 1 hour before the
procedure. ➤ Wear gloves and gowns throughout
the procedure.
➤ The patient is placed on an examina-
tion table in the left lateral decubitus
position or the knee-chest position Post-test:
and draped with the buttocks
exposed. The buttocks are placed at ➤ Instruct the patient to resume
or extending slightly beyond the normal activity, medication, and diet
edge of the examination table or after the procedure, unless other-
bed, preferably on a special examin- wise indicated.
ing table that tilts the patient into the ➤ Monitor for any rectal bleeding.
desired position. Instruct the patient to expect slight
➤ The physician visually inspects the rectal bleeding for 2 days after
perianal area and then performs a removal of polyps or biopsy speci-
digital rectal examination with a mens, but that heavy rectal bleeding
well-lubricated, gloved finger. A fecal must be immediately reported to the
specimen may be obtained from the physician.
glove when the finger is removed ➤ Emphasize that any abdominal pain,
from the rectum. tenderness, or distention; pain on
➤ A lubricated anoscope (7 cm in defecation; or fever must be
length) is inserted, and the anal reported to the physician immedi-
canal is inspected (anoscopy). The ately.
anoscope is removed, and a lubri- ➤ Inform the patient that any bloating
cated proctoscope (27 cm in length) or flatulence is the result of air insuf-
or flexible sigmoidoscope (35 to 60 flation.
cm in length) is inserted.
➤ Encourage the patient to drink
➤ The scope is manipulated gently to
several glasses of water to help
facilitate passage, and air may be
replace fluid lost during test prepara-
insufflated through the scope to
tion.
improve visualization. Suction and
cotton swabs also are used to ➤ A physician specializing in this
remove materials that hinder visuali- branch of medicine sends a written
zation. Examination is done as the report to the ordering provider, who
scope is gradually withdrawn. discusses the results with the
➤ The patient is instructed to take patient.
deep breaths to aid in movement of ➤ Inform the patient that further exam-
the scope downward through the inations may be necessary to evalu-
ascending colon to the cecum and ate progression of the disease
into the terminal portion of the process or to determine the need for
ileum. a change in therapy.
➤ Air is insufflated to distend the GI ➤ Evaluate test results in relation to
tract, as needed. Biopsy specimens, the patient’s symptoms and other
cultures, or any exudate may be tests performed. Related diagnostic
obtained. tests include kidney, ureter, and
➤ Polyps or tissue is removed and bladder (KUB) film; and ultrasound,
placed in appropriate specimen positron emission tomography, com-
containers, labeled properly, and puted tomography, and magnetic
sent to the laboratory. resonance imaging of the pelvis.
PROGESTERONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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
DESCRIPTION: Progesterone is a • Identify patients at risk for ectopic

female sex hormone. Its function is to pregnancy and assessment of corpus
prepare the uterus for pregnancy and luteum function
the breasts for lactation. Progesterone
• Monitor patients ovulating during
testing can be used to confirm human chorionic gonadotropin
that ovulation has occurred and to (HCG), human menopausal
assess the functioning of the corpus gonadotropin, follicle-stimulating
luteum. Serial measurements can be hormone/luteinizing hormone–
performed to help determine the day releasing hormone, or clomiphene
of ovulation. ■ induction (serial measurements can
assist in pinpointing the day of ovula-
INDICATIONS: tion)
• Assist in the diagnosis of luteal phase
defects (performed in conjunction • Monitor patients receiving
with endometrial biopsy) progesterone-replacement therapy
• Evaluate patients at risk for early or
spontaneous abortion RESULT
Progesterone 825
Increased in: herbs, nutritional supplements, and

• Chorioepithelioma of the ovary nutraceuticals. The requesting health
• Congenital adrenal hyperplasia should be advised if the patient
• Hydatidiform mole that their effects can be taken into
• Lipoid ovarian tumor consideration when reviewing
results.
• Theca lutein cyst ➤ Note any recent procedures that
may interfere with test results.
Decreased in:
• Galactorrhea-amenorrhea syndrome tion restrictions unless by medical
• Primary or secondary hypogonadism direction.
• Short luteal phase syndrome patient. Inform the patient that
• Threatened abortion multiple specimens may be
required.
10 minutes.
• Drugs that may increase progesterone Intratest:
levels include clomiphene, corti-
cotropin, hydroxyprogesterone, keto- ➤ Direct the patient to breathe
conazole, mifepristone, progesterone, normally and to avoid unnecessary
movement.
tamoxifen, and valproic acid.
• Drugs that may decrease progesterone follow the general guidelines in
levels include ampicillin, epostane, Appendix A. Perform a venipuncture,
goserelin, leuprolide, and prosta- and collect the specimen in a 5-mL
glandin F2. red- or tiger-top tube.
• Recent radioactive scans or radiation transport it to the laboratory.
fere with test results when radioim- Post-test:
pressure bandage.
Procedure ● ● ● ● ● ● ● ● ● ● ●
results and provide support. Provide
Pretest: the clinical implications of the
test results, as appropriate. Inform
➤ Obtain a history of the patient’s the patient, as appropriate, of the
complaints, including a list of known potential outcome based on test
allergens. results and offer grief counseling.
➤ Obtain a history of the patient’s Encourage the patient to discuss
endocrine and reproductive sys- additional alternatives for becoming
tems, as well as results of previously a parent with her health care
performed tests and procedures. provider.
For related tests, refer to the ➤ Evaluate test results in relation to
endocrine and reproductive system the patient’s symptoms and other
tables. tests performed. Related laboratory
➤ Obtain a list of the medications tests include HCG, estradiol, and
the patient is taking, including prolactin.
PROLACTIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Luteotropic hormone, lactogenic hormone, lacto-

gen, HPRL, PRL.
SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube. Specimen

should be transported tightly capped and in an ice slurry.
SI Units
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
DESCRIPTION: Prolactin is secreted • Assist in the diagnosis of suspected

by the pituitary gland. It is unique tumor involving the lungs or kidneys
among hormones in that it responds (elevated levels indicating ectopic
to inhibition by the hypothalamus prolactin production)
rather than to stimulation. The only • Evaluate failure of lactation in the
known function of prolactin is to postpartum period
induce milk production in female
• Evaluate suspected postpartum
breasts that are already stimulated by
hypophyseal infarction (Sheehan’s
high estrogen levels. When milk syndrome), as indicated by decreased
production is established, lactation levels
can continue without elevated
prolactin levels. Prolactin levels rise • Evaluate sexual dysfunction of
late in pregnancy, peak with the initi- unknown cause in men and women
ation of lactation, and surge each
time a woman breastfeeds. The func-
RESULT
tion of prolactin in males is Increased in:
unknown. ■ • Adrenal insufficiency
INDICATIONS: • Amenorrhea
• Assist in the diagnosis of primary
hypothyroidism, as indicated by
elevated levels • Breastfeeding
Prolactin 827
• Chiari-Frommel and Argonz–Del releasing hormone, trifluoperazine,

Castillo syndromes trimipramine, tumor necrosis
factor, veralipride, verapamil, and
• Chest wall injury
zometapine.
• Chronic renal failure
• Drugs and hormones that may de-
• Ectopic prolactin-secreting tumors crease prolactin levels include anticon-
(e.g., lung, kidney) vulsants, apomorphine, bromocriptine,
• Galactorrhea cabergoline, calcitonin, cyclosporine,
dexamethasone, dopamine, D-Trp-6-
• Hypothalamic and pituitary disorders LHRH, levodopa, metoclopramide,
• Hypothyroidism (primary) morphine, nifedipine, octreotide, per-
golide, ranitidine, rifampin, ritanserin,
• Insulin-induced hypoglycemia ropinirole, secretin, thyroid hormones,
• Liver failure and terguride.
• Pituitary tumor • Episodic elevations can occur in re-

sponse to sleep, stress, exercise, hypo-
• Polycystic ovary (Stein-Leventhal) glycemia, and breastfeeding.
syndrome
• Venipuncture can cause falsely elevated
• Pregnancy levels.
• Surgery (pituitary stalk section) • Prolactin secretion is subject to diurnal
variation, with highest levels occurring
Decreased in: in the morning.
• Sheehan’s syndrome

• Drugs and hormones that may increase

prolactin levels include amitryptyline, Pretest:
amoxapine, arginine, azosemide, ➤ Obtain a history of the patient’s
benserazide, butaperazine, butor- complaints, including a list of known
phanol, carbidopa, chlorophenylpiper- allergens.
azine, chlorpromazine, cimetidine, ➤ Obtain a history of the patient’s en-
clomipramine, desipramine, diethyl- docrine and reproductive systems,
stilbestrol, -endorphin, enflurane, as well as results of previously per-
fenfluramine, fenoldopam, flunarizine, formed tests and procedures. For re-
fluphenazine, growth hormone– lated tests, refer to the endocrine
releasing hormone, imipramine, in- and reproductive system tables.
sulin, interferon-, labetalol, loxapine, ➤ Obtain a list of medications the pa-
megestrol, mestranol, methyldopa, tient is taking, including herbs, nutri-
metoclopramide, molindone, mor- tional supplements, and nutraceuti-
phine, nitrous oxide, oral contracep- practitioner and laboratory should be
tives, oxcarbazepine, parathyroid hor- advised if the patient regularly uses
mone, pentagastrin, perphenazine, these products so that their effects
phenothiazines, phenytoin, pimozide, can be taken into consideration
prochlorperazine, promazine, raniti- when reviewing results.
dine, remoxipride, reserpine, sulpiride, ➤ There are no fluid or medication
sultopride, thiethylperazine, thiori- restrictions unless by medical direc-
dazine, thiothixene, thyrotropin- tion.
➤ The patient should fast for 12 hours Appendix A. Perform a venipuncture,

before specimen collection. and collect the specimen in a
➤ Review the procedure with the prechilled 5-mL red- or tiger-top
patient. tube.
➤ Inform the patient that specimen ➤ Label the specimen, and promptly
collection takes approximately 5 to transport it to the laboratory. The
10 minutes. specimen should be placed in an ice
slurry immediately after collection.
➤ Prepare an ice slurry in a cup or plas- Information on the specimen label
tic bag to have on hand for immedi- can be protected from water in the
ate transport of the specimen to the ice slurry if the specimen is first
laboratory. placed in a protective plastic bag.
Intratest:
Post-test:
➤ Specimen collection should occur
between 8 and 10 a.m. ➤ Observe venipuncture site for bleed-
➤ Ensure that the patient has complied pressure bandage.
pretesting restrictions. ➤ Evaluate test results in relation to
➤ Direct the patient to breathe tests performed. Related laboratory
normally and to avoid unnecessary tests include dehydroepiandros-
movement. terone, estradiol, follicle-stimulating
➤ Observe standard precautions and hormone, human chorionic gonado-
follow the general guidelines in tropin, and luteinizing hormone.
PROSTATE-SPECIFIC ANTIGEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: PSA.
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
DESCRIPTION: Prostate-specific anti- periurethral, and perirectal glands.

gen (PSA) is produced exclusively by Used in conjunction with the digital
the epithelial cells of the prostate, rectal examination, PSA is a useful
Prostate-Specific Antigen 829
test for monitoring adenocarcinoma

of the prostate. PSA circulates in a
free and bound (complexed) form. A
Procedure ● ● ● ● ● ● ● ● ● ● ●
low ratio of free to complexed PSA

Pretest:
(i.e., less than 10 percent) is sugges-
tive of prostate cancer; a ratio of ➤ Obtain a history of the patient’s
greater than 30 percent is rarely asso-
allergens.
ciated with prostate cancer. Serial
measurements are often performed
genitourinary, immune, and repro-
before and after surgery. Important ductive systems, as well as results
note: When following patients using of previously performed tests and
serial testing, use the same method of procedures. For related tests, refer
measurement consistently. ■ to the genitourinary, immune, and
INDICATIONS: ➤ Obtain a list of medications the
• Evaluate the effectiveness of treatment patient is taking, including herbs,
for prostate cancer (prostatectomy):
Levels decrease if treatment is effective; care practitioner and laboratory
rising levels are associated with recur- should be advised if the patient
rence and a poor prognosis. regularly uses these products so
• Investigate or evaluate an enlarged consideration when reviewing
prostate gland, especially if prostate results.
cancer is suspected.
• Stage prostate cancer. tion restrictions unless by medical
direction.
RESULT ➤ Review the procedure with the
patient.
Increased in: ➤ Inform the patient that specimen
• Benign prostatic hypertrophy collection takes approximately 5 to
10 minutes.
• Prostate cancer
• Prostatic infarct Intratest:
• Urinary retention ➤ Direct the patient to breathe

movement.
Decreased in: N/A
INTERFERING FACTORS: red- or tiger-top tube.
• Drugs that decrease PSA levels include ➤ Label the specimen, and promptly
buserelin, finasteride, and flutamide. transport it to the laboratory.
• Specimens should not be collected for
at least 4 weeks after digital rectal Post-test:
examination, biopsy, or other manipu- ➤ Observe venipuncture site for bleed-
lation of the prostate or else results may ing or hematoma formation. Apply
be falsely increased. pressure bandage.
➤ Recognize anxiety related to test dysfunction related to altered body

results and offer support. Provide function, drugs, or radiation may
teaching and information regarding occur.
the clinical implications of the ➤ Evaluate test results in relation to
test results. Educate the patient the patient’s symptoms and other
regarding access to counseling serv- tests performed. Related laboratory
ices, as appropriate. Counsel the tests include prostate biopsy and
patient, as appropriate, that sexual prostatic acid phosphatase.
PROTEIN C
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Protein C antigen, protein C functional.

REFERENCE VALUE: (Method: Chromogenic) 70 to 140 percent activity
(0.7–1.4 U/mL). Values are significantly reduced in children (0.4 to 1.1
U/mL) because of liver immaturity.
DESCRIPTION: Protein C is a vitamin Type II: Normal antigen but

K–dependent protein that originates decreased function, detected
in the liver and circulates in plasma. only by a functional assay
Protein C activation occurs on throm- Functional assays are recom-
bomodulin receptors on the endothe- mended for initial evaluation because
lial cell surface. Thrombin bound to of their greater sensitivity. ■
thrombomodulin receptors preferen-
INDICATIONS:
tially activates protein C. Freely circu- • Differentiate inherited deficiency from
lating thrombin mainly converts acquired deficiency
fibrinogen to fibrin. Other steps in
the activation process require calcium • Investigate the mechanism of idio-
pathic venous thrombosis
and protein S cofactor binding (see
monographs titled “Protein S” and RESULT
“Fibrinogen”). Activated protein C
exhibits potent anticoagulant effects Increased in: N/A
by degrading activated factors V and
VIII. There are two types of protein C Decreased in:
deficiency: • Congenital deficiency
Type I: Decreased antigen and • Liver disease
function, detected by
functional and antigenic assays • Oral anticoagulant therapy
Protein C 831
CRITICAL VALUES: N/A nutraceuticals. The requesting health

INTERFERING FACTORS: regularly uses these products so
• Drugs that may increase protein C that their effects can be taken into
levels include desmopressin and oral consideration when reviewing
contraceptives. results.
• Drugs that may decrease protein C ➤ There are no food, fluid, or medica-
levels include warfarin (Coumadin) tion restrictions unless by medical
and coumarin. direction.
• Placement of tourniquet for longer patient.
than 1 minute can result in venous
stasis and changes in the concentration collection takes approximately 5 to
of plasma proteins to be measured. 10 minutes.
under these conditions, causing erro- Intratest:
neous results.
• Vascular injury during phlebotomy can normally and to avoid unnecessary
activate platelets and coagulation movement.
factors, causing erroneous results. ➤ Observe standard precautions and
• Hemolyzed specimens must be rejected Appendix A. Perform a venipuncture,
because hemolysis is an indication of and collect the specimen in a 5-mL
platelet and coagulation factor activa- blue-top tube. Important note: Two
tion. different concentrations of sodium
• Incompletely filled tubes contaminated added to blue-top tubes for coagula-
with heparin or clotted specimens tion studies: 3.2% and 3.8%. The
must be rejected. National Committee for Clinical
Laboratory Standards (NCCLS)
with optical testing methods, produc- Laboratories establish reference
ing erroneous results. ranges for coagulation testing based
sodium citrate concentration, test
Nursing Implications and equipment, and test reagents. It is
Procedure ● ● ● ● ● ● ● ● ● ● ●
important to inquire from the labora-
tory which concentration it recom-
Pretest: mends, because each concentration
will have its own specific reference
➤ Obtain a history of the patient’s range.
complaints, including a list of known ➤ When multiple specimens are
allergens. drawn, the blue-top tube should be
➤ Obtain a history of the patient’s collected after sterile (i.e., blood
hematopoietic and hepatobiliary culture) and red-top tubes. When
systems, as well as results of previ- coagulation testing is the only work
ously performed tests and proce- to be done, an extra red-top tube
dures. For related tests, refer to the should be collected before the blue-
hematopoietic and hepatobiliary top tube to avoid contaminating the
system tables. specimen with tissue thromboplas-
➤ Obtain a list of medications the tin, which can falsely decrease
patient is taking, including herbs, values.
nutritional supplements, and ➤ Label the specimen, and promptly
transport it to the laboratory. The ing or hematoma formation. Apply

NCCLS recommendation for pro- pressure bandage.
cessed and unprocessed specimens ➤ Evaluate test results in relation to
stored in unopened tubes is that the patient’s symptoms and other
testing should be completed within tests performed. Related laboratory
1 to 4 hours of collection. tests include anticardiolipin antibody,
antithrombin III, complete blood
Post-test: count, factor V, fibrin degradation
products, fibrinogen, lupus anticoag-
➤ Observe venipuncture site for bleed- ulant, and protein S.
PROTEIN S
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Protein S antigen, protein S functional.

REFERENCE VALUE: (Method: Clot detection)
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.
DESCRIPTION: Protein S is a vitamin Type I: Decreased antigen and

K–dependent protein that originates function, detected by
in the liver and circulates in functional and antigenic assays
plasma. It is a cofactor required Type II: Normal antigen but
for the activation of protein C decreased function, detected
only by a functional assay
(see monographs titled “Protein
Functional assays are recom-
C” and “Fibrinogen”). Protein S
mended for initial evaluation because
exists in two forms, free (biologically
of their greater sensitivity. ■
active) and bound. Approximately
40 percent of protein S circulates
in the free form; the remainder is INDICATIONS: Investigate the cause of
bound and is functionally inactive. hypercoagulable states
There are two types of protein S
deficiency: RESULT
Protein S 833
Increased in: N/A complaints, including a list of known

allergens.
Decreased in: ➤ Obtain a history of the patient’s
• Chronic renal failure due to hyperten- hematopoietic and hepatobiliary
sion systems, as well as results of previ-
• Congenital deficiency dures. For related tests, refer to the
hematopoietic and hepatobiliary
• Coumarin-induced skin necrosis system tables.
• Diabetic neuropathy ➤ Obtain a list of medications the
• Disseminated intravascular coagula- nutritional supplements, and
tion nutraceuticals. The requesting health
• Liver disease care practitioner and laboratory
• Oral anticoagulant therapy regularly uses these products so
CRITICAL VALUES: N/A into consideration when reviewing
results.
• Drugs that may decrease protein S tion restrictions unless by medical
levels include oral contraceptives, direction.
warfarin (Coumadin), and coumarin. ➤ Review the procedure with the
• Placement of tourniquet for longer patient.
than 1 minute can result in venous ➤ Inform the patient that specimen
stasis and changes in the concentration collection takes approximately 5 to
of plasma proteins to be measured. 10 minutes.
under these conditions, causing erro- Intratest:
neous results. ➤ Direct the patient to breathe
• Vascular injury during phlebotomy can normally and to avoid unnecessary
activate platelets and coagulation movement.
factors, causing erroneous results. ➤ Observe standard precautions and
• Hemolyzed specimens must be rejected Appendix A. Perform a venipuncture,
because hemolysis is an indication of and collect the specimen in a 5-mL
platelet and coagulation factor activa- blue-top tube. Important note: Two
tion. different concentrations of sodium
• Incompletely filled tubes contaminated added to blue-top tubes for coagula-
with heparin or clotted specimens tion studies: 3.2% and 3.8%. The
must be rejected. National Committee for Clinical
• Icteric or lipemic specimens interfere Laboratory Standards (NCCLS)
with optical testing methods, produc- Laboratories establish reference
ing erroneous results. ranges for coagulation testing based
sodium citrate concentration, test
Nursing Implications and equipment, and test reagents. It is
Procedure ● ● ● ● ● ● ● ● ● ● ● important to inquire from the labora-
tory which concentration it recom-
Pretest: mends, because each concentration
will have its own specific reference
➤ Obtain a history of the patient’s range.
➤ When multiple specimens are testing should be completed within

drawn, the blue-top tube should be 1 to 4 hours of collection.
culture) and red-top tubes. When Post-test:
coagulation testing is the only work
to be done, an extra red-top tube ➤ Observe venipuncture site for bleed-
should be collected before the blue- ing or hematoma formation. Apply
top tube to avoid contaminating the pressure bandage.
specimen with tissue thromboplas- ➤ Evaluate test results in relation to
tin, which can falsely decrease the patient’s symptoms and other
values. tests performed. Related laboratory
➤ Label the specimen, and promptly tests include anticardiolipin antibody,
transport it to the laboratory. The antithrombin III, complete blood
NCCLS recommendation for pro- count, fibrin degradation products,
cessed and unprocessed specimens fibrinogen, lupus anticoagulant, and
stored in unopened tubes is that protein C.
PROTEIN, URINE: TOTAL

QUANTITATIVE AND FRACTIONS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
REFERENCE VALUE: (Method: Spectrophotometry for total protein, elec-

trophoresis for protein fractions)
SI Units
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.)
DESCRIPTION: Most proteins, with ketoacids. Ammonia is converted to

the exception of the immunoglobu- urea via the urea cycle. Urea is
lins, are synthesized and catabolized excreted in the urine. ■
in the liver, where they are broken
down into amino acids. The amino INDICATIONS:
acids are converted to ammonia and • Assist in the diagnosis of myeloma,
Protein, Urine: Total Quantitative and Fractions 835
Waldenström’s macroglobulinemia, gold, hydrogen sulfide, iodoalphionic

lymphoma, and amyloidosis acid, iodopyracet, iopanoic acid,
iophenoxic acid, ipodate, kanamycin,
• Assist in the detection of Bence Jones
corn oil (Lipomul), lithium, mefe-
proteins (light chains)
namic acid, melarsonyl, melarsoprol,
• Evaluate kidney function mercury compounds, methicillin,
methylbromide, meziocillin, mito-
RESULT mycin, nafcillin, naphthalene,
neomycin, nonsteroidal anti-
Increased in: inflammatory drugs, oxacillin, paralde-
• Postexercise period hyde, penicillamine, penicillin,
phenols, phenolphthalein, phensux-
• Diabetic nephropathy imide, phosphorus, picric acid,
• Fanconi’s syndrome piperacillin, plicamycin, polymyxin,
probenecid, promazine, pyrazolones,
• Heavy metal poisoning quaternary ammonium compounds,
• Malignancies of the urinary tract radiographic agents, rifampin, sodium
bicarbonate, streptokinase, sulfisoxa-
• Monoclonal gammopathies zole, suramin, tetracyclines, thallium,
• Multiple myeloma thiosemicarbazones, tolbutamide,
tolmetin, triethylenemelamine, and
• Nephrotic syndrome vitamin D.
• Other myeloproliferative and lympho- • Drugs that may decrease urine protein
proliferative disorders levels include captopril, cyclosporine,
• Sarcoidosis diltiazem, enalapril, fosinopril, inter-
feron, lisinopril, prednisolone, and
• Sickle cell disease quinapril.
• Urinary tract infections • All urine voided for the timed collec-
tion period must be included in the
Decreased in: N/A collection or else falsely decreased
values may be obtained. Compare
CRITICAL VALUES: N/A output records with volume collected
to verify that all voids were included in
INTERFERING FACTORS: the collection.
increase urine protein levels include
acetaminophen, aminosalicylic acid, Nursing Implications and
amphotericin B, ampicillin, antimony Procedure ● ● ● ● ● ● ● ● ● ● ●
compounds, antipyrine, arsenicals,

ascorbic acid, bacitracin, bismuth Pretest:
subsalicylate, bromate, capreomycin, ➤ Obtain a history of the patient’s
captopril, carbamazepine, carbarsone, complaints, including a list of known
carbenoxolone, carbutamide, cephalo- allergens.
glycin, cephaloridine, chlorpromazine, ➤ Obtain a history of the patient’s
chlorpropamide, chlorthalidone, genitourinary and immune systems,
chrysarobin, colistimethate, colistin, as well as results of previously
corticosteroids, cyclosporine, demeclo- performed tests and procedures. For
cycline, 1,2-diaminopropane, diatri- related tests, refer to the genitouri-
zoic acid, dihydrotachysterol, nary and immune system tables.
doxycycline, enalapril, gentamicin, ➤ Obtain a list of medications the
patient is taking, including herbs, ➤ Instruct the female patient to (1)

nutritional supplements, and thoroughly wash her hands; (2)
nutraceuticals. The requesting health cleanse the labia from front to back;
care practitioner and laboratory (3) while keeping the labia sepa-
should be advised if the patient rated, void a small amount into the
regularly uses these products so toilet; and (4) without interrupting
that their effects can be taken into the urine stream, void directly into
consideration when reviewing the specimen container.
results.
➤ There are no food, fluid, or medica- Indwelling catheter:
tion restrictions unless by medical ➤ Put on gloves. Empty drainage tube
direction. of urine. It may be necessary to
➤ Review the procedure with the clamp off the catheter for 15 to 30
patient. Provide a nonmetallic urinal, minutes before specimen collection.
bedpan, or toilet-mounted collection Cleanse specimen port with antisep-
device. tic swab, and then aspirate 5 mL of
➤ Usually a 24-hour time frame for urine with a 21- to 25-gauge needle
urine collection is ordered. Inform and syringe. Transfer urine to a ster-
the patient that all urine must ile container.
be saved during that 24-hour period.
Instruct the patient not to void Timed specimen:
directly into the laboratory collection ➤ Obtain a clean 3-L urine specimen
container. Instruct the patient container, toilet-mounted collection
to avoid defecating in the collection device, and plastic bag (for transport
device and to keep toilet tissue of the specimen container). The
out of the collection device to specimen must be refrigerated or
prevent contamination of the kept on ice throughout the entire
specimen. Place a sign in the bath- collection period. If an indwelling
room to remind the patient to save urinary catheter is in place, the
all urine. drainage bag must be kept on ice.
➤ Instruct the patient to void all urine ➤ Begin the test between 6 and 8
into the collection device and then to a.m., if possible. Collect first voiding
pour the urine into the laboratory and discard. Record the time the
collection container. Alternatively specimen was discarded as the
the specimen can be left in the beginning of the timed collection
collection device for a health care period. The next morning, ask the
staff member to add to the labora- patient to void at the same time the
tory collection container. collection was started and add this
Intratest: ➤ If an indwelling catheter is in place,
➤ Observe standard precautions and replace the tubing and container
follow the general guidelines in system at the start of the collection
Appendix A. time. Keep the container system on
Random specimen (collect in empty the urine into a larger
early morning): container periodically during the
collection period; monitor to ensure
Clean-catch specimen: the test the next morning at the
➤ Instruct the male patient to (1) thor- same hour the collection was
oughly wash his hands, (2) cleanse begun.
the meatus, (3) void a small amount ➤ At the conclusion of the test,
into the toilet, and (4) void directly compare the quantity of urine with
into the specimen container. the urinary output record for the
Prothrombin Time and International Normalized Ratio 837
collection; if the specimen contains Post-test:

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 include glucose, glycated
transport it to the laboratory. Include hemoglobin, serum and urine
on the label the amount of urine, immunofixation electrophoresis,
test start and stop times, and inges- microalbumin, serum and urine
tion of any foods or medications that osmolality, serum protein and frac-
can affect test results. tions, and urinalysis.
PROTHROMBIN TIME AND

INTERNATIONAL NORMALIZED RATIO
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SYNONYM/ACRONYM: Pro-time, PT.

REFERENCE VALUE: (Method: Clot detection) 10 to 13 seconds.

International normalized ratio (INR) 2.0 to 3.0 for patients receiving
treatment for venous thrombosis, pulmonary embolism, and valvular
heart disease.
INR 2.5 to 3.5 for patients with mechanical heart valves and/or receiving
treatment for recurrent systemic embolism.
DESCRIPTION: Prothrombin time INR using a standardized thrombo-

(PT) is a coagulation test performed plastin reagent to assist in making
to measure the time it takes for a firm decisions regarding oral anticoagula-
fibrin clot to form after tissue throm- tion therapy. Some inferences of
boplastin (factor III) and calcium are factor deficiency can be made by
added to the sample. It is used to comparison of results obtained from
evaluate the extrinsic pathway of the the activated partial thromboplastin
coagulation sequence in patients time (APTT) and PT tests. A normal
receiving oral warfarin or coumarin- APTT with a prolonged PT can
type anticoagulants. Prothrombin is a occur only with factor VII deficiency.
vitamin K–dependent protein pro- A prolonged APTT with a normal
duced by the liver; measurement is PT could indicate a deficiency in
reported as time in seconds or factors XII, XI, IX, and VIII as well as
percentage of normal activity. PT VIII:C (von Willebrand factor).
evaluation can now be based on an Factor deficiencies can also be identi-
fied by correction or substitution • Hereditary deficiencies of factors II, V,

studies using normal serum. These VII, and X
studies are easy to perform and are • Intravascular coagulation
accomplished by adding plasma from
a normal patient to a sample from a • Liver disease
suspected factor-deficient patient. • Poor fat absorption (tropical sprue,
When the PT is repeated and celiac disease, chronic diarrhea)
corrected, or within reference range, • Presence of circulating anticoagulant
it can be assumed that the prolonged
PT is due to a factor deficiency (see • Systemic lupus erythematosus
monograph titled “Coagulation • Vitamin K deficiency
Factors”). ■
Decreased in:
INDICATIONS: • Ovarian hyperfunction
• Differentiate between deficiencies of
clotting factors II, V, VII, and X, which • Regional enteritis or ileitis
prolong the PT; and congenital coagu-
lation disorders, such as hemophilia A
CRITICAL VALUES:
(factor VIII) and hemophilia B (factor Greater than 20 seconds
(uncoagulated)
IX), which do not alter the PT
Three times normal control
• Evaluate the response to anticoagulant (anticoagulated)
therapy with coumarin derivatives and Important signs to note are prolonged
determine dosage required to achieve bleeding, hematoma at the puncture site,
therapeutic results hemorrhage, blood in stool, bleeding
• Identify the possible cause of abnormal gums, and shock. Monitoring vital signs
bleeding, such as epistaxis, hematoma, and neurologic changes until PT is
gingival bleeding, hematuria, and within normal range is indicated.
menorrhagia Administration of vitamin K, a potent
anticoagulant, may be requested.
• Identify individuals who may be prone
to bleeding during surgical, obstetric, INTERFERING FACTORS:
dental, or invasive diagnostic proce- • Drugs that may increase PT in patients
dures receiving anticoagulation therapy
include acetaminophen, amiodarone,
• Monitor the effects of conditions such
anabolic steroids, anisindione, anistre-
as liver disease, protein deficiency, and
plase, antibiotics, antipyrine, acetylsal-
fat malabsorption on hemostasis
icylic acid (high doses), carbenicillin,
• Screen for prothrombin deficiency cathartics, chlorthalidone, cholestyra-
mine, clofibrate, corticotropin, deme-
• Screen for vitamin K deficiency
clocycline, dextrothyroxine, diazoxide,
RESULT diflunisal, diuretics, doxycycline,
erythromycin, glucagon, hydroxyzine,
Increased in: indomethacin, laxatives, mercapto-
purine, miconazole, nalidixic acid,
• Afibrinogenemia, dysfibrinogenemia,
neomycin, niacin, oxyphenbutazone,
or hypofibrinogenemia
phenytoin, quinine, sulfachlorpyri-
• Biliary obstruction dazine, and thyroxine.
• Disseminated intravascular coagula- • Drugs that may decrease PT in patients
tion receiving anticoagulation therapy
Prothrombin Time and International Normalized Ratio 839
include amobarbital, anabolic steroids, dures. The requesting health care

antacids, antihistamines, barbiturates, practitioner and laboratory should be
carbamazepine, chloral hydrate, chlor- advised if the patient regularly uses
dane, colchicine, corticosteroids, these products so that their effects
diuretics, oral contraceptives, peni- when reviewing results.
cillin, primidone, rifampin, simeth-
icone, spironolactone, tolbutamide, ➤ There are no food, fluid, or medica-
and vitamin K. direction.
• Traumatic venipunctures can activate ➤ Review the procedure with the
the coagulation sequence by contami- patient.
nating the sample with tissue thrombo- ➤ Inform the patient that specimen
plastin, and producing falsely collection takes approximately 5 to
shortened PT. 10 minutes.
• Failure to fill the tube sufficiently to Intratest:
yield proper blood-to-anticoagulant
ratio may cause a falsely lengthened ➤ Direct the patient to breathe
PT; an incompletely filled tube is normally and to avoid unnecessary
movement.
reason for specimen rejection.
• Excessive agitation causing sample follow the general guidelines in
hemolysis can falsely shorten the PT Appendix A. Perform a venipuncture,
because the hemolyzed cells activate and collect the specimen in a
plasma-clotting factors. 5-mL blue-top tube. Fill tube
Nursing Implications and added to blue-top tubes for coagula-
Procedure ● ● ● ● ● ● ● ● ● ● ● tion studies: 3.2% and 3.8%. The
Pretest: Laboratory Standards (NCCLS)
➤ Obtain a history of the patient’s Laboratories establish reference
complaints, including a list of known ranges for coagulation testing based
allergens. on numerous factors, including
➤ Obtain a history of the patient’s car- sodium citrate concentration, test
diovascular, hematopoietic, and he- equipment, and test reagents. It is
patobiliary systems, any bleeding important to inquire from the labora-
disorders, and results of previously tory which concentration it recom-
performed tests and procedures, mends, because each concentration
especially bleeding time, complete will have its own specific reference
blood count, clotting time, partial range.
thromboplastin time, prothrombin ➤ When multiple specimens are
time, and platelets. For related drawn, the blue-top tube should be
tests, refer to the cardiovascular, collected after sterile (i.e., blood
hematopoietic, and hepatobiliary culture) and red-top tubes. When
system tables. coagulation testing is the only work
➤ Obtain a list of medications the to be done, an extra red-top tube
patient is taking, including anticoag- should be collected before the blue-
ulant therapy, acetylsalicylic acid, top tube to avoid contaminating the
herbals, and nutraceuticals known to specimen with tissue thromboplas-
affect coagulation. It is recom- tin, which can falsely shorten PT.
mended that use be discontinued 14 ➤ Label the specimen, and promptly
days before dental or surgical proce- transport it to the laboratory. The
NCCLS recommendation for pro- bleeding, including the use of a soft

cessed and unprocessed samples bristle toothbrush, use of an electric
stored in unopened tubes is that razor, avoidance of constipation,
testing should be completed within avoidance of aspirin products, and
1 to 4 hours of collection. avoidance of intramuscular injec-
tions.
Post-test: ➤ Inform the patient of the importance
of periodic laboratory testing while
➤ Observe venipuncture site for bleed- taking an anticoagulant.
pressure bandage. ➤ Evaluate test results in relation to
➤ Instruct the patient to report bleed- tests performed. Related laboratory
ing from any areas of the skin or tests include alanine aminotrans-
mucous membranes. ferase, aspartate aminotransferase,
➤ Inform the patient with prolonged bilirubin, factor assays, -glutamyl
PT of the importance of taking transpeptidase, platelet count, and
precautions against bruising and vitamin K.
PSEUDOCHOLINESTERASE AND
DIBUCAINE NUMBER
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SYNONYMS/ACRONYMS: CHS, PCHE, AcCHS.

SPECIMEN: Plasma (1 mL) collected in a lavender-top (ethylenediaminete-
tra-acetic acid [EDTA]) tube. Serum (1 mL) collected in a red-top tube is
also acceptable.
REFERENCE VALUE: (Method: Spectrophotometry, kinetic)
SI Units
Test Conventional Units (Conversion Factor 1)
Pseudocholinesterase 2–11 U/mL 2–11 kU/L
Fraction (%) of SI Units

Dibucaine Number Activity Inhibited (Conversion Factor 0.01)
Normal homozygote 79–84% 0.79–0.84 kU/L
Heterozygote 55–70% 0.55–0.70 kU/L
Abnormal homozygote 16–28% 0.16–0.28 kU/L
Pseudocholinesterase and Dibucaine Number 841
DESCRIPTION: There are two types Increased in:

of cholinesterase: acetylcholinesterase, • Diabetes
which is found in red blood cells, • Hyperthyroidism
lung, and brain (nerve) tissue (see
monograph titled “Red Blood Cell
Cholinesterase”); and cholinesterase, • Obesity
which is found mainly in the plasma,
liver, and heart. Pseudocholinesterase Decreased in:
is a nonspecific enzyme that hy- • Acute infection
drolyzes acetylcholine and noncholine • Anemia (severe)
esters; carbamate and organophos- • Carcinomatosis
phate insecticides (e.g., parathion,
malathion) inhibit its activity. • Cirrhosis
Patients with inherited pseudo- • Congenital deficiency
cholinesterase deficiency are at • Hepatic carcinoma
risk during anesthesia if succinyl-
choline is administered as an anes- • Hepatocellular disease
thetic. Succinylcholine, a short-acting • Infectious hepatitis
muscle relaxant, is a reversible • Insecticide exposure (organic phos-
inhi-bitor of acetylcholinesterase and phate)
is hydrolyzed by cholinesterase.
• Malnutrition
Succinylcholine-sensitive patients
may be unable to metabolize the anes- • Muscular dystrophy
thetic quickly, resulting in prolonged • Myocardial infarction
or unrecoverable apnea. Abnormal
genotypes of pseudocholinesterase are • Plasmapheresis
detected using the dibucaine and • Succinylcholine hypersensitivity
fluoride inhibition tests because, in • Tuberculosis
normal individuals, these chemicals
inhibit pseudocholinesterase activity. • Uremia
The prevalence of succinylcholate
CRITICAL VALUES: Notify the
sensitivity is 1 in 1500 patients. anesthesiologist if the test result is posi-
Widespread preoperative screening is tive and surgery is scheduled. A positive
not routinely performed. ■ result indicates that the patient is at risk
for prolonged or unrecoverable apnea
INDICATIONS: related to the inability to metabolize
• Assist in the evaluation of liver func- succinylcholine.
tion
• Screen for abnormal genotypes of • Drugs and substances that may
pseudocholinesterase in patients with a decrease pseudocholinesterase levels
family history of succinylcholate sensi- include ambenonium, barbiturates,
tivity who are about to undergo anes- cyclophosphamide, echothiophate,
thesia using succinylcholate. edrophonium, fluorides, ibuprofen,
iodipamide, iopanoic acid, iso-
RESULT flurophate, neostigmine, parathion,
procainamide, physostigmine, pyri- can be taken into consideration

dostigmine, estrogens, and oral contra- when reviewing results.
ceptives. ➤ There are no food, fluid, or medica-
• Drugs that may increase pseudo- direction.
cholinesterase levels include carba-
mazepine, phenytoin, and valproic acid. patient.
• Pregnancy decreases pseudocholin- ➤ Inform the patient that specimen
esterase levels by about 30 percent. collection takes approximately 5 to
10 minutes.
• Improper anticoagulant; fluoride inter-
feres with the measurement and causes Intratest:
a falsely decreased value.
movement.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
➤ Obtain a history of the patient’s lavender- or red-top tube.
allergens. Particularly important to transport it to the laboratory.
report is exposure to pesticides
causing symptoms including blurred Post-test:
vision, muscle weakness, nausea,
vomiting, headaches, pulmonary ➤ Observe venipuncture site for bleed-
edema, salivation, sweating, or ing or hematoma formation. Apply
convulsions. pressure bandage.
➤ Obtain a history of the patient’s ➤ The patient with decreased values
hepatobiliary and musculoskeletal should be observed for signs of fluid
systems, as well as results of previ- volume excess related to compro-
ously performed tests and proce- mised regulatory mechanisms,
dures. For related tests, refer to the decreased cardiac output related to
hepatobiliary and musculoskeletal decreased myocardial contractility or
system tables. arrhythmias, and pain related to
➤ Obtain a list of medications the inflammation or ischemia.
patient is taking, including herbs, ➤ Evaluate test results in relation
nutritional supplements, and nutra- to the patient’s symptoms and
ceuticals. The requesting health care other tests performed. Related
practitioner and laboratory should be laboratory tests include alanine
advised if the patient regularly uses aminotransferase and aspartate
these products so that their effects aminotransferase.
PULMONARY FUNCTION STUDIES

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SYNONYM/ACRONYM: Pulmonary function tests (PFTs).

Pulmonary Function Studies 843
AREA OF APPLICATION: Lungs, respiratory system.

CONTRAST: None.
DESCRIPTION: Pulmonary function INSPIRATORY RESERVE VOLUME:

studies provide information about Maximum amount of air inhaled after
the volume, pattern, and rates of normal inspirations.
airflow involved in respiratory func-
tion. These studies may also include
EXPIRATORY RESERVE VOLUME:
Maximum amount of air exhaled after a
tests involving the diffusing capabili- resting expiration (can be calculated by
ties of the lungs (i.e., volume of gases the vital capacity [VC] minus the inspi-
diffusing across a membrane). A ratory capacity [IC]).
complete pulmonary study profile
includes the determination of all lung VITAL CAPACITY: Maximum amount of
volumes, spirometry, diffusing capac- air exhaled after a maximum inspiration
ity, maximum voluntary ventilation, (can be calculated by adding the IC and
flow-volume loop (Fig. 1–1), and the expiratory reserve volume [ERV]).
maximum expiratory and inspiratory
pressures. Other studies include small TOTAL LUNG CAPACITY: Total amount
of air that the lungs can hold after maxi-
airway volumes.
mal inspiration (can be calculated by
Pulmonary function studies are adding the VC and the residual volume
classified according to lung volumes [RV]).
and capacities, rates of flow, and gas
exchange. The exception is the diffu- INSPIRATORY CAPACITY: Maximum
sion test, which records the move- amount of air inspired after normal expi-
ment of a gas during inspiration and ration (can be calculated by adding the
expiration. Lung volumes and capac- inspiratory RV and tidal volume).
ities constitute the amount of air
inhaled or exhaled from the lungs; FUNCTIONAL RESIDUAL CAPACITY:
this value is compared to normal Volume of air that remains in the lungs
after normal expiration (can be calcu-
reference values specific for the
lated by adding the RV and ERV).
patient’s age, height, and sex. The
following are volumes and capacities The volumes, capacities, and rates of
measured by spirometry that do not flow measured by spirometry that do
require timed testing. ■ require timed testing include the follow-
ing:
TIDAL VOLUME: Total amount of air
inhaled and exhaled with one breath. FORCED VITAL CAPACITY IN 1 SECOND:
Maximum amount of air that can be
RESIDUAL VOLUME: Amount of air re- forcefully exhaled after a full inspiration.
maining in the lungs after a maximum
expiration effort (not measured by FORCED EXPIRATORY VOLUME: Amount
spirometry, but can be calculated from of air exhaled in the first second (can also
the functional residual capacity [FRC] be determined at 2 or 3 seconds) of
minus the expiratory reserve volume forced vital capacity (FVC, which is
[ERV]). This indirect type of measure- the amount of air exhaled in seconds,
ment can be done by body plethysmog- expressed as a percent).
raphy (see monograph titled “Plethys-
mography”). MAXIMAL MIDEXPIRATORY FLOW: Also
known as forced expiratory flow rate ISOFLOW VOLUME: Flow-volume loop

(FEF25–75), maximal rate of air flow test followed by inhalation of a mix of
during a forced expiration. helium and oxygen to determine small
airway disease.
FORCED INSPIRATORY FLOW RATE:
Volume inspired from the RV at a point BODY PLETHYSMOGRAPHY: Measures
of measurement (can be expressed as a thoracic gas volume and airway resist-
percent to identify the corresponding ance.
volume pressure and inspired volume).
PEAK INSPIRATORY FLOW RATE:

BRONCHIAL PROVOCATION: Quantifies
airway response after inhalation of
Maximum airflow during a forced maxi-
methacholine.
mal inspiration.
PEAK EXPIRATORY FLOW RATE: ARTERIAL BLOOD GASES: Measures

Maximum airflow expired during FVC. oxygen, pH, and carbon dioxide in arte-
rial blood.
FLOW-VOLUME LOOPS: Flows and
volumes recorded during forced expira- Values are expressed in units of mL,
tory volume (FEV) and forced inspira- %, L, L/sec, and L/min, depending on
tory vital capacity (FIVC) procedures the test performed.
(Fig. 1–2).
INDICATIONS:
MAXIMAL INSPIRATORY-EXPIRATORY • Detect chronic obstructive pulmonary
PRESSURES: Measures the strength of disease (COPD) and/or restrictive
the respiratory muscles in neuromuscular pulmonary diseases that affect the
disorders. chest wall (e.g., neuromuscular disor-
ders, kyphosis, scoliosis) and lungs, as
MAXIMAL VOLUNTARY VENTILATION: evidenced by abnormal air flows and
Maximal volume of air inspired and volumes
expired in 1 minute (may be done for
shorter periods and multiplied to equal 1 • Determine the presence of lung disease
minute). when other studies, such as x-rays, do
not provide a definitive diagnosis or
Other studies for gas-exchange capac- determine the progression and severity
ity, small airway abnormalities, and of known COPD and restrictive
allergic responses in hyperactive airway pulmonary disease
disorders can be performed during the • Evaluate the cause of dyspnea occur-
conventional pulmonary function study. ring with or without exercise
These include the following:
• Determine the effectiveness of therapy
DIFFUSING CAPACITY OF THE LUNGS: regimens, such as bronchodilators, for
Rate of transfer of carbon monoxide pulmonary disorders
through the alveolar and capillary • Evaluate the respiratory system to
membrane in 1 minute. determine the patient’s ability to toler-
ate procedures such as surgery or diag-
CLOSING VOLUME: Measures the closure nostic studies
of small airways in the lower alveoli by
monitoring volume and percent of alveo- • Screen high-risk populations for early
lar nitrogen after inhalation of 100 detection of pulmonary conditions
percent oxygen. (e.g., patients with exposure to occupa-
tional or environmental hazards, smok- changes in lung volumes (decreased in

ers, patients with a hereditary predis- restrictive pulmonary disease, increased
position) in COPD and in elderly patients)
• Evaluate pulmonary function after • Determine the diffusing capacity of the
surgical pneumonectomy, lobectomy, lungs (DCOL)
or segmental lobectomy
• Evaluate pulmonary disability for legal RESULT
or insurance claims
• Determine airway response to Normal Findings:
inhalants in patients with an airway- • Normal respiratory volume and capac-
reactive disorder ities, gas diffusion, and distribution
• Evaluate lung compliance to determine • No evidence of COPD or restrictive
changes in elasticity evidenced by pulmonary disease
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.
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
• 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.
➤ Place a mouthpiece in the mouth test values with previous values to

and tell the patient to close his or determine response to medical
her lips around it to form a seal. problem or treatment.
➤ Tubing from the mouthpiece is ➤ Tell patient to resume medications
connected to a cylinder that is withheld before the test was
connected to a computer that meas- ordered or to contact the provider
ures, records, and calculates the ordering the test if he or she has any
values for the tests done. questions.
➤ Instruct the patient to inhale deeply ➤ Determine if the patient or family
and then to quickly exhale as members have any further ques-
much air as possible into the mouth- tions or concerns.
piece. ➤ A physician specializing in this
➤ Additional breathing maneuvers are branch of medicine sends a written
performed on inspiration and expira- report to the ordering provider, who
tion (normal, forced, and breath- discusses the results with the
holding). patient.
➤ Assess the patient for dizziness or tests performed. Related diagnostic
weakness after the testing. tests include x-ray, computed
tomography, magnetic resonance
➤ Allow the patient to rest as long as imaging, and positron emission
needed to recover. tomography of the chest; and elec-
➤ Compare new pulmonary function trocardiography.
Inspiratory Forced Forced

(IC) capacity expiratory
Inspiratory inspiratory
reserve volume volume
(FEV)
Tidal volume (FIV)
(TV) volume
Vital Expiratory Forced Total

capacity (FVC) vital lung (TLC)
reserve
(VC) volume (ERV) capacity capacity
Functional
residual (FRC) Residual
capacity volume
FIGURE 1–1
Normal Restrictive Obstructive
Small airway Fixed upper Variable upper Sleep Apnea

disease airway obstruction airway obstruction Disorder
FIGURE 1–2
PULSE OXIMETRY
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SYNONYMS/ACRONYM: Oximetry, Pulse Ox.

AREA OF APPLICATION: Earlobe, fingertip; for infants, use the large toe, top
or bottom of the foot, or sides of the ankle.
CONTRAST: None.
DESCRIPTION: Pulse oximetry is a as a percent. The results obtained

noninvasive study that provides may compare favorably with O2 satu-
continuous readings of arterial blood ration levels obtained by arterial
oxygen saturation (SPO2) using a blood gas (ABG) analysis without the
sensor site (earlobe or fingertip). The need to perform successive arterial
SPO2 equals the ratio of the amount punctures. The device used is a clip or
of O2 contained in the hemoglobin probe that produces a light beam
to the maximum amount of O2 with two different wavelengths. A
contained with hemoglobin expressed sensor on the opposite side measures
Pulse Oximetry 849
the absorption of each of the wave- carbon monoxide inhalation, because

lengths of light to determine the O2 levels may be falsely elevated
O2 saturation reading. The displayed
Factors that may result in
result is a ratio, expressed as a percent,
incorrect values:
between the actual O2 content of the
• Patients with anemic conditions
hemoglobin and the potential maxi- reflecting a reduction in hemoglobin,
mum O2-carrying capacity of the the O2-carrying component in the
hemoglobin. ■ blood
INDICATIONS: • Excessive light surrounding the
• Monitor oxygenation perioperatively patient, such as from surgical lights
and during acute illnesses • Impaired cardiopulmonary function
• Monitor oxygenation status in patients • Lipid emulsion therapy and presence
on a ventilator, during surgery, and of certain dyes
during bronchoscopy
• Movement of the finger or ear or
• Evaluate suspected nocturnal hypox- improper placement of probe or clip
emia in chronic obstructive pulmonary
• Nail polish, false fingernails, and skin
disease (COPD)
pigmentation when a finger probe is
• Monitor O2 saturation during activi- used
ties such as pulmonary exercise stress
• Vasoconstriction from cool skin
testing or pulmonary rehabilitation
temperature, drugs, hypotension, or
exercises to determine optimal toler-
vessel obstruction causing a decrease in
ance
blood flow
• Determine the effectiveness of
pulmonary gas exchange function Other considerations:
• Monitor response to pulmonary drug • Accuracy for most units is plus or
regimens, especially flow and O2 minus 4 percent with a standard devia-
content tion of 1 percent.
• Monitor oxygenation during testing
for sleep apnea Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
RESULT
Pretest:
Normal Findings:
• Greater than or equal to 95 percent ➤ Inform the patient that the proce-
dure is generally performed at the
bedside, in the operating room
Abnormal Findings: during a surgical procedure, or in a
• Abnormal gas exchange physician’s office.
• Hypoxemia with levels less than 95 ➤ Explain that the procedure lasts as
percent long as the monitoring is needed
and could be continuous.
• Impaired cardiopulmonary function ➤ Explain that no pain is associated
with the procedure.
INTERFERING FACTORS: ➤ Obtain a history of pulmonary disor-
ders, respiratory and cardiac status,
This procedure is contraindicated reason for monitoring procedure,
for: and ABG results. For related tests,
• Patients who smoke or have suffered refer to the respiratory system table.
➤ 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
➤ 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
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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.
REFERENCE VALUE: (Method: Spectrophotometry) 9–22 U/g hemoglobin.
DESCRIPTION: Pyruvate kinase is an glycolysis. Deficiency of this enzyme

enzyme that forms pyruvate and can be acquired by ingestion of a
adenosine diphosphate (ADP) during drug or as an effect of liver disease.
Pyruvate Kinase 851
There is also a hereditary form of ➤ Obtain a history of the patient’s

pyruvate kinase deficiency that can be hematopoietic system as well as
transmitted as an autosomal-recessive tests and procedures. For related
trait. Red blood cells lacking this tests, refer to the hematopoietic
enzyme have a membrane defect system table.
resulting from low levels of adenosine ➤ Obtain a list of medications
triphosphate (ATP) and are more the patient is taking, including
susceptible to hemolysis. ■ herbs, nutritional supplements, and
INDICATIONS: Evaluate chronic hemo- should be advised if the patient
lytic anemia is regularly using these products so
RESULT into consideration when reviewing
results.
Increased in: ➤ Note any recent procedures that can
• Carriers of Duchenne’s muscular interfere with test results.
dystrophy ➤ There are no food, fluid, or medica-
• Muscle disease
direction.
• Myocardial infarction ➤ Review the procedure with the
patient.
Decreased in: ➤ Inform the patient that specimen
• Hereditary pyruvate kinase deficiency: collection takes approximately 5 to
Congenital nonspherocytic 10 minutes.
hemolytic anemia
Intratest:
• Acquired pyruvate kinase deficiency:
Acute leukemia ➤ Direct the patient to breathe
Other anemias movement.
Aplasias ➤ Observe standard precautions and
INTERFERING FACTORS: yellow-top tube.
• Testing after blood transfusion may ➤ Label the specimen, and promptly
produce a falsely normal result. transport it to the laboratory.
• The enzyme is unstable. The specimen
Post-test:
should be refrigerated immediately
after collection. ➤ Observe venipuncture site for bleed-
pressure bandage.
Nursing Implications and ➤ Evaluate test results in relation to
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: tests include complete blood count,
osmotic fragility test, glucose-6-
➤ Obtain a history of the patient’s phosphate dehydrogenase, and
complaints, including a list of known paroxysmal nocturnal hemoglobin-
allergens. uria test.
RADIOACTIVE IODINE UPTAKE

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SYNONYM/ACRONYM: Thyroid uptake, RAIU.

AREA OF APPLICATION: Thyroid.
CONTRAST: Oral radioactive iodine.
DESCRIPTION: Radioactive iodine INDICATIONS:

uptake (RAIU) is a nuclear medicine • Evaluate hyperthyroidism and/or
study used for evaluating thyroid hypothyroidism
function. It directly measures the • Evaluate thyroiditis, goiter, or pituitary
ability of the thyroid gland to failure
concentrate and retain circulating
• Monitor response to therapy for
iodide for the synthesis of thyroid thyroid disease
hormone. RAIU assists in the diagno-
sis of both hyperthyroidism and • Evaluate neck pain
hypothyroidism, but it is more useful • Evaluate the patient as part of a
in the diagnosis of hyperthyroidism. complete thyroid evaluation for symp-
A very small dose of radioactive tomatic patients (e.g., swollen neck,
iodine-123 (I-123) or I-131 is neck pain, extreme sensitivity to heat
administered orally and at specified or cold, jitters, sluggishness)
intervals after the initial dose is
administered. The radionuclide emits
RESULT
gamma radiation, which allows exter- Normal Findings:
nal measurement. The uptake of
• Variations in normal ranges of iodine
radionuclide in the thyroid gland is uptake can occur with differences in
measured as the percentage of dietary intake, geographic location,
radionuclide absorbed in a specific and protocols among laboratories:
amount of time. The iodide not used
is excreted in the urine. The thyroid
Percentage of
gland does not distinguish between
Iodine Uptake Radionuclide
radioactive and nonradioactive
iodine. Uptake values are used in 2-hour absorption 1–13%
6-hour absorption 2–25%
conjunction with measurements of
24-hour absorption 15–45%
circulating thyroid hormone levels to
differentiate primary and secondary
thyroid disease, and serial measure- Abnormal Findings:
ments are helpful in long-term • Decreased iodine intake or increased
management of thyroid disease and iodine excretion
its treatment. ■ • Graves’ disease
Radioactive Iodine Uptake 853
• Hypoalbuminemia • Incorrect positioning of the patient,

• Iodine-deficient goiter
• Hashimoto’s thyroiditis (early)
• Recent use of iodinated contrast
• Hyperthyroidism, increased uptake of: medium for radiographic studies
(within the last 4 weeks) or nuclear
medicine procedures done within the
Percentage of
previous 24 to 48 hours
Iodine Uptake Radionuclide
1-h absorption 20% • Iodine deficiency (e.g., patients with
6-h absorption 25% inadequate dietary intake, patients on
24-h absorption 45% phenothiazine therapy), which can
increase radionuclide uptake
Rebound thyroid hormone • Certain drugs and other external

withdrawal sources of excess iodine, which can
decrease radionuclide uptake, as
Drugs and hormones such as
follows:
barbiturates, diuretics,
estrogens, lithium carbonate, Foods containing iodine (e.g.,
phenothiazines, and thyroid- iodized salt)
stimulating hormone Drugs such as aminosalicylic acid,
antihistamines, antithyroid
• Decreased uptake: medications (e.g.,
Hypothyroidism, with a response propylthiouracil, iodothiouracil),
of decreased uptake of 0 to 10 corticosteroids, cough syrup,
percent over a 24-hour period isoniazid, levothyroxine
• Thyrotoxicosis as a result of ectopic sodium/T4, Lugol’s solution,
thyroid metastasis nitrates, penicillins, potassium
iodide, propylthiouracil, saturated
• Subacute thyroiditis solution of potassium iodide
• Renal failure (SSKI), sulfonamides,
thiocyanate, thyroid extract, L-
• Malabsorption triiodothyronine, tolbutamide,
and warfarin
INTERFERING FACTORS: Multivitamins containing minerals
This procedure is contraindicated • Vomiting, severe diarrhea, and
for: gastroenteritis, which can affect
• Patients who are pregnant or suspected absorption of the oral radionuclide
of being pregnant, unless the potential dose
Factors that may impair clear which may inhibit organ visualization
imaging: and can produce unclear images
remain still during the procedure Other considerations:
because of age, significant pain, or • Failure to follow dietary restrictions
mental status before the procedure may cause the
exceed the weight limit for the equip- • Consultation with a physician should
ment occur before the procedure for radia-
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.
Radiography, Bone 855
RADIOGRAPHY, BONE
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SYNONYM/ACRONYM: Bone x-rays, hand x-rays, foot x-rays, wrist x-rays,

arm x-rays.
AREA OF APPLICATION: Skeleton.

CONTRAST: None.
DESCRIPTION: Skeletal x-rays are • Identify abnormalities of bones, joints,

used to evaluate extremity pain or and surrounding tissues
discomfort due to trauma, bone • Evaluate for child abuse
abnormalities, or fluid within a joint.
Serial skeletal x-rays are used to eval- RESULT
uate growth pattern. Radiation emit-
Normal Findings:
ted from the x-ray machine passes
through the patient onto a photo- • Infants and children: Thin plate of
cartilage, known as growth plate or
graphic plate or x-ray film. X-rays
epiphyseal plate, between the shaft and
pass through air freely and are mostly both ends
absorbed by the photographic media.
Bones and tissues absorb the x-rays in • Adolescents and adults: By age 17, calci-
fication of cartilage plate; no evidence
varying degrees, thereby causing
of fracture, congenital abnormalities,
white and shades of gray on the tumors, or infection
x-ray–recording media: Bones are
very dense and therefore absorb most Abnormal Findings:
of the x-ray and appear white; organs
• Arthritis
are denser than air but not as dense
as bone, so they appear in shades • Bone degeneration
of gray. All metals absorb x-rays. • Bone spurs
Because the x-ray is absorbed or • Foreign bodies
blocked, metal appears totally white
on the film and thus facilitates the • Fracture
search for foreign bodies in the • Genetic disturbance (achondroplasia,
patient. ■ dysplasia, dyostosis)
• Hormonal disturbance
INDICATIONS:
• Detect bone fracture, dislocation, • Infection, including osteomyelitis
deformity, and degeneration • Injury
• Monitor fracture-healing process • Joint dislocation or effusion
• Evaluate growth pattern • Nutritional or metabolic disturbances
• Osteoporosis or osteopenia overexposure can result from frequent

• Soft tissue abnormalities
room with the patient should stand
• Tumor or neoplastic disease (os- behind a shield or leave the area while
teogenic sarcoma, Paget’s disease, the examination is being done.
myeloma) Personnel working in the area where
the examination is being done should
INTERFERING FACTORS: wear badges that reveal their level of
exposure to radiation.
for:
benefits of the procedure far outweigh Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
Factors that may impair clear ➤ Inform the patient that the procedure
imaging: assesses bone discomfort, injury, or
• Inability of the patient to cooperate or healing and lasts 10 to 20 minutes.
remain still during the procedure ➤ Obtain a history of injury, as well as
because of age, significant pain, or any known congenital bone, meta-
mental status bolic, or genetic problems that could
affect the bones. For related tests,
• Improper adjustment of the radio- refer to the musculoskeletal system
graphic equipment to accommodate table.
obese or thin patients, which can cause ➤ Obtain a list of the medications the
overexposure or underexposure and patient is taking, including herbs,
poor-quality study nutritional supplements, and
nutraceuticals.
exceed the weight limit for the equip- ➤ Obtain previous x-rays of the injured
site, if available.
ment
• Incorrect positioning of the patient, period and possibility of pregnancy
which may produce poor visualization in perimenopausal women.
of the area to be examined ➤ Inform the patient that no pain is
• Prior barium studies, which can dimin- associated with the study.
ish the full radiographic visualization ➤ There are no food or fluid restric-
of some of the bones surrounding the tions.
abdominal cavity
Intratest:
tion field (e.g., jewelry or body rings), ➤ Make sure clothing, jewelry,
watches, chains, belts, and any
other metallic objects have been re-
and can produce unclear images moved from the area to be examined.
Other considerations: ➤ Have the patient put on a hospital
gown, as appropriate.
➤ Place patient in a standing, sitting, or
recumbent position in front of the x-
tion safety concerns regarding infants ray film holder or electronic receiver.
➤ Instruct the patient to inhale deeply
• Risks associated with radiographic and hold his or her breath while the
Red Blood Cell Cholinesterase 857
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.
➤ 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
➤ 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.
RED BLOOD CELL CHOLINESTERASE

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SYNONYMS/ACRONYMS: acetylcholinesterase (ACE), RBC.

REFERENCE VALUE: (Method: Spectrophotometry, kinetic)

SI Units
Test Conventional Units (Conversion Factor 1)
RBC cholinesterase 5–10 U/mL 5–10 kU/L
DESCRIPTION: There are two types toxicity. Organophosphate pesticides

of cholinesterase: acetylcholinesterase, bind irreversibly with cholinesterase,
which is found in red blood cells inhibiting normal enzyme activity.
(RBCs), lung, and brain (nerve) Carbamate insecticides bind reversi-
tissue; and cholinesterase, which is bly. Serum or plasma pseudocholi-
mainly found in the plasma, liver, nesterase is used more frequently to
and heart. RBC cholinesterase is used measure acute pesticide toxicity.
to assist in the diagnosis of chronic Patients with inherited cholin-
carbamate or organophosphate insec- esterase deficiency are at risk during
ticide (e.g., parathion, malathion) anesthesia if succinylcholine is ad-
ministered as an anesthetic. Succinyl- • Improper anticoagulant; fluoride inter-

choline, a short-acting muscle relax- feres with the measurement and causes
ant, is a reversible inhibitor of acetyl- a falsely decreased value.
cholinesterase and is hydrolyzed
by cholinesterase. Succinylcholine-
sensitive patients may be unable to
metabolize the anesthetic quickly, re-
Procedure ● ● ● ● ● ● ● ● ● ● ●
sulting in prolonged or unrecoverable Pretest:

apnea. This test, along with the
pseudocholinesterase test, is also used ➤ Obtain a history of the patient’s
to identify individuals with atypical allergens. Particularly important to
forms of the enzyme cholinesterase report is exposure to pesticides
(see monograph titled “Pseudo- causing symptoms including blurred
cholinesterase”). The prevalence of vision, muscle weakness, nausea,
vomiting, headaches, pulmonary
succinylcholate sensitivity is 1 in edema, salivation, sweating, or
1500 patients. Widespread preopera- convulsions.
tive screening is not routinely per- ➤ Obtain a history of exposure to
formed. ■ occupational hazards and medication
regimen.
• Verify suspected exposure to organic hematopoietic system and results of
phosphate insecticides previously performed tests and
procedures. For related tests refer to
• Monitor cumulative exposure to the hematopoietic system table.
organic phosphate insecticides
RESULT nutritional supplements, and nutra-
Increased in: practitioner and laboratory should be
• Sickle cell anemia advised if the patient regularly uses
Decreased in: can be taken into consideration
• Insecticide exposure (organic phos-
phate) ➤ There are no food, fluid, or medica-
• Late pregnancy direction.
• Paroxysmal nocturnal hemoglobinuria ➤ Review the procedure with the
patient.
• Relapse of megaloblastic anemia ➤ Inform the patient that specimen
CRITICAL VALUES: N/A 10 minutes.
INTERFERING FACTORS: Intratest:

• Drugs and substances that may ➤ Direct the patient to breathe
increase RBC cholinesterase levels normally and to avoid unnecessary
include echothiophate, parathion, and movement.
antiepileptic drugs such as carba- ➤ Observe standard precautions and
mazepine, phenobarbital, phenytoin, follow the general guidelines in
and valproic acid. Appendix A. Perform a venipuncture,
Red Blood Cell Count 859
and collect the specimen in a 5-mL ing or hematoma formation. Apply

lavender-top tube. pressure bandage.
➤ Label the specimen, and promptly ➤ Evaluate test results in relation to
Post-test: tests. Related laboratory tests
include complete blood count and
➤ Observe venipuncture site for bleed- pseudocholinesterase.
RED BLOOD CELL COUNT

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SYNONYM/ACRONYM: RBC.

SI Units
Cord Blood 4.14–4.69 106 cells/mm3 4.14–4.69 1012 cells/L
1d 5.33–5.47 106 cells/mm3 5.33–5.47 1012 cells/L
2 wk 4.32–4.98 106 cells/mm3 4.32–4.98 1012 cells/L
1 mo 3.75–4.95 106 cells/mm3 3.75–4.95 1012 cells/L
6 mo 3.71–4.25 106 cells/mm3 3.71–4.25 1012 cells/L
1y 4.40–4.48 106 cells/mm3 4.40–4.48 1012 cells/L
10 y 4.75–4.85 106 cells/mm3 4.75–4.85 1012 cells/L
Adult male 4.71–5.14 106 cells/mm3 4.71–5.14 1012 cells/L
Adult female 4.20–4.87 106 cells/mm3 4.20–4.87 1012 cells/L
DESCRIPTION: A component of the for the transport and exchange of

complete blood count (CBC), the red oxygen, the number of circulating
blood cell (RBC) count determines RBCs is important. Although the life
the number of RBCs per cubic mil- span of the normal RBC is 120 days,
limeters (expressed as the number of other factors besides cell age and
RBCs per liter of blood according to decreased production can cause
the international system of units decreased values; examples are abnor-
[SI]). Because RBCs contain hemo- mal destruction due to intravascular
globin (Hgb), which is responsible trauma caused by atherosclerosis or to
an enlarged spleen caused by • Determine the presence of hereditary

leukemia. The main sites of RBC pro- hematologic abnormality
duction in healthy adults include the • Monitor the effects of acute or chronic
bone marrow of the vertebrae, pelvis, blood loss
ribs, sternum, skull, and proximal
• Monitor patients with disorders associ-
ends of the femur and humerus. The
ated with elevated erythrocyte counts
main sites of RBC destruction are the (e.g., polycythemia vera, chronic
spleen and liver. Erythropoietin, a obstructive pulmonary disease
hormone produced by the kidneys, [COPD])
regulates RBC production. Normal
RBC development and function
emotional stress
are also dependent on adequate
levels of vitamin B12, folic acid, and • Monitor the progression of nonhema-
iron. A deficiency in vitamin E tologic disorders associated with
(-tocopherol), which is needed to elevated erythrocyte counts, such as
COPD, liver disease, hypothyroidism,
protect the RBC membrane from ox-
adrenal dysfunction, bone marrow fail-
idizers, can result in increased cellular ure, malabsorption syndromes, cancer,
destruction. and renal disease
Polycythemia is a term used in
conjunction with conditions resulting • Monitor the response to drugs or
chemotherapy and evaluate undesired
from an abnormal increase in Hgb,
reactions to drugs that may cause
hematocrit (Hct), and RBC count. blood dyscrasias
Anemia is a term associated with
conditions resulting from an abnor- • Provide screening as part of a CBC in a
mal decrease in Hgb, Hct, and RBC general physical examination, espe-
cially upon admission to a health care
count. Results of the Hgb, Hct, and
facility or before surgery
RBC count should be evaluated
simultaneously because the same RESULT
underlying conditions affect this triad
of tests similarly. The RBC count Increased in:
multiplied by three should approxi- • Bone marrow failure
mate the Hgb concentration. The • Anxiety or stress
Hct should be within three times the
Hgb if the RBC population is normal • Dehydration with hemoconcentration
in size and shape. The Hct plus six • High altitude
should approximate the first two • Erythremic erythrocytosis
figures of the RBC count within three
(e.g., Hct is 40 percent; therefore 40
6 46, and the RBC count should • COPD with hypoxia and secondary
be 4.3–4.9). (See monographs titled polycythemia
“Hematocrit,” “Hemoglobin,” and
Decreased in:
“Red Blood Cell Indices.”) ■
• Chemotherapy
INDICATIONS: • Dietary deficiencies
• Detect a hematologic disorder involv-
ing RBC destruction (e.g., hemolytic • Hemoglobinopathy
anemia) • Hemolytic anemia
Red Blood Cell Count 861
• Hemorrhage zole, sulfamethoxypyridine, sulfisoxa-

zole, suramin, thioridazine, tolbu-
• Hodgkin’s disease tamide trimethadione, and tripelen-
• Chronic inflammatory diseases namine.
• Leukemia • Drugs that may decrease RBC count
include those causing bone marrow
• Multiple myeloma suppression such as amphotericin B,
• Organ failure floxuridine, and phenylbutazone.
• Overhydration • Drugs and vitamins that may increase
the RBC count include glucocorticos-
• Pregnancy (normal dilutional effect) teroids, pilocarpine, and vitamin B12.
• Subacute endocarditis • Use of the neutraceutical liver extract is
strongly contraindicated in patients
CRITICAL VALUES: The presence with iron-storage disorders such as
of abnormal cells, other morphologic hemochromatosis because it is rich in
characteristics, or cellular inclusions heme (the iron-containing pigment in
may signify a potentially life-threatening Hgb).
or serious health condition and should
be investigated. Examples are the pres- • Hemodilution (e.g., excessive adminis-
ence of sickle cells, moderate numbers tration of intravenous fluids, normal
of spherocytes, marked schistocytosis, pregnancy) in the presence of a normal
oval macrocytes, basophilic stippling, number of RBCs may lead to false
nucleated RBCs (if the patient is not an decreases in RBC count.
infant), or malarial organisms. • Cold agglutinins may falsely increase
the mean corpuscular volume (MCV)
INTERFERING FACTORS: and decrease the RBC count. This can
• Drugs and substances that may be corrected by warming the blood or
decrease RBC count include those diluting the sample with warmed saline
causing hemolysis resulting from drug and repeating the analysis.
sensitivity or enzyme deficiency, such
as acetaminophen, aminopyrine, • Excessive exercise, anxiety, pain, and
aminosalicylic acid, amphetamine, dehydration may cause false elevations
antipyrine, arsenicals, benzene, busul- in RBC count.
fan, anticonvulsants, carbenicillin,
• A grossly elevated white blood cell
cephalothin, chemotherapy, chlorate,
count (greater than 500,000
chloroquine, chlorothiazide, chlorpro-
103/mm3) will cause a falsely elevated
mazine, colchicine, diphenhydramine,
RBC count. This can be corrected by
dipyrone, glucosulfone, gold,
diluting the sample with saline to
hydroflumethiazide, indomethacin,
obtain an accurate white blood cell
mephenytoin, nalidixic acid,
count and then correcting the RBC
neomycin, nitrofurantoin, penicillin,
mathematically.
phenacemide, phenazopyridine, and
phenothiazine. • Care in evaluating the CBC after trans-
fusion should be taken into considera-
• Drugs that may decrease RBC count
tion.
include those that result in anemia,
such as miconazole, penicillamine, • RBC counts can vary depending on
phenylhydrazine, primaquine, pro- the patient’s position, decreasing when
benecid, pyrazolones, pyrimethamine, the patient is recumbent as a result of
quinines, streptomycin, sulfamethi- hemodilution and increasing when the
patient rises as a result of hemocon- Intratest:

centration.
• Venous stasis can falsely elevate RBC normally and to avoid unnecessary
counts; therefore the tourniquet movement.
should not be left on the arm for ➤ Perform a venipuncture, and collect
longer than 60 seconds. the specimen in a 5-mL lavender-top
(EDTA) tube. Observe standard
• Failure to fill the tube sufficiently (i.e., precautions and follow the general
tube less than three-quarters full) may guidelines in Appendix A. Handle the
yield inadequate sample volume for specimen gently to avoid hemolysis.
automated analyzers and may be The specimen should be mixed
reason for specimen rejection. gently by inverting the tube 10
times. It is stable when stored for up
• Hemolyzed or clotted specimens to 6 hours at room temperature or
should be rejected for analysis. 24 hours if stored refrigerated. In
addition, if it is anticipated that the
Nursing Implications and 4 to 6 hours, two blood smears
Procedure ● ● ● ● ● ● ● ● ● ● ●
should be made immediately after
the venipuncture and submitted with
Pretest: the blood sample.
allergens.
Post-test:
gastrointestinal, hematopoietic, ➤ Observe venipuncture site for bleed-
hepatobiliary, immune, and respira- ing or hematoma formation. Apply
tory systems, as well as results of pressure bandage. Iron deficiency is
previously performed tests and the most common nutrient defi-
procedures. For related tests refer to ciency in the United States. Patients
the gastrointestinal, hematopoietic, at risk (e.g., children, pregnant
hepatobiliary, immune, and respira- women and women of childbearing
tory system tables. age, low-income populations) should
➤ Obtain a list of the medications the be instructed to include foods that
patient is taking, including herbs, are high in iron in their diet, such as
nutritional supplements, and meats (especially liver), eggs, grains,
nutraceuticals. The requesting health vegetables, and multivitamins with
care practitioner and laboratory iron. Iron absorption is affected by
should be advised if the patient numerous factors (see monograph
regularly uses these products so titled “Iron”).
that their effects can be taken into ➤ Patients at risk for vitamin B12 or
consideration when reviewing folate deficiency include those
results. with the following conditions:
➤ Note any recent procedures that can malnourishment (inadequate intake),
interfere with test results. pregnancy (increased need), infancy,
malabsorption syndromes (inade-
quate absorption/increased meta-
bolic rate), infections, cancer,
direction.
hyperthyroidism, serious burns,
➤ Review the procedure with the excessive blood loss, and gastroin-
patient. testinal damage. These patients
➤ Inform the patient that specimen should be instructed, as appropriate,
collection takes approximately 5 to to ingest food sources rich in
10 minutes. vitamin B12 such as meats, milk,
Red Blood Cell Indices 863
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.
RED BLOOD CELL INDICES

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: mean corpuscular hemoglobin (MCH), mean

corpuscular volume (MCV), mean corpuscular hemoglobin concentration
(MCHC), red blood cell distribution width (RDW).


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.
DESCRIPTION: Red blood cell (RBC) • Monitor the response to drugs or

indices provide information about chemotherapy, and evaluate undesired
the mean corpuscular volume reactions to drugs that may cause
(MCV), mean corpuscular hemoglo- blood dyscrasias
bin (MCH), mean corpuscular hemo- • Provide screening as part of a complete
globin concentration (MCHC), and blood count (CBC) in a general physi-
RBC distribution width (RDW). The cal examination, especially upon
hematocrit, RBC count, and total he- admission to a health care facility or
moglobin tests are used to determine before surgery
the RBC indices. MCV is determined
by dividing the hematocrit by the to-
RESULT
tal RBC count and is helpful in classi- MCV increased in:
fying anemias. MCH is determined
• Alcoholism
by dividing the total hemoglobin con-
centration by the RBC count. • Antimetabolite therapy
MCHC is determined by dividing to- • Liver disease
tal hemoglobin by hematocrit. He-
moglobin content is indicated as
normochromic, hypochromic, and • Vitamin B12/folate anemia
hyperchromic. The RDW is a meas-
urement of cell size distribution over MCV decreased in:
the entire RBC population measured. • Iron-deficiency anemia
It is an indication of anisocytosis or • Thalassemias
excessive variations in cell size. Cell
size is indicated as normocytic, micro- MCH increased in:
cytic, and macrocytic. (See mono- • Macrocytic anemias
graphs titled “Hemoglobin,” “Hema-
tocrit,” “Red Blood Cell Count,” and MCH decreased in:
“Red Blood Cell Morphology and • Hypochromic anemias
Inclusions.”) ■ • Microcytic anemias
INDICATIONS: MCHC increased in:

• Assist in the diagnosis of anemia • Thalassemia
• Detect a hematologic disorder, neo- • Spherocytosis
plasm or immunologic abnormality
• Determine the presence of a hereditary MCHC decreased in:
hematologic abnormality • Iron-deficiency anemia
• Monitor the effects of physical or RDW increased in:
emotional stress
• Anemias with heterogeneous cell size
• Monitor the progression of nonhema-
tologic disorders such as chronic ob- RDW decreased in:
structive pulmonary disease (COPD), • N/A
malabsorption syndromes, cancer, and
renal disease CRITICAL VALUES: N/A
Red Blood Cell Indices 865
INTERFERING FACTORS: Nursing Implications and

decrease MCHC include styrene Procedure ● ● ● ● ● ● ● ● ● ● ●
(occupational exposure).
Pretest:
• Drugs that may decrease MCV include
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.
• 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
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
• 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.
• 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,
• 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,
two blood smears should be made ing or hematoma formation. Apply

immediately after the venipuncture pressure bandage.
and submitted with the blood ➤ Evaluate test results in relation to
sample. the patient’s symptoms and other
transport it to the laboratory. tests include the other tests
included in a CBC, erythropoietin,
Post-test: ferritin, iron/total iron-binding capac-
ity, RBC morphology and inclusions,
➤ Observe venipuncture site for bleed- and reticulocyte count.
RED BLOOD CELL MORPHOLOGY

AND INCLUSIONS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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.
REFERENCE VALUE: (Method: Microscopic, manual review of stained blood

smear)
Red Within
Blood Cell Normal
Morphology Limits 1 2 3 4
Size
Anisocytosis 0–5 5–10 10–20 20–50 Greater than 50
Macrocytes 0–5 5–10 10–20 20–50 Greater than 50
Microcytes 0–5 5–10 10–20 20–50 Greater than 50
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 (teardrop cells) 0–2 2–5 5–10 10–20 Greater than 20
Codocytes (target cells) 0–2 2–10 10–20 20–50 Greater 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

867
868
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)
Red Blood Cell Morphology and Inclusions 869
DESCRIPTION: The decision to • Grossly elevated glucose (hyperos-

manually review a peripheral blood motic)
smear for abnormalities in red blood • Hemolytic disease of the newborn
cell (RBC) shape or size is made based
• Hypothyroidism
on criteria established by the report-
ing laboratory. Cues in the results of • Leukemia
the complete blood count (CBC) will • Lymphoma
point to specific abnormalities that
can be confirmed visually, by micro- • Metastatic carcinoma
scopic review of the sample on a • Myelofibrosis
stained blood smear. ■ • Myeloma
INDICATIONS: • Refractory anemia
• Assist in the diagnosis of anemia • Sideroblastic anemia
• Detect a hematologic disorder, • Vitamin B12/folate deficiency
neoplasm, or immunologic abnormal-
ity
Cell size decreased in:
• Determine the presence of a hereditary • Hemoglobin C disease
hematologic abnormality
• Hemolytic anemias
emotional stress • Hereditary spherocytosis
• Monitor the progression of nonhema- • Inflammation

tologic disorders, such as chronic • Iron-deficiency anemia
obstructive pulmonary disease
(COPD), malabsorption syndromes, • Thalassemias
cancer, and renal disease
Red Blood Cell Shape
• Monitor the response to drugs or
chemotherapy, and evaluate undesired Variations in cell shape are the result of
reactions to drugs that may cause hereditary conditions such as elliptocyto-
blood dyscrasias sis, sickle cell anemia, spherocytosis, tha-
lassemias, or hemoglobinopathies (e.g.,
• Provide screening as part of a CBC in a hemoglobin C disease). Irregularities in
general physical examination, espe- cell shape can also result from acquired
cially upon admission to a health care conditions, such as physical/mechanical
facility or before surgery cellular trauma, exposure to chemicals, or
reactions to medications.
RESULT
• Acquired spherocytosis can result from
Red Blood Cell Size Heinz body hemolytic anemia, mi-
croangiopathic hemolytic anemia, sec-
ondary isoimmunohemolytic anemia,
Cell size increased in: and transfusion of old banked blood.
• Alcoholism
• Acanthocytes are associated with
• Aplastic anemia acquired conditions such as alcoholic
cirrhosis with hemolytic anemia, disor-
• Chemotherapy
ders of lipid metabolism, hepatitis of
• Chronic hemolytic anemia newborns, malabsorptive diseases,
metastatic liver disease, postsplenec- Polychromasia is indicative of prema-

tomy, and pyruvate kinase deficiency. ture release of RBCs from bone
marrow secondary to increased
• Burr cells are commonly seen in
erythropoietin stimulation.
acquired renal insufficiency, burns,
cardiac valve disease, disseminated
intravascular coagulation (DIC), intra- Red Blood Cell Inclusions
venous fibrin deposition, hyperten- RBC inclusions can result from certain
sion, metastatic malignancy, normal types of anemia, abnormal Hgb precipi-
neonatal period, and uremia. tation, or parasitic infection.
• Codocytes are seen in hemoglo- • Cabot rings may be seen in mega-
binopathies, iron-deficiency anemia, loblastic and other anemias, lead
obstructive liver disease, and post- poisoning, and conditions in which
splenectomy. RBCs are destroyed before they are
• Dacryocytes are most commonly asso- released from bone marrow.
ciated with metastases to the bone
• Basophilic stippling is seen whenever
marrow, myelofibrosis, myeloid meta-
there is altered Hgb synthesis, as in
plasia, pernicious anemia, and tubercu-
thalassemias, megaloblastic anemias,
losis.
alcoholism, and lead or arsenic intoxi-
• Schistocytes are seen in burns, cardiac cation.
valve disease, DIC, glomerulonephri-
tis, hemolytic anemia, microangio- • Howell-Jolly bodies are seen in sickle
pathic hemolytic anemia, renal graft cell anemia, other hemolytic anemias,
rejection, thrombotic thrombocy- megaloblastic anemia, congenital
topenic purpura, uremia, and vasculi- absence of the spleen, and the post-
tis. splenectomy period.
• Pappenheimer bodies may be seen in
Red Blood Cell Hemoglobin cases of sideroblastic anemia,
Content thalassemias, refractory anemia, dys-
RBCs with a normal hemoglobin (Hgb) erythropoietic anemias, hemosiderosis,
level have a clear central pallor and are and hemochromatosis.
referred to as normochromic. • Heinz bodies are most often seen in the
• Cells with low Hgb and lacking in blood of patients who have ingested
central pallor are referred to as drugs known to induce the formation
hypochromic. Hypochromia is associ- of these inclusion bodies. They are also
ated with iron-deficiency anemia, seen in patients with hereditary
thalassemias, and sideroblastic anemia. glucose-6-phosphate dehydrogenase
(G-6-PD) deficiency.
• Cells with excessive Hgb levels are
referred to as hyperchromic, even • Hgb C crystals can often be identified
though they technically lack a central in stained peripheral smears of patients
pallor. Hyperchromia is usually associ- with hereditary hemoglobin C disease.
ated with an elevated mean corpuscular
• Parasites such as Plasmodium (trans-
Hgb concentration as well as hemolytic
mitted by mosquitoes and causing
anemias.
malaria) and Babesia (transmitted by
• Cells referred to as polychromic are ticks), known to invade human RBCs,
young erythrocytes that still contain can be visualized with Wright’s stain
ribonucleic acid (RNA). The RNA is and other special stains of the periph-
picked up by the Wright’s stain. eral blood.
Red Blood Cell Morphology and Inclusions 871
CRITICAL VALUES: The presence practitioner and laboratory should be

of sickle cells or parasitic inclusions advised if the patient regularly uses
should be brought to the immediate
attention of the requesting health care when reviewing results.
practitioner.
• Drugs and substances that may increase ➤ There are no food, fluid, or medica-
Heinz body formation as an initial
direction.
precursor to significant hemolysis
include acetanilid, acetylsalicylic acid, ➤ Review the procedure with the
patient.
aminopyrine, antimalarials, antipyret-
ics, furadaltone, furazolidone, methy- ➤ Inform the patient that specimen
lene blue, naphthalene, and nitrofurans. collection takes approximately 5 to
10 minutes.
• Care in evaluating the CBC after trans-
fusion should be taken into considera- Intratest:
tion. ➤ Direct the patient to breathe
• Leaving the tourniquet in place for normally and to avoid unnecessary
longer than 60 seconds can affect the movement.
results. ➤ Observe standard precautions and
• Morphology can be evaluated to some Appendix A. Perform a venipuncture,
extent via indices; therefore failure to and collect the specimen in a 5-mL
fill the tube sufficiently (i.e., tube less lavender-top (EDTA) tube. The speci-
than three-quarters full) may yield men should be mixed gently by
inadequate sample volume for auto- inverting the tube 10 times. It is
mated analyzers and may be reason for stable when stored for up to 6 hours
at room temperature or 24 hours if
specimen rejection.
stored refrigerated. In addition, if it is
• Hemolyzed or clotted specimens anticipated that the specimen will
should be rejected. not be analyzed within 4 to 6 hours,
two blood smears should be made
immediately after the venipuncture
and submitted with the blood
Nursing Implications and sample.
Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
hematopoietic, hepatobiliary, and ➤ Evaluate test results in relation to
immune systems, as well as results the patient’s symptoms and other
of previously performed tests and tests performed. Related laboratory
procedures. For related tests, refer tests include the other tests
to the hematopoietic, hepatobiliary, included in a CBC, -aminolevulinic
and immune system tables. acid, erythropoietin, ferritin, G-6-PD,
➤ Obtain a list of the medications the Hgb electrophoresis, iron/total iron-
patient is taking, including herbs, binding capacity, lead, reticulocyte
nutritional supplements, and nutra- count, and white blood cell count
ceuticals. The requesting health care and differential.
RENIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Plasma renin activity (PRA).

SPECIMEN: Plasma (3 mL) collected in a lavender-top (ethylenediaminete-
tra-acetic acid [EDTA]) tube.
SI Units
Age and Position Conventional Units (Conversion Factor 1)
Newborn 2.0–35.0 ng/mL per hour 2.0–35.0 g/L per hour

Supine, normal
sodium diet
1–12 mo 2.4–37.0 ng/mL per hour 2.4–37.0 g/L per hour
1–3 y 1.7–112 ng/mL per hour 1.7–112 g/L per hour
3–5 y 1.0–6.5 ng/mL per hour 1.0–6.5 g/L per hour
Adult 0.2–1.6 ng/mL per hour 0.2–1.6 g/L per hour
Upright, normal
sodium diet
Adult 0.7–3.3 ng/mL per hour 0.7–3.3 g/L per hour
Values vary according to the laboratory performing the test, as well as the patient’s age,
gender, dietary pattern, state of hydration, posture, and physical activity.
DESCRIPTION: Renin is an enzyme amounts of angiotensin II cause renal

that activates the renin-angiotensin hypertension. The renin assay screens
system. It is released into the renal for essential, renal, or renovascular
veins by the juxtaglomerular appara- hypertension. Plasma renin is ex-
tus in response to sodium depletion pressed as the rate of angiotensin I
and hypovolemia. Renin converts an- formation per unit of time. The ran-
giotensinogen to angiotensin I. An- dom collection of specimens without
giotensin I is converted to an- prior dietary preparations does not
giotensin II, the biologically active provide clinically significant informa-
form. Angiotensin II is a powerful tion. Values should also be evaluated
vasoconstrictor that stimulates aldos- along with simultaneously collected
terone production in the adrenal cor- aldosterone levels. (See mono-
tex. Angiotensin II and aldosterone graphs titled “Aldosterone” and
increase blood pressure. Excessive “Angiotensin-Converting Enzyme.”) ■
Renin 873
INDICATIONS: cilazapril, cromakalim, desmopressin,

• Assist in the identification of primary diazoxide, dihydralazine, doxazosin,
hyperaldosteronism resulting from enalapril, endralazine, felodipine,
aldosterone-secreting adrenal adenoma fenoldopam, fosinopril, furosemide,
hydralazine, hydrochlorothiazide, laxa-
• Assist in monitoring patients on tives, lisinopril, lithium, methyclo-
mineralocorticoid therapy thiazide, metolazone, muzolimine,
• Assist in the screening of the origin of nicardipine, nifedipine, opiates, oral
essential, renal, or renovascular hyper- contraceptives, perindopril, ramipril,
tension spironolactone, triamterene, and
xipamide.
RESULT • Drugs and substances that may de-
crease renin levels include angiotensin,
Increased in: angiotensin II, acetylsalicylic acid,
• Addison’s disease atenolol, bopindolol, bucindolol, car-
• Bartter’s syndrome benoxolone, carvedilol, clonidine, cy-
closporine A, dexfenfluramine, gly-
• Cirrhosis cyrrhiza, ibuprofen, indomethacin,
• Congestive heart failure levodopa, metoprolol, naproxen,
nicardipine, nonsteroidal anti-
• Gastrointestinal disorders with elec- inflammatory drugs (NSAIDs), oral
trolyte loss contraceptives, oxprenolol, propra-
• Hepatitis nolol, sulindac, and vasopressin.
• Hypokalemia • Upright body posture, stress, and
strenuous exercise can increase renin
• Malignant hypertension levels.
• Nephritis • Recent radioactive scans or radiation
• Nephropathies with sodium or potas- can interfere with test results when
sium wasting radioimmunoassay is the test method.
• Pheochromocytoma • Diet can significantly affect results
(e.g., low-sodium diets stimulate the
• Pregnancy release of renin).
• Renin-producing renal tumors • Hyperkalemia, acute increase in blood
• Renovascular hypertension pressure, and increased blood volume
may suppress renin secretion.
Decreased in:
• Essential hypertension
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Primary hyperaldosteronism
Pretest:
CRITICAL VALUES: N/A ➤ Obtain a history of the patient’s
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-
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).
nutraceuticals. The requesting health Post-test:
pressure bandage.
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.
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
therefore patients on a low-sodium
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
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Renocystography, renocystogram, radioactive

renogram, renal scintigraphy.
AREA OF APPLICATION: Kidneys.

DESCRIPTION: A renogram is a obtained. The radioactive material is

nuclear medicine study performed to detected by a gamma camera, which
assist in diagnosing renal disorders, can detect the gamma rays emitted by
such as abnormal blood flow, the radionuclide in the kidney.
collecting-system defects, and excre- Renography simultaneously tracks
tion dysfunction. Because renography the rate at which the radionuclide
uses no iodinated contrast medium, it flows into (vascular phase), through
is safe to use in patients who have (tubular phase), and out of (excretory
iodine allergies or compromised renal phase) the kidneys. The times are
function. plotted on a graph and compared to
After intravenous administration normal parameters of organ function.
of the radioisotope, information Differential estimates of left and right
about the structures of the kidneys is kidney contributions to glomerular
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
nephritis for:
• Evaluate chronic urinary tract infec- • Patients who are pregnant or suspected
tions, especially in children of being pregnant, unless the potential
• Determine the presence, location, and
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
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.
ment
Procedure ● ● ● ● ● ● ● ● ● ● ●

which may produce poor visualization Pretest:
of the area to be examined ➤ Inform the patient that the proce-
• Serum creatinine levels greater than or dure assesses the renal system.
equal to 3 mg/dL (depending on the ➤ Inform the patient that the proce-
radionuclide used), which can decrease dure is performed in a special
renal perfusion nuclear medicine department by a
technologist and usually takes
• Other nuclear scans done within the approximately 60 to 90 minutes, and
previous 24 to 48 hours that delayed images are needed 2 to
24 hours later. The patient may leave
• Medications such as antihypertensives, the department and return later to
angiotensin-converting enzyme (ACE) undergo delayed imaging.
inhibitors, and beta blockers taken
within 24 hours of the test, which can complaints, including a list of known
affect the results (depending on the allergens. Assess for allergy to the
reason for the study) radionuclide.
• Dehydration, which can accentuate ➤ Obtain a history of the patient’s
abnormalities; or overhydration, which renal and urinary systems, as well as
can mask abnormalities results of previously performed
tests and surgical procedures. For
• Metallic objects within the examina- related tests, refer to the genitouri-
tion field (e.g., jewelry or body rings), nary/renal system table.
which may inhibit organ visualization ➤ Obtain a list of the medications the
and can produce unclear images patient is taking.
Other considerations: period and possibility of pregnancy
• Failure to follow dietary restrictions in perimenopausal women.
before the procedure may cause the ➤ There are no food or fluid restric-
procedure to be canceled or repeated. tions, unless otherwise indicated.
• Consultation with a physician should Inform the patient that he or she will
occur before the procedure for radia- be asked to drink several glasses of
fluid before the study for hydration,
tion safety concerns regarding infants unless the patient has a restricted
of patients who are lactating. fluid intake for other reasons.
overexposure can result from frequent Intratest:
x-ray procedures. Personnel in the ➤ Ask the patient to void before the
room with the patient should stand procedure. Have the patient put on a
behind a shield or leave the area while hospital gown.
the examination is being done. ➤ Administer sedative to a child or to
Personnel working in the area where an uncooperative adult, as ordered.
the examination is being done should ➤ Ask the patient to lie still during the
wear badges that reveal their level of procedure because movement
exposure to radiation. produces unclear images. Make
sure jewelry, watches, chains, belts, administration and while handling

and any other metallic objects have the patient’s urine.
been removed from the renal area.
➤ Place the patient in a supine position Post-test:
on a flat table with foam wedges to ➤ Instruct the patient to resume
help maintain position and immobi- normal activity, medications, and
lization. diet, unless otherwise indicated.
➤ The radionuclide is administered ➤ Advise patient to drink increased
intravenously, and the kidney area is amounts of fluids for 24 hours to
scanned immediately with images eliminate the radionuclide from the
taken every minute for 30 minutes. body, unless contraindicated. Tell the
➤ During the flow and static imaging, patient that radionuclide is elimi-
the diuretic furosemide (Lasix) or nated from the body within 6 to 24
ACE inhibitor (captopril) can be hours.
administered intravenously and ➤ Instruct the patient to flush the toilet
images obtained. immediately after each voiding
➤ Renogram curves can be plotted following the procedure and to wash
concurrently with flow studies in hands meticulously with soap and
which blood flow is imaged and water after each voiding for 24 hours
recorded as it occurs. after the procedure.
➤ Urine and blood laboratory studies ➤ Tell all caregivers to wear gloves
are done after the renogram to when discarding urine for 24 hours
correlate findings before diagnosis. after the procedure. Wash gloved
➤ If a study for vesicoureteral reflux is hands with soap and water before
done, the patient is asked to void removing gloves. Then wash hands
and a catheter is placed into the after the gloves are removed.
bladder. The radionuclide is instilled ➤ A physician specializing in this
into the bladder, and multiple branch of medicine sends a written
images are obtained during bladder report to the ordering provider, who
filling. The patient is then requested discusses the results with the
to void, with the catheter in place or patient.
after catheter removal, depending ➤ Evaluate test results in relation to
on department policy. Imaging is the patient’s symptoms and other
continued during and after voiding. tests performed. Related diagnostic
Reflux is determined by calculating tests include intravenous pyelogram,
the urine volume and counts as well as computed tomography,
obtained by imaging. ultrasonography, and magnetic reso-
➤ Wear gloves during the radionuclide nance imaging of the abdomen.
RETICULOCYTE COUNT
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Retic count.

Reticulocyte Count 879
REFERENCE VALUE: (Method: Microscopic examination of specially stained

peripheral blood smear or automated analyzer)
Total As the formula shows, the RPI is

Age Erythrocyte Count* inversely proportional to Hct, as follows:
Newborn 3–7%
1–12 mo 0.2–2.8% Maturation
Adult 1.5–2.5% Hematocrit (%) Time (days)
* Values are expressed as percentage 45 1.0
of the red blood cell count. 35 1.5
25 2.0
DESCRIPTION: Normally, as it 15 2.5
matures, the red blood cell (RBC)
loses its nucleus. The remaining Increased in:
ribonucleic acid (RNA) will produce • Blood loss
a characteristic color when special
stains are used, making these cells • Hemolytic anemias
easy to identify and enumerate. The • Iron-deficiency anemia
presence of reticulocytes is an indica-
tion of the level of erythropoietic • Megaloblastic anemia
activity in the bone marrow. In
Decreased in:
abnormal conditions, reticulocytes
are prematurely released into • Alcoholism
circulation. (See monographs titled • Anemia of chronic disease
“Red Blood Cell Count” and “Red
• Aplastic anemia
Blood Cell Morphology and
Inclusions.”) ■ • Bone marrow replacement
• Endocrine disease
INDICATIONS:
• Evaluate erythropoietic activity • RBC aplasia
• Monitor response to therapy for • Renal disease
anemias • Sideroblastic anemia
RESULT: The reticulocyte production CRITICAL VALUES: N/A
index (RPI) is a good estimate of RBC
production. The calculation corrects the
count for anemia and for the premature
• Drugs that may increase reticulocyte
release of reticulocytes into the periph-
counts include acetanilid, acetylsali-
eral blood during periods of hemolysis or
cylic acid, amyl nitrate, antimalarials,
significant bleeding. The RPI also takes
antipyretics, antipyrine, arsenicals,
the maturation time of large polychro-
corticotropin, dimercaprol, furalta-
matophilic cells or nucleated RBCs seen
done, furazolidone, levodopa, methyl-
on the peripheral smear into considera-
dopa, nitrofurans, penicillin, pro-
tion.
cainamide, and sulfones.
RPI % reticulocytes [patient
hematocrit (Hct)/normal Hct] • Drugs that may decrease reticulocyte
(1/maturation time) counts include azathioprine, dactino-
mycin, hydroxyurea, methotrexate, ➤ Note any recent procedures that can

and zidovudine. interfere with test results.
• Reticulocyte count may be falsely ➤ There are no food, fluid, or medica-
increased by the presence of RBC direction.
inclusions (Howell-Jolly bodies, Heinz
bodies, and Pappenheimer bodies) that ➤ Review the procedure with the
patient.
stain with methylene blue.
• Reticulocyte count may be falsely collection takes approximately 5 to
decreased after a recent blood transfu- 10 minutes.
sion, as a result of the dilutional effect.
Intratest:
Nursing Implications and ➤ Direct the patient to breathe
Procedure ● ● ● ● ● ● ● ● ● ● ●
movement.
Pretest: ➤ Observe standard precautions and
complaints, including a list of known and collect the specimen in a 5-mL
allergens. lavender-top tube.
hematopoietic system and results of transport it to the laboratory.
procedures. For related tests, refer Post-test:
to the hematopoietic system table.
➤ Obtain a list of the medications the ➤ Observe venipuncture site for bleed-
patient is taking, including herbs, nu- ing or hematoma formation. Apply
tritional supplements, and nutraceu- pressure bandage.
ticals. The requesting health care ➤ Evaluate test results in relation
practitioner and laboratory should be to the patient’s symptoms and
advised if the patient regularly uses other tests performed. Related labo-
these products so that their effects ratory tests include complete blood
can be taken into consideration count and RBC morphology and
when reviewing results. inclusions.
RETROGRADE
URETEROPYELOGRAPHY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Retrograde.
AREA OF APPLICATION: Renal calyces, ureter.
CONTRAST: Radiopaque iodine-based contrast medium.
Retrograde Ureteropyelography 881
DESCRIPTION: Retrograde • Evaluate the effects of urinary system

ureteropyelography uses a contrast trauma
medium introduced through a • Evaluate placement of a ureteral stent
ureteral catheter during cystography or catheter
and radiographic visualization to view
the renal collecting system (calyces, RESULT
renal pelvis, and urethra). During a
cystoscopic examination, a catheter is Normal Findings:
advanced through the ureters and • Normal outline and opacification of
into the kidney; contrast medium renal pelvis and calyces
is injected through the catheter • Symmetrical and bilateral outline of
into the kidney. This procedure is structures
primarily used in patients who are • Normal size and uniform filling of the
known to be hypersensitive to ureters
intravenously injected iodine-based
contrast medium and when excretory Abnormal Findings:
ureterography does not adequately • Congenital renal or urinary tract
reveal the renal collecting system. The abnormalities
incidence of allergic reaction to the • Hydronephrosis
contrast medium is reduced because
there is less systemic absorption of the • Neoplasms
contrast medium when injected into • Obstruction as a result of tumor, blood
the kidney than when injected intra- clot, stricture, or calculi
venously. Retrograde ureteropyelogra- • Obstruction of ureteropelvic junction
phy sometimes provides more
information about the anatomy of the • Perinephric abscess
different parts of the collecting system • Perinephric inflammation or suppura-
than can be obtained by excretory tion
ureteropyelography. The procedure is • Polycystic kidney disease
not hampered by impaired renal func-
tion, but it carries the risk of urinary • Prostatic enlargement
tract infection and sepsis. ■ • Tumor of the kidneys or the collecting
system
INDICATIONS:
• Evaluate known or suspected ureteral CRITICAL VALUES: N/A
obstruction
• Evaluate the presence of calculi in the
kidneys, ureters, or bladder
• Evaluate the structure and integrity of for:
the renal collecting system • Patients with allergies to shellfish or
• Evaluate the renal collecting system
when excretory urography is unsuc-
cessful
• Evaluate space-occupying lesions or contrast medium may benefit from
congenital anomalies of the urinary premedication with corticosteroids or
system the use of nonionic contrast medium.
• Patients who are pregnant or suspected • Consultation with a physician should

of being pregnant, unless the potential occur before the procedure for radia-
benefits of the procedure far outweigh tion safety concerns regarding infants
the risks to the fetus and mother of patients who are lactating.
• Elderly and other patients who are • Risks associated with radiographic
chronically dehydrated before overexposure can result from frequent
the test, because of their risk of x-ray procedures. Personnel in the
contrast-induced renal failure. room with the patient should stand
the examination is being done.
• Patients with renal insufficiency, indi- Personnel working in the area where
cated by a blood urea nitrogen the examination is being done should
(BUN) value greater than 40 wear badges that reveal their level of
mg/dL, because contrast medium can exposure to radiation.
complicate kidney function.
Factors that may impair clear Nursing Implications and

imaging:
Procedure ● ● ● ● ● ● ● ● ● ● ●
remain still during the procedure Pretest:
mental status ➤ Inform the patient that the proce-
dure assesses the renal collecting
• Improper adjustment of the radio- system. Inform the patient that the
graphic equipment to accommodate procedure is done by a urologist and
obese or thin patients, which can cause support staff during a cystoscopic
overexposure or underexposure and examination in the surgical depart-
poor-quality study ment and takes approximately 60
minutes.
• Patients who are very obese, who may ➤ Obtain a history of the patient’s
exceed the weight limit for the equip- complaints, including a history of
ment allergies or sensitivities to contrast
medium or shellfish.
which may produce poor visualization ➤ Patients receiving metformin
• Gas or feces in the gastrointestinal (GI) discontinue the drug on the day of
tract resulting from inadequate cleans- the test and continue to withhold it
ing or failure to restrict food intake for 48 hours after the test. Failure to
before the study
• Retained barium from a previous radi- genitourinary and abdominal
ologic procedure systems, as well as results of previ-
• Metallic objects within the examina- dures, especially BUN and
tion field (e.g., jewelry or body rings), creatinine. For related tests, refer to
which may inhibit organ visualization the genitourinary system table.
and can produce unclear images ➤ Determine date of last menstrual
Other considerations: in perimenopausal women.
• Failure to follow dietary restrictions ➤ Obtain a written, informed consent
before the procedure may cause the before administering any medica-
procedure to be canceled or repeated. tions prior to the procedure.
Retrograde Ureteropyelography 883
➤ 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
tests performed. Related diagnostic computed tomography and mag-

tests include renogram, intravenous netic resonance imaging of the
pyelogram, renal ultrasound, and abdomen.
RHEUMATOID FACTOR
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: RF, RA.

SPECIMEN: Serum (1 mL) collected in a red-top tube
REFERENCE VALUE: (Method: Nephelometry) 0 to 20 IU/mL.
DESCRIPTION: Individuals with • Leprosy

rheumatoid arthritis harbor a • Malaria
macroglobulin-type antibody called
rheumatoid factor (RF) in their blood. • Rheumatoid arthritis
Patients with other diseases (e.g., • Sarcoidosis
systemic lupus erythematosus [SLE]
• Scleroderma
and occasionally tuberculosis, chronic
hepatitis, infectious mononucleosis, • Sjögren’s syndrome
and subacute bacterial endocarditis) • SLE
may also test positive for RF. RF
• Syphilis
antibodies are usually immunoglobu-
lin M (IgM) but may also be IgG • Tuberculosis
or IgA. ■ • Waldenström’s macroglobulinemia
INDICATIONS: Assist in the diagnosis of Decreased in: N/A
rheumatoid arthritis, especially when
clinical diagnosis is difficult
RESULT
Increased in: • Older patients may have higher values.
• Chronic hepatitis • Recent blood transfusion, multiple
vaccinations or transfusions, or an
• Chronic viral infections
inadequately activated complement
• Cirrhosis may affect results.
• Dermatomyositis • Serum with cryoglobulin or high lipid
levels may cause a false-positive test
and may require that the test be
• Leishmaniasis repeated after a fat-restriction diet.
Rubella Antibodies 885

Pretest: red-top tube.
complaints, including a list of known transport it to the laboratory.
allergens.
Post-test:
immune and musculoskeletal ➤ Observe venipuncture site for bleed-
systems, as well as results of previ- ing or hematoma formation. Apply
ously performed tests and proce- pressure bandage.
dures. For related tests, refer to the ➤ Advise the patient, as appropriate,
immune and musculoskeletal that additional studies may be
system tables. undertaken to determine treat-
➤ Obtain a list of the medications the ment regimen or to determine the
patient is taking, including herbs, possible causes of symptoms if the
nutritional supplements, and nutra- test is negative for rheumatoid
ceuticals. The requesting health care arthritis.
practitioner and laboratory should be ➤ Recognize anxiety related to test
advised if the patient regularly uses results and offer support and
these products so that their effects information regarding the clinical
can be taken into consideration implications of the test results.
when reviewing results. Provide support for anxiety related
➤ There are no food, fluid, or medica- to anticipated chronic pain resulting
tion restrictions unless by medical from joint inflammation, impairment
direction. in mobility, musculoskeletal defor-
➤ Review the procedure with the mity, and loss of independence.
patient. Educate the patient regarding
➤ Inform the patient that specimen appropriate.
tests include antinuclear antibodies,
➤ Direct the patient to breathe C-reactive protein, erythrocyte sedi-
normally and to avoid unnecessary mentation rate, synovial fluid analy-
movement. sis, and uric acid.
RUBELLA ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: German measles serology.

REFERENCE VALUE: (Method: Indirect immunofluorescence) Immune or

DESCRIPTION: Rubella, commonly • Determine presence of rubella antibod-

known as German measles, is a ies
communicable viral disease transmit- • Determine susceptibility to rubella,
ted by contact with respiratory secre- particularly in pregnant women
tions and aerosolized droplets of the
• Perform as part of routine prenatal
secretions. The incubation period is serologic testing
14 to 21 days. This disease produces a
pink, macular rash that disappears in RESULT
2 to 3 days. Rubella infection induces
immunoglobulin G (IgG) and IgM Positive findings in: Rubella infec-
antibody production. This test can tion (past or present)
determine current infection or immu-
nity from past infection. Rubella CRITICAL VALUES: N/A
serology is part of the TORCH (toxo-
plasmosis, rubella, cytomegalovirus,
herpes simplex type 2) panel routinely
performed on pregnant women. Fetal Nursing Implications and
infection during the first trimester Procedure ● ● ● ● ● ● ● ● ● ● ●
can cause spontaneous abortion or

congenital defects. Ideally the Pretest:
immune status of women of child- ➤ Obtain a history of the patient’s
bearing age should be ascertained complaints, including a list of known
before pregnancy, when vaccination allergens. Obtain a history of expo-
can be administered to provide life- sure to rubella.
long immunity. The presence of IgM ➤ Obtain a history of the patient’s
antibodies indicates acute infection. as well as results of previously
The presence of IgG antibodies indi- performed tests and procedures. For
cates current or past infection. related tests, refer to the immune
Susceptibility to rubella is indicated and reproductive system tables.
by a negative reaction. Many labora- ➤ Obtain a list of the medications the
tories use a qualitative assay that patient is taking, including herbs,
detects the presence of both IgM and nutraceuticals. The requesting health
IgG rubella antibodies. IgM- and care practitioner and laboratory
IgG-specific enzyme immunoassays should be advised if the patient
are also available to help distinguish regularly uses these products so
acute infection from immune status. that their effects can be taken into
A rise in titer greater than fourfold in results.
paired specimens is an indication of ➤ There are no food, fluid, or medica-
current infection. ■ tion restrictions unless by medical
direction.
INDICATIONS: ➤ Review the procedure with the
• Assist in the diagnosis of rubella infec- patient. Inform the patient that
tion several tests may be necessary to
Rubeola Antibodies 887
confirm diagnosis. Any individual is pregnant. Encourage the family

positive result should be repeated in to seek counseling if concerned
7 to 14 days to monitor a change in with pregnancy termination. Provide
titer. teaching and information regarding
➤ Inform the patient that each speci- the clinical implications of the test
men collection takes approximately results, as appropriate. Decisions
5 to 10 minutes. regarding elective abortion should
take place in the presence of
both parents. Provide a nonjudg-
Intratest: mental, nonthreatening atmosphere
➤ Direct the patient to breathe for discussing the risks and diffi-
normally and to avoid unnecessary culties of delivering and raising
movement. an abnormal infant, as well as explor-
ing other options (e.g., termina-
tion of pregnancy or adoption).
Educate the patient regarding
appropriate.
red-top tube.
precautions during time of commu-
nicability or contagion.
Post-test: ➤ Emphasize the need to return to
have a convalescent blood sample
➤ Observe venipuncture site for bleed- taken in 7 to 14 days.
➤ Recognize anxiety related to test re- tests performed. Related laboratory
sults and provide emotional support tests include cytomegalovirus, her-
if results are positive and the patient pes simplex, and Toxoplasma.
RUBEOLA ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Measles serology.

REFERENCE VALUE: (Method: Indirect immunofluorescence) Negative or
DESCRIPTION: Measles is caused by a ratory secretions and aerosolized

single-stranded ribonucleic acid droplets of the secretions. The incu-
(RNA) paramyxovirus that invades bation period is 10 to 11 days.
the respiratory tract and lymphoretic- Symptoms initially include conjunc-
ular tissues. It is transmitted by respi- tivitis, cough, and fever. Koplik’s
spots develop 4 to 5 days later, related tests, refer to the immune

followed by papular eruptions, body and reproductive system tables.
rash, and lymphadenopathy. The ➤ Obtain a list of the medications the
presence of immunoglobulin M patient is taking, including herbs,
(IgM) antibodies indicates acute ceuticals. The requesting health care
infection. The presence of IgG anti- practitioner and laboratory should be
bodies indicates current or past infec- advised if the patient regularly uses
tion. Susceptibility to measles is these products so that their effects
indicated by a negative reaction. when reviewing results.
Many laboratories use a qualitative
assay that detects the presence of both tion restrictions unless by medical
IgM and IgG rubeola antibodies. direction.
IgM- and IgG-specific enzyme ➤ Review the procedure with the
immunoassays are also available to patient. Inform the patient that
help distinguish acute infection from several tests may be necessary to
immune status. A rise in titer greater confirm the diagnosis. Any individual
positive result should be repeated in
than fourfold in paired specimens is 7 to 14 days to monitor a change in
an indication of current infection. ■ titer.
INDICATIONS: men collection takes approximately
• Determine resistance to or protection 5 to 10 minutes.
against measles virus
• Differential diagnosis of viral infection, Intratest:
especially in pregnant women with a ➤ Direct the patient to breathe
history of exposure to measles normally and to avoid unnecessary
movement.
RESULT ➤ Observe standard precautions and
Positive findings in: Measles Appendix A. Perform a venipuncture,
infection and collect the specimen in a 5-mL
red-top tube.
CRITICAL VALUES: N/A ➤ Label the specimen, and promptly
Post-test:
Nursing Implications and ing or hematoma formation. Apply
Procedure ● ● ● ● ● ● ● ● ● ● ● pressure bandage.
Pretest: precautions during time of commu-
➤ Obtain a history of the patient’s nicability or contagion.
complaints, including a list of known ➤ Emphasize the need to return to
allergens. Obtain a history of expo- have a convalescent blood sample
sure to measles. taken in 7 to 14 days.
immune and reproductive systems, the patient’s symptoms and other
as well as results of previously tests performed. A related labora-
performed tests and procedures. For tory test is rubella.
Semen Analysis 889
SEMEN ANALYSIS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
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
DESCRIPTION: Semen analysis is a Specimens can be tested with a leuko-

valid measure of overall male fertility. cyte esterase strip to detect the pres-
Semen contains a combination of ence of white blood cells. ■
elements produced by various parts
of the male reproductive system. INDICATIONS:
Spermatozoa are produced in the • Assist in the diagnosis of azoospermia
testes and account for only a small and oligospermia
volume of seminal fluid. Fructose and • Evaluate infertility
other nutrients are provided by fluid
• Evaluate vasectomy effectiveness
produced in the seminal vesicles. The
prostate gland provides acid phos- • Support or disprove sterility in pater-
phatase and other enzymes required nity suit
for coagulation and liquefaction of
semen. Sperm motility depends on
RESULT: There is marked intraindivid-
ual variation in sperm count. Indications
the presence of a sufficient level of of suboptimal fertility should be investi-
ionized calcium. If the specimen has gated by serial analysis of two to three
an abnormal appearance (e.g., samples collected over several months. If
bloody, oddly colored, turbid), the abnormal results are obtained, additional
patient may have an infection. testing may be requested.
Abnormality Test Ordered Normal Result

Decreased count Fructose Present (greater
than 150 mg/dL)
Decreased motility with Male antisperm Absent
clumping antibodies
Normal semen analysis Female antisperm Absent
with infertility antibodies
Increased in: N/A common reasons for specimen rejec-

tion.
Decreased in:
• Hyperpyrexia
• Obstruction of ejaculatory system
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Orchitis
Pretest:
• Postvasectomy period
• 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
• Varicocele tests and procedures. For related
tests, refer to the reproductive
CRITICAL VALUES: N/A system table.
INTERFERING FACTORS: patient is taking, including herbs,
• Drugs and substances that may nutritional supplements, and nutra-
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.
• 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
• 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
Sickle Cell Screen 891
any sexual activity for 3 days before Cervical vaginal specimen:

specimen collection. Instruct the
patient to bring the specimen to ➤ Assist the patient to the lithotomy
the laboratory within 30 to 60 position on the examination table. A
minutes of collection and to keep speculum is inserted, and the speci-
the specimen warm (close to men is obtained by direct smear or
body temperature) during trans- aspiration of saline lavage.
portation. Specimens collected from
skin or clothing:
Intratest:
➤ Dried semen may be collected by
➤ Observe standard precautions and sponging the skin with a gauze
follow the general guidelines in soaked in saline or soaking the
Appendix A. material in a saline solution.
Ejaculated specimen: Post-test:
➤ Ideally, the specimen is obtained by ➤ Provide a supportive, nonjudgmental
masturbation in a private location environment when assisting a
close to the laboratory. In cases in patient through the process of fertil-
which the patient expresses psycho- ity testing. Provide teaching and
logical or religious concerns about information regarding the clinical
masturbation, the specimen can be implications of the test results, as
obtained during coitus interruptus, appropriate.
through the use of a condom, or
through postcoital collection of ➤ Provide a supportive, nonjudgmental
samples from the cervical canal and environment when assisting a
vagina of the patient’s sexual part- patient through the process of fertil-
ner. The patient should be warned ity testing. Recognize anxiety
about the possible loss of the related to test results, and encour-
sperm-rich portion of the sample if age the patient or family to seek
coitus interruptus is the collection counseling and other support serv-
approach. If a condom is used, the ices if concerned with infertility.
patient must be carefully instructed ➤ Evaluate test results in relation to
to wash and dry the condom the patient’s symptoms and other
completely before use to prevent tests performed. Related laboratory
contamination of the specimen with tests include antisperm antibodies,
spermicides. estradiol, and testosterone.
SICKLE CELL SCREEN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Sickle cell test.

REFERENCE VALUE: (Method: Hemoglobin high-salt solubility) Negative.

DESCRIPTION: The sickle cell screen Negative findings in: N/A

is one of several screening tests for a
group of hereditary hemoglo- CRITICAL VALUES: N/A
binopathies. The test is positive in the
presence of rare sickling hemoglobin
• Drugs that may increase sickle cells in
(Hgb) variants such as Hgb S and vitro include prostaglandins.
Hgb C Harlem. Hgb S results from
an amino acid substitution during • A positive test does not distinguish
Hgb synthesis whereby valine replaces between the sickle trait and sickle cell
anemia; to make this determination,
glutamic acid. Hemoglobin C
follow-up testing by Hgb electrophore-
Harlem results from the substitution sis should be performed.
of lysine for glutamic acid.
Individuals with sickle cell disease • False-negative results may occur in
children younger than 3 months of
have chronic anemia because the
age.
abnormal Hgb is unable to carry
oxygen. The red blood cells of • False-negative results may occur in
affected individuals are also abnormal patients who have received a recent
in shape, resembling a crescent or blood transfusion before specimen
collection, as a result of the dilutional
sickle rather than the normal disk
effect.
shape. This abnormality, combined
with cell-wall rigidity, prevents the • False-positive results may occur in
cells from passing through smaller patients without the trait or disease
who have received a blood transfusion
blood vessels. Blockages in blood
from a sickle cell–positive donor; this
vessels result in hypoxia, damage, and effect can last for 4 months after the
pain. Individuals with the sickle cell transfusion.
trait do not have the clinical manifes-
tations of the disease but may pass the • Test results are unreliable if the patient
has pernicious anemia or poly-
disease on to children if the other
cythemia.
parent has the trait (or the disease) as
well. ■
• Detect sickled red blood cells

• Evaluate hemolytic anemias Pretest:
allergens.
Positive findings in: ➤ Obtain a history of the patient’s
• Combination of Hgb S with other hematopoietic system as well as
hemoglobinopathies
• Hgb C Harlem anemia tests, refer to the hematopoietic
system table.
• Sickle cell anemia ➤ Obtain a list of medications the
• Sickle cell trait patient is taking, including herbs,
• Thalassemias ceuticals. The requesting health care
Sodium, Serum 893
practitioner and laboratory should be ing or hematoma formation. Apply

advised if the patient regularly uses pressure bandage.
these products so that their effects ➤ Inform the patient that further test-
can be taken into consideration ing may be indicated if results are
when reviewing results. positive.
➤ There are no food, fluid, or medica- ➤ Recognize anxiety related to test
tion restrictions unless by medical results and offer support, as appro-
direction. priate. Provide teaching and informa-
➤ Review the procedure with the tion regarding the clinical impli-
patient. Sensitivity to cultural and cations of the test results, as
social issues is important in provid- appropriate. Educate the patient
ing psychological support. regarding access to counseling
➤ Inform the patient that specimen services.
collection takes approximately 5 to ➤ Advise the patient with sickle cell
10 minutes. disease to avoid situations in which
hypoxia may occur, such as strenu-
Intratest: ous exercise, staying at high alti-
tudes, or traveling in an unpre-
➤ Direct the patient to breathe ssurized aircraft. Maternity and
normally and to avoid unnecessary surgical patients with sickle cell
movement. anemia are at risk for hypoxia and
➤ Observe standard precautions and therefore require close observation:
follow the general guidelines in Maternity patients are at risk for
Appendix A. Perform a venipuncture, hypoxia during the stress of labor
and collect the specimen in a 5-mL and delivery, and surgical patients
lavender-top tube. may become hypoxic while under
general anesthesia.
tests include complete blood count
➤ Observe venipuncture site for bleed- and Hgb electrophoresis.
SODIUM, SERUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

SYNONYM/ACRONYM: Serum Na .

Age Conventional Units SI Units (Conversion Factor 1)

Newborn 133–146 mEq/L 133–146 mmol/L
Infant 133–144 mEq/L 133–144 mmol/L
Child 135–145 mEq/L 135–145 mmol/L
Adult 135–145 mEq/L 135–145 mmol/L
DESCRIPTION: Sodium is the most • Diabetes

abundant cation in the extracellular • Diarrhea (water loss in excess of salt
fluid and, together with the accompa- loss)
nying chloride and bicarbonate
• Excessive intake
anions, accounts for 92 percent of
serum osmolality. Sodium plays a • Excessive saline therapy
major role in maintaining homeosta- • Excessive sweating
sis in a variety of ways, including
maintaining the osmotic pressure of • Fever
extracellular fluid, regulating renal • Hyperaldosteronism
retention and excretion of water, • Lactic acidosis
maintaining acid-base balance, regu-
lating potassium and chloride levels, • Nasogastric feeding with inadequate
stimulating neuromuscular reactions, fluid
and maintaining systemic blood pres- • Vomiting
sure. Hypernatremia (elevated sodium
level) occurs when there is excessive Decreased in:
water loss or abnormal retention of • Central nervous system disease
sodium. Hyponatremia (low sodium • Congestive heart failure
level) occurs when there is inadequate
sodium retention or inadequate • Cystic fibrosis
intake. ■ • Excessive antidiuretic hormone
production
INDICATIONS: • Excessive use of diuretics
• Determine whole-body stores of
sodium, because the ion is predomi- • Hepatic failure
nantly extracellular
• Hypoproteinemia
• Monitor the effectiveness of drug ther-
• Insufficient intake
apy, especially diuretics, on serum
sodium levels • Intravenous (IV) glucose infusion
• Metabolic acidosis
RESULT
• Mineralocorticoid deficiency
Increased in: (Addison’s disease)
• Azotemia • Nephrotic syndrome
• Burns
CRITICAL VALUES:
• Cushing’s disease
Hyponatremia: Less than 120
• Dehydration mmol/L
Sodium, Serum 895
Hypernatremia: Greater than 160

mmol/L Nursing Implications and
Note and report increased or decreased Procedure ● ● ● ● ● ● ● ● ● ● ●
values and symptoms of fluid imbalance

to the requesting health care practitioner. Pretest:
Signs and symptoms of hyponatremia ➤ Obtain a history of the patient’s
include confusion, irritability, convul- complaints, including a list of known
sions, tachycardia, nausea, vomiting, and allergens.
loss of consciousness. Possible interven- ➤ Obtain a history of the patient’s
tions include maintenance of airway, endocrine and genitourinary
monitoring for convulsions, fluid restric- systems, as well as results of previ-
tion, and performance of hourly neuro- ously performed tests and proce-
logic checks. Administration of saline for dures. For related tests, refer to the
replacement requires close attention to endocrine and genitourinary system
serum and urine osmolality. Signs and tables.
symptoms of hypernatremia include rest- ➤ Obtain a list of medications the
lessness, intense thirst, weakness, swollen patient is taking, including herbs,
tongue, seizures, and coma. Possible nutritional supplements, and
interventions include treatment of the nutraceuticals. The requesting health
underlying cause of water loss or sodium should be advised if the patient
excess, which includes sodium restriction regularly uses these products so
and administration of diuretics combined that their effects can be taken into
with IV solutions of 5% dextrose in water consideration when reviewing
(D5W). results.
INTERFERING FACTORS: tion restrictions unless by medical
• Drugs that may increase serum sodium direction.
levels include anabolic steroids, ➤ Review the procedure with the
angiotensin, bicarbonate, carbenox- patient.
olone, cisplatin, corticotropin, corti- ➤ Inform the patient that specimen
sone, gamma globulin, and mannitol. collection takes approximately 5 to
• Drugs that may decrease serum sodium 10 minutes.
levels include amphotericin B, bicar-
bonate, cathartics (excessive use), Intratest:
chlorpropamide, chlorthalidone, ➤ Direct the patient to breathe
diuretics, ethacrynic acid, fluoxetine, normally and to avoid unnecessary
furosemide, laxatives (excessive use), movement.
methyclothiazide, metolazone, nicar- ➤ Observe standard precautions and
dipine, quinethazone, theophylline (IV follow the general guidelines in
infusion), thiazides, and triamterene. Appendix A. Perform a venipuncture,
above an IV line because of the poten-
tial for dilution when the specimen ➤ Label the specimen, and promptly
and the IV solution combine in the
collection container, falsely decreasing
Post-test:
the result. There is also the potential of
contaminating the sample with the ➤ Observe venipuncture site for bleed-
substance of interest, contained in the ing or hematoma formation. Apply
IV solution, falsely increasing the pressure bandage.
result. ➤ Evaluate the patient for signs and
symptoms of dehydration. De- sodas, and root beer. Many over-the-

creased skin turgor, dry mouth, and counter medications including
multiple longitudinal furrows in the antacids, laxatives, analgesics, seda-
tongue are symptoms of dehydra- tives, and antitussives contain signif-
tion. Dehydration is a significant and icant amounts of sodium. The best
common finding in geriatric and advice is to emphasize the impor-
other patients in whom renal func- tance of reading all food, beverage,
tion has deteriorated. and medicine labels. In 1989, the
➤ If appropriate, educate patients with Subcommittee on the 10th Edition of
low sodium levels that the major the RDA established 500 mg as the
source of dietary sodium is found in recommended maximum daily
table salt. Many foods, such as milk intake for dietary intake of sodium.
and other dairy products, are also ➤ Evaluate test results in relation to
good sources of dietary sodium. the patient’s symptoms and other
Most other dietary sodium is avail- tests performed. Related laboratory
able through the consumption of tests include aldosterone, anion gap,
processed foods. Patients on low- chloride, kidney stone analysis,
sodium diets should be advised to serum and urine osmolality, serum
avoid beverages such as colas, and urine potassium, renin, and
ginger ale, sports drinks, lemon-lime urine sodium.
SODIUM, URINE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Urine Na.

Age Conventional Units SI Units (Conversion Factor 1)

6–10 y
Male 41–115 mEq/24 h 41–115 mmol/24 h
10–14 y
Male 63–177 mEq/24 h 63–177 mmol/24 h
Adult 27–287 mEq/24 h 27–287 mmol/24 h
Values vary markedly depending on dietary intake and hydration state.
DESCRIPTION: Regulating elec- kidneys, urine sodium levels increase

trolyte balance is a major function of when serum levels are high and
the kidneys. In normally functioning decrease when serum levels are low to
Sodium, Urine 897
maintain homeostasis. Analyzing • Prerenal azotemia

these urinary levels can provide • Sodium retention (premenstrual)
important clues to the functioning of
the kidneys and other major organs. CRITICAL VALUES: N/A
There is diurnal variation in excretion
of sodium, with values lower at night. INTERFERING FACTORS:
Urine sodium tests usually involve • Drugs that may increase urine
timed urine collections over a 12- or sodium levels include acetazolamide,
24-hour period. Measurement of amiloride, ammonium chloride, acetyl-
random specimens may also be salicylic acid, azosemide, benzthiazide,
bumetanide, calcitonin, chlorothia-
requested. ■
zide, clopamide, cyclothiazide,
diapamide, dopamine, ethacrynic acid,
INDICATIONS: furosemide, hydrocortisone, hydro-
• Determine potential cause of renal flumethiazide, isosorbide, levodopa,
calculi mercurial diuretics, methyclothiazide,
• Evaluate known or suspected metolazone, polythiazide, quinetha-
endocrine disorder zone, spironolactone, sulfates, tetracy-
cline, thiazides, torasemide, triam-
• Evaluate known or suspected renal terene, trichlormethiazide, triflocin,
disease verapamil, and vincristine.
• Evaluate malabsorption disorders • Drugs that may decrease urine sodium
levels include aldosterone, anesthetics,
RESULT angiotensin, corticosteroids, cortisone,
etodolac, indomethacin, levarterenol,
Increased in: lithium, and propranolol.
• Adrenal failure • Sodium levels are subject to diurnal
• Alkalosis variation (output being lowest at
night), which is why 24-hour collec-
• Diabetes tions are recommended.
• Diuretic therapy
• Excessive intake Nursing Implications and
• Renal tubular acidosis Procedure ● ● ● ● ● ● ● ● ● ● ●
• Salt-losing nephritis
Pretest:
• Adrenal hyperfunction complaints, including a list of known
allergens.
• Congestive heart failure ➤ Obtain a history of the patient’s
• Diarrhea endocrine and genitourinary
• Excessive sweating ously performed tests and proce-
• Extrarenal sodium loss with adequate endocrine and genitourinary system
hydration tables.
• Insufficient intake ➤ Obtain a list of medications the
• Postoperative period (first 24 to 48 nutritional supplements, and
hours) nutraceuticals. The requesting health
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.
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
drainage bag must be kept on ice.
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
Intratest: begun.
➤ 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
Random specimen (collect in output, some urine may have been
early morning): discarded, invalidating the test.
Clean-catch specimen: transport it to the laboratory. Include
on the label the amount of urine,
test start and stop times, and inges-
tion of any foods or medications that
can affect test results.
Post-test:
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
Synovial Fluid Analysis 899
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.
SYNOVIAL FLUID ANALYSIS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Arthrocentesis, joint fluid analysis, knee fluid

analysis.
SPECIMEN: Synovial fluid collected in a red-top tube for antinuclear anti-

bodies (ANAs), complement, crystal examination, protein, rheumatoid
factor (RF), and uric acid; sterile (red-top) tube for microbiologic testing;
lavender-top (ethylenediaminetetra-acetic acid [EDTA]) tube for complete
blood count (CBC) and differential; gray-top (sodium fluoride [NaFl]) tube
for glucose; green-top (heparin) tube for lactic acid and pH.
REFERENCE VALUE: (Method: Macroscopic evaluation of appearance; spec-

trophotometry for glucose, lactic acid, protein, and uric acid; Gram stain,
acid-fast stain, and culture for microbiology; microscopic examination of
fluid for cell count and evaluation of crystals; ion-selective electrode for pH;
nephelometry for RF and C3; indirect fluorescence for ANAs)
Color Colorless to pale yellow

Clarity Clear
Viscosity High
ANA Parallels serum level
C3 Parallels serum level
Glucose Less than 10 mg/dL of blood level
Lactic acid 5–20 mg/dL
pH 7.2–7.4
Protein Less than 3 g/dL

RF Parallels serum level

Uric acid Parallels serum level
Crystals None present
RBC count None
WBC count Less than 200/mm3
Neutrophils Less than 25%
WBC morphology No abnormal cells or inclusions
Gram stain and culture No organisms present
AFB smear and culture No AFB present
ANA antinuclear antibodies; C3 complement; RF rheumatoid factor; RBC red
blood cell; WBC white blood cell; AFB acid-fast bacilli.
DESCRIPTION: Synovial fluid analy- of neutrophils (approximately 70

sis is performed via arthrocentesis, an percent), presence of monosodium
invasive procedure involving insertion urate crystals, increased uric acid, and
of a needle into the joint space. complement levels paralleling those of
serum (may be elevated or decreased)
Synovial effusions are associated with
disorders or injuries involving the • Osteoarthritis, degenerative joint disease:
joints. The most commonly aspirated WBC count less than 5000/mm3 with
joint is the knee, although samples a normal differential and the presence
also can be obtained from the shoul- of cartilage cells
der, hip, elbow, wrist, and ankle, if • Pseudogout: Presence of calcium
clinically indicated. Joint disorders pyrophosphate crystals
can be classified into five categories: • Rheumatoid arthritis: WBC count
noninflammatory, inflammatory, 2000 to 100,000/mm3 with a predom-
septic, crystal-induced, and hemor- inance of neutrophils (30 to 50
rhagic. ■ percent), presence of ragocyte cells and
possibly Rice bodies, presence of
INDICATIONS: cholesterol crystals if effusion is
• Assist in the evaluation of joint effu- chronic, increased protein, increased
sions lactic acid, and presence of rheumatoid
• Differentiate gout from pseudogout factor (60 percent of cases)
• Systemic lupus erythematosus (SLE):
RESULT WBC count 2000 to 100,000/mm3
Fluid values increased in:
with a predominance of neutrophils
(30 to 40 percent), presence of SLE
• Acute bacterial arthritis: White blood cells, and presence of antinuclear anti-
cell (WBC) count 10,000 to bodies (20 percent of cases)
200,000/mm3, marked predominance
of neutrophils (90 percent of cases), • Trauma, joint tumors, or hemophilic
positive Gram stain (50 percent of arthritis: Elevated RBC count,
cases), positive cultures (30 to 80 increased protein level, and presence of
percent of cases), possible presence of fat droplets (if trauma involved)
Rice bodies, increased lactic acid, and
• Tuberculous arthritis: WBC count 2000
complement levels paralleling those
to 100,000/mm3 with a predominance
found in serum (may be elevated or
of neutrophils (30 to 60 percent),
decreased)
possible presence of Rice bodies, pres-
• Gout: WBC count 500 to ence of cholesterol crystals if effusion is
200,000/mm3 with a predominance chronic, in some cases a positive
Synovial Fluid Analysis 901
culture and smear for acid-fast bacilli nutritional supplements, and

(results frequently negative), and lactic nutraceuticals. The requesting health
acid care practitioner and laboratory
Fluid values decreased in regularly uses these products so
(analytes in parentheses are that their effects can be taken into
decreased): consideration when reviewing
results.
• Acute bacterial arthritis (glucose and
pH) ➤ There are no fluid restrictions unless
by medical direction. Fasting for at
• Gout (glucose) least 12 hours before the procedure
is recommended if fluid glucose
• Rheumatoid arthritis (glucose, pH, measurements are included in the
and complement) analysis.
• SLE (glucose, pH, and complement) ➤ Ensure that anticoagulant medica-
• Tuberculous arthritis (glucose and pH) tions and aspirin have been with-
held, as ordered.
patient. Inform the patient that it
INTERFERING FACTORS: may be necessary to shave the site
before specimen collection.
• Blood in the sample from traumatic
arthrocentesis may falsely elevate the ➤ Inform the patient that a local anes-
RBC count. thetic will be administered before
the procedure.
• Undetected hypoglycemia or hyper- ➤ Assess if the patient has an allergy
glycemia may produce misleading to local anesthetics, and inform the
glucose values. health care practitioner accordingly.
• Refrigeration of the sample may result ➤ Obtain written and informed
in an increase in monosodium urate consent before administering any
crystals secondary to decreased solubil- medications prior to the procedure.
ity of uric acid; exposure of the sample ➤ Inform the patient that the proce-
to room air with a resultant loss of dure will be performed by a physi-
carbon dioxide and rise in pH encour- cian specializing in this branch of
ages the formation of calcium medicine (possibly an orthopedic
surgeon) and can take approximately
pyrophosphate crystals. 20 minutes to complete.
Intratest:
Procedure ● ● ● ● ● ● ● ● ● ● ●
movement.
Pretest:
➤ Record baseline vital signs.
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.
➤ Assist the patient to the sitting or Post-test:

supine position, as appropriate;
cleanse the skin with antiseptic solu- ➤ Instruct the patient to resume usual
tion using sterile technique; and diet and medication, if withheld and
protect the site with sterile drapes. as directed by the requesting health
Inform the patient that injection of care practitioner.
the anesthetic can cause a stinging ➤ Compare vital signs with baseline
sensation. Also inform the patient values.
that some pain may be experienced ➤ Assess puncture site for bleeding,
as the aspirating needle is inserted bruising, inflammation, and exces-
into the joint space and the fluid sive drainage of synovial fluid
withdrawn. After the local anesthetic approximately every 4 hours for 24
is administered, the needle is hours and daily thereafter for several
inserted at the collection site, and days.
fluid is removed by syringe. Manual
pressure may be applied to facilitate ➤ Instruct the patient or caregiver to
fluid removal. handle linen and dispose of dress-
ings cautiously, especially if septic
➤ If medication is injected into the arthritis is suspected.
joint, the syringe containing the
sample is detached from the needle ➤ Instruct the patient to apply an ice
and replaced with the one contain- pack to the site for 24 to 48 hours,
ing the drug. The medication is and administer ordered analgesics
injected with gentle pressure. The as needed.
needle is withdrawn, and digital ➤ Instruct the patient to avoid exces-
pressure is applied to the site for a sive use of the joint for several days
few minutes. If there is no evidence to prevent pain and swelling.
of bleeding, a sterile dressing is ➤ Instruct the patient to report exces-
applied to the site. An elastic band- sive pain, bleeding, or swelling to
age can be applied to the joint. the requesting health care practi-
➤ Label the specimens, place them in tioner immediately and to return for
the appropriate containers, and a follow-up visit as scheduled.
promptly transport them to the labo- ➤ Evaluate test results in relation to
ratory. If bacterial culture and sensi- the patient’s symptoms and other
tivity tests are to be performed, tests performed. Related laboratory
record on the specimen containers tests include rheumatoid factor and
any antibiotic therapy the patient is uric acid.
receiving.
SYPHILIS SEROLOGY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Automated reagin testing (ART), fluorescent

treponemal antibody testing (FTA-ABS), microhemagglutination–
Treponema pallidum (MHA-TP), rapid plasma reagin (RPR), treponemal
studies, Venereal Disease Research Laboratory (VDRL) testing.

Syphilis Serology 903
REFERENCE VALUE: (Method: Darkfield microscopy, rapid plasma reagin,

enzyme-linked immunosorbent assay [ELISA], microhemagglutination,
fluorescence) Nonreactive or absence of treponemal organisms.
DESCRIPTION: There are numerous Chickenpox

methods for detecting Treponema Human immunodeficiency virus
pallidum, the organism known to Infectious mononucleosis
cause syphilis. Syphilis serology is Leprosy
routinely ordered as part of a prenatal Leptospirosis
workup and is required for evaluat- Lymphogranuloma venereum
ing donated blood units before Malaria
release for transfusion. Selection of Measles
the proper testing method is impor- Mumps
tant. Automated reagin testing Mycoplasma pneumoniae
(ART), rapid plasma reagin (RPR), Pneumococcal pneumonia
and Venereal Disease Research Labo- Psittacosis
ratory (VDRL) testing should be used Rickettsial disease
for screening purposes. Fluorescent
Relapsing fever
treponemal antibody testing (FTA-
Scarlet fever
ABS) and microhemagglutination–
Trypanosomiasis
Treponema pallidum (MHA-TP) are
Tuberculosis
confirmatory methods for samples
Vaccinia (live or attenuated)
that screen positive or reactive. Cere-
brospinal fluid should be tested only Viral hepatitis
by the FTA-ABS method. Cord blood • Noninfectious:
should not be submitted for testing Advanced cancer
by any of the aforementioned meth- Advancing age
ods; instead, the mother’s serum Chronic liver disease
should be tested to establish whether Connective tissue diseases
the infant should be treated. ■ Intravenous drug use
Multiple myeloma and other
INDICATIONS: immunologic disorders
• Screen for and confirm the presence of
syphilis Multiple blood transfusions
Narcotic addiction
• Monitor effectiveness of treatment for
Pregnancy
syphilis
RESULT False-positive or false-reactive

findings in confirmatory (FTA-
Positive or reactive findings in: ABS, MHA-TP) tests:
• Syphilis • Infectious:
Infectious mononucleosis
False-positive or false-reactive
findings in screening (RPR, VDRL) Leprosy
tests: Leptospirosis
• Infectious: Lyme disease
Bacterial endocarditis Malaria
Chancroid Relapsing fever
• Noninfectious: ➤ Observe standard precautions and

Systemic lupus erythematosus follow the general guidelines in
Negative or nonreactive findings red- or tiger-top tube.
in: N/A
Post-test:
INTERFERING FACTORS: N/A ➤ Observe venipuncture site for bleed-
pressure bandage.
Procedure ● ● ● ● ● ● ● ● ● ● ● results and offer support. Provide
Pretest: the clinical implications of the test
➤ Obtain a history of the patient’s patient regarding access to counsel-
complaints, including a list of known ing services.
allergens. Obtain a history of expo- ➤ Counsel the patient, as appropriate,
sure. regarding the risk of transmission
➤ Obtain a history of the patient’s and proper prophylaxis, and rein-
immune and reproductive systems, force the importance of strict adher-
as well as results of previously ence to the treatment regimen.
performed tests and procedures. For ➤ Inform the patient that positive find-
related tests, refer to the immune ings must be reported to local health
and reproductive system tables. department officials, who will ques-
➤ Obtain a list of medications the tion him or her regarding sexual part-
patient is taking, including herbs, ners.
nutritional supplements, and ➤ Offer support, as appropriate, to
nutraceuticals. The requesting health patients who may be the victim of
care practitioner and laboratory rape or sexual assault. Educate the
should be advised if the patient patient regarding access to counsel-
regularly uses these products so ing services. Provide a nonjudgmen-
that their effects can be taken into tal, nonthreatening atmosphere for a
consideration when reviewing discussion during which risks of
results. sexually transmitted diseases are
➤ There are no food, fluid, or medica- explained. It is also important to
tion restrictions unless by medical discuss problems the patient may
direction. experience (e.g., guilt, depression,
➤ Review the procedure with the anger).
patient. ➤ Inform the patient that repeat test-
➤ Inform the patient that specimen ing may be needed at 3-month inter-
collection takes approximately 5 to vals for 1 year to monitor the
10 minutes. effectiveness of treatment.
➤ Direct the patient to breathe tests include related cultures and
normally and to avoid unnecessary serologies for sexually transmitted
movement. diseases.
Testosterone, Total 905
TESTOSTERONE, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SI Units
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
1–5 mo
Male 1–177 ng/dL 0.03–6.14 nmol/L
6–11 mo
Male 2–7 ng/dL 0.07–0.24 nmol/L
1–5 y
6–9 y
10–11 y
12–14 y
Male 10–572 ng/dL 0.35–19.83 nmol/L
15–17 y
Male 220–800 ng/dL 7.63–27.74 nmol/L
Adult
Male 280–1100 ng/dL 9.71–38.14 nmol/L
DESCRIPTION: Testosterone is the • Trophoblastic tumors during preg-

major androgen responsible for sexual nancy
differentiation. In males, testosterone • Virilizing ovarian tumors
is made by the Leydig cells in the
testicles and is responsible for sper- Decreased in:
matogenesis and the development of • Anovulation
secondary sex characteristics. In • Cryptorchidism
females, the ovary and adrenal gland
• Delayed puberty
secrete small amounts of this
hormone; however, most of the • Down’s syndrome
testosterone in females comes from • Excessive alcohol intake
the metabolism of androstenedione.
• Hepatic insufficiency
In males, a testicular, adrenal, or pitu-
itary tumor can cause an overabun- • Impotence
dance of testosterone, triggering • Klinefelter’s syndrome
precocious puberty. In females, adre-
• Malnutrition
nal tumors, hyperplasia, and medica-
tions can cause an overabundance of • Myotonic dystrophy
this hormone, resulting in masculin- • Orchiectomy
ization or hirsutism. ■ • Primary and secondary hypogonadism
INDICATIONS: • Primary and secondary hypopitu-
• Assist in the diagnosis of hyper- itarism
gonadism • Uremia
• Assist in the diagnosis of male sexual
precocity before age 10 CRITICAL VALUES: N/A
• Distinguish between primary and INTERFERING FACTORS:
secondary hypogonadism • Drugs that may increase testosterone
• Evaluate hirsutism levels include barbiturates, bromocrip-
tine, cimetidine, flutamide,
• Evaluate male infertility gonadotropin, levonorgestrel, mifepris-
tone, moclobemide, nafarelin (males),
RESULT nilutamide, oral contraceptives,
rifampin, and tamoxifen.
Increased in:
• Drugs that may decrease testosterone
• Adrenal hyperplasia
levels include cyclophosphamide,
• Adrenocortical tumors cyproterone, danazol, dexamethasone,
diethylstilbestrol, digoxin, D-Trp-6-
• Hirsutism
LHRH, fenoldopam, goserelin, keto-
• Hyperthyroidism conazole, leuprolide, magnesium
sulfate, medroxyprogesterone, methyl-
• Idiopathic sexual precocity
prednisone, nandrolone, oral contra-
• Polycystic ovaries ceptives, pravastatin, prednisone,
pyridoglutethimide, spironolactone,
• Syndrome of androgen resistance
stanozolol, tetracycline, and thiori-
• Testicular or extragonadal tumors dazine.
Thyroglobulin 907
• Recent radioactive scans or radiation ➤ Review the procedure with the

within 1 week before the test can inter- patient.
fere with test results when radioim- ➤ Inform the patient that specimen
munoassay is the test method. collection takes approximately 5 to
10 minutes.

Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Direct the patient to breathe
Pretest: movement.
➤ Obtain a history of the patient’s red- or tiger-top tube.
endocrine and reproductive sys-
tems, as well as results of previously ➤ Label the specimen, and promptly
performed tests and procedures. For transport it to the laboratory.
related tests, refer to the endocrine
and reproductive system tables. Post-test:
➤ Obtain a list of medications the ➤ Observe venipuncture site for bleed-
patient is taking, including herbs, ing or hematoma formation. Apply
nutritional supplements, and pressure bandage.
nutraceuticals. The requesting health ➤ Recognize anxiety related to test
care practitioner and laboratory results and offer support, as appro-
should be advised if the patient priate. Educate the patient regarding
regularly uses these products so access to counseling services.
consideration when reviewing ➤ Evaluate test results in relation to
results. the patient’s symptoms and other
➤ Note any recent procedures that can tests include adrenocorticotropic
interfere with test results. hormone, cortisol, dehydroepi-
➤ There are no food, fluid, or medica- androsterone sulfate, follicle-
tion restrictions unless by medical stimulating hormone, and luteinizing
direction. hormone.
THYROGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Tg.
SI Units
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
DESCRIPTION: Thyroglobulin is an • Thyrotoxicosis

iodinated glycoprotein secreted by
follicular epithelial cells of the thyroid Decreased in:
gland. It is the storage form of the • Administration of thyroid hormone
thyroid hormones thyroxine (T4) and • Congenital athyrosis (neonates)
triiodothyronine (T3). When thyroid
• Thyrotoxicosis factitia
hormones are released into the blood-
stream, they split from thyroglobulin CRITICAL VALUES: N/A
in response to thyroid-stimulating
hormone. Values greater than 50 INTERFERING FACTORS:
ng/mL are indicative of tumor recur- • Drugs that may decrease thyroglobulin
rence in athyrotic patients. ■ levels include neomycin and T4.
INDICATIONS: • Autoantibodies to thyroglobulin can

• Assist in the diagnosis of subacute cause decreased values.
thyroiditis • Recent radioactive scans or radiation
• Assist in the diagnosis of suspected can interfere with test results when
disorders of excess thyroid hormone radioimmunoassay is the test method.
• Management of differentiated or • Recent thyroid surgery or needle

metastatic cancer of the thyroid biopsy can interfere with test results.
• Monitor response to treatment of
goiter Nursing Implications and
• Monitor T4 therapy in patients with Procedure ● ● ● ● ● ● ● ● ● ● ●
solitary nodules
Pretest:
Increased in:
allergens.
• Differentiated thyroid cancer
• Graves’ disease (untreated) endocrine system as well as results
• Neonates procedures. For related tests, refer
• Pregnancy to the endocrine system table.
• 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
• Thyroiditis regularly using these products so
Thyroid-Binding Inhibitory Immunoglobulin 909
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.
patient.
10 minutes.
Intratest: to the patient’s symptoms and
➤ 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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Thyrotropin-receptor antibodies, thyrotropin-

binding inhibitory immunoglobulin, TBII.

REFERENCE VALUE: (Method: Radioreceptor) Less than 10 percent inhibi-
tion. (Note: In patients with Graves’ disease, inhibition is expected to be 10
to 100 percent.)
DESCRIPTION: There are two for thyroid-stimulating hormone

functional types of thyroid- (TSH; see monograph titled
receptor immunoglobulins: thyroid- “Thyroid-Stimulating Immuno-
stimulating immunoglobulin (TSI) globulin”); TBII blocks the action of
and thyroid-binding inhibitory TSH and is believed to cause certain
immunoglobulin (TBII). TSI reacts types of hyperthyroidism. These anti-
with the receptors, activates intracel- bodies were formerly known as long-
lular enzymes, and promotes acting thyroid stimulators. High levels
epithelial cell activity that operates in pregnancy may have some predic-
outside the feedback regulation tive value for neonatal thyrotoxicosis:
A positive result indicates that the complaints, including a list of known

antibodies are stimulating (TSI); a allergens.
negative result indicates that the ➤ Obtain a history of the patient’s
antibodies are blocking (TBII). TBII endocrine system as well as results
testing measures thyroid-receptor procedures. For related tests, refer
immunoglobulin levels in the evalua- to the endocrine system table.
tion of thyroid disease. ■ ➤ Obtain a list of medications the
INDICATIONS: nutritional supplements, and
• Evaluate suspected acute toxic goiter nutraceuticals. The requesting health
• Investigate suspected neonatal thyroid should be advised if the patient
disease secondary to maternal thyroid regularly uses these products so
disease that their effects can be taken into
• Monitor hyperthyroid patients at risk results.
for relapse or remission
RESULT
Increased in: tion restrictions unless by medical
direction.
• Graves’ disease
• Hyperthyroidism (various forms) patient.
• Toxic goiter ➤ Inform the patient that specimen
• Maternal thyroid disease 10 minutes.
• Neonatal thyroid disease Intratest:
Decreased in: N/A ➤ Direct the patient to breathe
movement.
INTERFERING FACTORS: follow the general guidelines in
• Lithium may cause false-positive and collect the specimen in a 5-mL
results. red-top tube.
• Recent radioactive scans or radiation ➤ Label the specimen, and promptly
within 1 week before the test can inter- transport it to the laboratory.
munoassay is the test method. Post-test:
Pretest: tests performed. Related laboratory
tests include TSH and thyroid-
➤ Obtain a history of the patient’s stimulating immunoglobulins.
Thyroid Scan 911
THYROID SCAN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Thyroid scintiscan, iodine thyroid scan, tech-

netium thyroid scan.
AREA OF APPLICATION: Thyroid.

CONTRAST: Oral radioactive iodine or intravenous technetium-99m
pertechnetate.
DESCRIPTION: The thyroid scan is a INDICATIONS:

nuclear medicine study performed to • Assess the presence of a thyroid nodule
assess thyroid size, shape, position, or enlarged thyroid gland
and function; it is useful for evaluat- • Detect thyroid dysfunction
ing thyroid nodules, multinodular
• Detect benign or malignant thyroid
goiter, and thyroiditis; assisting in the
tumors
differential diagnosis of masses in the
neck, base of the tongue, and medi- • Assess palpable nodules and differenti-
astinum; and ruling out possible ate between a benign tumor or cyst and
ectopic thyroid tissue in these areas. a malignant tumor
Thyroid scanning is performed after • Detect causes of neck or substernal
oral administration of radioactive masses
iodine-123 (I-123) or I-131, or intra- • Differentiate between Graves’ disease
venous (IV) injection of technetium- and Plummer’s disease, both of which
99m (Tc-99m). Increased or de- cause hyperthyroidism
creased uptake by the thyroid gland
• Evaluate thyroid function in hyperthy-
and surrounding area and tissue is roidism and hypothyroidism (analysis
noted: Areas of increased radionuclide combined with interpretation of labo-
uptake (“hot spots” ) are caused by ratory tests, thyroid function panel
hyperfunctioning thyroid nodules, including thyroxine and triiodothyro-
which are usually nonmalignant; areas nine, and thyroid uptake tests)
of decreased uptake (“cold spots”) are • Detect forms of thyroiditis (e.g., acute,
caused by hypofunctioning nodules, chronic, Hashimoto’s)
which are more likely to be malig-
nant. Ultrasound imaging may be RESULT
used to determine if the cold spot is a
solid, semicystic lesion or a pure cyst Normal Findings:
(cysts are rarely cancerous). To deter- • Normal size, contour, position, and
mine whether the cold spot depicts a function of the thyroid gland with
malignant neoplasm, however, a homogeneous uptake of the radionu-
biopsy must be performed. ■ clide
Abnormal Findings: • Ingestion of foods containing iodine

• Adenoma (iodized salt), medications containing
iodine (cough syrup, potassium iodide,
• Cysts vitamins, Lugol’s solution, thyroid
• Fibrosis replacement medications), which
can decrease the uptake of the radio-
• Goiter nuclide
• Graves’ disease (diffusely enlarged, • Antithyroid medications (propyl-
hyperfunctioning gland) thiouracil), corticosteroids, antihista-
• Hematoma mines, warfarin, sulfonamides,
nitrates, corticosteroids, thyroid
• Metastasis hormones, and isoniazid, which can
• Plummer’s disease (nodular hyperfunc- decrease the uptake of the radionuclide
tioning gland) • Increased uptake of iodine in persons
• Tumors, benign or malignant with an iodine-deficient diet or who
are on phenothiazine therapy
• Thyroiditis (Hashimoto’s)
• Vomiting and severe diarrhea, which
• Thyrotoxicosis could affect absorption of orally
administered radionuclide
• Gastroenteritis, which can interfere
INTERFERING FACTORS: with absorption of orally administered
radionuclide
for:
• Patients who are pregnant or suspected which may inhibit organ visualization
of being pregnant, unless the potential and can produce unclear images
the risks to the fetus or mother Other considerations:
imaging: that allows the tracer to seep deep into
the muscle tissue can produce erro-
neous hot spots.
because of age, significant pain, or • Recent use of iodinated contrast
mental status medium for radiographic studies or
recently performed nuclear medicine
procedures can affect the uptake of the
radionuclide.
overexposure or underexposure and a • Consultation with a physician should
poor-quality study occur before the procedure for radia-
ment • Risks associated with radiographic
• Other nuclear scans done within the shield, or leave the area while the
previous 24 to 48 hours examination is being done. Personnel
Thyroid Scan 913
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.
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.
allergens.
➤ 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
hours.
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
➤ Determine date of last menstrual water after each voiding for 24 hours
period and possibility of pregnancy after the procedure.
➤ 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
to 12 hours before the procedure,
Intratest:
patient.
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.
THYROID-STIMULATING HORMONE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Thyrotropin, TSH.

SPECIMEN: Serum (1 mL) collected in a red- or tiger-top tube; for a
neonate, use filter paper.
SI Units
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
DESCRIPTION: Thyroid-stimulating tal defect in T4-binding globulin, or

hormone (TSH) is produced by the (2) transient congenital hypothy-
pituitary gland in response to stimu- roidism owing to hypoxia or prema-
lation by thyrotropin-releasing turity. Early diagnosis and treatment
hormone (TRH), a hypothalamic- in the neonate are crucial for the
releasing factor. TRH regulates the prevention of cretinism and mental
release and circulating levels of retardation. ■
thyroid hormones in response to vari-
ables such as cold, stress, and INDICATIONS:
increased metabolic need. Thyroid • Assist in the diagnosis of congenital
hypothyroidism
and pituitary function can be evalu-
ated by TSH measurement. TSH • Assist in the diagnosis of hypothy-
exhibits diurnal variation, peaking roidism or hyperthyroidism or
between midnight and 4 a.m. and suspected pituitary or hypothalamic
troughing between 5 and 6 p.m. TSH dysfunction
values are high at birth but reach • Differentiate functional euthyroidism
adult levels in the first week of life. from true hypothyroidism in debili-
Elevated TSH levels combined with tated individuals
decreased thyroxine (T4) levels indi-
cate hypothyroidism and thyroid
RESULT
gland dysfunction. In general, Increased in:
decreased TSH and T4 levels indicate
• Congenital hypothyroidism in the
secondary congenital hypothyroidism neonate (filter paper test)
and pituitary hypothalamic dysfunc-
tion. A normal TSH level and a • Ectopic TSH-producing tumors (lung,
depressed T4 level may indicate (1) breast)
hypothyroidism owing to a congeni- • Primary hypothyroidism
Thyroid-Stimulating Hormone 915
• Secondary hyperthyroidism owing to complaints, including a list of known

pituitary hyperactivity allergens.
• Thyroid hormone resistance
• Thyroiditis (Hashimoto’s autoimmune previously performed tests and
disease) procedures. For related tests, refer
Decreased in: ➤ Obtain a list of medications the
• Excessive thyroid hormone replace-
ment nutraceuticals. The requesting health
• Graves’ disease care practitioner and laboratory
• Primary hyperthyroidism regularly uses these products so
• Secondary hypothyroidism (pituitary consideration when reviewing
involvement) results.
• Tertiary hypothyroidism (hypothala- ➤ There are no food, fluid, or medica-
mic involvement) tion restrictions unless by medical
direction.
patient.
• Drugs and hormones that may increase collection takes approximately 5 to
TSH levels include amiodarone, 10 minutes.
benserazide, erythrosine, flunarizine
(males), iobenzamic acid, iodides, Intratest:
lithium, methimazole, metoclo-
pramide, morphine, propranolol, radi- normally and to avoid unnecessary
ographic agents, TRH, and valproic movement.
acid.
• Drugs and hormones that may follow the general guidelines in
decrease TSH levels include amio- Appendix A. Perform a venipuncture,
darone, anabolic steroids, acetylsali- and collect the specimen in a 5-mL
red- or tiger-top tube. Label the spec-
cylic acid, carbamazepine, cortico- imen, and promptly transport it to
steroids, dopamine, glucocorticoids, the laboratory.
hydrocortisone, insulin-like growth
factor-I, interferon-alfa-2b, iodamide, Filter paper test (neonate):
josamycin, levodopa, levothyroxine,
methergoline, nifedipine, pyridoxine, ➤ Obtain kit and cleanse heel with
antiseptic. Observe standard
T4, and triiodothyronine (T3).
precautions and follow the general
• Failure to let the filter paper sample dry guidelines in Appendix A. Use gauze
may affect test results. to dry the stick area completely.
Perform heel stick, gently squeeze
infant’s heel, and touch filter paper
to the puncture site. Completely fill
Nursing Implications and the circles on the filter paper, satu-
Procedure ● ● ● ● ● ● ● ● ● ● ●
rating the filter paper with blood.
Apply pressure to the heel stick with
Pretest: a gauze pad to stop the bleeding.
Allow the filter paper to dry thor-
➤ Obtain a history of the patient’s oughly, label the specimen, and
promptly transport it to the labora- ing or hematoma formation. Apply

tory. Alternatively, if a specimen pressure bandage.
collection kit is used, follow instruc-
tions for labeling and mailing to the
testing laboratory.
Post-test: tests include adrenocorticotropic
hormone, TRH stimulation test, T4,
➤ Observe venipuncture site for bleed- free T4, and T3.
THYROID-STIMULATING
IMMUNOGLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Thyrotropin-receptor antibodies, TSI.

REFERENCE VALUE: (Method: Radioimmunoassay) Less than 130 percent of
basal activity.
DESCRIPTION: There are two func- antibodies are stimulating (TSI); a

tional types of thyroid-receptor negative result indicates that the
immunoglobulins: thyroid-stimulating antibodies are blocking (TBII). TSI
immunoglobulin (TSI) and thyroid- testing measures thyroid-receptor
binding inhibitory immunoglobulin immunoglobulin levels in the evalua-
(TBII). TSI reacts with the receptors, tion of thyroid disease. ■
activates intracellular enzymes, and
promotes epithelial cell activity that INDICATIONS:
operates outside the feedback regula- • Follow-up to positive TBII assay
tion for thyroid-stimulating hormone in differentiating antibody stimula-
(TSH; see monograph titled tion from neutral or suppressing
“Thyroid-Stimulating Immuno- activity
globulin”); TBII blocks the action of • Monitor hyperthyroid patients at risk
TSH and is believed to cause certain for relapse or remission
types of hyperthyroidism. These anti-
bodies were formerly known as long- RESULT
acting thyroid stimulators. High levels
in pregnancy may have some predic- Increased in: Graves’ disease
tive value for neonatal thyrotoxicosis:
A positive result indicates that the Decreased in: N/A
Thyrotropin-Releasing Hormone Stimulation Test 917
CRITICAL VALUES: N/A ➤ Note any recent procedures that can

• Lithium may cause false-positive TBII tion restrictions unless by medical
results. direction.
• Recent radioactive scans or radiation patient.
can interfere with test results when
radioimmunoassay is the test method. collection takes approximately 5 to
10 minutes.

Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest: movement.
endocrine system as well as results red-top tube.
of previously performed tests and ➤ Label the specimen, and promptly
procedures. For related tests, refer transport it to the laboratory.
➤ Obtain a list of medications the Post-test:
nutritional supplements, and ➤ Observe venipuncture site for bleed-
nutraceuticals. The requesting health ing or hematoma formation. Apply
care practitioner and laboratory pressure bandage.
regularly uses these products so the patient’s symptoms and other
that their effects can be taken into tests performed. Related laboratory
consideration when reviewing tests include thyroglobulin, TBII, and
results. TSH.
THYROTROPIN-RELEASING HORMONE
STIMULATION TEST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: TRH stimulation.

REFERENCE VALUE: (Method: Immunoassay) Minimal rise of 1 to 2 mIU/L
above baseline; typical response is a 5- to 10-fold increase above baseline.
DESCRIPTION: In the thyrotropin- endocrine system and results of

releasing hormone (TRH) stimula-
tion test, TRH is administered to the endocrine system table.
intravenously after collection of a ➤ Obtain a list of medications the
baseline measurement of thyroid- patient is taking, including herbs,
stimulating hormone (TSH). nutritional supplements, and
Subsequent specimens are collected nutraceuticals. The requesting health
for TSH measurement at 30- and 60-
minute intervals. An exaggerated regularly uses these products so
response is an indication of abnormal that their effects can be taken into
thyroid gland function or disorders of consideration when reviewing
the hypothalamic pituitary axis. results.
Third-generation or “sensitive” TSH ➤ There are no food, fluid, or medica-
assays are now preferred over TRH
direction.
stimulation. ■
➤ The test should be performed in the
morning because of the diurnal vari-
INDICATIONS: ation in TSH secretion.
• Assist in the diagnosis and treatment of
hypothalamic and pituitary disorders ➤ Review the procedure with the
patient. Inform the patient that
• Differentiation of mania from schizo- multiple specimens will be
phrenia collected.
RESULT men collection takes approximately
5 to 10 minutes.
Increased in:
Intratest:
• Pregnancy
• Primary hypothyroidism normally and to avoid unnecessary
movement.
Decreased in: ➤ Inform the patient that he or she
• Major depressive illnesses may experience temporary nausea
(mild), flushing, dizziness, peculiar
• Primary hyperthyroidism taste, rise in blood pressure, and an
• Secondary hypothyroidism urge to urinate as the infusion
begins.
INTERFERING FACTORS: N/A Appendix A. Perform a venipuncture,
Nursing Implications and ➤ Begin intravenous infusion of 500 g
of protirelin (Thypinone), and collect
Procedure ● ● ● ● ● ● ● ● ● ● ●
specimens at 30- and 60-minute
intervals.
Pretest:
➤ Monitor the patient’s blood pressure
➤ Obtain a history of the patient’s if dizziness or other unusual symp-
complaints, including a list of known toms are reported.
Thyroxine-Binding Globulin 919

➤ Observe venipuncture and intra- tests include adrenocorticotropin
venous sites for bleeding or hormone, follicle-stimulating hor-
hematoma formation. Apply pres- mone, growth hormone, luteinizing
sure bandage. hormone, thyroxine, and free
➤ Evaluate test results in relation to thyroxine.
THYROXINE-BINDING GLOBULIN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: TBG.
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
DESCRIPTION: Thyroxine-binding • Identify deficiency or excess TBG due

globulin (TBG) is the predominant to hereditary abnormality
protein carrier for circulating thyrox-
ine (T4) and triiodothyronine (T3). RESULT
T4-binding prealbumin and T4-bind-
ing albumin are the other transport Increased in:
proteins. Conditions that affect TBG • Acute intermittent porphyria
levels and binding capacity also affect • Genetically high TBG
free T3 and free T4 levels. ■
• Hypothyroidism
INDICATIONS: • Infectious hepatitis and other liver
• Differentiate elevated T4 due to hyper- diseases
thyroidism from increased TBG bind-
ing in euthyroid patients • Neonates
• Evaluate hypothyroid patients • Pregnancy
Decreased in: endocrine system as well as results

• Acromegaly of previously performed tests and
• Chronic hepatic disease to the endocrine system table.
• Genetically low TBG ➤ Obtain a list of medications the
• Marked hypoproteinemia, malnutri- nutritional supplements, and
tion nutraceuticals. The requesting health
• Major illness should be advised if the patient
• Nephrotic syndrome regularly uses these products so
• Ovarian hypofunction consideration when reviewing
results.
• Surgical stress
• Testosterone-producing tumors interfere with test results.
direction.
• Drugs and hormones that may increase patient.
TBG levels include estrogens, oral ➤ Inform the patient that specimen
contraceptives, tamoxifen, and collection takes approximately 5 to
perphenazine. 10 minutes.
• Drugs that may decrease TBG levels Intratest:
include anabolic steroids, androgens,
asparaginase, corticosteroids, corti- ➤ Direct the patient to breathe
cotropin, danazol, phenytoin, and normally and to avoid unnecessary
movement.
propranolol.
• Recent radioactive scans or radiation follow the general guidelines in
within 1 week before the test can inter- Appendix A. Perform a venipuncture,
fere with test results when radioim- and collect the specimen in a 5-mL
munoassay is the test method. red- or tiger-top tube.
Procedure ● ● ● ● ● ● ● ● ● ● ●

pressure bandage.
complaints, including a list of known the patient’s symptoms and other
allergens. tests performed. Related tests
➤ Obtain a history of the patient’s include T4, free T4, T3, and free T3.
Thyroxine, Free 921
THYROXINE, FREE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Free T4, FT4.

SI Units
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
DESCRIPTION: Thyroxine (T4) is a cient information. Free T4 and TSH

hormone produced and secreted by levels are inversely proportional.
the thyroid gland. Newborns are Measurement of free T4 is also recom-
commonly tested for decreased T4 mended during treatment for hyper-
levels by a filter paper method (see thyroidism, until symptoms have
monograph titled “Thyroxine, abated and levels have decreased into
Total”). Most T4 in the serum (99.97 the normal range. ■
percent) is bound to thyroxine-
binding globulin (TBG), prealbu- INDICATIONS:
min, and albumin. The remainder • Evaluate signs of hypothyroidism or
hyperthyroidism
(0.03 percent) circulates as unbound
or free T4, which is the physiologi- • Monitor response to therapy for
cally active form. Levels of free T4 are hypothyroidism or hyperthyroidism
proportional to levels of total T4. The
RESULT
advantage of measuring free T4
instead of total T4 is that, unlike total Increased in:
T4 measurements, free T4 levels are • Hyperthyroidism
not affected by fluctuations in TBG
levels; as a result, free T4 levels are • Hypothyroidism treated with T4
considered the most accurate indica- Decreased in:
tor of T4 and its thyrometabolic • Hypothyroidism
activity. Free T4 measurements are
useful in evaluating thyroid disease • Hypothyroidism treated with
when thyroid-stimulating hormone triiodothyronine (T3)
(TSH) levels alone provide insuffi- • Pregnancy (late)
CRITICAL VALUES: N/A consideration when reviewing

results.
• Drugs that may increase free T4 levels tion restrictions unless by medical
include amiodarone, acetylsalicylic direction.
acid, halofenate, heparin, iopanoic ➤ Review the procedure with the
acid, levothyroxine, methimazole, and patient.
radiographic agents. ➤ Inform the patient that specimen
• Drugs that may decrease free T4 levels collection takes approximately 5 to
10 minutes.
include amiodarone, anabolic steroids,
asparaginase, methadone, methima-
Intratest:
zole, oral contraceptives, and
phenylbutazone. ➤ Direct the patient to breathe
movement.
allergens.
endocrine system as well as results
of previously performed tests and ➤ Observe venipuncture site for bleed-
to the endocrine system table. pressure bandage.
➤ Obtain a list of medications the ➤ Evaluate test results in relation to
patient is taking, including herbs, the patient’s symptoms and other
nutritional supplements, and tests performed. Related laboratory
nutraceuticals. The requesting health tests include antithyroglobulin and
care practitioner and laboratory antiperoxidase antibodies, thyroid-
should be advised if the patient stimulating immunoglobulins,
regularly uses these products so thyroid-binding inhibitory immuno-
that their effects can be taken into globulins, TSH, T4, T3, and free T3.
THYROXINE, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: T4.

Thyroxine, Total 923
SI Units
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
DESCRIPTION: Thyroxine (T4) is a • Monitor response to therapy for

hormone produced and secreted by hypothyroidism or hyperthyroidism
the thyroid gland. Newborns are
commonly tested for decreased T4
RESULT
levels by a filter paper method. Most Increased in:
T4 in the serum (99.97 percent) is • Acute psychiatric illnesses
bound to thyroxine-binding globulin
(TBG), prealbumin, and albumin. • Excessive intake of iodine
The remainder (0.03 percent) circu- • Hepatitis
lates as unbound or free T4, which is • Hyperemesis gravidarum
the physiologically active form. Levels
• Hyperthyroidism
of free T4 are proportional to levels of
total T4. The advantage of measuring • Obesity
free T4 instead of total T4 is that, • Thyrotoxicosis factitia
unlike total T4 measurements, free T4
• Thyrotoxicosis due to Graves’ disease
levels are not affected by fluctuations
in TBG levels; as a result, free T4 Decreased in:
levels are considered the most accu- • Decreased TBG (nephrotic syndrome,
rate indicator of T4 and its thyro- liver disease, gastrointestinal protein
metabolic activity. (See monograph loss, malnutrition)
titled “Thyroxine, Free.”) ■
• Hypothyroidism
INDICATIONS: • Panhypopituitarism
• Evaluate signs of hypothyroidism or • Strenuous exercise
hyperthyroidism and neonatal screen-
ing for congenital hypothyroidism CRITICAL VALUES:
(required in many states)
Hypothyroidism: Less than 2.0
• Evaluate thyroid response to protein g/dL
deficiency associated with severe Hyperthyroidism: Greater than 20.0
illnesses g/dL
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
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
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.
Total Protein and Fractions 925
Post-test: tests include adrenocorticotropic

hormone, antithyroglobulin and
➤ Observe venipuncture site for bleed- antithyroid peroxidase antibodies,
ing or hematoma formation. Apply thyroid-binding inhibitory immuno-
pressure bandage. globulin, thyroxine-binding globulin,
➤ Evaluate test results in relation to thyroid-stimulating hormone,
the patient’s symptoms and other thyroid-stimulating immunoglobulin,
tests performed. Related laboratory free T4, T3, and free T3.
TOTAL PROTEIN AND FRACTIONS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: TP, SPEP (fractions include albumin, 1-globu-

lin, 2-globulin, -globulin, and -globulin).

REFERENCE VALUE: (Method: Spectrophotometry for total protein, elec-
trophoresis for protein fractions)
Total Protein
SI Units
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
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
DESCRIPTION: Protein is essential to diseases, chronic infections, autoim-

all physiologic functions. Proteins mune disorders, hepatitis, cirrhosis,
consist of amino acids, the building and lymphoproliferative disorders
blocks of blood and body tissues. • Total protein:
Protein is also required for the regula- Dehydration
tion of metabolic processes, immu- Monoclonal and polyclonal
nity, and proper water balance. gammopathies
Total protein includes albumin and Myeloma
globulins. 1-Globulin includes 1- Sarcoidosis
antitrypsin, 1-fetoprotein, 1-acid Some types of chronic liver
glycoprotein, 1-antichymotrypsin, disease
inter-1-trypsin inhibitor, high- Tropical diseases (e.g., leprosy)
density lipoproteins, and group- Waldenström’s macroglobulinemia
specific component (vitamin D–
binding protein). 2-Globulin in- Decreased:
cludes haptoglobin, ceruloplasmin, • 1-Globulin proteins in hereditary
and 2-macroglobulin. -Globulin deficiency
includes transferrin, hemopexin, very- • 2-Globulin proteins in nephrotic
low-density lipoproteins, low-density syndrome, malignancies, numerous
lipoproteins, 2-microglobulin, subacute and chronic inflammatory
fibrinogen, complement, and C- disorders, recovery stage of severe
reactive protein. -Globulin includes burns
immunoglobulin G (IgG), IgA, IgM, • -Globulin proteins in hypo--
IgD, and IgE. After an acute infection lipoproteinemias and IgA deficiency
or trauma, many of the liver-derived
proteins increase, whereas albumin • -Globulin proteins in immune defi-
ciency or suppression
decreases; these conditions may not
reflect an abnormal total protein • Total protein
determination. ■ Administration of intravenous fluids
Burns
INDICATIONS: Chronic alcoholism
• Evaluation of edema, as seen in
Chronic ulcerative colitis
patients with low total protein and low
albumin levels Cirrhosis
Crohn’s disease
• Evaluation of nutritional status
Glomerulonephritis
RESULT Heart failure
Hyperthyroidism
Increased: Malabsorption
• 1-Globulin proteins in acute and Malnutrition
chronic inflammatory diseases Neoplasms
• 2-Globulin proteins occasionally in Nephrotic syndrome
diabetes, pancreatitis, and hemolysis Pregnancy
• -Globulin proteins in hyperlipopro- Prolonged immobilization
teinemias and monoclonal Protein-losing enteropathies
gammopathies Severe skin disease
• -Globulin proteins in chronic liver Starvation
Total Protein and Fractions 927
CRITICAL VALUES: N/A care practitioner and laboratory

INTERFERING FACTORS: that their effects can be taken into
• Drugs that may increase protein consideration when reviewing
levels include amino acids (if given results.
intravenously), anabolic steroids, ➤ There are no food, fluid, or medica-
angiotensin, anticonvulsants, carbeni- tion restrictions unless by medical
cillin, corticosteroids, corticotropin, direction.
digitalis, furosemide, insulin, ➤ Review the procedure with the
isotretinoin, levonorgestrel, oral patient.
contraceptives, progesterone, radio-
graphic agents, and thyroid agents. collection takes approximately 5 to
• Drugs and substances that may 10 minutes.
decrease protein levels include argi-
nine, acetylsalicylic acid, benzene, Intratest:
carvedilol, citrates, floxuridine, laxa- ➤ Direct the patient to breathe
tives, mercury compounds, oral normally and to avoid unnecessary
contraceptives, pentastarch, phosgene, movement.
pyrazinamide, rifampin, trimetha- ➤ Observe standard precautions and
dione, and valproic acid. follow the general guidelines in
• Values are significantly lower (5 to 10
percent) in recumbent patients. red- or tiger-top tube.
• Hemolysis can falsely elevate results. ➤ Label the specimen, and promptly
• Venous stasis can falsely elevate results;
the tourniquet should not be left on Post-test:
the arm for longer than 60 seconds.
pressure bandage.
➤ Educate the patient, as appropriate,
Procedure ● ● ● ● ● ● ● ● ● ● ●
that good dietary sources of
complete protein (containing all
Pretest: eight essential amino acids) include
meat, fish, eggs, and dairy products;
➤ Obtain a history of the patient’s and that good sources of incomplete
complaints, including a list of known protein (lacking one or more of the
allergens. eight essential amino acids) include
➤ Obtain a history of the patient’s grains, nuts, legumes, vegetables,
gastrointestinal, hepatobiliary, and and seeds.
immune systems, as well as results ➤ Evaluate test results in relation
of previously performed tests and to the patient’s symptoms and
procedures. For related tests, refer other tests performed. Related
to the gastrointestinal, hepatobiliary, laboratory tests include albumin,
and immune system tables. complete blood count, urine
➤ Obtain a list of medications the protein electrophoresis, serum
patient is taking, including herbs, and urine immunofixation elec-
nutritional supplements, and trophoresis, IgA, IgG, IgM, and urine
nutraceuticals. The requesting health protein.
TOXOPLASMA ANTIBODY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Toxoplasmosis serology, toxoplasmosis titer.

DESCRIPTION: Toxoplasmosis is a • Document past exposure or immunity

severe, generalized granulomatous • Serologic screening during pregnancy
central nervous system disease caused
by the protozoan Toxoplasma gondii. RESULT
Transmission to humans occurs by
ingesting undercooked meat or Positive findings in: Toxoplasma
infection
handling contaminated matter such
as cat litter. Immunoglobulin M
(IgM) antibodies develop approxi-
mately 5 days after infection and can INTERFERING FACTORS: N/A
remain elevated for 3 weeks to several
months. IgG antibodies develop 1 to
2 weeks after infection and can Nursing Implications and
remain elevated for months or years. Procedure ● ● ● ● ● ● ● ● ● ● ●
Toxoplasma serology is part of the

TORCH (toxoplasmosis, rubella, Pretest:
cytomegalovirus, herpes simplex type ➤ Obtain a history of the patient’s
2) panel routinely performed on complaints, including a list of known
pregnant women. Fetal infection allergens. Obtain a history of expo-
sure.
during the first trimester can cause
spontaneous abortion or congenital ➤ Obtain a history of the patient’s
defects. Immunocompromised indi- dietary history, and history of other
viduals are also at high risk for serious potential sources of exposure; as
complications if infected. The pres- well as results of previously
ence of IgM antibodies indicates performed tests and procedures.
acute or congenital infection; the
immune and reproductive system
presence of IgG antibodies indicates tables.
current or past infection. ■ ➤ Obtain a list of medications the
INDICATIONS: nutritional supplements, and
• Assist in establishing a diagnosis of nutraceuticals. The requesting
toxoplasmosis health care practitioner and labora-
Transferrin 929
tory should be advised if the patient ➤ Label the specimen, and promptly
regularly uses these products so transport it to the laboratory.
results.
➤ 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
➤ Direct the patient to breathe results, as appropriate. Educate the
normally and to avoid unnecessary patient regarding access to counsel-
movement. ing services.
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Siderophilin, TRF.

SI Units
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
DESCRIPTION: Transferrin is a glyco- levels include carbamazepine, danazol,

protein formed in the liver. It trans- mestranol, and oral contraceptives.
ports circulating iron obtained from • Drugs that may decrease transferrin
dietary intake and red blood cell levels include cortisone and dextran.
breakdown. Transferrin carries 50 to
• Transferrin levels are subject to diurnal
70 percent of the body’s iron; variation and should be collected in the
normally it is approximately one- morning, when levels are highest.
third saturated. Inadequate transfer-
rin levels can lead to impaired
hemoglobin synthesis and anemia. Nursing Implications and
Transferrin is subject to diurnal varia- Procedure ● ● ● ● ● ● ● ● ● ● ●
tion, and it is responsible for the vari-

ation in levels of serum iron Pretest:
throughout the day. (See monograph
titled “Iron-Binding Capacity [Total],
Transferrin, and Iron Saturation.”) ■ allergens.
INDICATIONS: hematopoietic system and results of
• Determine the iron-binding capacity previously performed tests and
of the blood procedures. For related tests, refer
to the hematopoietic system table.
• Evaluate iron metabolism in iron-
deficiency anemia ➤ Obtain a list of medications the
• Evaluate nutritional status nutritional supplements, and
• Screen for hemochromatosis care practitioner and laboratory
RESULT regularly uses these products so
Increased in: consideration when reviewing
results.
• Iron-deficiency anemia
Decreased in:
tion.
• Acute or chronic infection
• Cancer (especially of the gastrointesti- patient. Instruct the patient to fast
nal tract) for at least 12 hours before speci-
men collection.
• Excessive protein loss from renal ➤ Inform the patient that specimen
disease collection takes approximately 5 to
• Hepatic damage 10 minutes.
• Malnutrition Intratest:
• Hereditary atransferrinemia ➤ Ensure that the patient has complied
CRITICAL VALUES: N/A pretesting restrictions.
• Drugs that may increase transferrin movement.
Triglycerides 931
➤ Observe standard precautions and ing or hematoma formation. Apply

follow the general guidelines in pressure bandage.
diet as directed by the requesting
health care practitioner.
tests include ferritin and iron/total
➤ Observe venipuncture site for bleed- iron-binding capacity.
TRIGLYCERIDES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Trigs, TG.

SI Units
Conventional (Conversion Factor
Age Units 0.0113)
0–9 y
Male 30–100 mg/dL 0.34–1.13 mmol/L
10–20 y
Male 32–148 mg/dL 0.36–1.67 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
DESCRIPTION: Triglycerides are a necessary to provide energy for vari-

combination of three fatty acids and ous metabolic processes. Excess
one glycerol molecule. They are triglycerides are stored in adipose
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

Increased in: INTERFERING FACTORS:
• Acute myocardial infarction • Drugs that may increase triglyceride
levels include acetylsalicylic acid,
• Alcoholism
aldatense, atenolol, bendroflumethi-
• Anorexia nervosa azide, cyclosporine, danazol, glucocor-
ticoids, oral contraceptives, oxprenolol,
• Chronic ischemic heart disease
pindolol, prazosin, propranolol,
• Cirrhosis tamoxifen, and timolol.
Triglycerides 933
• Drugs and substances that may collection takes approximately 5 to

decrease triglyceride levels include 10 minutes.
ascorbic acid, bezafibrate, captopril,
carvedilol, celiprolol, chenodeoxy- Intratest:
cholic acid, cholestyramine, cilazapril, ➤ Ensure that the patient has complied
ciprofibrate, clofibrate, colestipol, with dietary preparations and other
dextrothyroxine, doxazosin, enalapril, pretesting restrictions.
eptastatin, fenofibrate, flaxseed oil, ➤ Direct the patient to breathe
gemfibrozil, glucagon, halofenate, normally and to avoid unnecessary
insulin, levonorgestrel, lovastatin, movement.
medroxyprogesterone, metformin, ➤ Observe standard precautions and
nafenopin, niacin, niceritrol, pinacidil, follow the general guidelines in
pindolol, pravastatin, prazosin, probu- Appendix A. Perform a venipuncture,
col, simvastatin, and verapamil. and collect the specimen in a 5-mL
Procedure ● ● ● ● ● ● ● ● ● ● ●
Post-test:

complaints, including a list of known ➤ Instruct the patient to resume usual
allergens. diet as directed by the requesting
➤ Obtain a history of the patient’s health care practitioner.
cardiovascular and gastrointestinal ➤ Increased triglyceride levels may be
systems, as well as results of previ- associated with atherosclerosis and
ously performed tests and proce- coronary artery disease.
cardiovascular and gastrointestinal ➤ Nutritional therapy is recommended
system tables. for individuals identified to be at
high risk for developing coronary
➤ Obtain a list of medications the artery disease. If overweight, these
patient is taking, including herbs, patients should be encouraged
nutritional supplements, and to achieve a normal weight. The
nutraceuticals. The health care prac- American Heart Association has
titioner and laboratory should be Step 1 and Step 2 diets that may be
advised if the patient regularly uses helpful in achieving a goal of lower-
these products so that their effects ing total cholesterol and triglyceride
can be taken into consideration levels. The Step 1 diet emphasizes a
when reviewing results. reduction in foods high in saturated
➤ The patient should fast for 12 hours fats and cholesterol. Red meats,
before specimen collection. Ideally eggs, and dairy products are the
the patient should be on a stable major sources of saturated fats and
diet for 3 weeks and avoid alcohol cholesterol. If triglycerides are also
consumption for 3 days before spec- elevated, patients should be advised
imen collection. to eliminate or reduce alcohol and
simple carbohydrates from their
➤ There are no fluid or medication diet. The Step 2 diet recommends
restrictions unless by medical direc- stricter reductions.
tion.
➤ Numerous studies point to the
➤ Review the procedure with the increased prevalence of excess body
patient. weight in American children and
➤ Inform the patient that specimen adolescents. Experts estimate that
25 percent of American children ➤ Evaluate test results in relation

aged 6 to 11 years are obese. The to the patient’s symptoms and
medical, social, and emotional other tests performed. Related
consequences of excess body laboratory tests include apolipopro-
weight are significant. tein A and B, cholesterol, high-
➤ Special attention should be given to density lipoprotein cholesterol, low-
instructing the pediatric patient and density lipoprotein cholesterol,
caregiver regarding health risks and homocysteine, and lipoprotein
weight control. electrophoresis.
TRIIODOTHYRONINE, FREE
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Free T3, FT3.

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)
DESCRIPTION: Unlike the thyroid proportional to levels of total T3. The

hormone thyroxine (T4), most T3 is advantage of measuring free T3
converted enzymatically from T4 in instead of total T3 is that, unlike total
the tissues rather than being T3 measurements, free T3 levels are
produced directly by the thyroid not affected by fluctuations in TBG
gland. (See monograph titled levels. T3 is four to five times more
“Thyroxine, Total.”) Approximately biologically potent than T4. This
one-third of T4 is converted to hormone, along with T4, is responsi-
T3. Most T3 in the serum (99.97 ble for maintaining a euthyroid state.
percent) is bound to thyroxine- Free T3 measurements are rarely
binding globulin (TBG), prealbu- required, but they are indicated in the
min, and albumin. The remainder diagnosis of T3 toxicosis and when
(0.03 percent) circulates as unbound certain drugs are being administered
or free T3, which is the physiologi- that interfere with the conversion of
cally active form. Levels of free T3 are T4 to T3. ■
Triiodothyronine, Free 935

• Adjunctive aid to thyroid-stimulating procedures. For related tests, refer
hormone (TSH) and free T4 assess-
ment ➤ Obtain a list of medications the
• Assist in the diagnosis of T3 toxicosis nutritional supplements, and
RESULT care practitioner and laboratory
• High altitude that their effects can be taken into
• Hyperthyroidism results.
• T3 toxicosis ➤ There are no food, fluid, or medica-
Decreased in: direction.
• Hypothyroidism ➤ Review the procedure with the
• Malnutrition patient.
• Nonthyroidal chronic diseases
• Pregnancy (late) 10 minutes.

• Drugs that may increase free T3 movement.
include amiodarone, acetylsalicylic
acid, and levothyroxine. ➤ Observe standard precautions and
• Drugs that may decrease free T3 Appendix A. Perform a venipuncture,
include amiodarone, methimazole, and collect the specimen in a 5-mL
phenytoin, propranolol, and radio- red- or tiger-top tube.
graphic agents. ➤ Label the specimen, and promptly

Procedure ● ● ● ● ● ● ● ● ● ● ●
Pretest:
pressure bandage.
complaints, including a list of known the patient’s symptoms and other
allergens. tests performed. Some related labo-
➤ Obtain a history of the patient’s ratory tests include TSH, T4, free T4,
endocrine system and results of and total T3.
TRIIODOTHYRONINE, TOTAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: T3.
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)
DESCRIPTION: Unlike the thyroid more biologically potent than T4.

hormone thyroxine (T4), most T3 is This hormone, along with T4, is
converted enzymatically from T4 in responsible for maintaining a euthy-
the tissues rather than being produced roid state. ■
directly by the thyroid gland. (See
monograph titled “Thyroxine, INDICATIONS: Adjunctive aid to thyroid-
stimulating hormone (TSH) and free T4
Total.”) Approximately one-third of
assessment
T4 is converted to T3. Most T3 in the
serum (99.97 percent) is bound to RESULT
thyroxine-binding globulin (TBG),
prealbumin, and albumin. The Increased in:
remainder (0.03 percent) circulates as • Conditions with increased TBG
unbound or free T3, which is the • Early thyroid failure
physiologically active form. Levels of
free T3 are proportional to levels of • Hyperthyroidism
total T3. The advantage of measuring • Iodine-deficiency goiter
free T3 instead of total T3 is that, • Pregnancy
unlike total T3 measurements, free T3
levels are not affected by fluctuations • T3 toxicosis
in TBG levels. T3 is four to five times • Thyrotoxicosis factitia
Triiodothyronine, Total 937
• Treated hyperthyroidism complaints, including a list of known

allergens.
• Acute and subacute nonthyroidal endocrine system and results of
disease previously performed tests and
• Conditions with decreased TBG to the endocrine system table.
• Hypothyroidism ➤ Obtain a list of medications the
CRITICAL VALUES: N/A ceuticals. The requesting health care
INTERFERING FACTORS: advised if the patient regularly uses
• Drugs that may increase total T3 levels these products so that their effects
include amiodarone, amphetamine, can be taken into consideration
benziodarone, clofibrate, fenoprofen, when reviewing results.
fluorouracil, halofenate, insulin, ➤ There are no food, fluid, or medica-
levothyroxine, methadone, opiates, tion restrictions unless by medical
oral contraceptives, phenytoin, direction.
prostaglandins, T3, and valproic acid. ➤ Review the procedure with the
• Drugs that may decrease total T3 levels patient.
include amiodarone, anabolic steroids, ➤ Inform the patient that specimen
asparaginase, acetylsalicylic acid, carba- collection takes approximately 5 to
mazepine, cholestyramine, clomi- 10 minutes.
phene, colestipol, cotrimoxazole,
Intratest:
dexamethasone, fenclofenac, furo-
semide, glucocorticoids, hydrocorti- ➤ Direct the patient to breathe
sone, interferon alfa-2b, iobenzamic normally and to avoid unnecessary
acid, iodides, ipodate, isotretinoin, movement.
lithium, methimazole, neomycin, ➤ Observe standard precautions and
netilmicin, oral contraceptives, penicil- follow the general guidelines in
lamine, phenobarbital, phenylacetic Appendix A. Perform a venipuncture,
acid derivatives, phenylbutazone, and collect the specimen in a 5-mL
phenytoin, potassium iodide, pred-
nisone, propranolol, propylthiouracil, ➤ Label the specimen, and promptly
radiographic agents, salicylate, sodium transport it to the laboratory.
ipodate, sulfonylureas, and tyropanoic Post-test:
acid.
Pretest: tests performed. Some related labo-
ratory tests include TSH hormone,
➤ Obtain a history of the patient’s T4, free T4, and free T3.
TROPONINS I AND T
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Cardiac troponin, cardiac troponin I (cTnI),

cardiac troponin T (cTnT).

mL) collected in green-top (heparin) tube is also acceptable. Serial sampling
is highly recommended. Care must be taken to use the same type of collec-
tion container if serial measurements are to be taken.
Troponin I Less than INDICATIONS:

0.35 ng/mL • Assist in establishing a diagnosis of MI
Troponin T Less than • Evaluate myocardial cell damage
0.20 g/L
RESULT
DESCRIPTION: Troponin is a Increased in:
complex of three contractile proteins • Acute MI
that regulate the interaction of actin • Minor myocardial damage
and myosin. Troponin C is the
calcium-binding subunit; it does not • Myocardial damage after coronary
artery bypass graft surgery or percuta-
have a cardiac muscle–specific
neous transluminal coronary angio-
subunit. Troponin I and troponin plasty
T, however, do have cardiac
muscle–specific subunits. They are • Unstable angina pectoris
detectable a few hours to 7 days after
Decreased in: N/A
the onset of symptoms. Troponin I is
thought to be a more specific marker
of cardiac damage than troponin T.
Cardiac troponin I begins to rise 2 to INTERFERING FACTORS: N/A
6 hours after myocardial infarction
(MI). It has a biphasic peak: It
initially peaks at 15 to 24 hours after Nursing Implications and
MI and then exhibits a lower peak Procedure ● ● ● ● ● ● ● ● ● ● ●
after 60 to 80 hours. Cardiac

troponin T levels rise 2 to 6 hours Pretest:
after MI and remain elevated. Both ➤ Obtain a history of the patient’s
proteins return to the reference range complaints, including a list of known
7 days after MI. ■ allergens.
Tuberculin Skin Tests 939

cardiovascular system and results of transport it to the laboratory.
to the cardiovascular system table.
Post-test:
➤ Obtain a list of medications the ➤ Observe venipuncture site for bleed-
patient is taking, including herbs, ing or hematoma formation. Apply
nutritional supplements, and pressure bandage.
nutraceuticals. The requesting health ➤ Increased troponin levels are associ-
care practitioner and laboratory ated with coronary artery disease.
should be advised if the patient Nutritional therapy is recommended
regularly uses these products so for individuals identified to be at high
that their effects can be taken into risk for developing coronary artery
consideration when reviewing disease. If overweight, these
results. patients should be encouraged to
➤ There are no food, fluid, or medica- achieve a normal weight. The
tion restrictions unless by medical American Heart Association has
direction. Step 1 and Step 2 diets that may
➤ Review the procedure with the be helpful in achieving a goal
patient. Inform the patient that a of lowering total cholesterol and
number of samples will be collected. triglyceride levels. The Step 1 diet
Collection at time of admission, 2 to emphasizes a reduction in foods
4 hours, 6 to 8 hours, and 12 hours high in saturated fats and choles-
after admission are the minimal terol. Red meats, eggs, and dairy
recommendations. Additional sam- products are the major sources of
ples may be requested. saturated fats and cholesterol. If
triglycerides are also elevated,
➤ Inform the patient that specimen patients should be advised to elimi-
collection takes approximately 5 to nate or reduce alcohol and simple
10 minutes. carbohydrates from their diet. The
Step 2 diet recommends stricter
Intratest: reductions.
➤ Observe standard precautions and tests include calcium, creatine
follow the general guidelines in kinase and isoenzymes, digoxin,
Appendix A. Perform a venipuncture, lactate dehydrogenase and isoen-
and collect the specimen in a 5-mL zymes, homocysteine, magnesium,
red- or tiger-top tube. myoglobin, and potassium.
TUBERCULIN SKIN TESTS

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: TB tine test, PPD, Mantoux skin test.

SPECIMEN: N/A.
REFERENCE VALUE: (Method: Intradermal skin test) Negative.
DESCRIPTION: Tuberculin skin tests • Evaluate patients with medical condi-

are done to determine past or present tions placing them at risk for tubercu-
exposure to tuberculosis. The multi- losis (e.g., acquired immunodeficiency
puncture or tine test, a screening syndrome [AIDS], lymphoma,
diabetes)
technique, uses either purified protein
derivative (PPD) of tuberculin or old • Screen infants with the tine test at the
tuberculin. A positive response at the time of first immunizations to deter-
puncture site indicates cell-mediated mine tuberculosis exposure
immunity to the organism or a • Screen populations at risk for develop-
delayed hypersensitivity caused by ing tuberculosis (e.g., health care prac-
interaction of the sensitized T titioners, nursing home residents,
lymphocytes. Verification of the correctional facility personnel, prison
patient’s positive response to the inmates, and residents of the inner city
multipuncture is done with the more living in poor hygienic conditions)
definitive Mantoux test using Aplisol
RESULT
or Tubersol administered by intrader-
mal injection. The Mantoux test is Positive findings in: Pulmonary
the test of choice in symptomatic tuberculosis
patients. It is also used in some
settings as a screening test. A negative CRITICAL VALUES: N/A
result is judged if there is no sign of
redness or induration at the site of the INTERFERING FACTORS:
injection or if the zone of redness and • Drugs such as immunosuppressive
induration is less than 5 mm in diam- agents or steroids can alter results.
eter. A positive result is evidenced by • Diseases such as hematologic cancers
an area of erythema and induration at or sarcoidosis can alter results.
the injection site that is greater than • Recent or present bacterial, fungal, or
10 mm. A positive result does not viral infections may affect results.
distinguish between active and False-positive results may be caused by
dormant infection. A positive the presence of nontuberculous
response to the Mantoux test is mycobacteria or by serial testing.
followed up with chest radiography • False-negative results can occur if sensi-
and bacteriologic sputum testing to tized T cells are temporarily decreased.
confirm diagnosis. ■ False-negative results also can occur in
the presence of bacterial infections,
INDICATIONS: immunologic deficiencies, immuno-
• Evaluate cough, weight loss, fatigue, suppressive agents, live-virus vaccina-
hemoptysis, and abnormal x-rays to tions (e.g., measles, mumps, polio,
determine if the cause of symptoms is rubella), malnutrition, old age, over-
tuberculosis whelming tuberculosis, renal failure,
and active viral infections (e.g., chick-
• Evaluate known or suspected exposure
enpox, measles, mumps).
to tuberculosis, with or without symp-
toms, to determine if tuberculosis is • Improper storage of the tuberculin
present solution (e.g., with respect to tempera-
Tuberculin Skin Tests 941
ture, exposure to light, and stability on patient is taking, including herbs,

opening) may affect the results. nutritional supplements, and
• Improper technique when performing care practitioner and laboratory
the intradermal injection (e.g., inject- should be advised if the patient
ing into subcutaneous tissue) may regularly uses these products so
cause false-negative results. that their effects can be taken into
• Incorrect amount or dilution of anti- results.
gen injected or delayed injection after ➤ There are no food, fluid, or medica-
drawing the antigen up into the syringe tion restrictions unless by medical
may affect the results. direction.
• Incorrect reading of the measurement ➤ Ensure that the patient does not
of response or timing of the reading have tuberculosis and has not had a
may interfere with results. positive skin test previously before
beginning the test.
• It is not known whether the test has ➤ Do not administer the test if the
teratogenic effects or reproduc- patient has a skin rash or other erup-
tive implications; the test should tions at the test site.
be administered to pregnant women ➤ Review the procedure with the
only when clearly indicated. patient. Inform the patient that a
moderate amount of pain may be
• The test should not be administered experienced when the intradermal
to a patient with a previously injection is performed.
positive tuberculin skin test
because of the danger of severe reac- dure takes approximately 5 minutes.
tion, including vesiculation, ulcera-
tion, and necrosis. ➤ Emphasize to the patient that the
area should not be scratched or
• The test does not distinguish between disturbed after the injection and
current and past infection. before the reading.
Intratest:
Nursing Implications and ➤ Have epinephrine hydrochloride
Procedure ● ● ● ● ● ● ● ● ● ● ● solution (1:1000) available in the
event of anaphylaxis.
Pretest: ➤ Observe standard precautions and
➤ Obtain a history of the patient’s Appendix A.
➤ 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
diameter of the largest indurated Post-test:

area, making sure the room is suffi-
ciently lighted to perform the read- ➤ Emphasize to the patient the need
ing. A palpable induration greater to return and have the test results
than or equal to 2 mm at one or read within the specified time frame
more of the punctures indicates a of 48 to 72 hours after injection.
positive test result. ➤ Inform the patient that the effects
from a positive response at the site
Mantoux (intradermal) test: can remain for 1 week.
➤ Prepare PPD or old tuberculin in a ➤ Educate the patient that a positive
tuberculin syringe with a short, 26- result may put him or her at risk for
gauge needle attached. Prepare the infection related to impaired primary
appropriate dilution and amount for defenses, impaired gas exchange
the most commonly used intermedi- related to decrease in effective lung
ate strength (5 tuberculin units in 0.1 surface, and intolerance to activity
mL) or a first strength usually used related to an imbalance between
for children (1 tuberculin unit in 0.1 oxygen supply and demand.
mL). Inject the preparation intrader- ➤ Recognize anxiety related to test
mally at the prepared site as soon as results and offer support. Provide
it is drawn up into the syringe. When teaching and information regarding
properly injected, a bleb or wheal 6 the clinical implications of the test
to 10 mm in diameter is formed results, as appropriate. Reinforce
within the layers of the skin. Record information about additional testing
the site, and remind the patient to needed, answer questions, or direct
return in 48 to 72 hours to have the questions to the appropriate profes-
test read. At the time of the reading, sionals.
use a plastic ruler to measure the
diameter of the largest indurated ➤ Educate the patient regarding
area, making sure the room is suffi- access to counseling services.
ciently lighted to perform the read- ➤ Evaluate test results in relation to
ing. Palpate for thickening of the the patient’s symptoms and other
tissue; a positive result is indicated tests performed. Related laboratory
by a reaction of 5 mm or more with tests include relevant acid-fast
erythema and edema. cultures and smears.
ULTRASOUND, ARTERIAL DOPPLER,

CAROTID STUDIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Carotid Doppler, carotid ultrasound, arterial ultra-

sound.
AREA OF APPLICATION: Arteries.

Ultrasound, Arterial Doppler, Carotid Studies 943
DESCRIPTION: Ultrasound proce- RESULT

dures are diagnostic, noninvasive, and
relatively inexpensive. They take a Normal Findings:
short time to complete, do not use • Normal blood flow through the carotid
radiation, and cause no harm to the arteries with no evidence of occlusion
patient. Using the duplex scanning or narrowing
method, carotid ultrasound records
sound waves to obtain information Abnormal Findings:
about the carotid arteries. The ampli- • Carotid artery occlusive disease (ather-
tude and waveform of the carotid osclerosis)
pulse are measured, resulting in a • Plaque or stenosis of carotid artery
two-dimensional image of the artery. • Reduction in vessel diameter of more
Carotid arterial sites used for the than 16 percent, indicating stenosis
studies include the common carotid,
external carotid, and internal carotid. CRITICAL VALUES: N/A
Blood flow direction, velocity, and the
presence of flow disturbances can be INTERFERING FACTORS
readily assessed. The sound waves hit
the moving red blood cells and are Factors that may impair clear
reflected back to the transducer, a imaging:
flashlight-shaped device. The sound • Inability of the patient to cooperate or
that is emitted by the equipment remain still during the procedure
corresponds to the velocity of the
mental status
blood flow through the vessel. The
result is the visualization of the artery • Incorrect placement of the transducer
to assist in the diagnosis (i.e., pres- over the desired test site
ence, amount, location) of plaques • An abnormally large neck, which may
causing vessel stenosis or atheroscle- make direct examination difficult
rotic occlusion affecting the flow of
blood to the brain. Depending on the
degree of stenosis causing a reduction Nursing Implications and
in vessel diameter, additional testing Procedure ● ● ● ● ● ● ● ● ● ● ●
can be performed to determine the

effect of stenosis on the hemody- Pretest:
namic status of the artery. ■ ➤ Inform the patient that the proce-
dure assesses the arteries.
INDICATIONS: ➤ Inform the patient that the proce-
• Detect plaque or stenosis of the carotid dure is performed in a special
artery, evidenced by turbulent blood nuclear medicine department by a
flow or changes in Doppler signals technologist and usually takes
indicating occlusion approximately 30 to 60 minutes.
• Detect irregularities in the structure of ➤ Obtain a history of previous arterial
studies, presence of disorders
the carotid arteries predisposing the patient to arterial
• Aid in the diagnosis of carotid artery thrombosis, or therapy received for
occlusive disease, evidenced by visuali- arterial abnormalities.
zation of blood flow disruption ➤ Assess the presence of disorders
predisposing the patient to cerebral dure because movement produces

arterial vascular problems. unclear images.
➤ Obtain the results of other tests,
treatments, therapies, surgeries, Post-test:
medication usage, and other proce- ➤ When the study is completed,
dures done to diagnose disorders of remove the gel from the area exam-
the cardiovascular system. For ined.
cular system table. ➤ Instruct the patient to resume
➤ Inform the patient that the proce- otherwise indicated.
dure is painless and carries no risks.
➤ Instruct the patient to report dizzi-
➤ Obtain and record baseline vital ness, syncope, or blurred vision
signs to use for comparison after the caused by impaired circulation to the
procedure, if needed. brain (transient ischemic attacks).
Intratest: ➤ A physician specializing in this
➤ Place the patient in a supine position report to the ordering provider, who
on a table or examining cart. discusses the results with the
➤ Expose the area to be examined and patient.
support the head to prevent move- ➤ Inform the patient that an abnormal
ment. examination may indicate the need
➤ Apply conductive gel to the skin, and for further studies.
slowly move the transducer over the ➤ Evaluate test results in relation to
site in the area of the common the patient’s symptoms and other
carotid artery to the bifurcation tests performed. Related diagnostic
and then to areas of the internal tests include computed tomog-
and external carotids. Ask the raphy and magnetic resonance
patient to lie still during the proce- angiography.
ULTRASOUND, ARTERIAL DOPPLER,

LOWER EXTREMITY STUDIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Arterial leg ultrasound, leg sonogram.

AREA OF APPLICATION: Arteries of the lower extremities.
DESCRIPTION: Ultrasound proce- patient. Using the duplex scanning

dures are diagnostic, noninvasive, and method, arterial leg ultrasound
relatively inexpensive. They take a records sound waves to obtain infor-
short time to complete, do not use mation about the arteries of the lower
radiation, and cause no harm to the extremities from the common
Ultrasound, Arterial Doppler, Lower Extremity Studies 945
femoral artery and their branches as • Arterial calcification or plaques

they extend into the calf area. The • Graft diameter reduction
amplitude and waveform of the pulses
are measured, resulting in a two- • Hemangioma
dimensional image of the artery. • Hematoma
Blood flow direction, velocity, and the
• Ischemia
presence of flow disturbances can be
readily assessed, and for diagnostic • Pseudoaneurysm
studies, the technique is done bilater- • Reduction in vessel diameter of more
ally. The sound waves hit the moving than 16 percent, indicating stenosis
red blood cells and are reflected back
• Vessel occlusion or stenosis
to the transducer, a flashlight-shaped
device. The sound that is emitted by CRITICAL VALUES: N/A
the equipment corresponds to the
velocity of the blood flow through the INTERFERING FACTORS:
vessel. The result is the visualization
of the artery to assist in the diagnosis Factors that may impair clear
and presence, amount, and location imaging:
of plaques causing vessel stenosis or • Inability of the patient to cooperate or
occlusion and to help determine the remain still during the procedure
cause of claudication. Arterial recon- because of age, significant pain, or
mental status
struction and graft condition and
patency can also be evaluated. ■ • Incorrect placement of the transducer
INDICATIONS:
• Detect plaque or stenosis of the lower • Cold extremities, resulting in vasocon-
extremity artery, evidenced by turbu- striction that can cause inaccurate
lent blood flow or changes in Doppler measurements
signals indicating occlusion • Occlusion proximal to the site being
• Detect irregularities in the structure of studied, which would affect blood flow
the arteries to the area
• Aid in the diagnosis of ischemia, • Open wound or incision overlying the
arterial calcification, or plaques, evi- area to be examined
denced by visualization of blood flow • Cigarette smoking, because nicotine
disruption can cause constriction of the peripheral
• Aid in the diagnosis of aneu- vessels
rysm, pseudoaneurysm, hematoma, • An abnormally large leg, making direct
arteriovenous malformation, or examination difficult.
hemangioma
RESULT
Normal Findings: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Normal blood flow through the lower

Pretest:
extremity arteries with no evidence of
vessel occlusion or narrowing ➤ Inform the patient that the proce-
dure assesses the arteries of the
Abnormal Findings: leg.
• Aneurysm ➤ Inform the patient that the proce-
dure is performed in a special slowly move the transducer over the

nuclear medicine department by a site in the area of the iliac artery. Ask
technologist and usually takes the patient to lie still during the
approximately 30 to 60 minutes. procedure because movement
➤ Obtain a history of previous arterial produces unclear images.
studies, presence of disorders ➤ For segmental blood pressure
predisposing the patient to arterial assessment, place numerous blood
thrombosis, or therapy received for pressure cuffs on the extremity from
arterial abnormalities. For related the thigh to the ankle. Inflate the
tests, refer to the cardiovascular cuffs and record pressure readings.
system table.
➤ Assess the presence of disorders Post-test:
predisposing the patient to periph- ➤ When the study is completed,
eral vascular problems. remove the gel from the area exam-
➤ Inform the patient that the proce- ined.
dure is painless and carries no risks. ➤ Instruct the patient to resume
➤ Obtain and record baseline vital normal activity and diet, unless
signs to use for comparison after the otherwise indicated.
procedure, if needed. ➤ A physician specializing in this
Intratest: report to the ordering provider, who
➤ Ask the patient to void before the patient.
hospital gown. ➤ Inform the patient that an abnormal
➤ Place the patient in a supine position for additional studies.
on a table or examining cart, and
allow the patient to rest for a mini- ➤ Evaluate test results in relation to
mum of 10 minutes before the the patient’s symptoms and other
examination is started. tests performed. Related diagnostic
tests found in this publication
➤ Expose the area to be examined and include venous Doppler ultrasound,
support the leg to prevent move- computed tomography angio-
ment. graphy, and magnetic resonance
➤ Apply conductive gel to the skin, and angiography.
ULTRASOUND, BLADDER
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Bladder sonography.

AREA OF APPLICATION: Bladder.
Ultrasound, Bladder 947
DESCRIPTION: Ultrasound proce- • Evaluate the cause of urinary tract

dures are diagnostic, noninvasive, and infection, urine retention, and flank
relatively inexpensive. They take a pain
short time to complete, do not use • Evaluate hematuria, urinary frequency,
radiation, and cause no harm to the dysuria, and suprapubic pain
patient. Bladder ultrasound evaluates
disorders of the bladder, such as RESULT
masses or lesions. Bladder position,
structure, and size are examined with Normal Findings:
the use of high-frequency waves of • Normal size, position, and contour of
various intensities delivered by a the bladder
transducer, a flashlight-shaped device.
Abnormal Findings:
Methods for imaging include the
• Bladder diverticulum
transrectal, transurethral, and trans-
vaginal approach. The waves are • Cyst
bounced back, converted to electrical • Cystitis
energy, amplified by the transducer,
and displayed on a monitor to evalu- • Malignancy of the bladder
ate the structure and position of the • Tumor
contents of the bladder. The examina- • Urinary tract obstruction
tion is helpful for monitoring patient
response to therapy for bladder • Ureterocele
disease. Bladder images can be
included in ultrasonography of the INTERFERING FACTORS:
kidneys, ureters, bladder, urethra, and
gonads in diagnosing renal/neuro- for:
logic disorders. Bladder ultrasound • Patients with latex allergies, if an inter-
may be the diagnostic examination of nal examination is required
choice because there is no radiation
used and in most cases the accuracy is Factors that may impair clear
sufficient to make the diagnosis with- imaging:
out any further imaging procedures. ■ • Inability of the patient to cooperate or
INDICATIONS: because of age, significant pain, or
• Detect tumor of the bladder wall or mental status
pelvis, evidenced by distorted position
or changes in bladder contour • Incorrect placement of the transducer
• Assess residual urine after voiding to
diagnose urinary tract obstruction • Incorrect positioning of the patient,
causing overdistention which may produce poor visualization
• Determine end-stage malignancy of
the bladder caused by extension of a • Patients who are very obese, who may
primary tumor of the ovary or other exceed the weight limit for the equip-
pelvic organ ment
• Measure urinary bladder volume by • Retained gas or barium from a previous
transurethral or transvaginal approach radiologic procedure
➤ Expose the lower abdomen and

Nursing Implications and drape the patient.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Place the transducer over the blad-
der and pelvic sites; the sound wave
Pretest: images are projected on the screen
➤ Inform the patient that the proce- and stored electronically for future
dure assesses the bladder. viewing or reproduced on a film. Ask
the patient to lie still during the
➤ Inform the patient that the proce- procedure because movement
dure is performed in a specialized produces unclear images.
area by a technologist and usually
takes approximately 30 minutes. ➤ If the patient is to be examined for
residual urine volume, ask the
➤ Determine whether the patient is patient to empty the bladder; repeat
allergic to latex. the procedure and calculate the
➤ Obtain a history of suspected or volume.
existing disorders of the bladder.
➤ Obtain the results of other tests and Post-test:
procedures done to diagnose blad-
der disorders, as well as a history of ➤ When the study is completed,
previous treatments, therapies, or remove the gel from the bladder
surgery performed for these disor- area.
ders. For related tests, refer to the ➤ Instruct the patient to resume
genitourinary system table. normal activity, medication, and diet,
➤ Assure the patient that his or her unless otherwise indicated.
privacy will be maintained. ➤ A physician specializing in this
➤ Instruct the patient to administer an branch of medicine sends a written
enema 1 hour before this examina- report to the ordering provider, who
tion. discusses the results with the
patient.
dure is painless and carries no risks. ➤ Inform the patient that an abnormal
➤ Do not restrict food or fluids before
for additional studies.
the procedure. Offer three to four
glasses of water within 2 hours ➤ Evaluate test results in relation
before the test and instruct the to the patient’s symptoms and
patient to refrain from voiding. other tests performed. Related
diagnostic tests include kidney,
Intratest: ureter, and bladder (KUB) film;
intravenous pyelography; cysto-
➤ Ask the patient to disrobe below the scopy; and computed tomography
waist and put on a hospital gown. and magnetic resonance imaging
➤ Place the patient in a supine position of the pelvis.
on the examining table.
ULTRASOUND, BREAST
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Mammographic ultrasound.

Ultrasound, Breast 949
AREA OF APPLICATION: Breast.

DESCRIPTION: Ultrasound proce- old). The procedure is indicated as a

dures are diagnostic, noninvasive, and guide for biopsy or other interven-
relatively inexpensive. They take a tional procedure and as a means of
short time to complete, do not use monitoring disease progression or the
radiation, and cause no harm to the effects of treatment. ■
patient. When used in conjunction
with mammography and clinical INDICATIONS:
examination, breast ultrasound is • Determine the presence of nonpalpa-
ble abnormalities viewed on mammog-
indispensable in the diagnosis and
raphy of dense breast tissue, and
management of benign and malig- monitor changes in these abnormalities
nant process. Both breasts are usually
examined during this procedure. The • Differentiate among types of breast
examination uses high-frequency masses (e.g., cyst, solid tumor, other
lesions) in dense breast tissue
waves of various intensities delivered
by a transducer, a flashlight-shaped • Detect very small tumors in combina-
device, pressed against the skin. The tion with mammography for diagnos-
waves are bounced back, converted to tic validation
electrical energy, amplified by the • Evaluate palpable masses in young (less
transducer, and displayed on a moni- than age 25), pregnant, and lactating
tor to determine the presence of patients
palpable and nonpalpable masses, • Identify an abscess in a patient with
their size, and structure. This proce- mastitis
dure is useful in patients with an
• Guide interventional procedures such
abnormal mass on a mammogram
as cyst aspiration, large-needle core
because it can determine whether the biopsy, fine-needle aspiration biopsy,
abnormality is cystic or solid; that is, abscess drainage, presurgical localiza-
it can differentiate between a palpation, and galactography
ble, fluid-filled cyst and a palpable,
solid breast lesion (benign or malig- RESULT
nant). It is especially useful in patients
with dense breast tissue and in those Normal Findings:
with silicone prostheses, because the • Normal subcutaneous, mammary, and
ultrasound beam easily penetrates in retromammary layers of tissue in both
these situations, allowing routine breasts; no evidence of pathologic
examination that cannot be lesions (cyst or tumor) in either breast
performed with x-ray mammography.
Abnormal Findings:
The procedure can be done as an
• Abscess
adjunct to mammography, or it can
be done in place of mammography in • Breast solid tumor, lesions
patients who refuse having x-ray • Cancer (ductal carcinoma, infiltrating
exposure or those in whom it is lobular carcinoma, medullary carci-
contraindicated (e.g., pregnant noma, tubular carcinoma, and papil-
women, women less than 25 years lary carcinoma)
• Cystic breast disease tests, refer to the reproductive

system table.
• Fibroadenoma
➤ Ensure that the patient has not
• Focal fibrosis applied lotions, bath powder, or
other substances to the chest and
• Galactocele breast area before the examination.
• Hamartoma (fibroadenolipoma) ➤ Inform the patient that the proce-
• Hematoma
➤ Do not restrict food before the
• Papilloma procedure.
• Phyllodes tumor
Intratest:
• Radial scar
➤ Ask the patient to put on a hospital
gown.
INTERFERING FACTORS
Factors that may impair clear on the examining table; other posi-
imaging: tions may be used during the exam-
ination.
remain still during the procedure ➤ Expose the breast and drape the
because of age, significant pain, or patient.
mental status ➤ Apply conductive gel to the area,
and move a handheld transducer
• Incorrect placement of the transducer over the skin; the sound wave
over the desired test site images are projected on the screen
and stored electronically for future
• Incorrect positioning of the patient, viewing or reproduced on a film. Ask
which may produce poor visualization the patient to lie still during the
of the area to be examined procedure because movement
• Patients who are very obese, who may produces unclear images. Note:
Women with back problems or
limited flexibility may have difficulty
ment maintaining the appropriate posi-
• Excessively large breasts tions for this procedure.
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.
Ultrasound, Kidney 951
ULTRASOUND, KIDNEY
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Renal ultrasound, renal sonography.

DESCRIPTION: Ultrasound proce- biopsy or other interventional proce-

dures are diagnostic, noninvasive, and dures, abscess drainage, and nephros-
relatively inexpensive. They take a tomy tube placement. Renal
short time to complete, do not use ultrasound may be the diagnostic
radiation, and cause no harm to the examination of choice because there
patient. Renal ultrasound is used to is no radiation used and in most cases
evaluate renal system disorders. It is the accuracy is sufficient to make the
valuable for determining the internal diagnosis without any further imag-
components of renal masses (solid ing procedures. ■
versus cystic) and for evaluating other
renal diseases, renal parenchyma, INDICATIONS:
perirenal tissues, and obstruction. • Detect masses and differentiate
between cysts or solid tumors,
Ultrasound uses high-frequency
evidenced by specific waveform
waves of various intensities delivered patterns or absence of sound waves
by a transducer, a flashlight-shaped
device, pressed against the skin. The • Provide the location and size of renal
waves are bounced back, converted to masses in patients who are unable to
undergo IVP because of poor renal
electrical energy, amplified by the
function or an allergy to iodinated
transducer, and displayed on a moni- contrast medium
tor to evaluate the structure, size, and
position of the kidney. Renal ultra- • Determine the presence and location
of renal or ureteral calculi and obstruc-
sound can be performed on the same
tion
day as a radionuclide scan or other
radiologic procedure, and is especially • Determine an accumulation of fluid in
valuable in patients who are in renal the kidney caused by backflow of
urine, hemorrhage, or perirenal fluid
failure, have hypersensitivity to
contrast medium, have a kidney that • Monitor kidney development in chil-
did not visualize on intravenous pyel- dren, when renal disease has been diag-
ography (IVP), or are pregnant. It nosed
does not rely on renal function or the • Determine the size, shape, and posi-
injection of contrast medium to tion of a nonfunctioning kidney to
obtain a diagnosis. The procedure is identify the cause
indicated for evaluation after a kidney • Aid in the diagnosis of the effect of
transplant and is used as a guide for chronic glomerulonephritis and end-
stage chronic renal failure on the • Incorrect positioning of the patient,

kidneys (e.g., decreasing size) which may produce poor visualization
• Locate the site and guide percutaneous
renal biopsy, aspiration needle inser- • Patients who are very obese, who may
tion, or nephrostomy tube insertion exceed the weight limit for the equip-
ment
• Evaluate renal transplantation for
changes in kidney size • Retained gas or barium from a previous
radiologic procedure
• Evaluate or plan therapy for renal
tumors
RESULT Nursing Implications and

Procedure ● ● ● ● ● ● ● ● ● ● ●
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
• 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-
• 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
gown and void.
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.
➤ 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
Ultrasound, Liver and Biliary System 953
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.
➤ 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
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, LIVER AND BILIARY

SYSTEM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Gallbladder ultrasound, liver ultrasound, hepato-

biliary sonography.
AREA OF APPLICATION: Liver, gallbladder, bile ducts.

DESCRIPTION: Ultrasound proce- ate the structure, size, and position of

dures are diagnostic, noninvasive, and the liver and gallbladder in the right
relatively inexpensive. They take a upper quadrant (RUQ) of the
short time to complete, do not use abdomen. The gallbladder and biliary
radiation, and cause no harm to the system collects, stores, concentrates,
patient. Hepatobiliary ultrasound and transports bile to the intestines to
uses high-frequency waves of various aid in digestion. This procedure
intensities delivered by a transducer, a allows visualization of the gallbladder
flashlight-shaped device, pressed and bile ducts when the patient may
against the skin. The waves are have impaired liver function, and it is
bounced back, converted to electrical especially helpful when done on
energy, amplified by the transducer, patients whose gallbladder is unable
and displayed on a monitor to evalu- to visualize gallstones with oral or
intravenous radiologic studies. Liver • Guide biopsy or tube placement

ultrasound can be done in combina-
tion with a nuclear scan to obtain RESULT
information about liver function and
Normal Findings:
density differences in the liver. The
procedure is indicated as a guide for • Normal size, position, and shape of the
liver and gallbladder, as well as patency
biopsy or other interventional proce-
of the cystic and common bile ducts
dures. Hepatobiliary ultrasound may
be the diagnostic examination of Abnormal Findings:
choice because there is no radiation • Biliary or hepatic duct
used and in most cases the accuracy is obstruction/dilation
sufficient to make the diagnosis with-
out any further imaging procedures. ■ • Cirrhosis
• Gallbladder inflammation, stones,
INDICATIONS: carcinoma, polyps
• Detect hepatic lesions, evidenced by
density differences and echo-pattern • Hematoma or trauma
changes • Hepatic tumors, metastasis, cysts,
• Determine patency and diameter of hemangioma, hepatitis
the hepatic duct for dilation or • Hepatocellular disease, adenoma
obstruction
• Hepatomegaly
• Differentiate between obstructive and
nonobstructive jaundice by determin- • Intrahepatic abscess
ing the cause • Subphrenic abscesses
• Determine the cause of unexplained
hepatomegaly and abnormal liver func-
tion tests
INTERFERING FACTORS
• Detect gallstones or inflammation
when oral cholecystography is incon- Factors that may impair clear
clusive imaging:
• Attenuation of the sound waves by the
• Detect cysts, polyps, hematoma,
ribs, which can impair clear imaging of
abscesses, hemangioma, adenoma,
the right lobe of the liver
metastatic disease, hepatitis, or solid
tumor of the liver or gallbladder • Inability of the patient to cooperate or
evidenced by echoes specific to tissue remain still during the procedure
density and sharply or poorly defined because of age, significant pain, or
masses mental status
• Determine cause of unexplained RUQ • Incorrect placement of the transducer
pain over the desired test site
• Evaluate response to therapy for tumor, • Incorrect positioning of the patient,
evidenced by a decrease in size of the which may produce poor visualization
organ of the area to be examined
• Guide catheter placement into the • Patients who are very obese, who may
gallbladder for stone dissolution and exceed the weight limit for the equip-
gallbladder fragmentation ment
Ultrasound, Liver And Biliary System 955
• Retained gas or barium from a previous study, if ordered, to remove any

radiologic procedure remaining barium.
Other considerations: on the examining table; other posi-
tions may be used during the exam-
• Failure to follow dietary restrictions ination. The right- or left-side-up
before the procedure may cause the position allows gravity to reposition
procedure to be canceled or repeated. the liver, gas, and fluid to facilitate
better organ visualization.
➤ Expose the abdomen and drape the
Nursing Implications and patient.
Procedure ● ● ● ● ● ● ● ● ● ● ● ➤ Apply a conductive gel to the skin of
the RUQ, and move the transducer
Pretest: over the area to obtain several
images of the area of interest,
➤ Inform the patient that the proce- including the liver, gallbladder, and
dure assesses the hepatobiliary bile ducts (cystic and common); the
system. sound wave images are projected on
the screen and stored electronically
for future viewing or reproduced on
a film. Ask the patient to lie still
ment produces unclear images.
➤ If necessary for better organ visuali-
existing disease of the liver or gall-
zation, ask the patient to inhale
bladder and duct system.
deeply and hold his or her breath.
➤ Obtain the results of other tests and ➤ Gallbladder contractibility is viewed
procedures done to diagnose disor- by scanning after administration of a
ders of or treatments to the liver, pharmaceutical that induces gall-
gallbladder, and duct system. For bladder contraction or after adminis-
related tests, refer to the hepatobil- tration of a fatty meal.
iary system table.
➤ Note recent administration of Post-test:
obscure the organ to examined. ➤ When the study is completed,
There should be 24 hours between remove the gel from the skin.
administration of barium and this ➤ Instruct the patient to resume
test. normal activity, medication, and diet,
➤ Endoscopy, endoscopic retrograde unless otherwise indicated.
cholangiopancreatography (ERCP), ➤ A physician specializing in this
colonoscopy, and computed tomo- branch of medicine sends a written
graphy (CT) of the abdomen, if report to the ordering provider, who
ordered, should be scheduled after discusses the results with the
this procedure. patient.
➤ Restrict food, fluid, smoking, and ➤ Inform the patient that an abnormal
gum chewing for 6 to 8 hours before examination may indicate the need
the procedure. for additional studies.
➤ Ask the patient to put on a hospital tests include ERCP, endoscopy,
gown and void. colonoscopy, hepatobiliary scan, and
➤ Administer an enema before the CT scan of the abdomen.
ULTRASOUND, LYMPH NODES AND

RETROPERITONEUM
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Lymph node sonography.

AREA OF APPLICATION: Abdomen, pelvis, and retroperitoneum.
DESCRIPTION: Ultrasound proce- sound may be the diagnostic exami-

dures are diagnostic, noninvasive, and nation of choice because there is no
relatively inexpensive. They take a radiation used and in most cases the
short time to complete, do not use accuracy is sufficient to make the
radiation, and cause no harm to the diagnosis without any further imag-
patient. Lymph node ultrasound uses ing procedures. ■
high-frequency waves of various
intensities delivered by a transducer, a INDICATIONS:
flashlight-shaped device, pressed • Determine the size or enlargement of
against the skin. The waves are aortic and iliac lymph nodes
bounced back, converted to electrical • Detect lymphoma
energy, amplified by the transducer,
• Determine the location of enlarged
and displayed on a monitor to evalu-
nodes to plan radiation and other ther-
ate the structure, size, and position of apy
the lymph nodes to examine the
retroperitoneum and surrounding • Evaluate the effects of medical, radia-
tissues. This procedure is used for the tion, or surgical therapy on the size of
nodes or tumors, evidenced by shrink-
evaluation of retroperitoneal pathol-
age or continued presence of the mass
ogy, usually lymph node enlarge- or nodes
ment. Ultrasound is the preferred
diagnostic method because this area is
RESULT
inaccessible to conventional radiogra-
phy in diagnosing lymphadenopathy, Normal Findings:
although it can be used in combina- • Normal retroperitoneal and intrapelvic
tion with lymphangiography, node size of 1.5 cm in diameter
magnetic resonance imaging, and
computed tomography (CT) to Abnormal Findings:
confirm the diagnosis. The procedure • Infection or abscess
may be used for monitoring the effect
of radiation or chemotherapy on the • Lymphoma
lymph nodes. Lymph node ultra- • Retroperitoneal tumor
Ultrasound, Lymph Nodes and Retroperitoneum 957
INTERFERING FACTORS: procedures done to diagnose disor-

ders of or treatments to the
Factors that may impair clear lymphatic system or retroperi-
imaging: toneum. For related tests, refer to
the hematopoietic system.
remain still during the procedure ➤ Inform the patient that the proce-
mental status ➤ Ensure that the patient has
abstained from smoking several
• Incorrect placement of the transducer hours before the procedure to
over the desired test site prevent swallowing of air.
• Incorrect positioning of the patient, ➤ Note recent administration of
which may produce poor visualization barium because residual barium can
obscure the organ to be examined.
There should be 24 hours between
• Patients who are dehydrated, resulting administration of barium and this
in failure to demonstrate the bound- test.
aries between organs and tissue struc- ➤ Restrict food and fluids 12 hours
tures before the procedure, but inform the
patient that clear liquids will be given
• Patients who are very obese, who may the morning of the procedure to fill
exceed the weight limit for the equip- the bladder and aid the study.
ment
• Retained gas or barium from a previous Intratest:
radiologic procedure ➤ Ask the patient to put on a front-
opening hospital gown.
• Ensure that the patient maintains a full on the examining table; other posi-
bladder if scanning is to be performed tions may be used during the exam-
below the umbilicus. ination.
• Ensure that the procedure is performed ➤ Expose the abdomen/pelvic area
before endoscopy, endoscopic retro- and drape the patient.
grade cholangiopancreatography ➤ Apply a conductive gel to the skin,
(ERCP), barium studies, and and move the transducer over the
colonoscopy. flank, pelvis, and abdominal areas to
obtain several images of the area of
interest; the sound wave images are
projected on the screen and stored
Nursing Implications and electronically for future viewing
Procedure ● ● ● ● ● ● ● ● ● ● ● or reproduced on a film. Ask the
patient to lie still during the proce-
Pretest: dure because movement produces
unclear images.
dure assesses the lymph nodes and
retroperitoneum. Post-test:
➤ Inform the patient that the proce- ➤ When the study is completed,
dure is performed in a specialized remove the gel from the skin.
area by a technologist and usually ➤ Instruct the patient to resume
takes approximately 45 minutes. normal activity, medication, and diet,
➤ Obtain a history of suspected or unless otherwise indicated.
existing tumor or lymphoma. ➤ A physician specializing in this
➤ Obtain the results of other tests and branch of medicine sends a written
report to the ordering provider, who ➤ Evaluate test results in relation to

discusses the results with the the patient’s symptoms and other
patient. tests performed. Related diagnostic
➤ Inform the patient that an abnormal tests include CT and magnetic reso-
examination may indicate the need nance imaging of the abdomen and
for additional studies. pelvis.
ULTRASOUND, OBSTETRIC
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: OB sonography, fetal age sonogram, gestational

age sonogram, pregnancy ultrasound, pregnancy echo, pregnant uterus
ultrasonography.
AREA OF APPLICATION: Pelvis and abdominal region.

DESCRIPTION: Ultrasound proce- of amniotic fluid, and multiple gesta-

dures are diagnostic, noninvasive, and tion. Obstetric ultrasound is used
relatively inexpensive. They take a to secure different types of informa-
short time to complete, do not use tion regarding the fetus, varying with
radiation, and cause no harm to the the trimester during which the proce-
patient. Obstetric ultrasound uses dure is done. This procedure can
high-frequency waves of various also be used in combination with
intensities delivered by a transducer, a Doppler monitoring of the fetal
flashlight-shaped device, pressed heart or respiratory movements to
against the skin or inserted into the detect high-risk pregnancy. The
vagina. The waves are bounced back, procedure is indicated as a guide
converted to electrical energy, ampli- for amniocentesis, cordocentesis,
fied by the transducer, and displayed fetoscopy, aspiration of multiple
on a monitor to visualize the fetus oocytes for in vitro fertilization, and
and placenta. This procedure is done other intrauterine interventional
by a transabdominal or transvaginal procedures. Because the pregnant
approach, depending on when the uterus is filled with amniotic fluid,
procedure is performed (e.g., first ultrasonography is an ideal method of
trimester [transvaginal], second evaluating the fetus and placenta; it is
trimester [transabdominal]). It is also the diagnostic examination of
the safest method of examination to choice because there is no radiation
evaluate the uterus and determine used and in most cases the accuracy
fetal size, growth, position, fetal is sufficient to make the diag-
structural abnormalities, ectopic nosis without any further imaging
pregnancy, placenta position, amount procedures. ■
Ultrasound, Obstetric 959
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
• 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
• Differentiate a tumor (hydatidiform
mole) from a normal pregnancy • Incorrect positioning of the patient,
which may produce poor visualization sterile sheath-covered probe will be

of the area to be examined inserted into the vagina.
• Patients who are dehydrated, resulting ➤ Note recent administration of
in failure to demonstrate the bound- obscure the organ to examined.
aries between organs and tissue struc- There should be 24 hours between
tures administration of barium and this
• Patients who are very obese, exceeding test.
the weight limit for the equipment and ➤ Do not restrict food or fluids before
preventing the sound beam from pene- the procedure. Inform the patient
trating to the site receiving transabdominal ultrasound
that the procedure requires a full
• Retained gas or barium from a previous bladder; instruct the patient to drink
radiologic procedure five to six glasses of fluid and not to
void before the procedure. Patients
• Insufficiently full bladder, which fails receiving transvaginal ultrasound do
to push the bowel from the pelvis and not need to have a full bladder.
the uterus from the symphysis pubis,
thereby prohibiting clear imaging of Intratest:
the pregnant uterus in transabdominal
imaging ➤ Ask the patient to put on a hospital
gown.
Nursing Implications and on the examining table; other posi-
Procedure ● ● ● ● ● ● ● ● ● ● ●
ination.
Pretest: ➤ Expose the abdomen and drape the
patient.
dure assesses the pelvis and ➤ Transabdominal approach: Apply
abdominal region. conductive gel to the area, and move
the transducer over the skin while
➤ Inform the patient that the proce- the bladder is distended; the sound
dure is performed in a specialized wave images are projected on the
area by a technologist and usually screen and stored electronically for
takes approximately 30 to 60 future viewing or reproduced on a
minutes. film. Ask the patient to lie still during
➤ Assess whether the patient is aller- the procedure because movement
gic to latex. If the patient is allergic produces unclear images.
to latex, consult with the ordering ➤ Transvaginal approach: A covered
physician before the patient has the and lubricated probe is inserted into
examination. the vagina and moved to different
➤ Obtain a history of menstrual dates, levels. Images are obtained and
previous pregnancy, and treatment recorded. A full bladder is not
received for high-risk pregnancy. required for transvaginal ultrasound.
Obtain the results of other tests,
treatments, and procedures done to Post-test:
diagnose and treat conditions of the
pregnancy. For related tests, refer to ➤ Allow the patient to void, as needed.
the reproductive system tables. ➤ When the study is completed,
➤ Inform the patient that the proce- remove the gel from the skin or the
dure is painless and carries no risks probe from the abdomen or vagina.
to the patient or fetus. ➤ Instruct the patient to resume
➤ For the transvaginal approach, normal activity, medication, and diet,
inform the patient that a latex or unless otherwise indicated.
Ultrasound, Pancreas 961
➤ A physician specializing in this ➤ Inform the patient that there may be

branch of medicine sends a written a need for additional studies.
report to the ordering provider, who ➤ Evaluate test results in relation to
discusses the results with the the patient’s symptoms and any
patient. related tests performed.
ULTRASOUND, PANCREAS
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Pancreatic ultrasonography.

AREA OF APPLICATION: Pancreas and upper abdomen.
DESCRIPTION: Ultrasound proce- however, it is usually done in combi-

dures are diagnostic, noninvasive, and nation with computed tomography
relatively inexpensive. They take a (CT) or magnetic resonance imaging
short time to complete, do not use of the pancreas. ■
radiation, and cause no harm to the
patient. Pancreatic ultrasound uses INDICATIONS:
high-frequency waves of various • Detect pancreatitis, evidenced by
intensities delivered by a transducer, a pancreatic enlargement with increased
flashlight-shaped device, pressed echoes
against the skin. The waves are • Detect pancreatic cancer, evidenced by
bounced back, converted to electrical a poorly defined mass or a mass in the
energy, amplified by the transducer, head of the pancreas that obstructs the
and displayed on a monitor to deter- pancreatic duct
mine the size, shape, and position of • Detect pseudocysts, evidenced by a
the pancreas; determine the presence well-defined mass with absence of
of masses or other abnormalities of echoes from the interior
the pancreas; and examine the
surrounding viscera. The procedure is • Monitor therapeutic response to
tumor treatment
indicated as a guide for biopsy, aspi-
ration, or other interventional proce- • Provide guidance for percutaneous
dures. Pancreatic ultrasound may be aspiration and fine-needle biopsy of
the diagnostic examination of choice the pancreas
because there is no radiation used and • Detect anatomic abnormalities as a
in most cases the accuracy is suffi- consequence of pancreatitis
cient to make the diagnosis without
any further imaging procedures; RESULT
Normal Findings: ➤ Inform the patient that the proce-

• Normal size, position, contour, and dure is performed in a specialized
texture of the pancreas area by a technologist and usually
minutes. The room may be darkened
Abnormal Findings:
for better visualization of the
• Acute pancreatitis pancreas.
• Calculi ➤ Obtain a history of suspected or
existing disease of the pancreas.
• Pancreatic duct obstruction
➤ Obtain the results of tests and
• Pancreatic tumor procedures done to diagnose disor-
ders of or treatments to the
• Pseudocysts pancreas. For related tests, refer to
the endocrine system table.
CRITICAL VALUES: N/A ➤ Inform the patient that the proce-
Factors that may impair clear obscure the organ to be examined.
imaging: There should be a 24-hour waiting
• Inability of the patient to cooperate or period between administration of
remain still during the procedure barium and this test.
because of age, significant pain, or ➤ Inform the patient to withhold food
mental status for 8 hours, but to drink increased
• Incorrect placement of the transducer amounts of fluids to distend the
stomach before and during the
over the desired test site procedure.
which may produce poor visualization Intratest:
• Patients who are very obese, who may gown.
exceed the weight limit for the equip- ➤ Place the patient in a supine position
ment on the examining table; other posi-
• Retained gas, feces, or barium from a ination.
previous radiologic procedure, inade-
quate cleansing, or failure to restrict ➤ Expose the abdomen and drape the
patient.
food intake before the study
➤ Apply conductive gel to the epigas-
Other considerations: tric area, and move the transducer
over the skin; the sound wave
• Failure to follow dietary restrictions images are projected on the
before the procedure may cause the screen and stored electronically
procedure to be canceled or repeated. for future viewing or reproduced
on a film. Ask the patient to lie
still during the procedure because
Nursing Implications and movement produces unclear
images.
Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ If necessary for better visualization

Pretest: of the pancreas and abdominal
organs, ask the patient to inhale
➤ Inform the patient that the proce- deeply, regulate breathing, hold his
dure assesses the pancreas. or her breath, or drink water.
Ultrasound, Pelvis (Gynecologic, Nonobstetric) 963
Post-test: ➤ Inform the patient that an abnormal

➤ When the study is completed, for additional studies.
➤ Instruct the patient to resume to the patient’s symptoms and
normal activity, medication, and diet, other tests performed. Related
unless otherwise indicated. diagnostic tests include kidney,
➤ A physician specializing in this ureter, and bladder (KUB) film;
branch of medicine sends a written endoscopic retrograde cholangio-
report to the ordering provider, who pancreatography (ERCP); and CT and
discusses the results with the magnetic resonance imaging of the
patient. abdomen.
ULTRASOUND, PELVIS (GYNECOLOGIC,

NONOBSTETRIC)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Pelvic sonography, lower abdomen ultrasound,

pelvic gynecologic (GYN) sonogram.
AREA OF APPLICATION: Pelvis and appendix region.

DESCRIPTION: Ultrasound proce- an intrauterine contraceptive

dures are diagnostic, noninvasive, and device (IUD)
relatively inexpensive. They take a Evaluate postmenopausal
short time to complete, do not use bleeding
radiation, and cause no harm to the Examine other abnormalities of
patient. Gynecologic ultrasound uses the uterus, ovaries, fallopian
tubes, and vagina
high-frequency waves of various
intensities delivered by a transducer, a This procedure is done by a transab-
flashlight-shaped device, pressed dominal or transvaginal approach.
against the skin or inserted into the The transabdominal approach
vagina. The waves are bounced back, provides a view of the pelvic organs
converted to electrical energy, ampli- posterior to the bladder. It requires a
fied by the transducer, and displayed full bladder, thereby allowing a
on a monitor in order to: window for transmission of the ultra-
Determine the presence, size, and sound waves, pushing the uterus
structure of masses and cysts; away from the pubic symphysis,
and determine the position of pushing the bowel out of the pelvis,
and acting as a reference for compari- • Detect pelvic abscess or peritonitis

son in the evaluation of the internal caused by a ruptured appendix or
structures of a mass or cyst being diverticulitis
examined. The transvaginal approach • Detect bleeding into the pelvis result-
focuses on the female reproductive ing from trauma to the area or ascites
organs and is often used to monitor associated with tumor metastasis
ovulation over a period of days in • Evaluate the thickness of the uterine
patients undergoing fertility assess- wall
ment. This approach is also used in
obese patients or in patients with • Monitor follicular size associated with
fertility studies or to remove follicles
retroversion of the uterus because the
for in vitro transplantation
sound waves are better able to reach
the organ from the vaginal site. • Detect pregnancy, including ectopic
Transvaginal images are significantly pregnancy
more accurate compared to anterior • Evaluate suspected fibroid tumor or
transabdominal images in identifying bladder tumor
paracervical, endometrial, and ovar-
ian pathology, and the transvaginal RESULT
approach does not require a full blad-
der. The procedure is indicated as a Normal Findings:
guide for biopsy or other interven- • Normal size, position, location, and
tional procedures. Pelvic ultrasound structure of pelvic organs (e.g., uterus,
ovaries, fallopian tubes, vagina); IUD
may be the diagnostic examination of
properly positioned within the uterine
choice because there is no radiation cavity
used and in most cases the accuracy is
sufficient to make the diagnosis with- Abnormal Findings:
out any further imaging procedures. ■ • Endometrioma
INDICATIONS: • Fibroids (leiomyoma)

• Monitor placement and location of an • Nonovarian cyst
IUD
• Ovarian cysts
• Detect masses in the pelvis and differ-
entiate them from cysts or solid • Pelvic abscess
tumors, evidenced by differences in • Peritonitis
sound-wave patterns
• PID
• Detect the presence of ovarian cysts
and malignancy and determine the • Uterine tumor or adnexal tumor
type, if possible, evidenced by size,
outline, and change in position of CRITICAL VALUES: N/A
other pelvic organs
• Detect and monitor the treatment of
pelvic inflammatory disease (PID) This procedure is contraindicated
when done in combination with other for:
laboratory tests
• Patients with latex allergy; the vaginal
• Evaluate the effectiveness of tumor probe requires the probe to be covered
therapy, evidenced by a reduction in with a condom-like sac, usually made
mass size from latex.
Ultrasound, Pelvis (Gynecologic, Nonobstetric) 965
Factors that may impair clear ➤ Obtain a history of suspected or

imaging: existing disease of the pelvic
• Inability of the patient to cooperate or organs.
remain still during the procedure ➤ Obtain the results of tests and
because of age, significant pain, or procedures done to diagnose disor-
mental status ders of or treatments to the pelvic
region and organs. For related tests,
• Incorrect placement of the transducer refer to the genitourinary and repro-
over the desired test site ductive systems tables.
• Incorrect positioning of the patient, ➤ Inform the patient that the proce-
which may produce poor visualization dure is painless and carries no risks
to the patient or fetus.
➤ For the transvaginal approach,
• Patients who are dehydrated, resulting inform the patient that a latex or
in failure to demonstrate the bound- sterile sheath-covered probe will be
aries between organs and tissue struc- inserted into the vagina.
tures ➤ Note recent administration of
• Patients who are very obese, exceeding barium because residual barium can
obscure the organ to examined.
the weight limit for the equipment and
There should be a 24-hour waiting
preventing the sound beam from pene- period between administration of
trating to the site barium and this test.
• Retained gas, feces, or barium from a ➤ Do not restrict food or fluids before
previous radiologic procedure, inade- the procedure. Inform the patient
quate cleansing, or failure to restrict receiving transabdominal ultrasound
food intake before the study that the procedure requires a full
bladder; instruct the patient to drink
• Insufficiently full bladder, which fails five to six glasses of fluid and not to
to push the bowel from the pelvis and void before the procedure. Patients
the uterus from the symphysis pubis, receiving transvaginal ultrasound do
thereby prohibiting clear imaging of not need to have a full bladder.
the pelvic organs in transabdominal
imaging Intratest:
gown.
Nursing Implications and ➤ Place the patient in a supine position
Procedure ● ● ● ● ● ● ● ● ● ● ● on the examining table; other posi-
Pretest: ination.
➤ Inform the patient that the proce- ➤ Expose the abdomen and drape the
dure assesses the pelvis and patient.
abdominal region. ➤ Transabdominal approach: Apply
➤ Inform the patient that the proce- conductive gel to the area, and move
dure is performed in a specialized the transducer over the skin while
area by a technologist and usually the bladder is distended; the sound
takes approximately 30 to 60 wave images are projected on the
minutes. screen and stored electronically for
future viewing or reproduced on a
film. Ask the patient to lie still during
gic to latex. If the patient is allergic
to latex, consult the ordering physi-
cian before ordering the examina-
tion. ➤ Transvaginal approach: A covered
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
Post-test: patient.
➤ Allow the patient to void, as needed. ➤ Inform the patient that an abnormal
➤ When the study is completed, for additional studies.
remove the gel from the skin or the
probe from the vagina.
the patient’s symptoms and any
➤ Instruct the patient to resume related tests performed.
ULTRASOUND, PERIPHERAL DOPPLER

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Doppler, venous ultrasound, arterial ultrasound,

duplex scan.
AREA OF APPLICATION: Veins and arteries.

DESCRIPTION: Ultrasound proce- Blood flow direction, velocity, and

dures are diagnostic, noninvasive, and the presence of flow disturbances can
relatively inexpensive. They take a be readily assessed. The velocity of
short time to complete, do not use the blood flow is transformed as a
radiation, and cause no harm to the “swishing” noise, audible through the
patient. Peripheral Doppler ultra- audio speaker. If the vein is occluded,
sound studies can be used to identify no swishing sound is heard.
narrowing or occlusions of the veins In arterial Doppler studies, arte-
or arteries. In venous Doppler stud- riosclerotic disease of the peripheral
ies, the Doppler identifies moving red vessels can be detected by slowly
blood cells (RBCs) within the vein. deflating blood pressure cuffs that are
The ultrasound beam is directed at placed on an extremity such as the
the vein and through the Doppler calf, ankle, or upper extremity. The
transducer while the RBCs reflect the systolic pressure of the various arteries
beam back to the transducer. The of the extremities can be measured.
reflected sound waves or echoes can The Doppler transducer can detect
be transformed by a computer into the first sign of blood flow through
scans, graphs, or audible sounds. the cuffed artery, even the most mini-
Ultrasound, Peripheral Doppler 967
mal blood flow, as evidenced by a • Normal reduction in systolic blood

swishing noise. There is normally a pressure (i.e., less than 20 mm Hg)
reduction in systolic blood pressure when compared to a normal extremity
from the arteries of the arms to the • Normal ankle-to-brachial arterial
arteries of the legs; a reduction blood pressure (ankle pressure [A]
exceeding 20 mm Hg is indicative of divided by brachial [B] pressure;
occlusive disease (deep vein thrombo- normal AB pressure index is greater
sis [DVT]) proximal to the area being than 0.85)
tested. This procedure may also be
used to monitor the patency of a Abnormal venous findings:
graft, status of previous corrective • Venous narrowing or occlusion
surgery, vascular status of the blood secondary to thrombosis or throm-
flow to a transplanted organ, blood bophlebitis
flow to a mass, or the extent of vascu-
Abnormal arterial findings:
lar trauma. ■
• Large- or small-vessel arterial occlusive
INDICATIONS: disease
• Aid in the diagnosis of venous occlu- • Embolic arterial occlusion
sion secondary to thrombosis or
thrombophlebitis • Spastic arterial occlusive disease, such
as Raynaud’s phenomenon
• Aid in the diagnosis of small- or large-
vessel arterial occlusive disease • AB pressure index less than 0.85, indi-
cating significant arterial occlusive
• Aid in the diagnosis of spastic arterial disease within the extremity
disease, such as Raynaud’s phenome-
non CRITICAL VALUES: N/A
• Aid in the diagnosis of embolic arterial
occlusion INTERFERING FACTORS:
• Evaluate the origin of pain related to
vascular inflammation
for:
• Determine the patency of a vascular • Patients with an open or draining
graft, stent, or previous surgery lesion
• Evaluate possible arterial trauma
Factors that may alter test
RESULT results:
• Cigarette smoking
Normal venous findings:
• Normal Doppler venous signal that remain still during the procedure
occurs spontaneously with the client’s because of age, significant pain, or
respiration mental status
• Normal venous system, with no • Incorrect placement of the transducer
evidence of occlusion over the desired test site
Normal arterial findings: • Incorrect positioning of the patient,
• No evidence of arterial occlusion which may produce poor visualization
• Normal arterial systolic and diastolic
Doppler signals • Patients who are very obese, who may
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.
Arterial Doppler studies:

Procedure ● ● ● ● ● ● ● ● ● ● ●
➤ Place blood pressure cuffs on the
thigh, calf, and ankle.
Pretest: ➤ Apply a conductive get to the skin
over the area distal to the cuff.
dure assesses the veins and ➤ Inflate the proximal cuff to a level
arteries. above the patient’s systolic pressure
found in the normal extremity.
dure is performed in a specialized ➤ Place the Doppler transducer to the
area by a technologist and usually inflated cuff, and slowly release the
takes approximately 30 to 60 pressure in the cuff.
minutes. ➤ When the swishing sound is heard,
➤ Obtain a history of previous arterial record it at the highest level audible.
studies, presence of disorders The test is repeated at each succes-
predisposing the patient to DVT, or sive level.
therapy received for arterial abnor-
malities. For related tests, refer to Post-test:
the cardiovascular system table. ➤ When the study is completed,
➤ Inform the patient that the proce- remove the gel from the leg.
dure is painless and carries no risks. ➤ Instruct the patient to resume
➤ Obtain and record baseline vital normal activity, medication, and diet,
signs to use for comparison after the unless otherwise indicated.
procedure, if needed. ➤ A physician specializing in this
Intratest: report to the ordering provider, who
patient.
gown and void.
Venous studies: examination may indicate the need
for additional studies.
on a table or examining cart. ➤ Note test results in relation to other
test performed and the patient’s
➤ Expose the area to be examined. symptoms. Related diagnostic tests
➤ Inform the patient that movement include venous Doppler ultrasound,
during the procedure will affect the computed tomographic angio-
results and make interpretation graphy, and magnetic resonance
difficult. angiography.
Ultrasound, Prostate (Transrectal) 969
ULTRASOUND, PROSTATE
(TRANSRECTAL)
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Prostate sonography.

AREA OF APPLICATION: Prostate, seminal vesicles.
DESCRIPTION: Ultrasound proce- The examination is helpful in moni-

dures are diagnostic, noninvasive, and toring patient response to therapy for
relatively inexpensive. They take a prostatic disease. Micturition disor-
short time to complete, do not use ders can also be evaluated by this
radiation, and cause no harm to the procedure. Prostate ultrasound may
patient. Prostate ultrasound is used be the diagnostic examination of
for the evaluation of disorders of the choice because there is no radiation
prostate, especially in response to an used and in most cases the accuracy is
elevated concentration of prostate- sufficient to make the diagnosis with-
specific antigen (PSA) on a blood test out any further imaging procedures. ■
and as a complement to a digital
rectal examination. It uses high- INDICATIONS:
frequency waves of various intensities • Aid in prostate cancer diagnosis
delivered by a transducer, a candle- • Assess prostatic calcifications
shaped device, which is lubricated,
• Determine prostatic cancer staging
sheathed with a condom, and
inserted a few inches into the rectum. • Detect prostatitis
The waves are bounced back, • Aid in the diagnosis of micturition
converted to electrical energy, ampli- disorders
fied by the transducer, and displayed
• Assist in guided needle biopsy of a
on a monitor to evaluate the struc- suspected tumor
ture, size, and position of the
contents of the prostate (e.g., masses), • Assist in radiation seed placement
as well as other prostate pathology. It
RESULT
aids in the diagnosis of prostatic
cancer by evaluating palpable nodules Normal Findings:
and is useful as a guide to biopsy. This • Normal size, consistency, and contour
procedure can evaluate prostate of the prostate gland
tissue, the seminal vesicles, and
surrounding perirectal tissue. It can Abnormal Findings:
also be used to stage carcinoma and • Benign prostatic hypertrophy or
to assist in radiation seed placement. hyperplasia
• Micturition disorders ➤ Inform the patient that the proce-

• Perirectal abscess area by a technologist and usually
• Perirectal tumor takes approximately 30 minutes.
➤ Determine whether the patient is
• Prostate abscess allergic to latex. If the patient is aller-
• Prostate cancer gic to latex, consult with the order-
ing physician before the patient has
• Prostatitis the examination.
• Rectal tumor ➤ Obtain a history of suspected or
existing disorder of the prostate
• Seminal vesicle tumor gland.
➤ Obtain the results of other tests and
CRITICAL VALUES: N/A procedures done to diagnose disor-
ders of or treatments to the prostate
INTERFERING FACTORS: gland. For related tests, refer to the
genitourinary system table.
This procedure is contraindicated ➤ Inform the patient that the proce-
for: dure is painless and carries no risks.
• Patients with latex allergy; the rectal ➤ Assure the patient that his privacy
probe requires the probe to be covered will be maintained.
with a condom, usually made from ➤ Instruct the patient to administer an
latex. enema 1 hour before this examina-
tion.
Factors that may impair clear ➤ Do not restrict food or fluids before
imaging: the procedure.
remain still during the procedure Intratest:
because of age, significant pain, or ➤ Ask the patient to put on a hospital
mental status gown and void.
• Incorrect placement of the transducer ➤ Place the patient on the examining
over the desired test site table on his left side with his knees
bent toward the chest.
• Incorrect positioning of the patient, ➤ To ensure that no feces remain in
which may produce poor visualization the rectum, perform a digital rectal
of the area to be examined examination.
• Patients who are very obese, who may ➤ Cover the rectal probe with a lubri-
exceed the weight limit for the equip- cated condom and insert it into the
rectum. Inform the patient that he
ment
may feel slight pressure as the trans-
• Retained gas or barium from a previous ducer is inserted. Water may be
radiologic procedure, inadequate introduced through the sheath
cleansing, or failure to restrict food surrounding the transducer. The
scan is performed at several levels.
intake before the study
Ask the patient to lie still during the
Procedure ● ● ● ● ● ● ● ● ● ● ●
Post-test:
➤ When the study is completed,
Pretest: remove the gel from the rectal and
➤ Inform the patient that the proce- genital areas.
dure assesses the prostate. ➤ Instruct the patient to resume
Ultrasound, Scrotal 971
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
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Scrotal sonography, ultrasound of the testes, testicu-

lar ultrasound.
AREA OF APPLICATION: Scrotum.

DESCRIPTION: Ultrasound proce- further clarification of a testicular

dures are diagnostic, noninvasive, and mass. Extratesticular lesions such as
relatively inexpensive. They take a hydrocele, hematocele (blood in the
short time to complete, do not use scrotum), pyocele (pus in the scro-
radiation, and cause no harm to the tum) can be identified, as well as
patient. Scrotal ultrasound is used for cryptorchidism (undescended testi-
the evaluation of disorders of the cles). Scrotal ultrasound may be the
scrotum. It is valuable in determining diagnostic examination of choice
the internal components of masses because there is no radiation used and
(solid versus cystic) and for the evalu- in most cases the accuracy is suffi-
ation of the testicle, extratesticular cient to make the diagnosis without
and intrascrotal tissues, benign and any further imaging procedures. ■
malignant tumors, and other scrotal
pathology. It uses high-frequency INDICATIONS:
waves of various intensities delivered • Aid in the diagnosis of a mass and
differentiate between a cyst and a solid
by a transducer, a flashlight-shaped
tumor, evidenced by specific waveform
device, which is pressed against the patterns or the absence of sound
skin. The waves are bounced back, waves, respectively
converted to electrical energy, ampli-
fied by the transducer, and displayed • Determine the cause of chronic scrotal
swelling or pain
on a monitor to evaluate the struc-
ture, size, and position of the • Aid in the diagnosis of scrotal or
contents of the scrotum. Scrotal testicular size, abnormality, or pathol-
ultrasound can be performed before ogy
or after a radionuclide scan for • Aid in the diagnosis of a chronic
inflammatory condition such as INTERFERING FACTORS:

epididymitis
• Determine the presence of a hydrocele, imaging:
pyocele, spermatocele, or hernia before • Inability of the patient to cooperate or
surgery remain still during the procedure
• Aid in the diagnosis of testicular because of age, significant pain, or
torsion and associated testicular infarc- mental status
tion • Incorrect placement of the transducer
• Evaluate the effectiveness of treatment over the desired test site
for testicular infections • Incorrect positioning of the patient,
• Locate an undescended testicle which may produce poor visualization
• Assist ultrasound-guided needle biopsy • Patients who are very obese, who may
of a suspected testicle tumor exceed the weight limit for the equip-
ment
RESULT
Normal Findings: Nursing Implications and
• Normal size, position, and shape of the Procedure ● ● ● ● ● ● ● ● ● ● ●
scrotum and structure of the testes

Pretest:
Abnormal Findings:
• Abscess dure assesses the scrotum.
• Epididymal cyst ➤ Inform the patient that the proce-
• Epididymitis area by a technologist and usually
• Hematoma
• Hydrocele existing disorder of the scrotum or
testes.
• Infarction
• Microlithiasis procedures done to diagnose disor-
ders of or treatments to the scrotum
• Orchitis or testes. For related tests, refer to
the genitourinary system table.
• Pyocele
• Scrotal hernia dure is painless and carries no risks.
• Spermatocele ➤ Assure the patient that his privacy
will be maintained.
• Torsion ➤ Do not restrict food or fluids before
the procedure.
• Tumor, benign or malignant
• Tunica albuginea cyst Intratest:
• Undescended testicle (cryptorchidism). ➤ Ask the patient to put on a hospital

gown and void.
• Varicocele ➤ Place the patient in a supine position
with the patient’s legs apart on the
CRITICAL VALUES: N/A examining table.
Ultrasound, Spleen 973
➤ Expose the scrotal area and drape Post-test:

the patient.
➤ When the study is completed,
➤ Lift the penis upward and gently remove the gel from the scrotal
tape it to the lower part of the area.
abdomen. Elevate the scrotum with
a rolled towel or sponge for immobi- ➤ Instruct the patient to resume
lization. Display particular sensitivity normal activity, medication, and diet,
toward the patient regarding any unless otherwise indicated.
embarrassment he may feel during
this part of the procedure. ➤ A physician specializing in this
➤ Apply a conductive gel to the skin, report to the ordering provider, who
and move the transducer over the discusses the results with the
area to obtain several images of the patient.
area of interest; the sound wave
images are projected on the screen ➤ Inform the patient that an abnormal
and stored electronically for future examination may indicate the need
viewing or reproduced on a film. Ask for additional studies. Evaluate test
the patient to lie still during the results in relation to the patient’s
procedure because movement symptoms and any related tests
produces unclear images. performed.
ULTRASOUND, SPLEEN
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Spleen ultrasonography.

AREA OF APPLICATION: Spleen/left upper quadrant.
DESCRIPTION: Ultrasound proce- ate the structure, size, and position of

dures are diagnostic, noninvasive, the spleen. This test is valuable for
and relatively inexpensive. They take determining the internal components
a short time to complete, do not of splenic masses (solid versus cystic)
use radiation, and cause no harm to and evaluating other splenic pathol-
the patient. Spleen ultrasound uses ogy, splenic trauma, and left upper
high-frequency waves of various quadrant perisplenic tissues. It can
intensities delivered by a transducer, a be performed to supplement a
flashlight-shaped device, pressed radionuclide scan or computed
against the skin. The waves are tomography (CT). It is especially
bounced back, converted to electrical valuable in patients who are in renal
energy, amplified by the transducer, failure, are hypersensitive to contrast
and displayed on a monitor to evalu- medium, or are pregnant because
it does not rely on adequate renal RESULT

function or the injection of contrast
medium to obtain a diagnosis. The Normal Findings:
procedure may also be used as a guide • Normal size, position, and contour of
for biopsy, other interventional proce- the spleen and associated structures
dures, or abscess drainage. Spleen
ultrasound may be the diagnostic Abnormal Findings:
examination of choice because there • Abscesses
is no radiation used and in most cases • Accessory or ectopic spleen
the accuracy is sufficient to make the
diagnosis without any further imag- • Infection
ing procedures. ■ • Lymphatic disease, lymph node
enlargement
INDICATIONS: • Splenic calcifications
• Detect splenic masses; differentiate
between cysts or solid tumors (in • Splenic masses, tumors, cysts, or
combination with CT), evidenced by infarction
specific waveform patterns or absence
• Splenic trauma
of sound waves, respectively; and deter-
mine whether they are intrasplenic or • Splenomegaly
extrasplenic
• Determine the presence of
splenomegaly, and assess the size and
volume of the spleen in these cases, INTERFERING FACTORS
evidenced by increased echoes and visi-
bility of the spleen Factors that may impair clear
imaging:
• Detect the presence of a subphrenic • Attenuation of the sound waves by the
abscess after splenectomy ribs and an aerated left lung, which can
• Evaluate the extent of abdominal impair clear imaging of the spleen
trauma and spleen involvement, • Inability of the patient to cooperate or
including enlargement or rupture, after remain still during the procedure
a recent trauma because of age, significant pain, or
• Differentiate spleen trauma from mental status
blood or fluid accumulation between • Incorrect placement of the transducer
the splenic capsule and parenchyma over the desired test site
• Evaluate the spleen before splenectomy • Incorrect positioning of the patient,
performed for thrombocytopenic which may produce poor visualization
purpura of the area to be examined
• Determine late-stage sickle cell disease, • Masses near the testing site, which can
evidenced by decreased spleen size and displace the spleen and cause inaccu-
presence of echoes rate results if confused with
splenomegaly
• Evaluate the effect of medical or surgi-
cal therapy on the progression or reso- • Patients who are dehydrated, resulting
lution of splenic disease in failure to demonstrate the bound-
Ultrasound, Spleen 975
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.
dure is performed in a specialized Post-test:
takes approximately 45 minutes. ➤ When the study is completed,
existing disease of or trauma to the
normal activity, medication, and diet,
spleen.
ders of or treatments to the splenic
system. For related tests, refer to
the hematopoietic and gastrointesti-
patient.
nal system tables.
➤ 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
➤ 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.
ULTRASOUND, THYROID AND

PARATHYROID
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Thyroid sonography, parathyroid sonography,

thyroid echo.
AREA OF APPLICATION: Thyroid, parathyroid, and anterior neck region.

DESCRIPTION: Ultrasound proce- Thyroid and parathyroid ultrasound

dures are diagnostic, noninvasive, and may be the diagnostic examination of
relatively inexpensive. They take a choice because there is no radiation
short time to complete, do not use used and in most cases the accuracy is
radiation, and cause no harm to the sufficient to make the diagnosis with-
patient. Thyroid and parathyroid out any further imaging procedures;
ultrasound uses high-frequency waves it is clearly the procedure of choice
of various intensities delivered by a when examining the glands of preg-
transducer, a flashlight-shaped device, nant patients. This procedure is
pressed against the skin. The waves usually done in combination with
are bounced back, converted to elec- nuclear medicine imaging procedures
trical energy, amplified by the trans- and computed tomography (CT) of
ducer, and displayed on a monitor to the neck. Despite the advantages of
determine the position, size, shape, the procedure, in some cases it may
weight, presence of masses of the not detect small nodules and lesions
thyroid gland, enlargement of the (less than 1 cm), leading to false-
parathyroid glands, and other abnor- negative findings. ■
malities of the thyroid and parathy-
roid glands and surrounding tissues. INDICATIONS:
The primary purpose of this proce- • Aid in determining the presence of a
tumor, evidenced by an irregular
dure is to determine whether a
border and shadowing at the distal
nodule is a fluid-filled cyst (usually edge, peripheral echoes, or high- and
benign) or a solid tumor (possibly low-amplitude echoes, depending on
malignant). This procedure is useful the density of the tumor mass; and
in evaluating the glands’ response to diagnosing tumor type (e.g., benign,
medical treatment or assessing the adenoma, carcinoma)
remaining tissue after surgical resec- • Aid in diagnosing the presence of a
tion. The procedure may be indicated cyst, evidenced by a smoothly
as a guide for biopsy, aspiration, or outlined, echo-free amplitude except
other interventional procedures. at the far borders of the mass
Ultrasound, Thyroid and Parathyroid 977
• Differentiate among a nodule, solid which may produce poor visualization

tumor, or fluid-filled cyst of the area to be examined
• Aid in diagnosis in the presence of a • Patients who are very obese, who may
parathyroid enlargement indicating a exceed the weight limit for the equip-
tumor or hyperplasia, evidenced by an ment
echo pattern of lower amplitude than
that for a thyroid tumor Other considerations:
• Evaluate the effect of a therapeutic • Nodules less than 1 cm in diameter
regimen for a thyroid mass or Graves’ may not be detected.
disease by determining the size and • Nonthyroid cysts may appear the same
weight of the gland as thyroid cysts.
• Determine the need for surgical biopsy
of a tumor or fine-needle biopsy of a
cyst Nursing Implications and
• Evaluate thyroid abnormalities during Procedure ● ● ● ● ● ● ● ● ● ● ●
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
• 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-
INTERFERING FACTORS ➤ Do not restrict food or fluids before
the procedure.
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.
• 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
on the examining table; other posi- Post-test:

ination. ➤ When the study is completed,
➤ Hyperextend the neck and place
a pillow under the patient’s shoul-
normal activity, medication, and diet,
ders to maintain a comfortable
position.
➤ Apply the conductive gel to the branch of medicine sends a written
neck, and move the transducer over report to the ordering provider, who
the entire thyroid site; the sound discusses the results with the
wave images are projected on the patient.
screen and stored electronically for
future viewing or reproduced on a ➤ Inform the patient that an abnormal
film. Ask the patient to lie still during examination may indicate the need
the procedure because movement for additional studies.
produces unclear images. (An alter- ➤ Evaluate test results in relation to
native method of imaging includes the patient’s symptoms and other
the use of a bag filled with water or tests performed. Related diagnostic
gel placed over the neck area; the tests include biopsy, thyroid scan,
bag serves as a transmitter of the thyroid uptake, magnetic resonance
waves from the transducer to the imaging of the neck, and CT of the
thyroid.) spine.
ULTRASOUND, VENOUS DOPPLER,

EXTREMITY STUDIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Venous ultrasound, venous sonogram, venous

ultrasonography, venous duplex.
AREA OF APPLICATION: Veins of the upper and lower extremities.

DESCRIPTION: Ultrasound proce- lower extremities. Ultrasound waves

dures are diagnostic, noninvasive, and are sent into the body by a small
relatively inexpensive. They take a transducer pressed against the body.
short time to complete, do not use The transducer sends the sound
radiation, and cause no harm to the waves into the body and also receives
patient. Venous Doppler ultrasound the returning sound waves, which are
records sound waves to obtain infor- deflected back as they bounce off
mation about the patency of the various structures. The transducer
venous vasculature in the upper and converts and amplifies the returning
Ultrasound, Venous Doppler, Extremity Studies 979
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
• Incorrect placement of the transducer Intratest:

• Cold extremities, resulting in vasocon- gown and void.
striction that can cause inaccurate ➤ Place the patient in a supine position
measurements on a table or examining cart, and
allow the patient to rest for a mini-
• Occlusion proximal to the site being mum of 10 minutes before starting
studied, which would affect blood flow the examination.
to the area
➤ Expose the area to be examined and
• Open wound or incision overlying the support the extremity to prevent
area to be examined movement. Ask the patient to lie still
• Cigarette smoking, because nicotine ment produces unclear images.
can cause constriction of the peripheral ➤ Apply conductive gel to the skin, and
vessels slowly move the transducer over the
• An abnormally large or swollen leg, site and in the area of the vein.
making sonic penetration difficult. Waveforms are visualized and
recorded with variations in respira-
tions. Images with and without
compression are performed proxi-
Nursing Implications and mally or distally to an obstruction to
Procedure ● ● ● ● ● ● ● ● ● ● ● obtain information about a venous
occlusion or obstruction. The proce-
Pretest: dure can be performed for both arms
and legs to obtain bilateral blood
➤ Inform the patient that the proce- flow determination.
dure assesses the veins of the leg.
➤ Do not place the transducer on an
➤ Inform the patient that the proce- ulcer site when there is evidence of
dure is performed in a special ultra- venous stasis or ulcer.
sound or vascular department by a
Post-test:
➤ Report the presence of a lesion that ➤ When the study is completed,
is open or draining; maintain clean, remove the gel from the skin.
dry dressing for the ulcer; protect ➤ Instruct the patient to resume
the limb from trauma. normal activity, medications, and
➤ Obtain a history of previous venous diet, unless otherwise indicated.
studies, presence of disorders ➤ Instruct the patient to report skin
predisposing to venous thrombosis lesions (open or draining) and skin
or other peripheral vascular prob- discoloration.
lems, or therapy received for venous
abnormalities. For related tests, ➤ A physician specializing in this
refer to the cardiovascular system branch of medicine sends a written
table. report to the ordering provider, who
➤ Ensure that the patient has refrained patient.
from smoking for at least 30
minutes before the test. ➤ Inform the patient that an abnormal
➤ Inform the patient that the proce- for additional studies.
➤ Obtain and record baseline vital the patient’s symptoms and other
signs to use for comparison after the tests performed. Related diagnostic
procedure, if needed. tests include computed tomographic
➤ Do not restrict food or fluids before angiography and magnetic reso-
the procedure. nance angiography.
Upper Gastrointestinal and Small Bowel Series 981
UPPER GASTROINTESTINAL AND

SMALL BOWEL SERIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Stomach series, gastric radiography, small bowel

study, upper GI series, UGI.
AREA OF APPLICATION: Esophagus, stomach, and small intestine.

CONTRAST: Barium sulfate.
DESCRIPTION: The upper gastroin- scopic screen, recorded, and stored

testinal (GI) series is a radiologic electronically or on x-ray film for
examination of the esophagus, stom- review by a physician. Drugs such as
ach, and small intestine after inges- glucagon may be given during an
tion of barium sulfate, which is a upper GI series to relax the GI
milkshakelike, radiopaque substance. tract; drugs such as metoclopramide
A combination of x-ray and fluo- (Reglan) may be given to accelerate
roscopy techniques is used to record the passage of the barium through the
the study. Air may be instilled to stomach and small intestine.
provide double contrast and better When the small bowel series is
visualization of the lumen of the performed separately, the patient may
esophagus, stomach, and duodenum. be asked to drink several glasses of
If perforation or obstruction is barium or enteroclysis may be used to
suspected, a water-soluble iodinated instill the barium. With enteroclysis,
contrast medium is used. This test is a catheter is passed through the nose
especially useful in the evaluation of or mouth and advanced past the
patients experiencing dysphagia, pylorus and into the duodenum.
regurgitation, gastroesophageal Barium, followed by methylcellulose
reflux (GER), epigastric pain, solution, is instilled via the catheter
hematemesis, melena, and unex- directly into the small bowel. ■
plained weight loss. This test is also
used to evaluate the results of gastric INDICATIONS:
• Determine the cause of regurgitation
surgery, especially when an anasto-
or epigastric pain
motic leak is suspected. When a small
bowel series is included, the test • Evaluate unexplained weight loss or
detects disorders of the jejunum and anemia
ileum. The patient’s position is • Determine the presence of neoplasms,
changed during the examination to ulcers, diverticula, obstruction, foreign
allow visualization of the various body, and hiatal hernia
structures and their function. The • Identify and locate the origin of
images are visualized on a fluoro- hematemesis
• Evaluate suspected GER, inflamma- Factors that may impair clear

tory process, congenital anomaly, imaging:
motility disorder, or structural change • Inability of the patient to cooperate or
mental status
Normal Findings: • Patients who are very obese, who may
• Normal size, shape, position, and func- exceed the weight limit for the equip-
tioning of the esophagus, stomach, and ment
small bowel
Abnormal Findings:
• Achalasia
• Cancer of the esophagus graphic equipment to accommodate
• Chalasis obese or thin patients, which can cause
• Congenital abnormalities poor-quality study
• Duodenal cancer, diverticula, and • Metallic objects within the examina-
ulcers tion field (e.g., jewelry or body rings),
• Esophageal diverticula, motility disor- which may inhibit organ visualization
ders, ulcers, varices, and inflammation and can produce unclear images
• Gastric cancer, tumors, and ulcers Other considerations:

• Gastritis • Failure to follow dietary restrictions
• Hiatal hernia procedure to be canceled or repeated.
• Perforation of the esophagus, stomach, • Patients with swallowing problems
or small bowel may aspirate the barium, which could
• Polyps interfere with the procedure and cause
patient complications.
• Small bowel tumors
• Possible constipation or partial bowel
• Strictures obstruction caused by retained barium
in the small bowel or colon may affect
CRITICAL VALUES: N/A test results.
• This procedure should be done after a
INTERFERING FACTORS kidney x-ray (intravenous pyelography)
or computed tomography (CT) of the
This procedure is contraindicated abdomen or pelvis.
for:
• Patients who are pregnant or suspected overexposure can result from frequent
of being pregnant, unless the potential x-ray procedures. Personnel in the
benefits of the procedure far outweigh room with the patient should stand
the risks to the fetus and mother behind a shield or leave the area while
• Patients with an intestinal obstruction the examination is being done.
Personnel working in the area where
• Patients suspected of upper GI perfora- the examination is being done should
tion, in whom barium should not be wear badges that reveal their level of
used exposure to radiation.
Upper Gastrointestinal and Small Bowel Series 983
➤ Instruct the patient to take several

Nursing Implications and swallows of the barium mixture
Procedure ● ● ● ● ● ● ● ● ● ● ● through a straw while images are
taken of the pharyngeal motion.
Pretest: Drinking through a straw allows
some air to be introduced into the
➤ Inform the patient that the proce- abdomen. This permits detailed
dure assesses the upper GI system examination of the stomach’s lining.
and/or small bowel. This same effect can be achieved by
➤ Explain to the patient that he or administering an effervescent agent.
she will be asked to drink a ➤ While the patient continues to drink
milkshakelike solution that has a the barium solution, images of the
chalky taste. esophageal area are recorded from a
➤ Inform the patient that the proce- variety of angles.
dure is done by a physician and/or ➤ Instruct the patient to finish the
technologist and takes 30 to 60 barium mixture while images are
minutes for the stomach images and taken at different angles and posi-
as long as 5 hours for the small tions to aid in the evaluation of stom-
bowel images. ach filling and emptying into the
duodenum.
➤ Determine whether the patient has
any allergies or sensitivities to Small bowel series:
contrast medium, shellfish, or
barium. ➤ If the small bowel is to be examined
➤ Obtain a history of the patient’s after the upper GI series, instruct the
complaints and medications the patient to drink an additional glass of
patient is taking. barium while the small intestine is
observed for passage of barium.
➤ Obtain a history of the patient’s Images are taken at 30- to 60-minute
upper GI system and the results of intervals until the barium reaches
previously performed tests, surger- the ileocecal valve. This process can
ies, therapies, and procedures. For last up to 5 hours, with a follow-up
related tests, refer to the gastroin- film taken at 24 hours.
testinal system table.
➤ Determine date of last menstrual Post-test:
➤ Instruct the patient to resume food,
fluids, and medications withheld
➤ Withhold food and fluids for 8 hours before the procedure.
before the test.
inations may be necessary to evalu-
Intratest: ate progression of the disease
process or to determine the need for
gown.
➤ Monitor for reaction to iodinated
contrast medium including tachycar-
dia, hyperpnea, hypertension, or
palpitations, if iodine is used.
➤ Remove any wires connected to ➤ Instruct the patient to take a mild
electrodes, if allowed. laxative and increase fluid intake
(four glasses) to aid in the elimina-
Upper gastrointestinal series: tion of barium, unless contraindi-
➤ Place the patient on the x-ray table in cated.
a supine position, or ask the patient ➤ Inform the patient that his or her
to stand in front of an x-ray fluo- stool will be white or light in color for
roscopy screen. 2 to 3 days. If the patient is unable to
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.
UREA NITROGEN, BLOOD

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: BUN.
SI Units
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
DESCRIPTION: Urea is a nonprotein creatinine should be approximately

nitrogen compound formed in the 0.6 to 1.0 mg/dL). BUN is used in
liver from ammonia as an end prod- the following calculation to estimate
uct of protein metabolism. Urea serum osmolality:
diffuses freely into extracellular and [(2[Na])(glucose/18)
intracellular fluid and is ultimately (BUN/2.8)] ■
excreted by the kidneys. Blood urea
nitrogen (BUN) levels reflect the INDICATIONS:
balance between the production and • Evaluate renal function
excretion of urea. BUN and creati- • Evaluate liver function
nine values are commonly evaluated
together. The normal BUN/creati- • Evaluate hydration
nine ratio is 15:1 to 24:1. (e.g., if a • Monitor the effects of drugs known to
patient has a BUN of 15 mg/dL, the be nephrotoxic or hepatotoxic
Urea Nitrogen, Blood 985
• Evaluate hemodialysis therapy coma. Possible interventions include

treatment of the cause, administration of
• Assess nutritional support
intravenous bicarbonate, a low-protein
• Evaluate patients with lymphoma after diet, hemodialysis, and caution with
chemotherapy (tumor lysis) respect to prescribing and continuing
nephrotoxic medications.
RESULT
Increased in: • Drugs, substances, and vitamins that
• Acute renal failure may increase BUN levels include acet-
aminophen, alanine, aldatense, alka-
• Chronic glomerulonephritis line antacids, amphotericin B,
• Congestive heart failure antimony compounds, arsenicals, baci-
tracin, bismuth subsalicylate, capre-
• Decreased renal perfusion omycin, carbenoxolone, carbutamide,
• Diabetes cephalosporins, chloral hydrate, chlor-
amphenicol, chlorthalidone, colis-
• Excessive protein ingestion timethate, colistin, cotrimoxazole,
• Gastrointestinal (GI) bleeding (exces- dexamethasone, dextran, diclofenac,
sive blood protein in the GI tract) doxycycline, ethylene glycol, genta-
micin, guanethidine, guanoxan,
• Hyperalimentation ibuprofen, ifosfamide, ipodate,
• Hypovolemia kanamycin, mephenesin, metolazone,
mitomycin, neomycin, phosphorus,
• Ketoacidosis plicamycin, tertatolol, tetracycline,
• Muscle wasting from starvation triamterene, triethylenemelamine,
viomycin, and vitamin D.
• Neoplasms
• Drugs that may decrease BUN
• Nephrotoxic agents levels include acetohydroxamic acid,
• Pyelonephritis chloramphenicol, fluorides, para-
methasone, phenothiazine, and strep-
• Shock tomycin.
• Urinary tract obstruction
Decreased in: Nursing Implications and

• Inadequate dietary protein Procedure ● ● ● ● ● ● ● ● ● ● ●
• Low-protein/high-carbohydrate diet
Pretest:
• Malabsorption syndromes
• Pregnancy complaints, including a list of known
allergens.
• Severe liver disease
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,
nutritional supplements, and ➤ Monitor intake and output for fluid

nutraceuticals. The requesting health imbalance in renal dysfunction and
care practitioner and laboratory dehydration.
➤ Nitrogen balance is commonly used
as a nutritional assessment tool to
indicate protein change. In healthy
individuals, protein anabolism and
results.
catabolism are in equilibrium. During
➤ There are no food, fluid, or medica- various disease states, nutritional
tion restrictions unless by medical intake decreases, resulting in a
direction. negative balance. During recovery
➤ Review the procedure with the from illness and with proper nutri-
patient. tional support, the nitrogen balance
becomes positive. BUN is an impor-
tant analyte to measure during
administration of total parenteral
10 minutes.
nutrition (TPN). Educate the patient,
as appropriate, in dietary adjust-
Intratest: ments required to maintain proper
➤ Direct the patient to breathe nitrogen balance. Inform the patient
normally and to avoid unnecessary that the requesting health care prac-
movement. titioner may prescribe TPN as part of
the treatment plan.
follow the general guidelines in ➤ Evaluate test results in relation
Appendix A. Perform a venipuncture, to the patient’s symptoms and
and collect the specimen in a 5-mL other tests performed. Related labo-
red- or tiger-top tube. ratory tests include anion gap,
➤ Label the specimen, and promptly blood and urine creatinine, creati-
transport it to the laboratory. nine clearance, blood and urine
electrolytes, gentamicin, kidney
Post-test: stone analysis, microalbumin, blood
and urine osmolality, tobramycin,
➤ Observe venipuncture site for bleed- urine urea nitrogen, BUN/creatinine
ing or hematoma formation. Apply ratio, blood and urine uric acid, and
pressure bandage. vancomycin.
UREA NITROGEN, URINE

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Urea Nitrogen, Urine 987
SI Units
12–20 g/24 h 428–714 mmol/24 h
DESCRIPTION: Urea is a nonprotein • Drugs that may decrease urine urea

nitrogen compound formed in the nitrogen levels include furosemide,
liver from ammonia as an end prod- growth hormone, insulin, and testos-
uct of protein metabolism. Urea terone.
diffuses freely into extracellular and • All urine voided for the timed collec-
intracellular fluid and is ultimately tion period must be included in the
excreted by the kidneys. Urine urea collection or else falsely decreased
nitrogen levels reflect the balance values may be obtained. Compare
between the production and excre- output records with volume collected
tion of urea. ■ to verify that all voids were included in
the collection.
INDICATIONS:
• Evaluate renal disease
• Predict the impact that other condi- Procedure ● ● ● ● ● ● ● ● ● ● ●
tions, such as diabetes and liver
disease, will have on the kidneys Pretest:
allergens.
Increased in:
• Diabetes
• Hyperthyroidism systems, as well as results of previ-
• Increased dietary protein dures. For related tests, refer to the
• Postoperative period system tables.
➤ Obtain a list of medications
Decreased in:
• Liver disease herbs, nutritional supplements,
and nutraceuticals. The requesting
• Low-protein/high-carbohydrate diet
• Normal-growing pediatric patients tory should be advised if the patient
• Pregnancy that their effects can be taken into
• Renal disease results.
• Toxemia ➤ There are no food, fluid, or medica-
CRITICAL VALUES: N/A direction.
INTERFERING FACTORS: patient. Provide a nonmetallic urinal,
• Drugs that may increase urine urea bedpan, or toilet-mounted collection
nitrogen levels include alanine and device.
glycine. ➤ Usually a 24-hour time frame for
urine collection is ordered. Inform collection period. If an indwelling

the patient that all urine must be urinary catheter is in place, the
saved during that 24-hour period. drainage bag must be kept on ice.
Instruct the patient not to void ➤ Begin the test between 6 and 8
directly into the laboratory collection a.m., if possible. Collect first voiding
container. Instruct the patient to and discard. Record the time the
avoid defecating in the collection specimen was discarded as the
device and to keep toilet tissue out beginning of the timed collection
of the collection device to prevent period. The next morning, ask the
contamination of the specimen. patient to void at the same time the
➤ Place a sign in the bathroom to collection was started and add this
remind the patient to 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
Intratest: the test the next morning at the
➤ Observe standard precautions and begun.
Appendix A. ➤ At the conclusion of the test,
Random specimen (collect in the urinary output record for the
early morning):
Clean-catch specimen: discarded, invalidating the test.
➤ Instruct the male patient to (1) thor- ➤ Label the specimen, and promptly
oughly wash his hands, (2) cleanse transport it to the laboratory. Include
the meatus, (3) void a small amount on the label the amount of urine,
into the toilet, and (4) void directly test start and stop times, and inges-
into the specimen container. tion of any medications that can
affect test results.
Post-test:
(3) while keeping the labia sepa- ➤ Evaluate test results in relation to
rated, void a small amount into the the patient’s symptoms and other
toilet; and (4) without interrupting tests performed.
➤ Related laboratory tests include
the specimen container.
anion gap, blood and urine creati-
Timed specimen: nine, creatinine clearance, blood and
urine electrolytes, gentamicin,
➤ Obtain a clean 3-L urine specimen kidney stone analysis, microalbumin,
container, toilet-mounted collection blood urea nitrogen (BUN),
device, and plastic bag (for transport BUN/creatinine ratio, blood and
of the specimen container). The urine osmolality, tobramycin, blood
specimen must be refrigerated or and urine uric acid, urinalysis, and
kept on ice throughout the entire vancomycin.
Urethrography, Retrograde 989
URETHROGRAPHY, RETROGRADE
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SYNONYM/ACRONYM: None.
AREA OF APPLICATION: Urethra.
CONTRAST: Radiopaque contrast medium.
DESCRIPTION: Retrograde urethrog- Abnormal Findings:

raphy is performed almost exclusively • Congenital anomalies, such as urethral
in male patients. It uses contrast valves and perineal hypospadias
medium, either injected or instilled • False passages in the urethra
via a catheter into the urethra, to
visualize the membranous, bulbar, • Prostatic enlargement
and penile portions, particularly after • Tumors of the urethra
surgical repair of the urethra to assess • Urethral calculi
the success of the surgery. The poste-
rior portion of the urethra is visual- • Urethral diverticula
ized better when the procedure is • Urethral fistulas
performed with voiding cysto-
• Urethral strictures and lacerations
urethrography. In women, it may be
performed after surgical repair of the CRITICAL VALUES: N/A
urethra to assess the success of the
surgery and to assess structural abnor- INTERFERING FACTORS:
malities in conjunction with an eval-
uation for voiding dysfunction. ■ This procedure is contraindicated
for:
INDICATIONS: Aid in the diagnosis of • Patients with allergies to shellfish
urethral strictures, lacerations, divertic- or iodinated dye. The contrast
ula, and congenital anomalies medium used may cause a life-
RESULT contrast medium may benefit from
premedication with corticosteroids
Normal Findings: or the use of nonionic contrast
• Normal size, shape, and course of the medium.
membranous, bulbar, and penile
portions of the urethra in male • Patients who are pregnant or suspec-
patients ted of being pregnant, unless the
potential benefits of the procedure far
• If the prostatic portion can be visual- outweigh the risks to the fetus and
ized, it also should appear normal mother.

chronically dehydrated before Nursing Implications and
the test, because of their risk of Procedure ● ● ● ● ● ● ● ● ● ● ●

Pretest:
• Patients who are in renal failure. ➤ Inform the patient that the proce-
dure assesses the urethra
Factors that may impair clear dure is performed in a cystoscopy
imaging: room by a urologist and takes
• Inability of the patient to cooperate or approximately 30 minutes.
remain still during the procedure ➤ Obtain a history of known or
because of age, significant pain, or suspected hypersensitivity to radio-
mental status graphic contrast medium or shell-
fish.
• Patients who are very obese, who may ➤ Obtain a history of the patient’s
exceed the weight limit for the equip- complaints.
ment
• Incorrect positioning of the patient, genitourinary system and the results
which may produce poor visualization procedures, specifically blood urea
of the area to be examined nitrogen and creatinine. For related
tests, refer to the genitourinary
• Improper adjustment of the radio- system table.
obese or thin patients, which can cause (Glucophage) for non–insulin-
overexposure or underexposure and a dependent (type 2) diabetes should
poor-quality study discontinue the drug on the day of
• Metallic objects within the examina- for 48 hours after the test. Failure to
tion field (e.g., jewelry or body rings), do so may result in lactic acidosis.
which may inhibit organ visualization ➤ Obtain a written, informed consent
and can produce unclear images for the procedure from the patient, if
needed.
Other considerations: ➤ If the contrast medium is instilled
through a catheter, inform the
• Consultation with a physician should patient that some pressure may be
occur before the procedure for radia- experienced when the catheter is
tion safety concerns regarding infants inserted and contrast medium is
of patients who are lactating. instilled.
• Risks associated with radiographic period and possibility of pregnancy
overexposure can result from frequent in perimenopausal women.
x-ray procedures. Personnel in the ➤ Do not withhold food and fluids
room with the patient should stand before the test.
the examination is being done. Intratest:
Personnel working in the area where
the examination is being done should ➤ Ask the patient to put on a hospital
wear badges that reveal their level of gown.
exposure to radiation. ➤ Make sure jewelry, watches, chains,
Urethrography, Retrograde 991
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
Post-test: patient.
➤ 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.
URIC ACID, BLOOD

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SYNONYM/ACRONYM: Urate.
SI Units
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
DESCRIPTION: Uric acid is the end dominant genetic disorder) or signs

product of purine metabolism. and symptoms of gout, indicated by
Purines are important constituents of elevated uric acid levels
nucleic acids; purine turnover occurs • Determine the cause of known or
continuously in the body, producing suspected renal calculi
substantial amounts of uric acid even • Evaluate the extent of tissue destruc-
in the absence of purine intake from tion in infection, starvation, excessive
dietary sources such as organ meats exercise, malignancies, chemotherapy,
(e.g., liver, thymus gland and/ or radiation therapy
or pancreas [sweetbread], kidney),
• Evaluate possible liver damage in
legumes, and yeasts. Uric acid is eclampsia, indicated by elevated uric
filtered, absorbed, and secreted by the acid levels
kidneys and is a common constituent
• Monitor the effects of drugs known to
of urine. Serum urate levels are
alter uric acid levels, either as a side
affected by the amount of uric acid effect or as a therapeutic effect
produced and by the efficiency of
renal excretion. ■ RESULT
INDICATIONS: Increased in:
• Assist in the diagnosis of gout when • Acute tissue destruction as a result of
there is a family history (autosomal- starvation or excessive exercise
Uric Acid, Blood 993
• Alcoholism acid, chlorambucil, chlorthalidone,

cisplatin, corn oil, cyclosporine,
• Chemotherapy and radiation therapy
cyclothiazide, cytarabine, diapamide,
• Chronic lead toxicity diazoxide, diuretics, ergothioneine,
ethacrynic acid, ethambutol, ethoxzo-
lamide, etoposide, flumethiazide,
• Diabetes hydroflumethiazide, hydroxyurea,
ibufenac, ibuprofen, levarterenol,
• Down’s syndrome
levodopa, mefruside, mercaptopurine,
• Eclampsia methicillin, methotrexate, methoxyflu-
rane, methyclothiazide, mitomycin,
• Excessive dietary purines
morinamide, polythiazide, prednisone,
• Glucose-6-phosphate dehydrogenase pyrazinamide, salicylate, spironolac-
deficiency tone, theophylline, thiazide diuretics,
thioguanine, thiotepa, thiouric acid,
• Gout
triamterene, trichlormethiazide, vin-
• Hyperparathyroidism cristine, warfarin, and xylitol.
• Hypertension • Drugs that may decrease uric acid
levels include allopurinol, aspirin (high
• Hypoparathyroidism
doses), azathioprine, acetohexamide,
• Lactic acidosis benzbromaron, benziodarone, canola
oil, chlorothiazide (given intra-
• Lead poisoning
venously), chlorpromazine, chlorpro-
• Lesch-Nyhan syndrome thixene, cinchophen, corticotropin,
corticosteroids, clofibrate, coumarin,
diatrizoic acid, dicumarol, dipyrone,
• Pernicious anemia enalapril, fenofibrate, flufenamic acid,
guaifenesin, hydralazine, iodipamide,
• Polycystic kidney disease
iodopyracet, iopanoic acid, ipodate,
• Polycythemia lisinopril, mefenamic acid, mersalyl,
methotrexate, oxyphenbutazone,
• Psoriasis
phenindione, phenolsulfonphthalein,
• Sickle cell anemia probenecid, seclazone, sulfinpyrazone,
and verapamil.
• Type III hyperlipidemia
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
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
results of previously performed Post-test:

tests, refer to the genitourinary, ➤ Observe venipuncture site for bleed-
hepatobiliary, and musculoskeletal ing or hematoma formation. Apply
system tables. pressure bandage.
➤ Obtain a list of medications the ➤ Increased uric acid levels may
patient is taking, including herbs, be associated with the formation
nutritional supplements, and of kidney stones. Educate the
nutraceuticals. The requesting health patient, if appropriate, on the impor-
care practitioner and laboratory tance of drinking a sufficient amount
should be advised if the patient is of water when kidney stones are
regularly using these products so suspected.
that their effects can be taken into ➤ Increased uric acid levels may be
consideration when reviewing associated with gout. Nutritional
results. therapy may be appropriate for
➤ There are no food, fluid, or medica- some patients identified as having
tion restrictions unless by medical gout. Educate the patient that foods
direction. high in oxalic acid include caffeinated
beverages, raw blackberries, goose-
➤ Review the procedure with the berries and plums, whole-wheat
patient. bread, beets, carrots, beans,
➤ Inform the patient that specimen rhubarb, spinach, dry cocoa, and
collection takes approximately 5 to Ovaltine. Foods high in purines
10 minutes. include organ meats. In other cases,
the requesting health care practi-
Intratest: tioner may not prescribe a low-
purine or purine-restricted diet for
treatment of gout because medica-
tions can control the condition easily
movement.
and effectively.
creatinine, creatinine clearance,
➤ Label the specimen, and promptly kidney stone analysis, synovial fluid
transport it to the laboratory. analysis, and urine uric acid.
URIC ACID, URINE

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SYNONYM/ACRONYM: Urine urate.

SPECIMEN: Urine (5 mL) from a random or timed specimen collected in a
clean plastic, unrefrigerated collection container. Sodium hydroxide preser-
vative may be recommended to prevent precipitation of urates.

Uric Acid, Urine 995
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.
DESCRIPTION: Uric acid is the end • Pernicious anemia

product of purine metabolism. • Polycythemia vera
Purines are important constituents of
nucleic acids; purine turnover occurs
continuously in the body, producing Decreased in:
substantial amounts of uric acid even • Folic acid deficiency
in the absence of purine intake from
dietary sources such as organ meats • Lead toxicity
(e.g., liver, thymus gland and/ • Severe renal damage (possibly resulting
or pancreas [sweetbread], kidney), from chronic glomerulonephritis,
legumes, and yeasts. Uric acid is collagen disorders, diabetic glomeru-
filtered, absorbed, and secreted by the losclerosis, lactic acidosis, ketoacidosis,
and alcohol abuse)
kidneys and is a common constituent
of urine. ■ CRITICAL VALUES: N/A
• Compare urine and serum uric acid • Drugs that may increase urine uric acid
levels to provide an index of renal levels include acetaminophen, aceto-
function hexamide, ampicillin, ascorbic acid,
• Detect enzyme deficiencies and meta- azapropazone, benzbromarone, chlor-
bolic disturbances that affect the promazine, chlorprothixene, corti-
body’s production of uric acid cotropin, coumarin, cytotoxics,
diatrizoic acid, dicumarol, ethyl
• Monitor the response to therapy with
biscoumacetate, glycine, iodipamide,
uricosuric drugs
iodopyracet, iopanoic acid, ipodate,
• Monitor urinary effects of disorders levodopa, mannose, merbarone,
that cause hyperuricemia mercaptopurine, mersalyl, methotrex-
ate, niacinamide, phenindione,
RESULT phenolsulfonphthalein, phenylbuta-
zone, phloridzin, probenecid, salicy-
Increased in: lates (long-term, large doses),
• Disorders associated with impaired seclazone, sulfinpyrazone, theoph-
renal tubular absorption, such as ylline, verapamil, and xylitol.
Fanconi’s syndrome and Wilson’s
disease • Drugs that may decrease urine uric
acid levels include acetylsalicylic acid
• Disorders of purine metabolism (small doses), ascorbic acid, azathio-
• Excessive dietary intake of purines prine, benzbromaron, bumetanide,
chlorothiazide, chlorthalidone, citrates,
• Gout ethacrynic acid, ethambutol, ethoxzo-
• Neoplastic disorders, such as leukemia, lamide, hydrochlorothiazide, levar-
lymphosarcoma, and multiple terenol, niacin, pyrazinoic acid, and
myeloma thiazide diuretics.
• 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
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:
Procedure ● ● ● ● ● ● ● ● ● ● ● Appendix A.
Pretest: Random specimen (collect in

early morning):
allergens. Clean-catch specimen:
➤ Obtain a history of the patient’s ➤ Instruct the male patient to (1) thor-
genitourinary system and results of oughly wash his hands, (2) cleanse
previously performed tests and the meatus, (3) void a small amount
procedures. For related tests, refer into the toilet, and (4) void directly
to the genitourinary system table. into the specimen container.
➤ Obtain a list of medications the ➤ Instruct the female patient to (1)
patient is taking, including herbs, thoroughly wash her hands; (2)
nutritional supplements, and cleanse the labia from front to back;
nutraceuticals. The requesting health (3) while keeping the labia sepa-
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.
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
➤ Usually a 24-hour time frame for urinary catheter is in place, the
urine collection is ordered. Inform drainage bag must be kept on ice.
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
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.
➤ 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
REFERENCE VALUE: (Method: Macroscopic evaluation by dipstick and

microscopic examination) Urinalysis comprises a battery of tests including a
description of the color and appearance of urine; measurement of specific
gravity and pH; and semiquantitative measurement of protein, glucose,
ketones, urobilinogen, bilirubin, hemoglobin, nitrites, and leukocyte
esterase. Urine sediment may also be examined for the presence of crystals,
casts, renal epithelial cells, transitional epithelial cells, squamous epithelial
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
Red blood cells Less than 5/hpf

White blood cells Less than 5/hpf
Renal cells None seen
Transitional cells None seen
Squamous cells Rare; usually no clinical significance
Casts Rare hyaline; otherwise, none seen
Crystals in acid urine Uric acid, calcium oxalate, amorphous urates
Crystals in alkaline urine Triple phosphate, calcium phosphate, ammonium
biurate, calcium carbonate, amorphous
phosphates
Bacteria, yeast, parasites None seen
DESCRIPTION: Routine urinalysis, provide valuable information regard-

one of the most widely ordered labo- ing the overall health of the patient
ratory procedures, is used for basic and the patient’s response to disease
screening purposes. It is a group of and treatment. The urine dipstick has
tests that evaluate the kidneys’ ability a number of pads on it to indicate
to selectively excrete and reabsorb various biochemical markers. Urine
substances while maintaining proper pH is an indication of the kidneys’
water balance. The results can ability to help maintain balanced
Urinalysis 999
hydrogen ion concentration in the urine based on patient population

blood. Specific gravity is a reflection (e.g., pediatric, oncology, urology),
of the concentration ability of the unusual appearance, and biochemical
kidneys. Urine protein is the most reactions. ■
common indicator of renal disease,
although there are conditions that can
cause benign proteinuria. Glucose is INDICATIONS:
• Determine the presence of a genitouri-
used as an indicator of diabetes.
nary infection or abnormality
The presence of ketones indicates
impaired carbohydrate metabolism. • Monitor the effects of physical or
Hemoglobin indicates the presence of emotional stress
blood, which is associated with renal
• Monitor fluid imbalances or treatment
disease. Bilirubin is used to assist in for fluid imbalances
the detection of liver disorders.
Urobilinogen indicates hepatic or • Monitor the response to drug therapy
hematopoietic conditions. Nitrites and evaluate undesired reactions to
and leukocytes are used to test for drugs that may impair renal function
bacteriuria and other sources of • Provide screening as part of a general
urinary tract infections (UTIs). Most physical examination, especially on
laboratories have established criteria admission to a health care facility or
for the microscopic examination of before surgery
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
Test Increased in Decreased in

pH Ingestion of citrus fruits High-protein diets
Metabolic and respiratory Ingestion of fruits
alkalosis (e.g., cranberries)
Vegetarian diets Metabolic or
respiratory
acidosis

Protein Benign proteinuria owing to N/A
stress, physical exercise,
exposure to cold, or standing
Diabetic nephropathy
Glomerulonephritis
Nephrosis
Toxemia of pregnancy
Glucose Diabetes N/A
Ketones Diabetes N/A
Fever
Fasting
Postanesthesia period
High-protein diets
Isopropanol intoxication
Starvation
Vomiting
Hemoglobin Diseases of the bladder N/A
Exercise (March hemoglobinuria)
Glomerulonephritis
Hemolytic anemia or other causes
of hemolysis (e.g., drugs,
parasites, transfusion reaction)
Malignancy
Menstruation
Paroxysmal cold hemoglobinuria
Paroxysmal nocturnal
hemoglobinuria
Pyelonephritis
Snake or spider bites
Trauma
Tuberculosis
Urinary tract infections
Urolithiasis
Urobilinogen Cirrhosis Antibiotic therapy
Heart failure (suppresses
Hemolytic anemia normal intestinal
Hepatitis flora)
Infectious mononucleosis Obstruction of the
Malaria bile duct
Pernicious anemia
Bilirubin Cirrhosis N/A
Hepatic tumor
Hepatitis

Urinalysis 1001

Nitrites Presence of nitrite-forming N/A
bacteria (e.g., Citrobacter,
Enterobacter, Escherichia coli,
Klebsiella, Proteus,
Pseudomonas, Salmonella, and
some species of
Staphylococcus)
Leukocyte Bacterial infection N/A
esterase Calculus formation
Fungal or parasitic infection
Glomerulonephritis
Interstitial nephritis
Tumor
Formed Elements in Urine acute drug or substance (salicylate,

Sediment lead, or ethylene glycol) intoxication,
or chemotherapy, resulting in desqua-
mation, urolithiasis, and kidney trans-
Cellular Elements:
plant rejection.
• Clue cells (cell wall of the bacteria
causes adhesion to epithelial cells) are • Squamous cells line the vagina and
present in nonspecific vaginitis caused distal portion of the urethra. The pres-
by Gardnerella vaginitis, Mobiluncus ence of normal squamous epithelial
cortisii, and Mobiluncus mulieris. cells in female urine is generally of no
clinical significance. Abnormal cells
• RBCs are present in glomerulonephri- with enlarged nuclei indicate the need
tis, lupus nephritis, focal glomeru- for cytologic studies to rule out malig-
lonephritis, calculus, malignancy, nancy.
infection, tuberculosis, infarction,
renal vein thrombosis, trauma, • Transitional cells line the renal pelvis,
hydronephrosis, polycystic kidney, ureter, bladder, and proximal portion
urinary tract disease, prostatitis, of the urethra. Increased numbers are
pyelonephritis, appendicitis, salpingi- seen with infection, trauma, and
tis, diverticulitis, gout, scurvy, subacute malignancy.
bacterial endocarditis, infectious • WBCs are present in acute UTI, tubu-
mononucleosis, hemoglobinopathies, lointerstitial nephritis, lupus nephritis,
coagulation disorders, heart failure, pyelonephritis, kidney transplant rejec-
and malaria. tion, fever, and strenuous exercise.
• Renal cells that have absorbed choles-
terol and triglycerides are also known Casts:
as oval fat bodies. • Granular casts are formed from protein
or by the decomposition of cellular
• Renal cells come from the lining of elements. They may be seen in renal
the collecting ducts, and increased disease, viral infections, or lead intoxi-
numbers indicate acute tubular cation.
damage as seen in acute tubular necro-
sis, pyelonephritis, malignant nephro- • Large numbers of hyaline casts may be
sclerosis, acute glomerulonephritis, seen in renal diseases, hypertension,
congestive heart failure, nephrotic may give urine an unusual odor. An

syndrome, and in more benign condi- ammonia-like odor may be produced
tions such as fever, exposure to cold by the presence of bacteria. Urine with
temperatures, exercise, or diuretic use. a maple syrup–like odor may indicate a
congenital metabolic defect (maple
• RBC casts may be found in acute
syrup urine disease).
glomerulonephritis, lupus nephritis,
and subacute bacterial endocarditis. • The various biochemical strips are
subject to interference that may
• Waxy casts are seen in chronic renal
produce false-positive or false-negative
failure or conditions such as kidney
results. Consult the laboratory for
transplant rejection, in which there is
specific information regarding limita-
renal stasis.
tions of the method in use and a listing
• WBC casts may be seen in lupus of interfering drugs.
nephritis, acute glomerulonephritis,
• The dipstick method for protein detec-
interstitial nephritis, and acute
tion is mostly sensitive to the presence
pyelonephritis.
of albumin; light-chain or Bence Jones
proteins may not be detected by this
Crystals: method. Alkaline pH may produce
• Crystals found in freshly voided urine false-positive protein results.
have more clinical significance than
crystals seen in a urine sample that has • Large amounts of ketones or ascorbic
been standing for more than 2 to 4 acid may produce false-negative or
hours. decreased color development on the
glucose pad. Contamination of the
• Calcium oxalate crystals are found in collection container or specimen with
ethylene glycol poisoning, urolithiasis, chlorine, sodium hypochlorite, or
high dietary intake of oxalates, and peroxide may cause false-positive
Crohn’s disease. glucose results.
• Cystine crystals are seen in patients • False-positive ketone results may be
with cystinosis or cystinuria. produced in the presence of ascorbic
• Leucine or tyrosine crystals may be acid, levodopa metabolites, valproic
seen in patients with severe liver acid, phenazopyridine, phenylketones,
disease. or phthaleins.
• 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
Urinalysis 1003
the bladder before voiding or the pres-

ence of pathogenic organisms that do Nursing Implications and
not reduce nitrates to nitrites. Procedure ● ● ● ● ● ● ● ● ● ● ●
• False-positive leukocyte esterase reac- Pretest:

tions result from specimens contami-
nated by vaginal secretions. The ➤ Obtain a history of the patient’s
presence of high glucose, protein, or allergens.
ascorbic acid concentrations may
cause false-negative results. Specimens ➤ Obtain a history of the patient’s
endocrine, genitourinary, immune,
with high specific gravity may also hematopoietic, hepatobiliary, and
produce false-negative results. Patients reproductive systems, as well as
with neutropenia (e.g., oncology results of previously performed
patients) may also have false-negative tests and procedures. For related
results because they do not produce tests, refer to the endocrine, geni-
enough WBCs to exceed the sensitivity tourinary, immune, hematopoietic,
of the biochemical reaction. hepatobiliary, and reproductive
system tables.
• Specimens that cannot be delivered to ➤ Obtain a list of medications the
the laboratory or tested within 1 hour patient is taking, including herbs,
should be refrigerated or should have a nutritional supplements, and
preservative added that is recom- nutraceuticals. The requesting health
mended by the laboratory. Specimens care practitioner and laboratory
collected more than 2 hours before should be advised if the patient is
submission may be rejected for analysis. regularly using these products so
• Because changes in the urine specimen consideration when reviewing
occur over time, prompt and proper results.
specimen processing, storage, and ➤ There are no food, fluid, or medica-
analysis are important to achieve accu- tion restrictions unless by medical
rate results. Changes that may occur direction.
over time include: ➤ Review the procedure with the
• Production of a stronger odor and an patient. If a catheterized specimen is
to be collected, explain this proce-
increase in pH (bacteria in the urine dure to the patient, and obtain a
break urea down to ammonia) catheterization tray.
• A decrease in clarity (as bacterial ➤ Inform the patient that specimen
growth proceeds or precipitates form) collection takes approximately 5 to
10 minutes.
• A decrease in bilirubin and urobilino-
gen (oxidation to biliverdin and Intratest:
urobilin)
• A decrease in ketones (lost through follow the general guidelines in
volatilization) Appendix A.
• Decreased glucose (consumed by Random specimen (collect in
bacteria) early morning):
• An increase in bacteria (growth over
time) Clean-catch specimen:
• Disintegration of casts, WBCs, and ➤ Instruct the male patient to (1) thor-
RBCs oughly wash his hands, (2) cleanse
• An increase in nitrite (overgrowth of into the toilet, and (4) void directly
bacteria) into the specimen container.
➤ Instruct the female patient to (1) General:

cleanse the labia from front to back; ➤ Label the specimen, indicate
(3) while keeping the labia sepa- whether the specimen is clean catch
rated, void a small amount into the or catheter, and promptly transport it
toilet; and (4) without interrupting to the laboratory. Indicate on the
the urine stream, void directly into label the date and time of collection
the specimen container. and any medications that may inter-
fere with test results.
Pediatric urine collector:
Post-test:
➤ Put on gloves. Appropriately cleanse
the genital area and allow the area ➤ Instruct the patient to report symp-
to dry. Remove the covering over toms, such as pain related to tissue
the adhesive strips on the collector inflammation, pain or irritation during
bag and apply over the genital void, bladder spasms, or alterations
area. Diaper the child. When speci- in urinary elimination.
men is obtained, place the entire ➤ Observe for signs of inflammation if
collection bag in a sterile urine the specimen is obtained by supra-
container. pubic aspiration.
➤ Instruct the patient to begin antibi-
Indwelling catheter: otic therapy, as prescribed, and
➤ Put on gloves. Empty drainage tube instruct the patient in the impor-
of urine. It may be necessary to tance of completing the entire
clamp off the catheter for 15 to 30 course of antibiotic therapy even if
minutes before specimen collection. symptoms are no longer present.
Cleanse specimen port with antisep- ➤ Instruct the patient with a UTI, as
tic swab, and then aspirate 5 mL of appropriate, on the proper technique
urine with a 21- to 25-gauge needle for wiping the perineal area (front to
and syringe. Transfer urine to a ster- back) after a bowel movement.
ile container. ➤ UTIs are more common in women
who use diaphragm/spermicide
Urinary catheterization: contraception. These patients can be
➤ Place female patient in lithotomy educated, as appropriate, in the
position or male patient in supine proper insertion and removal of the
position. Using sterile technique, contraceptive device to avoid recur-
open the straight urinary catheteriza- rent UTIs.
tion kit and perform urinary catheter- ➤ Evaluate test results in relation to
ization. Place the retained urine in a the patient’s symptoms and other
sterile specimen container. tests performed. Related laboratory
tests include blood and urine amino
Suprapubic aspiration: acids, anti–glomerular basement
membrane antibody, bladder biopsy,
➤ Place the patient in a supine posi- kidney biopsy, bladder cancer
tion. Cleanse the area with antisep- marker, urine calcium, complete
tic and drape with sterile drapes. blood count, blood and urine creati-
Using sterile technique, insert nine, relevant cultures, blood and
needle and remove sterile sample. urine electrolytes, glucose, glycated
Place the returned sample in a hemoglobin, blood and urine
sterile specimen container. Place a ketones, kidney stone analysis,
dry sterile dressing over the site. microalbumin, urine osmolality, urine
➤ Do not collect urine from the pouch oxalate, urine protein, blood and
from the patient with a urinary diver- urine protein immunofixation elec-
sion (e.g., ilieal conduit). Instead trophoresis, urine phosphorus, blood
perform catheterization through the and urine urea nitrogen, and blood
stoma. and urine uric acid.
Vanillylmandelic Acid, Urine 1005
VANILLYLMANDELIC ACID, URINE

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: VMA.
tic collection container with 6N hydrochloric acid as a preservative.
SI Units
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
DESCRIPTION: Vanillylmandelic acid Decreased in: N/A

(VMA) is a major metabolite of
epinephrine and norepinephrine. It is CRITICAL VALUES: N/A
elevated in conditions that also are
marked by overproduction of cate- INTERFERING FACTORS:
cholamines. Creatinine is usually • Drugs that may increase VMA levels
include ajmaline, chlorpromazine,
measured simultaneously to ensure
glucagon, guaifenesin, guanethidine,
adequate collection and to calculate isoproterenol, methyldopa, nitroglyc-
an excretion ratio of metabolite to erin, oxytetracycline, phenazopyridine,
creatinine. ■ phenolsulfonphthalein, prochlorper-
azine, rauwolfia, reserpine, sulfobro-
INDICATIONS: mophthalein, and syrosingopine.
toma, ganglioneuroma, or pheochro- • Drugs that may decrease VMA levels
mocytoma include brofaromine, guanethidine,
guanfacine, imipramine, isocarbox-
• Evaluate hypertension of unknown azid, monoamine oxidase inhibitors,
cause methyldopa, morphine, nialamide (in
schizophrenics), and reserpine.
RESULT
• Stress, hypoglycemia, hyperthy-
Increased in: roidism, strenuous exercise, smoking,
• Ganglioneuroma and drugs can produce elevated cate-
cholamines.
• Hypertension
• Failure to collect all urine and store 24-
• Neuroblastoma
hour specimen properly will result in a
• Pheochromocytoma falsely low result.

Nursing Implications and patient. Provide a nonmetallic urinal,
Procedure ● ● ● ● ● ● ● ● ● ● ● bedpan, or toilet-mounted collection
device.
Pretest: ➤ Usually a 24-hour time frame for
allergens.
➤ Obtain a history of the patient’s directly into the laboratory collection
endocrine system and results of container. Instruct the patient to
previously performed tests and avoid defecating in the collection
procedures. For related tests, refer device and to keep toilet tissue out
to the endocrine system table. of the collection device to prevent
➤ Obtain a list of medications the contamination of the specimen.
patient is taking, including herbs, Place a sign in the bathroom to
nutritional supplements, and remind the patient to save all urine.
nutraceuticals. The requesting health ➤ Instruct the patient to void all urine
care practitioner and laboratory into the collection device and then to
should be advised if the patient pour the urine into the laboratory
regularly uses these products so collection container. Alternatively
that their effects can be taken into the specimen can be left in the
consideration when reviewing collection device for a health care
results. staff member to add to the labora-
➤ There are no fluid restrictions unless tory collection container.
by medical direction.
➤ Instruct the patient to abstain from Intratest:
smoking tobacco for 24 hours before ➤ Ensure that the patient has complied
testing. with dietary preparations and other
➤ Inform the patient of the following pretesting restrictions.
dietary, medication, and activity
restrictions in preparation for the
test:
Appendix A.
The patient should not consume
foods high in amines for 48 Timed specimen:
hours before testing (bananas,
avocados, beer, aged cheese, ➤ Obtain a clean 3-L urine specimen
chocolate, cocoa, coffee, fava container, toilet-mounted collection
beans, grains, tea, vanilla, device, and plastic bag (for transport
walnuts, and Chianti wine). of the specimen container). The
specimen must be refrigerated or
The patient should avoid self- kept on ice throughout the entire
prescribed medications collection period. If an indwelling
(especially aspirin) and urinary catheter is in place, the
prescribed medications drainage bag must be kept on ice.
(especially pyridoxine, levodopa,
amoxicillin, carbidopa, ➤ Begin the test between 6 and 8
a.m., if possible. Collect first voiding
reserpine, and disulfiram) for 2
and discard. Record the time the
weeks before testing and as
specimen was discarded as the
directed. beginning of the timed collection
The patient should continue to period. The next morning, ask the
avoid excessive exercise and patient to void at the same time the
stress during the 24-hour collection was started and add this
collection of urine. last voiding to the container.
Varicella Antibodies 1007
➤ If an indwelling catheter is in place, ➤ Label the specimen, and promptly

replace the tubing and container transport it to the laboratory. Include
system at the start of the collection on the label the amount of urine,
time. Keep the container system on test start and stop times, and inges-
ice during the collection period, or tion of any foods or medications that
empty the urine into a larger can affect test results.
container periodically during the
collection period; monitor to ensure Post-test:
the test the next morning at the ➤ Instruct the patient to resume usual
same hour the collection was diet, medications, and activity, as
begun. appropriate and as directed by the
➤ At the conclusion of the test, requesting health care practitioner.
compare the quantity of urine with ➤ Evaluate test results in relation
the urinary output record for the to the patient’s symptoms and
collection; if the specimen contains other tests performed. Related
less than what was recorded as laboratory tests include catechol-
output, some urine may have been amines, homovanillic acid, and
discarded, invalidating the test. metanephrines.
VARICELLA ANTIBODIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Varicella zoster antibodies, chickenpox, VZ.

DESCRIPTION: Varicella zoster is a severe complications, including

double-stranded DNA herpesvirus pneumonia. Neonatal infection from
that is responsible for two clinical the mother is possible if exposure
syndromes, chickenpox and shingles. occurs during the last 3 weeks of
The incubation period is 2 to gestation. Shingles results when the
3 weeks, and it is highly contagious presumably latent virus is reactivated.
for about 2 weeks beginning 2 The presence of immunoglobulin M
days before a rash develops. It is (IgM) antibodies indicates acute
transmitted in respiratory secretions. infection. The presence of IgG anti-
The primary exposure to the highly bodies indicates current or past infec-
contagious virus usually occurs in tion. A reactive varicella antibody
susceptible school-age children. result indicates immunity but does
Adults without prior exposure and not protect an individual from
who become infected may have shingles. ■
INDICATIONS: Determine susceptibility ➤ Inform the patient that several tests

or immunity to chickenpox may be necessary to confirm diag-
nosis. Any individual positive result
should be repeated in 7 to 14 days to
RESULT monitor a change in titer.
Positive findings in: Varicella infec-
tion
5 to 10 minutes.
Negative findings in: N/A Intratest:

CRITICAL VALUES: N/A normally and to avoid unnecessary
movement.
INTERFERING FACTORS: N/A ➤ Observe standard precautions and
Procedure ● ● ● ● ● ● ● ● ● ● ●
red-top tube.
allergens. Obtain a history of expo- ➤ Observe venipuncture site for bleed-
sure to varicella. ing or hematoma formation. Apply
immune and reproductive systems, ➤ Instruct the patient in isolation
as well as results of previously precautions during the time of
performed tests and procedures. For communicability or contagion.
related tests, refer to the immune ➤ Emphasize the need to return to
and reproductive system tables. have a convalescent blood sample
➤ Obtain a list of medications the taken in 7 to 14 days.
patient is taking, including herbs, ➤ Recognize anxiety related to test
nutritional supplements, and results and provide emotional
nutraceuticals. The requesting health support if results are positive and
care practitioner and laboratory the patient is pregnant. Provide
should be advised if the patient is teaching and information regarding
regularly using these products so the clinical implications of the test
that their effects can be taken into results, as appropriate. Educate the
consideration when reviewing patient regarding access to counsel-
results. ing services. Inform the patient with
➤ There are no food, fluid, or medica- shingles regarding access to pain
tion restrictions unless by medical management.
➤ Review the procedure with the the patient’s symptoms and other
patient. tests performed.
Venography, Lower Extremity Studies 1009
VENOGRAPHY, LOWER EXTREMITY

STUDIES
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Phlebography, lower limb venography, venogram.

AREA OF APPLICATION: Veins of the lower extremities.
DESCRIPTION: Venography allows x- • Assess deep vein valvular competence

ray visualization of the venous vascu- • Locate a vein for arterial bypass graft
lature system of the extremities after surgery
injection of an iodinated contrast • Determine the cause of extremity
medium. Lower extremity studies swelling or pain
identify and locate thrombi within
• Determine the source of pulmonary
the venous system of the lower
emboli
limbs. After injection of the contrast
medium, x-ray films are taken at RESULT
timed intervals. Usually both extrem-
ities are studied, and the unaffected Normal Findings: No obstruction
side is used for comparison for the to flow or filling defects after injection
of radiopaque dye; steady opacification
side suspected of having deep vein
of superficial and deep vasculature
thrombosis (DVT) or other venous with no filling defects
abnormalities, such as congenital
malformations or incompetent Abnormal Findings: Abnormal
valves. Thrombus formation usually results may indicate DVT, deep vein
occurs in the deep calf veins and at valvular incompetence, or venous
the venous junction and its valves. If obstruction
DVT is not treated, it can lead to
femoral and iliac venous occlusion, or CRITICAL VALUES: N/A
the thrombus can become an embo- INTERFERING FACTORS:
lus, causing a pulmonary embolism.
Venography is accurate for thrombi This procedure is contraindicated
in veins below the knee. ■ for:
INDICATIONS: iodinated dye. The contrast
• Confirm a diagnosis of DVT medium used may cause a life-
• Distinguish clot formation from threatening allergic reaction. Patients
venous obstruction with a known hypersensitivity to the
• Evaluate congenital venous malforma- premedication with corticosteroids or
tions the use of nonionic contrast medium.
• 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.
• 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.
• Patients who are in renal failure. overexposure can result from frequent
• Patients with bleeding disorders. room with the patient should wear 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.

ment
Procedure ● ● ● ● ● ● ● ● ● ● ●

which may produce poor visualization Pretest:
• Improper adjustment of the radio- dure assesses the venous system of
graphic equipment to accommodate the lower extremities.
overexposure or underexposure and a dure is performed by a physician and
poor-quality study takes approximately 60 minutes.
suspected hypersensitivity to radio-
tion field (e.g., jewelry or body rings), graphic contrast medium or shell-
which may inhibit organ visualization fish.
➤ Obtain a history pertinent to the
• Movement of the leg being tested, venogram to be performed. For
excessive tourniquet constriction, related tests, refer to the cardiovas-
insufficient injection of contrast cular system table.
medium, and delay between injection ➤ Determine previous abnormalities in
and the x-ray laboratory tests and diagnostic
procedures. Ascertain recent coagu-
• Severe edema of the legs, making lation times, blood urea nitrogen
venous access impossible (BUN), creatinine, and renal function
values, as ordered.
• Weight bearing on the leg being tested,
➤ Withhold anticoagulant medication
which prevents the contrast medium
or reduce dosage before the proce-
from filling the veins dure, as ordered.
Other considerations: (Glucophage) for non–insulin-
• Improper injection of the radionuclide dependent (type 2) diabetes should
Venography, Lower Extremity Studies 1011
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.
➤ 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.
➤ 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.
➤ Monitor for complications after ➤ A physician specializing in this

venography, including bacteremia, branch of medicine sends a written
cellulitis, embolism, and throm- report to the ordering provider, who
bophlebitis. discusses the results with the
patient.
➤ Check pulse rate on the dorsalis
pedis, popliteal, and femoral arteries ➤ Evaluate test results in relation to
after the procedure. the patient’s symptoms and other
➤ Assess peripheral color, motion, tests include angiography of the leg,
temperature, and sensation of the magnetic resonance angiography,
lower extremities on a regular basis and computed tomography angiog-
in accordance with hospital protocol. raphy.
VITAMIN B12
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: Cyanocobalamin.
SI Units
Newborn 160–1300 pg/mL 118–959 pmol/L
Adult 200–900 pg/mL 148–664 pmol/L
DESCRIPTION: Vitamin B12 has a blood cell (RBC) mean corpuscular

ringed crystalline structure that volume may be an important indica-
surrounds an atom of cobalt. It is tor of vitamin B12 deficiency. ■
essential in DNA synthesis,
hematopoiesis, and central nervous INDICATIONS:
system integrity. It is derived solely • Assist in the diagnosis of central nerv-
ous system disorders
from dietary intake. Animal products
are the richest source of vitamin • Assist in the diagnosis of megaloblastic
B12. Its absorption depends on the anemia
presence of intrinsic factor. • Evaluate alcoholism
Circumstances that may result in a • Evaluate malabsorption syndromes
deficiency of this vitamin include the
presence of stomach or intestinal RESULT
disease as well as insufficient dietary
intake of foods containing vitamin Increased in:
B12. A significant increase in red • Chronic granulocytic leukemia
Vitamin B12 1013
• Chronic renal failure • Recent radioactive scans or radiation

(COPD)
• Diabetes
• Specimen collection soon after blood
• Leukocytosis transfusion can falsely increase vitamin
B12 levels.
• Liver cell damage (hepatitis, cirrhosis)
• Obesity
• Polycythemia vera Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Protein malnutrition
• Severe congestive heart failure Pretest:
• Some carcinomas ➤ Obtain a history of the patient’s
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-
• Crohn’s disease gastrointestinal and hematopoietic
system tables.
• Dietary deficiency (e.g., in vegetarians)
• Diphyllobothrium (fish tapeworm) patient is taking, including herbs,
infestation nutritional supplements, and
• Gastric or small intestine surgery care practitioner and laboratory
• Hypochlorhydria should be advised if the patient is
• Inflammatory bowel disease that their effects can be taken into
• Intestinal malabsorption results.
• Intrinsic factor deficiency ➤ Note any recent procedures that can
• Late pregnancy
➤ Instruct the patient to fast at least 12
• Pernicious anemia hours before specimen collection.
CRITICAL VALUES: N/A restrictions unless by medical direc-
tion.
• Drugs that may increase vitamin B12 patient.
levels include chloral hydrate.
• 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
normally and to avoid unnecessary as directed by the requesting health

movement. care practitioner.
➤ Observe standard precautions and ➤ Instruct the patient with a deficiency
follow the general guidelines in of vitamin B12, as appropriate, in the
Appendix A. Perform a venipuncture, use of vitamin supplements. Inform
and collect the specimen in a 5-mL the patient, as appropriate, that the
red- or tiger-top tube. best dietary sources of vitamin B12
are meats, fish, poultry, eggs, and
➤ Label the specimen, protect it from milk.
light, and promptly transport it to the
laboratory. ➤ Evaluate test results in relation to
Post-test: tests include complete blood count,
folate, homocysteine, intrinsic factor
antibodies, peripheral blood smear
for RBC morphology and presence
pressure bandage.
of hypersegmented neutrophils, and
➤ Instruct the patient to resume usual RBC indices for mean corpuscular
diet and medication, if withheld and volume.
VITAMIN D
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Cholecalciferol, vitamin D,25-dihydroxy.

collected in green-top (heparin) tube is also acceptable.
REFERENCE VALUE: (Method: Radiobinding assay for vitamin D

25-dihydroxy, radioreceptor assay for vitamin D 1,25-dihydroxy)
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
DESCRIPTION: There are two meta- orally ingested. Cholecalciferol (vita-

bolically active forms of vitamin D. min D3) if formed when the skin is
Ergocalciferol (vitamin D2) is formed exposed to sunlight or ultraviolet
when ergosterol in plants is exposed light. Vitamins D2 and D3 enter the
to sunlight. Ergocalciferol is absorbed bloodstream after absorption.
by the stomach and intestine when Vitamin D3 is converted to vitamin
Vitamin D 1015
D 25-hydroxy by the liver and is the can be avoided by consulting a qualified

major circulating form of the vitamin. nutritionist for recommended daily
Vitamin D2 is converted to vitamin D dietary and supplemental allowances.
1,25-dihydroxy by the kidneys and is Signs and symptoms of vitamin D toxic-
the more biologically active form. ity include nausea, loss of appetite,
vomiting, polyuria, muscle weakness, and
Vitamin D acts with parathyroid
constipation.
hormone and calcitonin to regulate
calcium metabolism and osteoblast INTERFERING FACTORS:
function. ■ • Drugs that may increase vitamin D
levels include etidronate disodium and
INDICATIONS: pravastatin.
• Differential diagnosis of disorders of
calcium and phosphorus metabolism
decrease vitamin D levels include
• Evaluate deficiency or suspected toxic- aluminum hydroxide, anticonvulsants,
ity cholestyramine, colestipol, glucocorti-
coids, isoniazid, mineral oil, and
• Investigate bone diseases
rifampin.
• Investigate malabsorption
RESULT fere with test results when radioim-
Increased in:
• Vitamin D intoxication
Decreased in: Procedure ● ● ● ● ● ● ● ● ● ● ●
• Bowel resection
Pretest:
• Celiac disease
• Inflammatory bowel disease complaints, including a list of known
• Malabsorption allergens.
• Osteitis fibrosa cystica gastrointestinal and musculoskeletal
• Osteomalacia systems, as well as results of previ-
• Pancreatic insufficiency dures. For related tests, refer to the
gastrointestinal and musculoskeletal
• Rickets system tables.
• Thyrotoxicosis ➤ Obtain a list of medications the
CRITICAL VALUES: Vitamin toxic- nutritional supplements, and
ity can be as significant as problems nutraceuticals. The requesting health
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.

patient.
10 minutes.
➤ Educate the patient with vitamin D
deficiency, as appropriate, that the
Intratest: main dietary sources of vitamin D
are fortified dairy foods and cod liver
➤ Direct the patient to breathe oil. Explain to the patient that vita-
normally and to avoid unnecessary min D is also synthesized by the
movement. body, in the skin, and is activated by
➤ Observe standard precautions and sunlight.
follow the general guidelines in ➤ Evaluate test results in relation to
Appendix A. Perform a venipuncture, the patient’s symptoms and other
and collect the specimen in a 5-mL tests performed. Related laboratory
red-top tube. tests include calcium, urine calcium,
➤ Label the specimen, and promptly kidney stone analysis, osteocalcin,
transport it to the laboratory. and phosphorus.
VITAMIN E
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYM/ACRONYM: -Tocopherol.
SI Units
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
DESCRIPTION: Vitamin E is a barrier against air pollution and

powerful fat-soluble antioxidant that protect red blood cell membrane
prevents the oxidation of unsaturated integrity from oxidation. Oxidation
fatty acids, which can combine with of fatty acids in red blood cell
polysaccharides to form deposits in membranes can result in irreversible
tissue. For this reason, vitamin E is membrane damage and hemolysis.
believed to reduce the risk of coro- Studies are in progress to confirm the
nary artery disease. Vitamin E suspicion that oxidation also
reserves in lung tissue provide a contributes to the formation of
Vitamin E 1017
cataracts and macular degeneration of INTERFERING FACTORS:

the retina. Because vitamin E is found • Drugs that may increase vitamin E
in a wide variety of foods, a deficiency levels include anticonvulsants (in
secondary to inadequate dietary women).
intake is rare. ■ • Drugs that may decrease vitamin E
levels include anticonvulsants (in
INDICATIONS: men).
• Evaluate neuromuscular disorders in
premature infants and adults • Exposure of the specimen to light
decreases vitamin E levels, resulting in
• Evaluate patients with malabsorption a falsely low result.
disorders
• Evaluate suspected hemolytic anemia
in premature infants and adults Nursing Implications and
Procedure ● ● ● ● ● ● ● ● ● ● ●
• Monitor patients on long-term
parenteral nutrition Pretest:
Increased in: allergens.
• Obstructive liver disease ➤ Obtain a history of the patient’s
cardiovascular, gastrointestinal,
• Vitamin E intoxication hematopoietic, and hepatobiliary
Decreased in: ously performed tests and proce-
• A--lipoproteinemia dures. For related tests, refer to
the cardiovascular, gastrointestinal,
• Hemolytic anemia hematopoietic, and hepatobiliary
system tables.
• Malabsorption disorders, such as
biliary atresia, cirrhosis, cystic fibrosis,
chronic pancreatitis, pancreatic carci- nutritional supplements, and
noma, and chronic cholestasis nutraceuticals. The requesting health
CRITICAL VALUES: Vitamin toxic- should be advised if the patient
ity can be as significant as problems regularly uses these products so
brought about by vitamin deficiencies. that their effects can be taken into
The potential for toxicity is especially consideration when reviewing
important to consider with respect to fat- results.
soluble vitamins, which are not elimi- ➤ There are no food, fluid, or medica-
nated from the body as quickly as tion restrictions unless by medical
water-soluble vitamins and can accumu- direction.
late in the body. Most cases of toxicity are ➤ Review the procedure with the
brought about by oversupplementing and patient.
can be avoided by consulting a qualified ➤ Inform the patient that specimen
nutritionist for recommended daily collection takes approximately 5 to
dietary and supplemental allowances. 10 minutes.
Note: Excessive supplementation (greater
Intratest:
than 60 times the Recommended Dietary
Allowance over a period of 1 year ➤ Direct the patient to breathe
or longer) can result in excessive bleed- normally and to avoid unnecessary
ing, delayed healing of wounds, and movement.
depression. ➤ Observe standard precautions and
follow the general guidelines in ➤ Educate the patient with a vitamin E

Appendix A. Perform a venipuncture, deficiency, if appropriate, that the
and collect the specimen in a 5-mL main dietary sources of vitamin E
red- or tiger-top tube. are vegetable oils, whole grains,
➤ Label the specimen, and promptly wheat germ, milk, eggs, meats, fish,
transport it to the laboratory. and green leafy vegetables. Vitamin
E is fairly stable at most cooking
temperatures (except frying) and
Post-test: when exposed to acidic foods.
➤ Observe venipuncture site for bleed- ➤ Evaluate test results in relation to
ing or hematoma formation. Apply the patient’s symptoms and other
pressure bandage. tests performed.
VITAMIN K
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: Phylloquinone, phytonadione.

SI Units
0.13–1.19 ng/mL 0.29–2.64 nmol/L
DESCRIPTION: Vitamin K is one which is found in foods; vitamin K2,

of the fat-soluble vitamins. It is essen- or menaquinone, which is synthe-
tial for the formation of prothrom- sized by intestinal bacteria; and
bin; factors VII, IX, and X; and vitamin K3, or menadione, which
proteins C and S. Vitamin K also is the synthetic, water-soluble, phar-
works with vitamin D in synthesizing maceutical form of the vitamin.
bone protein and regulating calcium Vitamin K3 is two to three times
levels (see monograph titled more potent than the naturally occur-
“Vitamin D.”) Vitamin K levels are ring forms. ■
not often requested, but vitamin K is
often prescribed as a medication. INDICATIONS: Evaluation of bleeding of
Approximately one-half of the unknown cause (e.g., frequent nose-
bleeds, bruising)
body’s vitamin K is produced by
intestinal bacteria; the other half RESULT
is obtained from dietary sources.
There are three forms of vitamin Increased in:
K: vitamin K1, or phylloquinone, • Excessive administration of vitamin K
Vitamin K 1019
Decreased in: hematopoietic and hepatobiliary

• Antibiotic therapy (by decreasing system tables.
intestinal flora) ➤ Obtain a list of medications the
• Chronic fat malabsorption nutritional supplements, and
• Cystic fibrosis nutraceuticals. The requesting health
• Diarrhea (in infants) should be advised if the patient
• Gastrointestinal disease that their effects can be taken into
• Hemorrhagic disease of the newborn results.
• Hypoprothrombinemia ➤ There are no food, fluid, or medica-
• Liver disease direction.
• Obstructive jaundice ➤ Review the procedure with the
patient.
• Pancreatic disease
CRITICAL VALUES: Vitamin toxic- collection takes approximately 5 to
10 minutes.
ity can be as significant as problems
brought about by vitamin deficiencies.
Intratest
The potential for toxicity is especially
important to consider with respect to fat- ➤ Direct the patient to breathe
soluble vitamins, which are not elimi- normally and to avoid unnecessary
nated from the body as quickly as movement.
water-soluble vitamins and can accumu- ➤ Observe standard precautions and
late in the body. The naturally occurring follow the general guidelines in
forms, vitamin K1 and K2, do not cause Appendix A. Perform a venipuncture,
toxicity. Signs and symptoms of vitamin and collect the specimen in a 5-mL
K3 toxicity include bleeding and jaun- red-top tube.
dice. Possible interventions include with- ➤ Label the specimen, and promptly
holding the source. transport it to the laboratory.
INTERFERING FACTORS: Drugs and Post-test:

substances that may decrease vitamin K
levels include antibiotics, cholestyramine, ing or hematoma formation. Apply
coumarin, mineral oil, and warfarin. pressure bandage.
➤ Inform the patient with a vitamin K
deficiency, as appropriate, that the
Nursing Implications and main dietary sources of vitamin K
Procedure ● ● ● ● ● ● ● ● ● ● ●
are cabbage, cauliflower, spinach
and other green leafy vegetables,
pork, liver, soybeans, and vegetable
Pretest: oils.
➤ Obtain a history of the patient’s ➤ Instruct the patient to report bleed-
complaints, including a list of known ing from any areas of the skin or
allergens. mucous membranes.
➤ Obtain a history of the patient’s ➤ Inform the patient of the importance
hematopoietic and hepatobiliary of taking precautions against bleed-
systems, as well as results of previ- ing or bruising, including the use of a
ously performed tests and proce- soft bristle toothbrush, use of an
dures. For related tests, refer to the electric razor, avoidance of constipa-
tion, avoidance of aspirin products, the patient’s symptoms and other

and avoidance of intramuscular tests performed. Related laboratory
injections. tests include antithrombin III and
➤ Evaluate test results in relation to prothrombin time.
VITAMINS A, B1, B6, AND C

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYMS: Vitamin A: retinol, carotene; vitamin B1:

thiamine; vitamin B6: niacin, pyroxidine, P-5’-P, pyridoxyl-5-phosphate;
vitamin C: ascorbic acid.
SPECIMEN: Serum (1 mL) collected in a red-top tube each for vitamins A

and C; plasma (1 mL) collected in a lavender-top (ethylenediaminetetra-
acetic acid [EDTA]) tube each for vitamins B1 and B6.
REFERENCE VALUE: (Method: Chromatography for vitamins A, B1, and B6;

capillary electrophoresis for vitamin C)
Vitamin Age Conventional Units SI Units

Vitamin A 1–6 y 20–43 g/dL 0.70–1.50 mol/L
7–12 y 26–49 g/dL 0.91–1.71 mol/L
13–19 y 26–72 g/dL 0.91–2.51 mol/L
Adult 30–80 g/dL 1.05–2.80 mol/L
Vitamin B1 0.21–0.43 g/dL 6.2–12.8 mol/L
Vitamin B6 5–30 ng/mL 20–121 nmol/L
Vitamin C 0.2–1.9 mg/dL 11.4–107.9 mol/L
DESCRIPTION: Vitamin assays are blindness; contributes to growth of

used in the measurement of nutri- bone, teeth, and soft tissues; supports
tional status. Low levels indicate thyroxine formation; maintains
inadequate oral intake, poor nutri- epithelial cell membranes, skin, and
tional status, or malabsorption prob- mucous membranes; and acts as an
lems. High levels indicate excessive anti-infection agent. Vitamins B1, B6,
intake, vitamin intoxication, or and C are water soluble. Vitamin B1
absorption problems. Vitamin A is a acts as an enzyme and plays an
fat-soluble nutrient that promotes important role in the Krebs cycle.
normal vision and prevents night Vitamin B6 is important in heme
Vitamins A, B1, B6, and C 1021
synthesis and functions as a coenzyme Carcinoid syndrome

in amino acid metabolism and Chronic infections
glycogenolysis. It includes pyridoxine, Cystic fibrosis
pyridoxal, and pyridoxamine. Disseminated tuberculosis
Vitamin C promotes collagen synthe- Hypothyroidism
sis, maintains capillary strength, facil- Infantile blindness
itates release of iron from ferritin to Liver, gastrointestinal, or pancreatic
form hemoglobin, and functions in disease
the stress response. ■ Night blindness
Protein malnutrition
INDICATIONS Sterility and teratogenesis
Vitamin A: Zinc deficiency
• Assist in the diagnosis of night blind- • Vitamin B1:
ness Alcoholism
• Evaluate skin disorders Carcinoid syndrome
• Investigate suspected vitamin A defi- Hartnup’s disease
ciency Pellagra
• Vitamin B6:
Vitamin B1:
Alcoholism
• Investigate suspected beriberi
Asthma
• Monitor the effects of chronic alco- Carpal tunnel syndrome
holism
Gestational diabetes
Vitamin B6: Lactation
• Investigate suspected vitamin B6 defi- Malabsorption
ciency Malnutrition
Neonatal seizures
• Investigate suspected malabsorption or
malnutrition Normal pregnancies
Occupational exposure to
Vitamin C: hydrazine compounds
• Investigate suspected metabolic or Pellagra
malabsorptive disorders Preeclamptic edema
• Investigate suspected scurvy Renal dialysis
Uremia
RESULT • Vitamin C:
Alcoholism
Increases in:
Anemia
• Vitamin A:
Chronic kidney disease Cancer
Idiopathic hypercalcemia in infants Hemodialysis
Vitamin A toxicity Hyperthyroidism
Malabsorption
Decreases in: Pregnancy
• Vitamin A: Rheumatoid disease
A--lipoproteinemia Scurvy
CRITICAL VALUES: Vitamin toxic- which are thiamine antagonists, may

ity can be as significant as problems cause decreased vitamin B1 levels.
brought about by vitamin deficiencies. • Long-term hyperalimentation may
The potential for toxicity is especially result in decreased vitamin levels.
important to consider with respect to fat-
soluble vitamins, which are not elimi- • Exposure of the specimen to light
nated from the body as quickly as decreases vitamin levels, resulting in a
water-soluble vitamins and can accumu- falsely low results.
late in the body. Most cases of toxicity are • Chronic tobacco smoking decreases
brought about by oversupplementing and vitamin C levels.
can be avoided by consulting a qualified
nutritionist for recommended daily
dietary and supplemental allowances.
Signs and symptoms of vitamin A toxic- Nursing Implications and
ity may include headache, blurred vision, Procedure ● ● ● ● ● ● ● ● ● ● ●
bone pain, joint pain, dry skin, and loss

of appetite. Pretest:
INTERFERING FACTORS: complaints, including a list of known
• Drugs and substances that may allergens.
increase vitamin A levels include ➤ Obtain a history of the patient’s
probucol, alcohol (moderate intake), gastrointestinal, genitourinary, hepa-
and oral contraceptives. tobiliary, immune, and muscu-
loskeletal systems, as well as
• Drugs and substances that may results of previously performed
decrease vitamin A levels include alco- tests and procedures. For related
hol (chronic intake, alcoholism), allo- tests, refer to the gastrointestinal,
genitourinary, hepatobiliary,
purinol, cholestyramine, colestipol,
immune, and musculoskeletal
mineral oil, and neomycin. system tables.
• Drugs that may decrease vitamin B1 ➤ Obtain a list of medications the
levels include glibenclamide, isoniazid, patient is taking, including herbs,
and valproic acid. nutritional supplements, and
• Drugs that may decrease vitamin B6 care practitioner and laboratory
levels include amiodarone, anticonvul- should be advised if the patient
sants, cycloserine, disulfiram, ethanol, regularly uses these products so
hydralazine, isoniazid, levodopa, oral that their effects can be taken into
contraceptives, penicillamine, pyrazi- consideration when reviewing
results.
noic acid, and theophylline.
➤ Instruct the patient to fast at least 12
• Drugs and substances that may hours before specimen collection for
decrease vitamin C levels include vitamin A.
aminopyrine, acetylsalicylic acid, ➤ There are no fluid or medication
barbiturates, estrogens, heavy metals, restrictions unless by medical direc-
oral contraceptives, nitrosamines, and tion.
paraldehyde. ➤ Review the procedure with the
patient.
• Various diseases may affect vitamin
levels (see Results section). ➤ Inform the patient that specimen
• Diets high in freshwater fish and tea, 10 minutes.
Vitamins A, B1, B6, and C 1023
Intratest: is destroyed easily by light and

oxidation.
with dietary preparations and other Vitamin B1:
pretesting restrictions before speci-
men collection for vitamin A level. ➤ Vitamin B1 is the most stable to
environmental elements. It is found
➤ Direct the patient to breathe in meats, coffee, peanuts, and
normally and to avoid unnecessary legumes. The body is also capable of
movement. making some vitamin B1 by convert-
➤ Observe standard precautions and ing the amino acid tryptophan to
follow the general guidelines in niacin.
and collect the specimen in a 5-mL Vitamin B6:
red- or lavender-top tube.
➤ Good sources of vitamin B6 include
➤ Label the specimen, and promptly meats (especially beef and pork),
transport it to the laboratory. whole grains, wheat germ, legumes,
potatoes, oatmeal, and bananas. As
Post-test: with other water-soluble vitamins, it
is best preserved by rapid cooking,
➤ Observe venipuncture site for bleed- although it is relatively stable at
ing or hematoma formation. Apply most cooking temperatures (except
pressure bandage. frying) and when exposed to acidic
➤ Instruct the patient to resume usual foods. This vitamin is destroyed
diet, as directed by the requesting rapidly by light and alkalis.
health care practitioner.
➤ Educate the patient with a specific Vitamin C:
vitamin deficiency, as appropriate, ➤ Citrus fruits are excellent dietary
regarding dietary sources of these sources of vitamin C. Other good
vitamins. Advise the patient to ask a sources are green and red peppers,
nutritionist to develop a diet plan tomatoes, white potatoes, cabbage,
recommended for his or her specific broccoli, chard, kale, turnip greens,
needs. asparagus, berries, melons, pineap-
ple, and guava. Vitamin C is
Vitamin A: destroyed by exposure to air, light,
➤ The main source of vitamin A comes heat, or alkalis. Boiling water before
from carotene, a yellow pigment cooking eliminates dissolved oxygen
noticeable in most fruits and vegeta- that destroys vitamin C in the
bles, especially carrots, sweet process of boiling. Vegetables
potatoes, squash, apricots, and should be crisp and cooked as
cantaloupe. It is also present in quickly as possible.
spinach, collards, broccoli, and ➤ Evaluate test results in relation to
cabbage. This vitamin is fairly stable the patient’s symptoms and other
at most cooking temperatures, but it tests performed.
WHITE BLOOD CELL COUNT AND

CELL DIFFERENTIAL
● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: WBC with diff, leukocyte count, white cell count.


impedance or light pulses as the cells pass in front of a laser. Many of these
analyzers are capable of determining a five-part WBC differential.) The
WBC count and differential enumerates and identifies granulocytes,
lymphocytes, monocytes, eosinophils, basophils, and platelets.
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.
White Blood Cell Count and Cell Differential 1025
DESCRIPTION: White blood cells absolute value and as a percentage.

(WBCs) constitute the body’s The relative percentages of cell types
primary defense system against are arrived at by basing the enumera-
foreign organisms, tissues, and other tion of each cell type on a 100-cell
substances. The life span of a normal count. The absolute value is obtained
WBC is 13 to 20 days. Old WBCs by multiplying the relative percentage
are destroyed by the lymphatic system value of each cell type by the total
and excreted in the feces. The main WBC count.
WBC types are neutrophils, Acute leukocytosis is initially
eosinophils, basophils, monocytes, accompanied by changes in the WBC
and lymphocytes. They are produced count population, followed by
in the bone marrow, although changes within the individual WBCs.
lymphocytes can be produced in Leukocytosis usually occurs by way of
other sites as well. The WBC count increase in a single WBC family
can be performed alone with the rather than a proportional increase in
differential cell count or as part of the all cell types. Toxic granulation and
complete blood count (CBC). An vacuolation are commonly seen in
increased WBC count is termed leukocytosis accompanied by a shift to
leukocytosis, and a decreased WBC the left, or increase in the percentage
count is termed leukopenia. A total of immature band neutrophils to
WBC count indicates the degree of mature segmented neutrophils. These
response to a pathologic process, but changes are most commonly associ-
a more complete evaluation for ated with an infectious process,
specific diagnoses for any one disor- usually bacterial, but they can occur
der is provided by the differential in healthy individuals who are under
count. The WBCs in the count and stress, such as women in childbirth
differential are reported as an and very young infants. The WBC
Lymphocytes Monocytes Eosinophils Basophils

(Absolute) (Absolute) (Absolute) (Absolute)
and % and % and % and %
(2.0–11) 31% (0.4–3.1) 5.8% (0.02–0.85) 2.2% (0–0.64) 0.6%

(2.0–11.5) 31% (0.2–3.1) 5.8% (0.02–0.95) 2.0% (0–0.30) 0.5%
(2.0–17.0) 48% (0.2–2.4) 8.8% (0.07–1.0) 3.1% (0–0.23) 0.4%
(2.5–16.5) 56% (0.15–2.0) 6.5% (0.07–0.90) 2.8% (0–0.20) 0.5%
(4.0–13.5) 61% (0.1–1.3) 4.8% (0.07–0.75) 2.5% (0–0.20) 0.4%
(4.0–10.5) 61% (0.05–1.1) 4.8% (0.05–0.70) 2.6% (0–0.20) 0.4%
(1.5–6.5) 38% (0–0.8) 4.3% (0–0.60) 2.4% (0–0.20) 0.5%
(1.0–4.8) 34% (0–0.8) 4.0% (0–0.45) 2.7% (0–0.20) 0.5%
count and differential of an actively cytes, and suppressor (CD8) lympho-

crying infant may show an overall cytes.
increase in WBCs with a shift to the Monocytes are mononuclear cells
left. Any stressful situation causing similar to lymphocytes, but they are
production of epinephrine results in a related more closely to granulocytes
rapid increase in WBC count. Before in terms of their function. They are
initiating any kind of intervention, it formed in the bone marrow from the
is important to determine whether an same cells as those that produce
increased WBC count is the result of neutrophils. The major function of
a normal condition involving physio- monocytes is phagocytosis. Mono-
logic stress versus a pathologic cytes stay in the peripheral blood for
processes. The use of multiple speci- about 70 hours, after which they
men types may confuse the interpre- migrate into the tissues and become
tation of results in infants. Multiple macrophages.
samples from the same collection site The function of eosinophils is
(i.e., capillary versus venous) may be phagocytosis of antigen-antibody
necessary to obtain an accurate assess- complexes. They become active in
ment of the WBC picture in these the later stages of inflammation.
young patients. Eosinophils respond to allergic and
Neutrophils are normally found as parasitic diseases: They have granules
the predominant WBC type in the that contain histamine used to kill
circulating blood. Also called polymor- foreign cells in the body and prote-
phonuclear cells, they are the body’s olytic enzymes that damage parasitic
first line of defense through the worms (see monograph titled
process of phagocytosis. They also “Eosinophil Count”).
contain enzymes and pyogens, which Basophils are found in small
combat foreign invaders. Lympho- numbers in the circulating blood.
cytes are agranular, mononuclear They have a phagocytic function
blood cells that are smaller than gran- and, similar to eosinophils, contain
ulocytes. They are found in the next numerous specific granules. Baso-
highest percentage in normal circula- philic granules contain heparin, hista-
tion. mines, and serotonin. Basophils may
Lymphocytes are classified as B also be found in tissue and as such
cells and T cells. Both types are are classified as mast cells. Basophilia
formed in the bone marrow, but B is noted in conditions such as
cells mature in the bone marrow and leukemia, Hodgkin’s disease, poly-
T cells mature in the thymus. cythemia vera, ulcerative colitis,
Lymphocytes play a major role in nephrosis, and chronic hypersensitiv-
the body’s natural defense system. ity states. ■
B cells differentiate into immuno-
globulin-synthesizing plasma cells. INDICATIONS:
T cells function as cellular mediators • Assist in confirming suspected bone
of immunity and comprise helper/ marrow depression
inducer (CD4) lymphocytes, delayed • Assist in determining the cause of an
hypersensitivity lymphocytes, cyto- elevated WBC count (e.g., infection,
toxic (CD8 or CD4) lympho- inflammatory process)
White Blood Cell Count And Cell Differential 1027
• Detect hematologic disorder, neo- (COPD), malabsorption syndromes,

plasm, or immunologic abnormality cancer, and renal disease
• Determine the presence of a hereditary • Monitor the response to drugs or
hematologic abnormality chemotherapy, and evaluate undesired
reactions to drugs that may cause
• Monitor the effects of physical or blood dyscrasias
emotional stress
• Provide screening as part of a CBC in
• Monitor the progression of nonhema- a general physical examination, espe-
tologic disorders, such as chro- cially on admission to a health care
nic obstructive pulmonary disease facility or before surgery
RESULT
WBC Abnormalities Associated Condition

Alder-Reilly cytoplasmic Hereditary condition, ucopolysaccharidosis
granulations
Auer bodies or Auer rods Acute myelocytic leukemia, yelomonocytic
leukemia
Chédiak-Higashi lysosomal Hereditary condition, albinism, leukopenia,
granulations thrombocytopenia
Döhle bodies Infections, inflammatory conditions, burns,
myelocytic leukemia
Hypersegmented Megaloblastic anemia
neutrophils
Systemic lupus SLE and other collagen diseases, drug
erythematosus (SLE) reactions, chronic hepatitis
cells
Left shift Infections, intoxication, tissue necrosis,
leukemia, pernicious anemia
Leukemic cells (immature Leukemia, leukemoid reaction, severe
blast forms) infection, myeloproliferative disorders,
intoxication, malignancy, recovery from
bone marrow suppression
May-Hegglin anomaly Hereditary condition with thrombocytopenia
and giant platelets
Smudge cells Leukemias
Pelger-Huët cells Hereditary condition, myelocytic leukemia,
myeloproliferative disorders
Tart cell Drug reactions
Toxic granulation Infections, inflammatory conditions
Increased in (leukocytosis): Increased epinephrine secretion

• Normal physiologic and environmen- Menstruation
tal conditions:
Pregnancy and labor
Early infancy
Emotional stress Strenuous exercise
Exposure to cold Ultraviolet light
• Pathologic conditions: • Physiologic stress (e.g., allergies,

Acute hemolysis, transfusion asthma, exercise, childbirth, surgery)
reactions
• Tissue necrosis (burns, crushing
All types of infections injuries, abscesses, myocardial infarc-
Anemias tion)
Appendicitis
• Tissue poisoning with toxins and
Collagen disorders venoms
Cushing’s disease
Inflammatory disorders Neutrophils decreased
Leukemias and other malignancies (neutropenia):
Parasitic infestations • Acromegaly
Polycythemia vera • Addison’s disease
Decreased in (leukopenia): • Anaphylaxis

• Normal physiologic conditions: • Anorexia nervosa, starvation, malnutri-
Diurnal rhythms tion
• Pathologic conditions: • Vitamin B12 or folate deficiency
Alcoholism
• Bone marrow depression (viruses, toxic
Anemias chemicals, overwhelming infection,
Bone marrow depression radiation, Gaucher’s disease)
SLE and other autoimmune
disorders • Disseminated SLE
Malaria • Thyrotoxicosis
Malnutrition
• Viral infection (mononucleosis, hepati-
Radiation
tis, influenza)
Rheumatoid arthritis
Toxic and antineoplastic drugs
Lymphocytes increased
Viral infections (lymphocytosis):
Neutrophils increased
(neutrophilia): • Felty’s syndrome
• Acute hemolysis • Infections
• Acute hemorrhage
• Lymphocytic leukemia
• Extremes in temperature
• Lymphomas
• Infectious diseases
• Lymphosarcoma
• Inflammatory conditions (rheumatic
fever, gout, rheumatoid arthritis, • Malnutrition
vasculitis, myositis) • Myeloma
• Malignancies • Rickets
• Metabolic disorders (uremia, eclamp-
• Thyrotoxicosis
sia, diabetic ketoacidosis, thyroid
storm, Cushing’s syndrome) • Ulcerative colitis
• Myelocytic leukemia • Waldenström’s macroglobulinemia
White Blood Cell Count And Cell Differential 1029
Lymphocytes decreased • Sarcoidosis

(lymphopenia):
• Antineoplastic drugs • SLE
• Aplastic anemia • Thrombocytopenic purpura
• Bone marrow failure • Ulcerative colitis
• Burns CRITICAL VALUES:

• Gaucher’s disease Less than 2500 WBC/mm3 (on
admission)
• Hemolytic disease of the newborn Greater than 30,000 WBC/mm3 (on
• High doses of adrenocorticosteroids admission)
The presence of abnormal cells, other
• Hodgkin’s disease morphologic characteristics, or cellular
inclusions may signify a potentially life-
• Hypersplenism
threatening or serious health condition
• Immunodeficiency diseases and should be investigated. Examples are
hypersegmented neutrophils, agranular
• Pernicious anemia neutrophils, blasts or other immature
• Pneumonia cells, Auer rods, Döhle bodies, marked
toxic granulation, or plasma cells.
• Radiation
• Rheumatic fever INTERFERING FACTORS:
• Drugs that may decrease the overall
• Septicemia WBC count include acetyldigitoxin,
• Thrombocytopenic purpura acetylsalicylic acid, aminoglute-
thimide, aminopyrine, aminosalicylic
• Toxic chemical exposure acid, ampicillin, amsacrine, antazoline,
anticonvulsants, antineoplastic agents
• Transfusion reaction
(therapeutic intent), antipyrine,
barbiturates, busulfan, carbutamide,
Monocytes increased carmustine, chlorambucil, chloram-
(monocytosis): phenicol, chlordane, chlorophe-
• Carcinomas nothane, chlortetracycline, chlor-
thalidone, cisplatin, colchicine,
• Cirrhosis colistimethate, cycloheximide, cyclo-
• Collagen diseases phosphamide, cytarabine, dacarbazine,
dactinomycin, diaprim, diazepam,
• Gaucher’s disease diethylpropion, digitalis, dipyri-
• Hemolytic anemias damole, dipyrone, fumagillin,
glaucarubin, glucosulfone, hexa-
• Hodgkin’s disease chlorobenzene, hydroflumathiazide,
hydroxychloroquine, iothiouracil,
• Infections iproniazid, lincomycin, local anesthet-
• Lymphomas ics, mefenamic acid, mepazine,
meprobamate, mercaptopurine,
• Monocytic leukemia methotrexate, methylpromazine, mito-
• Polycythemia vera mycin, paramethadione, parathion,
penicillin, phenacemide, phenindione,
• Radiation phenothiazine, pipamazine, pred-
nisone (by Coulter S method), yield inadequate sample volume for

primaquine, procainamide, procar- automated analyzers and may be
bazine, prochlorperazine, promazine, reason for specimen rejection.
promethazine, pyrazolones, quina-
• Hemolyzed or clotted specimens
crine, quinines, radioactive com-
should be rejected for analysis.
pounds, razoxane, ristocetin, sulfa
drugs, tamoxifen, tetracycline, thenali- • The presence of nucleated red blood
dine, thioridazine, tolazamide, tolazo- cells or giant or clumped platelets
line, tolbutamide, trimethadione, and affects the automated WBC, requiring
urethan. a manual correction of the WBC
• A significant decrease in basophil count.
count occurs rapidly after intravenous • Care should be taken in evaluating the
injection of propanidid and thiopental. CBC during the first few hours after
• A significant decrease in lymphocyte transfusion.
count occurs rapidly after administra- • Patients with cold agglutinins or
tion of corticotropin, mechlor- monoclonal gammopathies may have a
ethamine, methylsergide, and x-ray falsely decreased WBC count as a result
therapy; and after megadoses of niacin, of cell clumping.
pyradoxine, and thiamine.
• Drugs that may increase the overall
WBC count include amphetamine, Nursing Implications and
amphotericin B, chloramphenicol, Procedure ● ● ● ● ● ● ● ● ● ● ●
chloroform (normal response to anes-
thesia), colchicine (leukocytosis follows Pretest:
leukopenia), corticotropin, erythromy-
cin, ether (normal response to anesthe- ➤ Obtain a history of the patient’s
sia), fluroxene (normal response complaints, including a list of known
to anesthesia), isoflurane (normal allergens.
response to anesthesia), niacinamide, ➤ Obtain a history of the patient’s
phenylbutazone, prednisone, and hematopoietic, immune, and respira-
quinine. tory systems, as well as results of
• Drug allergies may have a significant procedures. For related tests, refer
effect on eosinophil count and may to the hematopoietic, immune, and
affect the overall WBC count. Refer to respiratory system tables.
the specific monograph for a detailed ➤ Obtain a list of medications
listing of interfering drugs. the patient is taking, including
• The WBC count may vary depending nutraceuticals. The requesting health
on the patient’s position, decreasing care practitioner and laboratory
when the patient is recumbent owing should be advised if the patient
to hemodilution and increasing when regularly uses these products so
the patient rises owing to hemoconcen- that their effects can be taken
tration. into consideration when reviewing
results.
• Venous stasis can falsely elevate results;
the tourniquet should not be left on
the arm for longer than 60 seconds.
• Failure to fill the tube sufficiently (i.e., tion restrictions unless by medical
tube less than three-quarters full) may direction.
White Blood Cell Scan 1031

patient.
10 minutes.
➤ Infection, fever, sepsis, and trauma
Intratest: can result in an impaired nutritional
status. Malnutrition can occur for
➤ Direct the patient to breathe many reasons, including fatigue, lack
normally and to avoid unnecessary of appetite, and gastrointestinal
movement. distress.
➤ Observe standard precautions and ➤ Adequate intake of vitamins A and C
follow the general guidelines in are also important for regenerating
Appendix A. Perform a venipuncture, body stores depleted by the effort
and collect the specimen in a 5-mL exerted in fighting infections.
lavender-top tube. The specimen Educate the patient or caregiver
should be mixed gently by inverting regarding the importance of follow-
the tube 10 times. It is stable when ing the prescribed diet.
stored for up to 6 hours at room ➤ Evaluate test results in relation to
temperature or 24 hours if stored the patient’s symptoms and other
refrigerated. In addition, if it is antic- tests performed. Related laboratory
ipated that the specimen will not tests include anti–cytoplasmic
be analyzed within 4 to 6 hours, neutrophilic antibody, lymph node
two blood smears should be made biopsy, bone marrow biopsy,
immediately after the venipuncture infectious mononucleosis, other
and submitted with the blood tests included in a CBC, eosinophil
sample. count, peripheral blood smear,
➤ Label the specimen, and promptly leukocyte alkaline phosphatase, and
transport it to the laboratory. zinc.
WHITE BLOOD CELL SCAN

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
SYNONYMS/ACRONYM: WBC imaging, inflammatory scan, labeled leuko-

cyte scan, infection scintigraphy, labeled autologous leukocytes.
AREA OF APPLICATION: Whole body.

CONTRAST: Intravenous radionuclide combined with white blood cells.
DESCRIPTION: Because white blood determine the site of an acute infec-

cells (WBCs) naturally accumulate in tion or confirm the presence or
areas of inflammation, the WBC scan absence of infection or inflammation
uses radiolabeled WBCs to help at a suspected site. A gamma camera
detects the radiation emitted from the • Infection

injected radionuclide, and a represen-
• Inflammation
tative image of the radionuclide
distribution is obtained and recorded • Inflammatory bowel disease
on film or stored electronically. • Osteomyelitis
Because of its better image resolution
and greater specificity for acute infec- CRITICAL VALUES: N/A
tions, the WBC scan has replaced
scanning with gallium-67 citrate INTERFERING FACTORS:
(Ga-67). Some chronic infections
associated with pulmonary disease, This procedure is contraindicated
however, may be better imaged with for:
Ga-67. The WBC scan is especially • Patients who are pregnant or suspected
helpful in detecting postoperative of being pregnant, unless the potential
infection sites and in documenting benefits of the procedure far outweigh
lack of residual infection after a
course of therapy. ■
imaging:
INDICATIONS: • Inability of the patient to cooperate or
• Aid in the diagnosis of infectious or remain still during the procedure
inflammatory diseases because of age, significant pain, or
• Evaluate patients with fever of mental status
unknown origin • Patients who are very obese, who may
• Evaluate suspected osteomyelitis exceed the weight limit for the equip-
ment
• Differentiate infectious from noninfec-
tious process • Incorrect positioning of the patient,
• Evaluate the effects of treatment of the area to be examined
• Evaluate postsurgical sites and wound • Retained barium from a previous radi-
infections ologic procedure, which may inhibit
visualization of an abdominal lesion
• Evaluate inflammatory bowel disease
• Other nuclear scans done within 48
• Evaluate suspected infection of an hours and Ga-67 scans within 4 weeks
orthopedic prostheses before the procedure
RESULT • Lesions smaller than 1 to 2 cm, which
may not be detectable
Normal Findings: • A distended bladder, which may
• No focal localization of the radionu- obscure pelvic detail
clide, along with some slight localiza-
tion of the radionuclide within the Other considerations:
reticuloendothelial system (liver, • Improper injection of the radionuclide
spleen, and bone marrow) that allows the tracer to seep deep into
the muscle tissue produces erroneous
Abnormal Findings: hot spots.
• Abscess
• Patients with a low WBC count may
• Arthritis need donor WBCs to complete the
White Blood Cell Scan 1033
radionuclide labeling process; other- ➤ Assure the patient and family

wise, Ga-67 scanning should be members that radiation exposure is
performed instead. minimal and similar to that involved
in other nuclear medicine proce-
• False-negative images may be a result dures.
of hemodialysis, hyperglycemia, hyper- ➤ Determine date of last menstrual
alimentation, steroid therapy, and period and possibility of pregnancy
antibiotic therapy. in perimenopausal women.
• The presence of multiple myeloma or ➤ Do not restrict food or fluids unless
thyroid cancer can result in a false- otherwise indicated.
negative scan for bone abnormalities.
Intratest:
occur before the procedure for radia- ➤ Ask the patient to void before the
tion safety concerns regarding infants hospital gown.
• Risks associated with radiographic an uncooperative adult, as ordered.
overexposure can result from frequent ➤ Ask the patient to lie still during
x-ray procedures. Personnel in the the procedure because movement
room with the patient should stand produces unclear images. Make
behind a shield or leave the area while sure jewelry, watches, chains, belts,
the examination is being done. and any other metallic objects have
Personnel working in the area where been removed from the area to be
the examination is being done should scanned.
wear badges that reveal their level of ➤ On the day of the test, draw a 40- to
exposure to radiation. 60-mL sample of blood for an in
vitro process of labeling and separat-
ing the WBCs from the blood. An
Nursing Implications and injection of radionuclide-labeled
Procedure ● ● ● ● ● ● ● ● ● ● ●
autologous WBCs is administered.
Delayed views may be taken 4 to 24
Pretest: hours after the injection.
➤ If abdominal abscess or infection is
suspected, laxatives or enemas may
dure assesses the presence of
be ordered before delayed imaging.
inflammation or infection.
➤ Wear gloves during the radionuclide
administration and while handling
the patient’s urine.
nuclear medicine department by a
approximately 60 minutes, and that
Post-test:
delayed images are needed 24 hours ➤ Instruct the patient to resume
later. The patient may leave the normal activity, medications, and
department and return later to diet after imaging is complete,
undergo delayed imaging. unless otherwise indicated.
➤ Obtain a list of known allergens. ➤ Advise patient to drink increased
➤ Obtain a medical history of the amounts of fluids for 24 hours to
patient’s complaints as well as eliminate the radionuclide from the
results of previously performed body, unless contraindicated. Tell the
tests, treatments, and surgical patient that radionuclide is elimi-
procedures. For related tests, refer nated from the body within 48 to
to the immunologic system table. 72 hours.
➤ Obtain a list of medications the ➤ Instruct the patient to flush the
patient is taking. toilet immediately after each voiding
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.
➤ 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
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
DESCRIPTION: Zinc is found in all tissue repair. It is also required for

body tissues, but the highest concen- the formation of collagen and the
trations are found in the eye, bone, production of active vitamin A (for
and male reproductive organs. Zinc is the visual pigment rhodopsin). Zinc
involved in RNA and DNA synthesis also functions as a chelating agent to
and is essential in the process of protect the body from lead and
Zinc 1035
cadmium poisoning. Zinc is absorbed • Acquired immunodeficiency syn-

from the small intestine. Its absorp- drome (AIDS)
tion and excretion seem to be • Burns
through the same sites as those for
iron and copper. The body does not • Cirrhosis
store zinc as it does copper and iron. • Conditions that decrease albumin
Untreated zinc deficiency in infants • Diabetes
may result in a condition called acro-
dermatitis enteropathica. Symptoms • Long-term total parenteral nutrition
include growth retardation, diarrhea, • Malabsorption
impaired wound healing, and
frequent infections. Adolescents and
adults with zinc deficiency exhibit • Nephrotic syndrome
similar adverse effects on growth, • Nutritional deficiency
sexual development, and immune
• Pulmonary tuberculosis
function, as well as altered taste and
smell, emotional instability, impaired • Pregnancy
adaptation to darkness, impaired
night vision, tremors, and a bullous, CRITICAL VALUES: N/A
pustular rash over the extremities. ■
• Drugs that may increase zinc levels
INDICATIONS: include auranofin, chlorthalidone,
• Assist in confirming acrodermatitis corticotropin, oral contraceptives, and
enteropathica penicillamine.
• Evaluate nutritional deficiency • Drugs that may decrease zinc levels
• Evaluate possible toxicity include anticonvulsants, cisplatin,
citrates, corticosteroids, estrogens,
• Monitor replacement therapy in indi- interferon, and oral contraceptives.
viduals with identified deficiencies
• Monitor therapy of individuals with
Wilson’s disease
Procedure ● ● ● ● ● ● ● ● ● ● ●
RESULT Pretest:
• 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
Decreased in: to the gastrointestinal, immune,
• Acrodermatitis enteropathica hepatobiliary, and musculoskeletal
system tables.
• Acute infections
• Acute stress patient is taking, including herbs,
nutritional supplements, and 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 ➤ Instruct the patient to resume usual
consideration when reviewing diet and medication, if withheld and
results. as directed by the requesting health
➤ There are no food, fluid, or medica- care practitioner.
tion restrictions unless by medical ➤ Topical or oral supplementation may
direction. be ordered for patients with zinc
➤ Review the procedure with the deficiency. Dietary sources high in
patient. zinc include shellfish, red meat,
wheat germ, and processed foods
➤ Inform the patient that specimen such as canned pork and beans
collection takes approximately 5 to and canned chili. Patients should
10 minutes. be informed that diets high in
phytates from whole grains, coffee,
Intratest: cocoa, or tea bind zinc and prevent
it from being absorbed. Decreases
➤ Direct the patient to breathe in zinc also can be induced by
normally and to avoid unnecessary increased intake of iron, copper, or
movement. manganese. Vitamin and mineral
➤ Observe standard precautions and supplements with a greater than 3:1
follow the general guidelines in iron/zinc ratio inhibit zinc absorption.
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
royal blue–top tube. tests performed. Related laboratory
➤ Label the specimen, and promptly tests include albumin, iron, and
transport it to the laboratory. copper.
SYSTEM TABLES
CARDIOVASCULAR SYSTEM
Laboratory Tests Associated with the Cardiovascular System
Anion gap 81 Hemoglobin 566

Apolipoprotein A 133 Homocysteine and
Apolipoprotein B 136 methylmalonic acid 592
Aspartate aminotranspeptidase International normalized ratio
143 (INR) 837
Atrial natriuretic factor 146 Lactate dehydrogenase and
Blood gases 216 isoenzymes 645
C-reactive protein 247 Lactic acid 648
Calcium, serum 259 Lidocaine 84
Calcium, ionized 256 Lipoprotein electrophoresis 668
Chloride 293 Magnesium, serum 689
Cholesterol, HDL, LDL 310 Myoglobin 743
Cholesterol, total 314 Pericardial fluid analysis 769
Creatine kinase and isoenzymes Potassium, serum 810
401 Procainamide 84
D-Dimer 439 Prothrombin time and INR 837
Digoxin 84 Quinidine 84
Disopyramide 84 Triglycerides 931
Fibrin degradation products 509 Troponins I and T 938
Flecainide 84 Vitamin E 1016
Hematocrit 562
1037
Diagnostic Tests Associated with the Cardiovascular System
Angiography, coronary 64 Myocardial scan 736

Angiography, magnetic Plethysmography 789
resonance 68 Positron emission tomography,
Blood pool imaging 231 heart 804
Chest x-ray 289 Stress echocardiography 493
Computed tomography, Ultrasound, arterial Doppler,
angiography 351 carotid 942
Echocardiography 450 Ultrasound, arterial Doppler,
Echocardiography, lower extremity studies 944
transesophageal 453 Ultrasound, peripheral Doppler
Electrocardiogram 456 966
Exercise stress test 493 Ultrasound, venous Doppler,
Holter monitoring 590 extremity studies 978
Magnetic resonance imaging, Venography, lower extremity
chest 701 studies 1009
ENDOCRINE SYSTEM
Laboratory Tests Associated with the Endocrine System
Adrenocorticotropic hormone Chloride, sweat 297

(and challenge tests) 7 Cortisol and challenge tests 7
Albumin 14 Dehydroepiandrosterone sulfate
Aldosterone 19 444
Amylase 51 Dexamethasone suppression test
Angiotensin-converting enzyme 398
78 Estradiol 485
Anion gap 81 Estrogen and progesterone
Antibodies, antithyroglobulin receptor assays 487
and antithyroid peroxidase 103 Follicle-stimulating hormone 515
Antidiuretic hormone 122 Fructosamine 517
Biopsy, thyroid 210 Gastrin and gastrin stimulation
C-peptide 244 test 527
Calcitonin 253 Glucagon 534
Calcium, ionized 256 Glucose (random, 2-hour
Calcium, urine 263 postprandial) 537
Catecholamines, urine 277 Glucose tolerance tests 542
Chloride, serum 293 Glycated hemoglobin A1C 549

System Tables: Endocrine System 1039
Laboratory Tests Associated with the Endocrine System
Growth hormone, stimulation Potassium, urine 815

and suppression tests 554 Prealbumin 818
Homovanillic acid 594 Progesterone 824
Human chorionic gonadotropin Prolactin 826
597 Renin 872
5-Hydroxyindoleacetic acid 605 Sodium, serum 893
Insulin and insulin response to Sodium, urine 896
glucose 624 Testosterone, total 905
Insulin antibodies 627 Thyroglobulin 907
Ketones, blood and urine 638 Thyroid-binding inhibitory
Lactic acid 648 antibodies 909
Luteinizing hormone 681 Thyroid-stimulating hormone
Magnesium, serum 689 914
Magnesium, urine 691 Thyroid-stimulating
Metanephrines 724 immunoglobulins 916
Metyrapone stimulation 398 Thyrotropin-releasing hormone
Microalbumin 729 917
Osmolality, serum and urine 744 Thyroxine-binding globulin 919
Parathyroid hormone: Intact, Thyroxine, free 921
C-terminal, and N-terminal 759 Thyroxine, total 922
Phosphorus, serum 775 Triiodothyronine, free 934
Phosphorus, urine 778 Triiodothyronine, total 936
Potassium, serum 810 Vanillylmandelic acid 1005
Diagnostic Tests Associated with the Endocrine System
Adrenal gland scan 4 Magnetic resonance imaging,

Angiography, adrenal 60 pituitary 707
Computed tomography, pancreas Parathyroid scan 761
367 Radioactive iodine uptake 852
Computed tomography, pituitary Thyroid scan 911
374 Ultrasound, pancreas 961
Magnetic resonance imaging, Ultrasound, thyroid and
pancreas 714 parathyroid 976
GASTROINTESTINAL SYSTEM
Laboratory Tests Associated with the Gastrointestinal System
Albumin and albumin/globulin Hematocrit 562

ratio 14 Hemoglobin 566
Ammonia 45 5-Hydroxyindoleacetic acid 605
Amylase 51 Immunoglobulins A, E, G,
Anion gap 81 and M 616
Antibodies, anticytoplasmic Intrinsic factor antibodies 632
neutrophilic 94 Lactose tolerance test 650
Antibodies, gliadin Lipase 666
(immunoglobulin G and Magnesium, serum 689
immunoglobulin A) 106 Magnesium, urine 691
Bacterial culture, stool 160 Ova and parasites 751
Biopsy, intestinal 191 Oxalate 753
CA 19-9 252 Peritoneal fluid analysis 772
Calcium, serum 259 Phosphorus, serum 775
Carcinoembryonic antigen 272 Potassium, serum 810
Chloride, serum 293 Potassium, urine 815
Cholesterol, total 314 Prealbumin 818
Complete blood count 340 Red blood cell count 859
Culture, viral 419 Red blood cell indices 863
D-Xylose tolerance test 441 Total protein and fractions 834
Fecal analysis 496 Triglycerides 931
Fecal fat 498 Vitamin A 1020
Folate 513 Vitamin B1 1020
Fructosamine 517 Vitamin B6 1020
Gastric acid stimulation test 522 Vitamin B12 1012
Gastrin and gastrin stimulation Vitamin C 1020
test 527 Vitamin D 1014
Gram stain 551 Vitamin E 1016
Helicobacter pylori 561 Zinc 1034
Diagnostic Tests Associated with the Gastrointestinal System
Barium enema 167 Cholangiography, postoperative

Barium swallow 170 304
Cholangiography, percutaneous Cholangiopancreatography,
transhepatic 301 endoscopic retrograde 307

System Tables: Genitourinary System 1041
Diagnostic Tests Associated with the Gastrointestinal System
Colonoscopy 330 Hepatobiliary imaging 582

Computed tomography, abdomen Kidney, ureter, and bladder study
347 641
Computed tomography, pancreas Laparoscopy 652
367 Liver scan 671
Esophageal manometry 479 Magnetic resonance imaging,
Esophagogastroduodenoscopy abdomen 694
482 Proctosigmoidoscopy 820
Gastric emptying scan 524 Ultrasound, liver and biliary
Gastroesophageal reflux scan 529 system 953
Gastrointestinal blood loss scan Upper gastrointestinal and small
531 bowel series 981
GENITOURINARY SYSTEM
Laboratory Tests Associated with the Genitourinary System
Acetaminophen 54 Carbon dioxide 267

Acid phosphatase, prostatic 2 Chloride, serum 293
Albumin and albumin/globulin Creatinine, serum 404
ratio 14 Creatinine, urine, and creatinine
Aldosterone 19 clearance, urine 407
Amikacin 90 Culture, viral 419
Ammonia 45 Cyclosporine 619
Anion gap 81 Cytology, urine 435
Antibodies, anticytoplasmic Erythropoietin 477
neutrophilic 94 Gentamicin 90
Antibodies, anti–glomerular Gram stain 551
basement membrane 95 Lithium 126
Antidiuretic hormone 122 Magnesium, serum 689
Bacterial culture, urine 164 Magnesium, urine 691
Biopsy, bladder 176 Methotrexate 619
Biopsy, kidney 193 Microalbumin 729
Bladder cancer markers, urine 2-Microglobulin 732
212 Osmolality, serum and urine 744
Calcitonin and calcitonin Oxalate, urine 753
stimulation tests 253 Phosphorus, serum 775
Calcium, ionized 256 Phosphorus, urine 778
Calcium, serum 259 Potassium, serum 810
Calcium, urine 263 Potassium, urine 815
Calculus, kidney stone panel 266 Prostate-specific antigen 828

Laboratory Tests Associated with the Genitourinary System
Protein, urine 834 Urea nitrogen, blood 984

Renin 872 Urea nitrogen, urine 986
Salicylate 54 Uric acid, blood 992
Sodium, serum 893 Uric acid, urine 994
Sodium, urine 896 Urinalysis 997
Tobramycin 90 Vancomycin 90
Diagnostic Tests Associated with the Genitourinary System
Angiography, renal 74 Renogram 875

Computed tomography, renal 377 Ultrasound, bladder 946
Cystometry 422 Ultrasound, kidney 951
Cystoscopy 425 Ultrasound, pelvis 963
Cystourethrography, voiding 428 Ultrasound, prostate 969
Intravenous pyelography 628 Ultrasound, scrotum 971
Kidney, ureter, and bladder study Urethrography, retrograde 989
641
HEMATOPOIETIC SYSTEM
Laboratory Tests Associated with the Hematopoietic System
-Aminolevulinic acid 43 Coombs’ antiglobulin, direct 391

Anion gap 81 Coombs’ antiglobulin, indirect
Antithrombin III 128 393
Antibody, cardiolipin, Copper 395
immunoglobulin G and D-Dimer 439
immunoglobulin M 105 Eosinophil count 470
Biopsy, bone marrow 181 Erythrocyte protoporphyrin,
Bleeding time 214 free 472
Blood groups and antibodies 227 Erythrocyte sedimentation rate
Calcium, serum 259 474
Cholesterol, total 314 Erythropoietin 477
Clot retraction 320 Ferritin 501
Coagulation factor assays 322 Fibrin degradation products 509
Complete blood count 340 Fibrinogen 511
System Tables: Hematopoietic System 1043
Laboratory Tests Associated with the Hematopoietic System
Folate 513 Lupus anticoagulant antibodies

Glucose-6-phosphate 679
dehydrogenase 540 Methemoglobin 727
Ham’s test for paroxysmal Osmotic fragility 748
nocturnal hemoglobinuria 557 Partial thromboplastin time
Haptoglobin 559 764
Hematocrit 562 Plasminogen 781
Hemoglobin 566 Platelet antibodies 783
Hemoglobin electrophoresis 570 Platelet count 784
Hemosiderin 573 Porphyrins, urine 797
Homocysteine and Protein C 830
methylmalonic acid 592 Protein S 832
Immunoglobulins A, E, G, and Prothrombin time and INR 837
M 616 Pyruvate kinase 850
Immunofixation electrophoresis, Red blood cell cholinesterase
serum and urine 612 857
International normalized ratio Red blood cell count 859
(INR) 837 Red blood cell indices 863
Intrinsic factor antibodies 632 Red blood cell morphology and
Iron 633 inclusions 866
Iron-binding capacity (total), Reticulocyte count 878
transferrin, and iron saturation Sickle cell screen 891
636 Transferrin 929
Kleihauer-Betke test 644 Vitamin B12 1012
Lactate dehydrogenase and Vitamin E 1016
isoenzymes 645 Vitamin K 1018
Lead 660 White blood cell count and cell
Leukocyte alkaline phosphatase differential 1024
664
Diagnostic Tests Associated with the Hematopoietic System
Angiography, abdomen 56 Meckel’s diverticulum scan 719

Computed tomography, spleen Liver and spleen scan 671
384
Gastrointestinal blood loss scan Ultrasound, lymph nodes and
531 retroperitoneum 956
Lymphangiography 685 Ultrasound, spleen 973
HEPATOBILIARY SYSTEM
Laboratory Tests Associated with the Hepatobiliary System
Acetaminophen 54 Hepatitis A, antibody 574

Acetylsalicylic acid 54 Hepatitis B, core antibody 577
Alanine aminotransferase 12 Hepatitis B, surface antibody 577
Albumin 14 Hepatitis B, surface antigen 576
Aldolase 17 Hepatitis Be, antibody and
Alkaline phosphatase and antigen 576
isoenzymes 22 Hepatitis C, antibody 579
1-Antitrypsin and 1-antitrypsin Hepatitis D, antibody 581
phenotyping 130 Infectious mononucleosis screen
Amitryptyline 118 622
Ammonia 45 Imipramine 118
Amylase 51 International normalized ratio
Antibodies, anticytoplasmic (INR) 837
neutrophilic 94 Lactate dehydrogenase and
Antibody, antimitochondrial 108 isoenzymes 645
Antibody, anti–smooth muscle Lactic acid 648
109 Lipase 666
Aspartate aminotranspeptidase Nortriptyline 118
143 Partial thromboplastin time 764
Bilirubin and bilirubin fractions Phenobarbital 112
173 Phenytoin 112
Biopsy, liver 196 Prealbumin 818
Calcium, serum 259 Primidone 112
Carbamazepine 112 Protein C 830
Ceruloplasmin 287 Protein S 832
Cholesterol, total 314 Protein, total and fractions 834
Coagulation factor assays 322 Prothrombin time and INR 837
Copper 395 Pseudocholinesterase 840
Desipramine 118 Red blood cell count 859
Diazepam 118 Red blood cell morphology and
Doxepin 118 inclusions 866
Ethosuximide 112 Urea nitrogen, blood 984
Fibrinogen 511 Uric acid, blood 992
-Glutamyltransferase 547 Valproic acid 112
Haloperidol 126 Vitamin E 1016
Haptoglobin 559 Vitamin K 1018
Hematocrit 562 Zinc 1034
Hemoglobin 566
System Tables: Immune System 1045
Diagnostic Tests Associated with the Hepatobiliary System
Angiography, abdomen 56 Computed tomography, liver 354

Angiography, magnetic Computed tomography,
resonance 68 angiography 351
Cholangiography, percutaneous Hepatobiliary scan 582
transhepatic 301
Cholangiography, postoperative Magnetic resonance imaging,
304 abdomen 694
Cholangiopancreatography, Ultrasound, liver and biliary
endoscopic retrograde 307 system 953
IMMUNE SYSTEM
Laboratory Tests Associated with the Immune System
Acid phosphatase, prostatic 2 Antibody, anti–smooth muscle

Allergen-specific immunoglobulin 109
E 27 Antibody, Jo-1 111
Amikacin 90 Antideoxyribonuclease-B,
Angiotensin-converting enzyme streptococcal 116
78 Antigens/antibodies,
Anion gap 81 anti–extractable nuclear 124
Antibodies, anticytoplasmic Bacterial culture, anal/genital,
neutrophilic 94 ear, eye, skin, and wound 148
Antibodies, anti–glomerular Bacterial culture, blood 153
basement membrane 95 Bacterial culture, sputum 156
Antibodies, antinuclear, anti- Bacterial culture, stool 160
DNA, and anticentromere 97 Bacterial culture, throat or nasal
Antibodies, antiscleroderma 99 pharyngeal 162
Antibodies, antisperm 100 Bacterial culture, urine 164
Antibodies, antistreptolysin O Biopsy, bladder 176
102 Biopsy, bone 179
Antibodies, antithyroglobin and Biopsy, bone marrow 181
antithyroid peroxidase 103 Biopsy, breast 185
Antibodies, cardiolipin, Biopsy, cervical 187
immunoglobulin G and Biopsy, intestinal 191
immunoglobulin M 105 Biopsy, kidney 193
Antibodies, gliadin 106 Biopsy, liver 196
Antibody, antimitochondrial 108 Biopsy, lung 198

Biopsy, lymph node 201 Haptoglobin 559

Biopsy, muscle 204 Helicobacter pylori antibody 561
Biopsy, prostate 206 Hematocrit 562
Biopsy, skin 208 Hemoglobin 566
Biopsy, thyroid 210 Hepatitis A, antibody 574
Bladder cancer markers 212 Hepatitis B, core antibody 577
Blood groups and antibodies 227 Hepatitis B, surface antibody 577
C-reactive protein 247 Hepatitis B, surface antigen 576
CA 125 249 Hepatitis Be, antibody and anti-
CA 15-3 250 gen 576
CA 19-9 252 Hepatitis C, antibody 579
Carcinoembryonic antigen 272 Hepatitis D, antibody 581
CD4/CD8 enumeration 280 Her-2/neu oncoprotein 585
Cerebrospinal fluid analysis 282 Human chorionic gonadotropin
Chlamydia group antibody 291 597
Cold agglutinin titer 325 Human immunodeficiency virus
Complement C3 and complement type 1 and type 2 antibodies
C4 336 599
Complement, total 338 Human T-lymphotropic virus
Complete blood count 340 type I and type II antibodies 603
Copper 395 Human leukocyte antigen B27
Cryoglobulin 411 601
Culture and smear, mycobacteria 5-Hydroxyindoleacetic acid 605
412 Hypersensitivity pneumonitis 607
Culture, fungal 417 Immunofixation electrophoresis,
Culture, specific body fluid 551 serum and urine 612
Culture, synovial fluid 899 Immunoglobulins A, D, G, and M
Culture, viral 419 616
Cytology, sputum 431 Infectious mononucleosis screen
Cytology, urine 435 627
Cytomegalovirus, Insulin antibodies 627
immunoglobulin G and Latex allergy 658
immunoglobulin M 437 Leukocyte alkaline phosphatase
Eosinophil count 470 664
Erythrocyte sedimentation rate Lupus anticoagulant antibodies
474 679
Estrogen and progesterone Lyme antibody 684
receptor assays 487 2-Microglobulin 732
1-Fetoprotein 505 Mumps serology 735
Gentamicin 90 Ova and parasites, stool 751
Gram stain 551 Papanicolaou smear 756

System Tables: Immune System 1047
Parvovirus B19 immunoglobulin Red blood cell indices 863

G and immunoglobulin M Rheumatoid factor 884
antibody 767 Rubella 885
Pericardial fluid analysis 769 Rubeola 887
Peritoneal fluid analysis 772 Streptococcal screen, rapid 553
Platelet antibodies 783 Synovial fluid analysis 899
Platelet count 784 Syphilis serology 902
Pleural fluid analysis 793 Tobramycin 90
Potassium 810 Toxoplasma antibody 928
Prostate-specific antigen 828 Tuberculin skin tests 939
Protein, total and fractions 834 Vancomycin 90
Protein, urine, total quantitative Varicella 1007
and fractions 834 White blood cell count and cell
Red blood cell count 859 differential 1024
Red blood cell morphology and Zinc 1034
inclusions 866
Diagnostic Tests Associated with the Immune System
Gallium scan 519 White blood cell scan 1031
MUSCULOSKELETAL SYSTEM
Laboratory Tests Associated with the Musculoskeletal System
Acetylcholine receptor antibody Antigens/antibodies,

1 anti–extractable nuclear 124
Aldolase 17 Biopsy, bone 179
Alkaline phosphatase and Biopsy, lymph node 201
isoenzymes 22 Biopsy, muscle 204
Angiotensin-converting enzyme Biopsy, skin 208
78 Calcitonin and calcitonin
Antibodies, anticytoplasmic stimulation tests 253
neutrophilic 94 Calcium, serum 259
Antibodies, antinuclear, anti- Calcium, urine 263
DNA, and anticentromere 97 Cerebrospinal fluid analysis 282
Antibodies, antiscleroderma 99 Collagen crosslinked
Antibody, Jo-1 111 N-telopeptides 327

Laboratory Tests Associated with the Musculoskeletal System
Creatine kinase and isoenzymes Lyme antibody 684

401 Myoglobin 743
Creatinine, serum 404 Osteocalcin 749
Hematocrit 562 Phosphorus 775
Hemoglobin 566 Pseudocholinesterase and
Human leukocyte antigen B27 dibucaine number 840
601 Rheumatoid factor 884
Immunoglobulins A, D, G, and M Synovial fluid analysis 899
616 Uric acid, blood 992
Lactate dehydrogenase and Vitamin D 1014
isoenzymes 645 Zinc 1034
Lactic acid 648
Lupus anticoagulant antibodies
679
Diagnostic Tests Associated with the Musculoskeletal System
Arthrogram 138 Electromyography, pelvic floor

Bone mineral density 234 sphincter 466
Bone scan 238 Electroneurography 468
Computed tomography, Evoked brain potentials 489
brain 357 Magnetic resonance imaging,
Computed tomography, musculoskeletal 704
spine 381 Radiography, bone 855
Electroencephalography 460 Positron emission tomography,
Electromyography 463 brain 800
REPRODUCTIVE SYSTEM
Laboratory Tests Associated with the Reproductive System
Acid phosphatase, prostatic 2 Antibodies, cardiolipin,

Amino acid screen, blood 34 immunoglobulin G and
Amino acid screen, urine 38 immunoglobulin M 105
Amniotic fluid analysis 47 Bacterial culture, anal/genital 148
Antibodies, antisperm 100 Biopsy, breast 185

System Tables: Reproductive System 1049
Laboratory Tests Associated with the Reproductive System
Biopsy, cervical 187 Human chorionic gonadotropin

Biopsy, chorionic villus 189 597
Biopsy, prostate 206 Human immunodeficiency virus
CA 125 249 type 1 and type 2 antibodies
CA 15-3 250 599
Carcinoembryonic antigen 272 Kleihauer-Betke test 644
Chlamydia group antibody 291 Lecithin/sphingomyelin ratio 661
Chromosome analysis, blood 317 Lupus anticoagulant antibodies
Collagen crosslinked 679
N-telopeptides 327 Luteinizing hormone 681
Culture, viral 419 Magnesium 689
Cytomegalovirus, Papanicolaou smear 756
immunoglobulin G and Progesterone 824
immunoglobulin M 437 Prolactin 826
Estradiol 485 Prostate-specific antigen 828
Estrogen and progesterone Rubeola 885
receptor assays 487 Rubella 887
Fetal fibronectin 503 Semen analysis 889
1-Fetoprotein 505 Syphilis serology 902
Follicle-stimulating hormone 515 Testosterone, total 905
Gram stain 551 Toxoplasma antibody 928
Her-2/neu oncoprotein 585 Urinalysis 997
Hexosaminidase A and B 587 Varicella 1007
Diagnostic Tests Associated with the Reproductive System
Colposcopy 333 Mammography 717

Computed tomography, pelvis Positron emission tomography,
370 pelvis 807
Hysterosalpingography 609 Ultrasound, obstetric 958
Laparoscopy, abdominal 652 Ultrasound, pelvic 963
Laparoscopy, gynecologic 655 Ultrasound, scrotal 971
Magnetic resonance imaging,
pelvis 710
RESPIRATORY SYSTEM
Laboratory Tests Associated with the Respiratory System
Allergen-specific immunoglobulin Culture, viral 419

E 27 Cytology, sputum 431
Alveolar/arterial gradient and D-Dimer 439
arterial/alveolar oxygen ratio Eosinophil count 470
29 Erythrocyte sedimentation rate
Angiotensin-converting enzyme 474
78 Fecal fat 498
Anion gap 81 Gram stain 551
Antibodies, anti–glomerular Hematocrit 562
basement membrane 95 Hemoglobin 566
1-Antitrypsin and 1-antitrypsin Hypersensitivity pneumonitis 607
phenotyping 130 Immunoglobulin E 614
Bacterial culture, sputum 156 Lactic acid 648
Bacterial culture, throat 162 Lecithin/sphingomyelin ratio 661
Biopsy, lung 198 Pleural fluid analysis 793
Blood gases 216 Potassium 810
Carbon dioxide 267 Rapid streptococcal screen 553
Carboxyhemoglobin 270 Red blood cell count 859
Chloride 293 Red blood cell indices 863
Chloride, sweat 297 Tuberculin skin tests 939
Cold agglutinin titer 325 White blood cell count and cell
Complete blood count 340 differential 1024
Culture and smear, mycobacteria
412
Diagnostic Tests Associated with the Respiratory System
Angiography, pulmonary 71 Lung ventilation scan 677

Bronchoscopy 241 Magnetic resonance imaging,
chest 701
Chest x-ray 289 Mediastinoscopy 722
Computed tomography, chest Pulmonary function studies 842
388 Pulse oximetry 848
Lung perfusion scan 674
System Tables: Therapeutic Drug Monitoring and Toxicology 1051
THERAPEUTIC DRUG MONITORING AND TOXICOLOGY
Laboratory Tests Associated with Therapeutic Drug Monitoring and

Toxicology
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

APPENDIX A
Patient Preparation Before Diagnostic

and Laboratory Procedures
The first step in any laboratory or diagnostic procedure is patient preparation or

patient teaching before the performance of the procedure. This pretesting explanation
to the patient or caregiver follows essentially the same pattern for all sites and types of
studies and includes the following:
• Statement of the purpose of the study. The level of detail provided to patients about the
test purpose depends on numerous factors and should be individualized appropri-
ately in each particular setting.
• Description of the procedure, including site and method. It is a good idea to explain to
the patient that you will be wearing gloves throughout the procedure. The explana-
tion should help the patient understand that the use of gloves is standard practice
established for his or her protection as well as yours. Many institutions require hand
washing at the beginning and end of each specimen collection encounter and
between each patient.
• Description of the sensations, including discomfort and pain, the patient may experience
during the specimen collection procedure. Address concerns about pain related to the
procedure and suggest breathing or visualization techniques to promote relaxation.
For pediatric patients, a doll may be used to “show” the procedure. Where appro-
priate, the use of anesthetizing agents may assist in allaying anxiety the patient may
experience that is related to anticipation of pain associated with the procedure.
Sensitivity to cultural and social issues, as well as concern for modesty is important
in providing psychological support.
• Instruction regarding pretesting preparations related to diet, liquids, medications, and
activity as well as any restrictions regarding diet, liquids, medications, activity, known
allergies, therapies, or other procedures that might affect test results. To increase patient
compliance, the instructions should include an explanation of why strict adherence
to the instructions is required.
• Recognition of anxiety related to test results. Provide a compassionate, reassuring envi-
ronment. Be prepared to educate the patient regarding access to the appropriate
counseling services. Encourage the patient to ask questions and verbalize his or her
concerns.
1053
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
Appendix A : Patient Preparation Before Diagnostic and Laboratory Procedures 1055
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).
Also, preservatives present in collection containers, such as sodium fluoride,

may exhibit a chemical interference with test reagents that can cause underes-
timation or overestimation of measured values. Other preservatives, such as
ethylenediaminetetra-acetic acid (EDTA), can block the analyte of interest in
the sample from participating in the test reaction, invalidating test results.
Finally, it is possible that some high-throughput, robotic equipment systems
require specific and standardized collection containers.
• Prompt and proper specimen processing, storage, and analysis are important to
achieve accurate results. Specimens collected in containers with solid or liquid
preservatives or with gel separators should be mixed by inverting the tube 10
times immediately after the tube has been filled. Handle the specimen gently
to avoid hemolysis. Specimens should always be transported to the laboratory
as quickly as possible after collection.
Results that are evaluated outside the entire context of the preparatory, collection,
and handling process may be interpreted erroneously if consideration is not given to
the above-listed general guidelines.
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.
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.
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.
Axillary
Brachial
Radial
Ulnar
Deep palmar arch
Superficial palmar arch
FIGURE A–4
Selection of Blood Collection Equipment

In many cases when a blood sample is required, serum is the specimen type of choice.
Plasma also may be frequently substituted, however. Specimen processing is more
rapid for plasma samples than serum samples because the anticoagulated sample does
not need to clot before centrifugation. Plasma samples also require less centrifugation
time to achieve adequate separation. Consult with the testing laboratory regarding
recommended specimen types. The basic blood collection tubes are shown on the
inside cover of this book. Consider latex allergy when selecting the collection equip-
ment appropriate for each patient. Equipment used in specimen collection includes:
• Gloves and other personal protective equipment depending on the situation
• Tourniquet
• Materials to cleanse or disinfect the collection site (alcohol preparations
[70% alcohol], povidone-iodine solution [Betadine], or green soap are the
most commonly used materials)
• Gauze (to wipe collection site dry after cleansing)
• Sterile lancet (capillary puncture)
• Syringe and needle (arterial puncture or venipuncture)
• Vial of heparin and syringe or heparin unit dose
• Sterile normal saline in 50-mL syringe (for indwelling devices such as
Groshong catheter)
• Sterile cap or hub (for indwelling devices when the cap or hub will be replaced
after specimen procurement)
• Needle and holder for vacuumized collection tube system (arterial puncture or
venipuncture)
• Butterfly or winged infusion set (venipuncture)

• Collection container (vacuumized collection tube, capillary tube, or
Microtainer)
• Bandage (to cover puncture site after specimen collection)
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).
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-
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
preprinted collection instructions tailored to their methods. The specimen should be

transported promptly to the laboratory after collection.
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
precautions.
Random: These samples are mainly used for routine screening and can be collected
at any time of the day. The patient should be instructed to void either directly into the
collection container (if there is no preservative) or into a collection device for transfer
First Morning: Urine on rising in the morning is very concentrated. These speci-
mens are indicated when screening for substances that may not be detectable in a more
dilute random sample. These specimens are also necessary for testing conditions such
as orthostatic proteinuria, in which levels vary with changes in posture.
Second Voided: In some cases, it is desirable to test freshly produced urine to eval-
uate the patient’s current status, as with glucose and ketones. Explain to the patient
that he or she should first void and then drink a glass of water. The patient should be
instructed to wait 30 minutes and then void either directly into the collection
container or into a collection device for transfer into the collection container.
Clean Catch: These midstream specimens are generally used for microbiologic or
cytologic studies. They also may be requested for routine urinalysis to provide a spec-
imen that is least contaminated with urethral cells, microorganisms, mucus, or other
substances that may affect the interpretation of results. Instruct the male patient first
to wash hands thoroughly, then cleanse the meatus, void a small amount into the
toilet, and void either directly into the specimen container or into a collection device
for transfer into the specimen container. Instruct the female patient first to wash hands
thoroughly, and then to cleanse the labia from front to back. While keeping the labia
separated, the patient should void a small amount into the toilet, and then without
interrupting the urine stream, void either directly into the specimen container or into
a collection device for transfer into the specimen container.
Catheterized Random or Clean Catch: “Straight catheterization” is indicated when
the patient is unable to void, when the patient is unable to prepare properly for clean-
catch specimen collection, or when the patient has an indwelling catheter in place and
from which a urine sample may be obtained. Before collecting a specimen from the
catheter, observe the drainage tube to ensure that it is empty, and then clamp the tube
distal to the collection port 15 minutes before specimen collection. Cleanse the port
with an antiseptic swab such as 70% alcohol and allow the port to dry. Use a needle
and syringe (sterile if indicated) to withdraw the required amount of specimen.
Unclamp the tube.
Timed: To quantify substances in urine, 24-hour urine collections are used. They are
also used to measure substances whose level of excretion varies over time. The use of
preservatives and the handling of specimens during the timed collection may be
subject to variability among laboratories. The testing laboratory should be consulted
regarding specific instructions before starting the test. Many times the specimen must
be refrigerated or kept on ice throughout the entire collection period. Explain to the
patient that it is crucial for all urine to be included in the collection. The test should
begin between 6 and 8 a.m., if possible. Instruct the patient to collect the first void of
the day and discard it. The start time of the collection period begins at the time the
first voided specimen was discarded and should be recorded along with the date on the
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.
Body Fluid, Stool, and Tissue

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, or to latex
if latex gloves will be used in the procedure.
Specific collection techniques vary by site, study required, and level of invasiveness.
These techniques are described in the individual monographs.
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.
Organ/Disease Panels (with CPT Codes) 1065
APPENDIX B
Organ/Disease Panels (with CPT Codes)
Acute Hepatitis Panel 80074 (serum in Comprehensive Metabolic Panel 80053

5-mL red- or tiger-top tube): (serum in 3- or 5-mL red- or tiger-top
tube or plasma in 3- or 5-mL green-top
Hepatitis A antibody, IgA 86709 tube):
Hepatitis B core antibody, IgM
86705 Albumin 82040
Hepatitis B surface antigen 87340 Aminotransferase, alanine (ALT)
Hepatitis C antibody 86803 84460
Aminotransferase, aspartate (AST)
Arthritis Panel 80072 (serum in 3- or 84450
5-mL red- or tiger-top tube; whole Bilirubin, total 82247
blood in 5-mL lavender- or gray-top Calcium 82310
tube): Carbon dioxide 82374
Chloride 82435
Erythrocyte sedimentation rate,
Creatinine 82565
nonautomated 85651
Glucose 82947
Rheumatoid factor, qualitative
Phosphatase, alkaline 84075
86430
Potassium 84132
Screen for noninfectious agent, each
Protein, total 84155
antibody (such as antinuclear
Sodium 84295
antibody or antistreptolysin O
Urea nitrogen 84520
antibody) 86255
Uric acid 84550 Electrolyte Panel 80051 (serum in 3- or
5-mL red- or tiger-top tube or plasma in
Basic Metabolic Panel 80048 (serum in
3- or 5-mL green-top tube):
3- or 5-mL red- or tiger-top tube or
plasma in 3- or 5-mL green-top tube): Carbon dioxide 82374
Chloride 82435
Calcium 82310
Potassium 84132
Carbon dioxide 82374
Sodium 84295
Chloride 82435
Creatinine 82565 General Health Panel 80050 (serum in
Glucose 82947 3- or 5-mL red- or tiger-top tube or
Potassium 84132 plasma in 3- or 5-mL green-top tube;
Sodium 84295 whole blood in 3- or 5-mL lavender-top
Urea nitrogen 84520 tube):
1065
Comprehensive metabolic panel Antibody, rubella 86762

80053 Antibody screen, RBC 86850
Hemogram, and platelet count, Blood type, ABO 86900; and
automated, and automated Blood typing, Rh 86901
complete WBC differential 85025 Hemogram, automated and manual
Hemogram, automated and manual WBC 85022; or
WBC 85022; or Hemogram, and platelet count,
Thyroid-stimulating hormone 84443 automated, and automated
Hepatic Function Panel 80076 (serum complete WBC differential 85025
in 3- or 5-mL red- or tiger-top tube or Hepatitis B surface antigen 87340
plasma in 3- or 5-mL green-top tube): Syphilis test, qualitative 86592
Renal Function Panel 80069 (serum
Albumin 82040
in 3- or 5-mL red- or tiger-top tube
Aminotransferase, alanine (ALT)
or plasma in 3- or 5-mL green-top
84460
tube):
Aminotransferase, aspartate (AST)
84450 Albumin 82040
Bilirubin, direct 82248 Calcium 82310
Bilirubin, total 82247 Carbon dioxide 82374
Phosphatase, alkaline 84075 Chloride 82435
Protein, total 84155 Creatinine 82565
Lipid Panel 80061 (serum in 5-mL red- Glucose 82947
or tiger-top tube): Phosphorus, inorganic 84100
Potassium 84132
Cholesterol, HDL 83718 Sodium 84295
Cholesterol, total 82465 Urea nitrogen 84520
Triglycerides 84478
TORCH Antibody Panel 80090 (serum
Obstetric Panel 80055 (serum in 5-mL in 5-mL red- or tiger-top tube):
red- or tiger-top tube for serology;
whole blood in 3- or 5-mL lavender-top Antibody, CMV 86644
tube for hemogram; serum in 5-mL red- Antibody, herpes simplex 86694
top tube for blood bank; whole blood in Antibody, rubella 86762
5-mL lavender-top tube for blood Antibody, Toxoplasma 86777
bank):
Potential Nursing Diagnoses Associated with Laboratory and Diagnostic Testing 1067
APPENDIX C
Potential Nursing Diagnoses Associated

with Laboratory and Diagnostic Testing
Pretest Phase Intratest Phase

Anxiety related to undiagnosed health Risk for injury related to developmental
problems age, psychological factors, and test
Anxiety related to perceived threat to procedures
health status Risk for infection or allergic reaction
Anxiety and fear related to anticipated related to altered immune function,
diagnostic results history of chronic illness, allergens, or
Anxiety and fear related to perception of infectious agent
diagnostic procedure as frightening or Risk for latex allergy response associated
embarrassing with test equipment
Powerlessness related to unfamiliar Pain, nausea, vomiting, or diarrhea
procedure, equipment, environment, related to laboratory and diagnostic
or personnel procedures
Knowledge deficit related to lack of Injury, actual or risk for, related to
information or possible invasive procedure associated with
misinterpretation of information laboratory or diagnostic testing
provided about the procedure Risk for infection related to invasive
Knowledge deficit related to legal procedures
implications of testing Risk for bleeding associated with altered
Potential for noncompliance with test bleeding tendencies related to invasive
protocols related to inability to procedures
understand or follow instructions Fatigue related to diagnostic procedure
Potential for noncompliance to test Anxiety and fear related to arterial
protocols related to presence of high puncture or venipuncture
anxiety, confusion, or denial Risk for injury, bleeding, hematoma, or
Potential for noncompliance to test infection related to arterial puncture
protocols related to lack of knowledge or venipuncture
or appropriate instruction Pain related to arterial puncture or
Potential for noncompliance to test venipuncture
protocols related to confusion, Risk for impaired skin integrity
weakness, and other individual Potential impairment of gas exchange
factors associated with test procedure
1067
Post-Test Phase Anticipatory grieving related to test

Knowledge deficit related to significance outcomes
of test results and potential need for Anticipatory or actual grieving related to
further testing perceived loss of health or threat of
Knowledge deficit related to test out- death associated with diagnostic
come deviation that may necessitate outcomes
medication or lifestyle alterations Decisional conflict related to test
Anxiety and fear related to test outcome outcome and potential for
deviation that may necessitate interventional procedures
medication or lifestyle alterations Potential alteration in tissue perfusion:
Ineffective coping related to test cerebral, cardiopulmonary, or
outcome and potential for other peripheral
interventional techniques or Knowledge deficit related to care after
procedures procedure
Appendix D: Guidelines for Age-Specific Communication 1069
APPENDIX D
Guidelines for Age-Specific

Communication
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.
Infants (Birth to 1 year) May show fear of strangers

May exhibit separation anxiety
Physical
Rapid gains in height and weight Interventions
Gradual shift from reflexive movements
to intentional actions Keep a parent or primary caregiver in
view
Motor and Sensory Involve significant persons in care if
appropriate
Responds to light and sound Provide consistency in health care staff
Progresses to raising and turning head, to limit the number of strangers
bringing hand to mouth, rolling over, Face the infant when providing care
sitting upright, and standing Use soothing nonverbal communication,
such as holding, rocking, and
Cognitive
cuddling
Learns by imitation Assess immunizations
Progresses to recognize familiar objects Maintain safety and keep crib side rails
and people up at all times
Advances to speaking three or four words
Toddler (1 to 4 years)
Psychosocial
Physical
Significant persons are parents or
primary caregivers Learning bladder and bowel control
Develops sense of trust and security if Temporary teeth erupt
needs are met Physiologic systems mature
1069
Motor and Sensory Child (5 to 12 years)

Developing a higher level of manual Physical
dexterity (builds towers with
Growth is slow and regular
blocks)
Permanent teeth erupt
Progresses to walking, jumping, and
Pubescent changes start
climbing
May experience growing pains
Loves to experiment
May experience fatigue
Cognitive Motor and Sensory

Has a short attention span Skips and hops
Understands simple directions and Dresses and undresses independently
requests Throws and catches a ball
Uses common utensils and tools
Psychosocial Draws, paints, and likes quiet as well as
active games
Significant persons are parents
Asserts independence
Cognitive
Understands ownership
Attached to security objects Major cognitive skill is communication
Knows own gender Understands numbers and can count
Plays simple games Constructs sentences and asks questions
Capable of logical thinking and can
Interventions reason
Takes pride in accomplishments
Face the toddler during interactions Develops increased attention span
Give one direction at a time
Tie words to action (toddlers learn by
Psychosocial
example)
Use firm, direct approach; avoid Significant persons are parents, siblings,
harsh/excited words or actions peers, teachers (prefers friends to
Use distraction techniques family)
Use soothing nonverbal communication, Increases independence and begins to
such as rocking, cuddling, and assert self (may be physically
holding aggressive)
Communicate through play (dolls, Masters new tasks and acquires new
puppets, music) skills
Prepare shortly before a procedure Behavior can be modified by rewards
Allow choices when possible and punishment
Encourage mother or parent to stay with Works hard to be successful
the child as appropriate
Encourage parents to participate in care Interventions
as appropriate
Maintain safety and keep crib side rails Clearly define and reinforce behavior
up at all times limits
Appendix D: Guidelines for Age-Specific Communication 1071
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)
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
Appendix E: Effects of Natural Products on Laboratory Values 1073
APPENDIX E
Effects of Natural Products on

Laboratory Values
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.
Herbs That May Affect Cardiovascular Frangula

Disorders or Interact with Garlic
Therapeutics (Including Hypertension Ginseng
and Hypotension) Golden seal
Adonis Green tea (with caffeine)
Aloe Henbane
Buckthorn Horsetail
Bromelain Lily of the valley
Cascara Ma-huang
Chinese rhubarb Reishi
Coleus Senna
Dong quai Squill
Elder Tylophora
Ephedra Valerian
Ergot Yohimbe bark
1073
Herbs and Nutraceuticals That May Nutraceuticals

Affect Endocrine Disorders or Interact
Betaine hydrochloride
with Therapeutics
Herbs Herbs and Nutraceuticals That May
Affect Genitourinary Disorders or
Bitter melon
Interact with Therapeutics
Bilberry
Bladderwrack Herbs
Blupleurum
Bugleweed Aloe
Echinacea Arabinoxylane
Ephedra Bladderwrack
Fenugreek Buckthorn
Garcinia Cascara
Garlic Chinese rhubarb
Ginseng Dandelion
Goat’s rue Echinacea
Green tea (with caffeine) Ephedra
Guggul Ergot
Licorice Frangula
Marshmallow Ginseng
Olive leaf Guarana
Psyllium Horse chestnut
Tylophora Horsetail
Licorice
Parsley oil (high doses)
Minerals
Saw palmetto
Chromium Senna
Stinging nettle
Nutraceuticals White oak
White willow
Alpha lipoic acid
Dehydroepiandrosterone Nutraceuticals
p-Aminobenzoic acid
Thyroid extract Creatine
Modified citrus pectin
Herbs and Nutraceuticals That May
Affect Gastrointestinal Disorders or Herbs and Nutraceuticals That May
Interact with Therapeutics Affect Bleeding Disorders or Interact
with Therapeutics
Herbs
Herbs
Bromelain
Cascara Arnica
Chinese rhubarb Astragalus
Dandelion Bilberry
Psyllium Bromelian
Senna Cat’s claw
Appendix E: Effects of Natural Products on Laboratory Values 1075
Cayenne Olive leaf

Coleus Parsley oil (large doses)
Cordyceps Peppermint
Devil’s claw Pennyroyal
Dong quai Ragwort
Evening primrose Red yeast rice
Feverfew Sweet clover
Garlic White oak
Ginger White willow
Gingko
Ginseng Nutraceuticals
Grape seed
Creatine
Green tea (with caffeine)
Guggui
Horse chestnut Herbs and Amino Acids That May
Papaya Affect Immune Disorders or Interact
Red clover with Therapeutics
Red yeast rice Herbs
Reishi
Turmeric Astragalus
White willow Black cohosh
Echinacea
Nutraceuticals Saw palmetto
Docosahexaenoic acid (DHA) Amino Acids

Fish oils (EPA and DHA)
Arginine
Herbs and Nutraceuticals That May
Affect Hepatobiliary Disorders or Herbs That May Affect Respiratory
Interact with Therapeutics Disorders or Interact with
Therapeutics
Herbs
Artichoke
Alkanet Cayenne
Alpine ragwort Chamomile
Coltsfoot Cordyceps
Comfrey Echinacea
Dusty miller Feverfew
Forget-me-not Garlic
Germander Peppermint oil
Groundsel White willow
APPENDIX F
Standard Precautions (CDC Isolation

Precautions)
Background and Summary

In January 1996, the Centers for Disease Control and Prevention (CDC) issued new
guidelines for isolation precautions in hospitals. The guidelines, based on the latest
epidemiologic information on transmission of infection in hospitals, are intended
primarily for use in acute-care hospitals, although some of the recommendations may
be applicable to subacute-care or extended-care facilities. The recommendations are
not intended for use in day care, well care, or domiciliary care programs.
The revised guidelines contain two tiers of precautions. In the first, and most
important, tier are precautions designed for the care of all patients in hospitals regard-
less of their diagnosis or presumed infection status. Implementation of these Standard
Precautions is the primary strategy for successful nosocomial infection control. In the
second tier are precautions designed only for the care of specified patients. These addi-
tional Transmission-Based Precautions are used for patients who are known or
suspected to be infected or colonized with epidemiologically important pathogens that
can be transmitted by airborne or droplet transmission or by contact with dry skin or
contaminated surfaces.
Standard Precautions synthesize the major features of Universal (Blood and Body
Fluid) Precautions (designed to reduce the risk of transmission of blood-borne
pathogens) and Body Substance Isolation (designed to reduce the risk of transmission
of pathogens from moist body substances). Standard Precautions apply to (1) blood;
(2) all body fluids, secretions, and excretions except sweat, regardless of whether they
contain visible blood; (3) nonintact skin; and (4) mucous membranes. Standard
Precautions are designed to reduce the risk of transmission of recognized and unrec-
ognized sources of infection in hospitals.
Transmission-Based Precautions are designed for patients documented or suspected
to be infected or colonized with highly transmissible or epidemiologically important
pathogens for which additional precautions beyond Standard Precautions are needed
to interrupt transmission in hospitals. There are three types of Transmission-Based
Precautions: Airborne Precautions, Droplet Precautions, and Contact Precautions.
They may be combined for diseases that have multiple routes of transmission. When
used either singly or in combination, they are to be used in addition to Standard
Precautions.
Airborne Precautions are designed to reduce the risk of airborne transmission of
infectious agents. Airborne transmission occurs by dissemination of either airborne
droplet nuclei (small-particle residue [5 m or smaller in size] of evaporated droplets
1076
Appendix F: Standard Precautions (CDC Isolation Precautions) 1077
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
• 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.
Mask, Eye Protection, Face Shield

Wear a mask and eye protection or a face shield to protect mucous membranes of
the eyes, nose, and mouth during procedures and patient care activities that are
likely to generate splashes or sprays of blood, body fluids, secretions, and
excretions.
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.
Patient Care Equipment

Handle used patient care equipment soiled with blood, body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposures,
contamination of clothing, and transfer of microorganisms to other patients and
environments.
Ensure that reusable equipment is not used for the care of another patient until it
has been cleaned and reprocessed appropriately. Ensure that single-use items are
discarded properly.
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.
Occupational Health and Blood-Borne Pathogens

Take care to prevent injuries when using needles, scalpels, and other sharp
instruments or devices; when handling sharp instruments after procedures; when
cleaning used instruments; and when disposing of used needles.
Never recap used needles or otherwise manipulate them using both hands or use any
other technique that involves directing the point of a needle toward any part of
the body; rather, use either a one-handed “scoop” technique or a mechanical
device designed for holding the needle sheath.
Do not remove used needles from disposable syringes by hand, and do not bend,
break, or otherwise manipulate used needle by hand.
Place used disposable syringes and needles, scalpel blades, and other sharp items in
appropriate puncture-resistant containers, which are located as close as practical to
the area in which the items were used, and place reusable syringes and needles in a
puncture-resistant container for transport to the reprocessing area.
Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to
mouth-to-mouth resuscitation methods in areas where the need for resuscitation is
predictable.
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.
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.
Additional Precautions for Preventing Transmission of Tuberculosis

Consult CDC “Guidelines for Preventing the Transmission of Tuberculosis in Health-
Care Facilities” for additional prevention strategies.1
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.
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
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.
Gloves and Hand Washing

In addition to wearing gloves as outlined under Standard Precautions, wear gloves
(clean, nonsterile gloves are adequate) when entering the room.
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
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.
Patient Care Equipment

When possible, dedicate the use of noncritical patient care equipment to a single
patient (or cohort of patients infected or colonized with the pathogen requiring
precautions) to avoid sharing between patients.
If use of common equipment or items is unavoidable, adequately clean and disinfect
them before use for another patient.
Additional Precautions for Preventing the Spread of Vancomycin Resistance

Consult the Hospital Infection Control Practices Advisory Committee report on
preventing the spread of vancomycin resistance for additional prevention strategies.
OSHA Blood-Borne Pathogens Standard

Who Is Covered?
The Occupational Safety and Health Administration (OSHA) standard protects
employees who may be occupationally exposed to blood and other potential infectious
materials, which includes but is not limited to physicians, physician’s assistants, nurses,
nurse practitioners, and other health care employees in clinics and physicians’ offices;
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.
Exposure Control Plan

A written exposure control plan is necessary for the safety and health of workers. At a
minimum, the plan must include the following:
Identify job classifications in which there is exposure to blood or other
potentially infectious materials.
Explain the protective measures currently in effect in the acute-care facility
or a schedule and methods of compliance to be implemented, including
hepatitis B vaccination and postexposure follow-up procedures, how
hazards are communicated to employees, personal protective equipment
(PPE), housekeeping, and record keeping.
Establish procedures for evaluating the circumstances of an exposure
incident.
The schedule of how and when the provisions of the standard will be implemented
may be a simple calendar with brief notations describing the compliance methods, an
annotated copy of the standard, or a part of another document, such as the infection
control plan. The written exposure control plan must be available to workers and
OSHA representatives and updated at least annually or whenever changes in proce-
dures create new occupational exposures.
Who Has Occupational Exposure?

The exposure determination must be based on the definition of occupational exposure
without regard to personal protective clothing and equipment. Exposure determina-
tion begins by reviewing job classifications of employees within the work environment,
and then making a list divided into two groups: classifications in which all of the
employees have occupational exposure and classifications in which some of the
employees have occupational exposure.
Where all employees are occupationally exposed, it is not necessary to list specific
work tasks. Some examples include phlebotomists, laboratory technicians, physicians,
nurses, nurse’s aides, surgical technicians, and emergency department personnel.
Where only some of the employees have exposure, specific tasks and procedures
causing exposure must be listed. Examples include ward clerks or secretaries who occa-
sionally handle blood or infectious specimens and housekeeping staff who may be
exposed to contaminated objects or environments some of the time.
When employees with occupational exposure have been identified, the next step is
to communicate the hazards of the exposure to the employees.
Communicating Hazards to Employees

The initial training for current employees must be scheduled within 90 days of the
effective date of the blood-borne pathogens standard, at no cost to the employee, and
during working hours.1 Training also is required for new workers at the time of their
initial assignment to tasks with occupational exposure or when job tasks change, caus-
ing occupational exposure, and annually thereafter.
Training sessions must be comprehensive in nature, including information on
blood-borne pathogens as well as on OSHA regulations and the employer’s exposure
control plan. Although HBV and HIV are specifically identified in the standard, the
term blood-borne pathogen includes any pathogenic microorganism that is present in
human blood or other potentially infectious materials and can infect and cause disease
in persons who are exposed to blood containing the pathogen. Pathogenic microor-
ganisms also can cause diseases such as hepatitis C, malaria, syphilis, babesiosis, brucel-
losis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease,
adult T-cell leukemia/lymphoma (caused by human T-cell leukemia/lymphoma virus

[HTLV-I]), HTLV-I-associated myelopathy, diseases associated with HTLV-II, and
viral hemorrhagic fever. The person conducting the training must be knowledgeable in
the subject matter as it relates to acute care facilities.
Specifically, the training program must do the following:
• Explain the regulatory text and make a copy of the regulatory text accessible.
• Explain the epidemiology and symptoms of blood-borne diseases.
• Explain the modes of transmission of blood-borne pathogens.
• Explain the employer’s written exposure control plan.
• Describe the methods to control transmission of HBV and HIV.
• Explain how to recognize occupational exposure.
• Inform workers about the availability of free hepatitis B vaccinations, vaccine
efficacy, safety, benefits, and administration.
• Explain the emergency procedures for and reporting of exposure incidents.
• Inform workers of the postexposure evaluation and follow-up available from
health care professionals.
• Describe how to select, use, remove, handle, decontaminate, and dispose of
personal protective clothing and equipment.
• Explain the use and limitations of safe work practices, engineering controls
(controls that isolate or remove the blood-borne pathogens hazard from the
workplace; examples include needleless devices, shielded needle devices, blunt
needles, plastic capillary tubes), and PPE.
• Explain the use of labels, signs, and color coding required by the standard.
• Provide a question-and-answer session on training.
In addition to communicating hazards to employees and providing training to iden-
tify and control hazards, other preventive measures must be taken to ensure employee
protection.
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.
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.
• Use puncture-resistant, leak-proof containers, color-coded red or labeled to

store contaminated reusable sharps until they are properly reprocessed.
• Store and process reusable contaminated sharps in a way that ensures safe
handling. Use a mechanical device to retrieve used instruments from soaking
pans in decontamination areas.
• Use puncture-resistant, leak-proof containers to collect, handle, process, store,
transport, or ship blood specimens and potentially infectious materials. Label
these specimens if shipped outside the facility. Labeling is not required when
specimens are handled by employees trained to use universal precautions with
all specimens and when these specimens are kept within the facility.
Labeling Requirements
Item No Label Needed Biohazard Red

If Universal Precau- Label Container
tions Are Used and
Specific Use of
Container Is Known
to All Employees
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
Item No Label Needed Biohazard Red

If Universal Precau- Label Container
tions Are Used and
Specific Use of
Container Is Known
to All Employees
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,
leak-proof, red or biohazard-labeled containers5 that are accessible, maintained

upright, and not allowed to be overfilled.
• Do not eat, drink, smoke, apply cosmetics, or handle contact lenses in areas of
potential occupational exposure. (Note: Use of hand lotions is acceptable.)
• Do not store food or drink in refrigerators or on shelves where blood or poten-
tially infectious materials are present.
• Use red, or affix biohazard labels to, containers to store, transport, or ship
blood or other potentially infectious materials, such as laboratory specimens
(Fig. A–6).
• Do not use mouth pipetting to suction blood or other potentially infectious
materials; it is prohibited.
FIGURE A–6
Additional Information on Engineering Controls

Effective Engineering Controls ECRI: Contact:
www.healthcare.ecri.org/site/whatsnew/press.releases/980724hdneedle.html. ECRI
(formerly Emergency Care Research Institute), designated as an evidence-based
practice center by the Agency for Healthcare Research and Quality, is a nonprofit
international health services research organization. This web site discusses the June
1998 issue of ECRI’s Health Devices, which evaluated 19 needle stick–prevention
devices, and provides information on how to obtain this document.
Food and Drug Administration (FDA) Safety Alert: Needlestick and other risks from
hypodermic needles on secondary IV administration sets—piggyback and
intermittent IV. Contact: www.fda.gov/cdrh/safety.html. Warns of the risk of
needlestick injuries from the use of hypodermic needles as a connection between
two pieces of intravenous (IV) equipment. Describes characteristics of devices that
have the potential to decrease the risk of needle stick injuries.
International Health Care Worker Safety Center, University of Virginia: Contact:
www.people.virginia.edu/epinet/products.html. Features a list of safety devices
with manufacturers and specific product names.
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.
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.
Personal Protective Equipment

In addition to instituting engineering and work practice controls, the standard requires
that appropriate PPE be used to reduce worker risk of exposure. Personal protective
equipment is specialized clothing or equipment used by employees to protect against
direct exposure to blood or other potentially infectious materials. Protective equip-
ment must not allow blood or other potentially infectious materials to pass through to
workers’ clothing, skin, or mucous membranes. This equipment includes, but is not
limited to, gloves, gowns, laboratory coats, face shields or masks, eye protection, and
resuscitator devices. Hypoallergenic gloves, glove liners, powderless gloves, or other
similar alternatives must be readily available and accessible at no cost to employees who
are allergic to the gloves normally provided.
The employer is responsible for providing, maintaining, laundering, disposing,
replacing, and ensuring the proper use of PPE. The employer is responsible for ensur-
ing that workers have access to the protective equipment, at no cost, including proper
sizes and types that take allergic conditions into consideration.
An employee may temporarily and briefly decline to wear PPE under rare and
extraordinary circumstances and when, in the employee’s professional judgment, it
prevents the delivery of health care or public safety services or poses an increased or
life-threatening hazard to employees. In general, appropriate PPE is expected to be
used whenever occupational exposure may occur.
The employer also must ensure that employees observe the following precautions
for safely handling and using PPE:
• Remove all PPE immediately after contamination and on leaving the work area
and place in an appropriately designated area or container for storing, washing,
decontaminating, or discarding.
• 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.
• Place other regulated waste7 in closable, leak-proof, red or biohazard-labeled

bags or containers. If outside contamination of the regulated waste container
occurs, place it in a second container that is closable, leak-proof, and appro-
priately labeled.
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.
What to Do If an Exposure Incident Occurs

An exposure incident is the specific eye, mouth, or other mucous membrane, nonin-
tact skin, or parenteral contact with blood or other potentially infectious materials that
results from the performance of an employee’s duties. An example of an exposure inci-
dent is a puncture from a contaminated sharp.
The employer is responsible for establishing the procedure for evaluating exposure
incidents. When evaluating an exposure incident, immediate assessment and confi-
dentiality are crucial issues. Employees should report exposure incidents immediately
to enable timely medical evaluation and follow-up by a health care professional as well
as a prompt request by the employer for testing of the source individual’s blood for
HIV and HBV. The “source individual” is any patient whose blood or body fluids are
the source of an exposure incident to the employee.
At the time of the exposure incident, the exposed employee must be directed to a
health care professional. The employer must provide the health care professional with
a copy of the blood-borne pathogens standard; a description of the employee’s job
duties as they relate to the incident; a report of the specific exposure, including route
of exposure; relevant employee medical records, including hepatitis B vaccination
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.
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.
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.)
Other Sources of OSHA Assistance
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.
Voluntary Protection Programs

Voluntary protection programs and on-site consultation services, when coupled with
an effective enforcement program, expand worker protection to help meet the goals of
the Occupational Safety and Health Act. The three voluntary protection programs —
Star, Merit, and Demonstration—are designed to recognize outstanding achievement
by companies that have incorporated comprehensive safety and health programs
successfully into their total management system. They motivate others to achieve
excellent safety and health results in the same outstanding way, and they establish a
cooperative relationship between employers, employees, and OSHA.
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
• An explanation of the types, uses, location, removal, handling, decontamina-

tion, and disposal of PPE
• An explanation of the basis for PPE selection
• Information on the hepatitis B vaccine, including information on its efficacy,
safety, method of administration, the benefits of being vaccinated, and that the
vaccine will be offered free of charge
• Information on the appropriate actions to take and persons to contact in an
emergency involving blood or OPIM
• An explanation of the procedure to follow if an exposure incident occurs,
including the method of reporting the incident and the medical follow-up that
will be made available
• Information on the postexposure evaluation and follow-up that the employer
is required to provide for the employee after an exposure incident
• An explanation of the signs and labels or color coding required by the standard
and used at this facility
• An opportunity for interactive questions and answers with the person conduct-
ing the training session
For more information on grants and training and education, contact the OSHA
Training Institute, Office of Training and Education, 1555 Time Drive, Des Plaines,
IL 60018, (708) 297-4810. For more information on AIDS, contact the Centers for
Disease Control National AIDS Clearinghouse, (800) 458-5231.
OSHA References for Hepatitis C and HIV

Occupational Exposure to Bloodborne Pathogens OSHA Instruction, Field Inspection
Manual. The current CDC recommendation for HCV is found in “Recommendations
for Prevention and Disease Control of Hepatitis C Virus (HCV) Infection and HCV-
Related Chronic Disease,” Morbidity and Mortality Weekly Report, vol 47, no. RR-19,
1998. Contact: www.cdc.gov/epo/mmwr/preview/mwrhtml/00055154.htm. The
most current HIV postexposure follow-up recommendations for an exposure incident
made applicable by the blood-borne pathogens standard are found in the CDC:
“Public Health Service Guidelines for the Management of Health-Care Worker
Exposures to HIV and Recommendations for Postexposure Prophylaxis,” Morbidity
and Mortality Weekly Report, vol 47, no. RR-7, 1998. Contact: www.cdc.gov/epo/
mmwr/preview/mmwrhtml/00052722.htm.
SOURCE: Bloodborne Pathogens and Acute Care Facilities (OSHA 3128), Occupational
Safety and Health Administration, Washington, DC, 1992.
Copyright 2001 by F. A. Davis Company.

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INDEX
A1AT. See 1-Antitrypsin ABR. See Auditory brain stem response

A1c. See Glycated hemoglobin A1c (ABR)
Abdomen Abruptio placentae, 50, 509, 959
CT of, 347–350, 354, 367–368, 384–385 Acalculous cholecystitis, 583
gastrointestinal blood loss scan and, Acanthocyte(s), 869
531–534 Accessory spleen, CT and, 385
KUB and, 641–643 AcCHS. See Pseudocholinesterase
liver and spleen scan and, 671 ACE. See Angiotensin-converting enzyme
Meckel’s diverticulum scan and, 719–722 (ACE)
MRI of, 694–697, 707–710 Acetaminophen, 54–56, 649
plethysmography and, 789 Acetone. See Ketones
ultrasound of, 961–966 Acetylcholine receptor antibody (AChR), 1-2
Abdominal angiogram/abdominal Acetylcholinesterase, 841
arteriography, 56–60 amniotic fluid analysis and, 47–50
Abdominal aortic aneurysm, 385, 695 red blood cells and, 857–858
Abdominal laparoscopy, 652–655 Acetylcysteine, acetaminophen intoxication
Abdominal malignancy, peritoneal fluid and, 55
analysis and, 773–774 Acetylsalicylic acid (ASA), 54–56
Abdominal pain clot retraction and, 321
acetaminophen intoxication and, 55 poisoning from, AGAP and, 82
BE and, 167 Achalasia, 171, 479, 982
differential diagnosis of, 52, 642 Achondroplasia, 855
laparoscopy and, 652 AChR. See Acetylcholine receptor antibody
LTT and, 650 (AChR)
Meckel’s diverticulum scan and, 720 Acid-base balance
proctosigmoidoscopy and, 821 blood gases and, 218–223, 227
urine porphyrins and, 798 carbon dioxide and, 268
Abdominal trauma, peritoneal fluid analysis chloride and, 294
and, 773 osmolality and, 745
Abdominal vascular diseases, MRA and, 69 potassium and, 811, 815
ABGs. See Blood gases serum sodium and, 894
ABO blood group system, 228, 617 Acid elution slide test. See Kleihauer-Betke
Abortion test
AFP and, 508 Acid-fast bacilli (AFB), 412–417, 795
amniotic fluid analysis and, 51 Acid perfusion test. See Esophageal
blood groups and antibodies and, 228 manometry
chromosome analysis and, 320 Acid phosphatase, prostatic (PAP), 2–4
CMV and, 438 Acid reflux test. See Esophageal manometry
HCG and, 597–598 Acidified hemolysis, Ham’s test for
parvovirus B19 and, 767 paroxysmal nocturnal hemoglobinuria
progesterone and, 824–825 reference value for, 557
1103
1104 Index
Acidosis carbon dioxide and, 268

fetus and, 49 cholesterol and, 315
calcium and, 257, 260 respiratory acidosis and, 222
chloride and, 294 TBG and, 919
ketones and, 639 Acute myeloblastic leukemia, bone marrow
lactic acid and, 648 biopsy and, 182
osmolality and, 746 Acute myelogenous leukemia, PAP levels in,
pH and, 218–223, 226–227 3
potassium and, 812, 816 Acute myeloid leukemia, platelet antibodies
Acoustic neuroma(s), 490, 699 and, 783
Acquired immuno hemolytic anemia, osmotic Acute myocardial infarction scan. See
fragility and, 748 Myocardial infarction, scan of
Acquired immunodeficiency syndrome Acute pancreatitis
(AIDS) ALT levels in, 12
Alzheimer’s disease markers and, 32 amino acid screen, blood, and, 36
CD4/CD8 enumeration and, 281 aspartate aminotranspeptidase levels and,
gallium scan and, 519 144
HIV antibodies and, 600 calcium and, 260
2-M and, 732 CT and, 368
Mycobacterium culture and smear and, 414 glucagon and, 535
platelet antibodies and, 783 Acute pelvic inflammatory disease,
sputum cytology and, 432 differential diagnosis of, 247
viral culture and, 419 Acute-phase reactions
zinc and, 1035 complement and, 337, 339
Acquired porphyria(s), 798 prealbumin and, 819
Acrodermatitis enteropathica, 1035 Acute porphyrias, -aminolevulinic acid and,
Acromegaly 43
calcium and, 260 Acute renal failure
creatinine and, 405, 408 amino acid screen, blood, and, 36
GH tests and, 555 BUN and, 985
glucagon and, 535 carbon dioxide and, 268
glucose and, 538 chloride and, 295
insulin response test and, 625 potassium and, 812
phosphorus and, 776 renogram and, 876
TBG and, 920 Acute respiratory distress syndrome, A/a
WBC and, 1028 gradient, a/A ratio and, 30
ACTH. See Adrenocorticotropic hormone Acute respiratory failure, viral culture and,
(ACTH) 419
Actinomyces, 418, 757 Acute stress, Apo B and, 137
Activated charcoal AD. See Alzheimer’s disease (AD)
anticonvulsant toxicity and, 114–115 Addison’s disease
antidepressant toxicity and, 120–121 ACTH and, 10
cardiac glycoside toxicity and, 87 aldosterone levels and, 20
haloperidol toxicity and, 127 chloride and, 295, 298
lithium toxicity and, 127 cortisol and, 399–400
salicylate toxicity and, 55–56 DHEAS and, 445
Activated partial thromboplastin time eosinophil count and, 471
(APTT), 764–767 fecal fat and, 499
lupus anticoagulant antibodies and, 680 glucose and, 538, 544
Activity intolerance, exercise stress test and, magnesium and, 689
494 pH and, 221
Acute bacterial arthritis, 900–901 potassium and, 812, 816
Acute hypertensive episode, catecholamines renin and, 873
and, 274–275, 278 serum sodium and, 894
Acute intermitten porphyria WBC and, 1028
ADH levels in, 123 Adenoma(s)
Index 1105
aldosterone levels and, 20 Agammaglobulinemia, IgE and, 615

CT of, 374–375, 378 Agglutination
glucose and, 538 blood groups and antibodies and, 228-230
liver and spleen scan and, 671 cold agglutinin titer and, 326
thyroid scan for, 912 DAT and, 391
ultrasound of, 954 IAT and, 393–394
Adenopathy, lymphangiography and, 686 Agitation, antidepressant toxicity and, 121
Adenosine diphosphate (ADP), pyruvate Agranulocytosis, 87, 183
kinase and, 850 AHF. See Antihemophilic factor (AHF)
Adenosine triphosphate (ATP), pyruvate AIDS. See Acquired immunodeficiency
kinase and, 851 syndrome (AIDS)
Adenovirus, culture of, 420 Air-contrast barium enema. See Barium
ADH. See Antidiuretic hormone (ADH) enema
Adhesions, laparoscopy and, 653, 656 Airway abnormalities, PFTs and, 844
Adrenal adenoma Airway obstruction, 268
adrenal angiography and, 61 Airway resistance, plethysmography and,
adrenal gland scan for, 5 789–790
cortisol levels and, 10, 399–400 Akinesia, blood pool imaging and, 232
Adrenal angiogram/adrenal arteriography, -ALA. See -aminolevulinic acid (-ALA)
60–64 Alanine, amino acid screens and, 34, 38
Adrenal carcinoma, 10, 61, 538 Alanine aminotransferase (ALT), 12–14
Adrenal corticosteroids, ACTH and, 10 acetaminophen intoxication and, 55
Adrenal dysfunction, 860, 897 aspartate aminotranspeptidase and, 144
Adrenal gland Albinism, 1027
ADH levels in, 123 Albright-type renal disease, 816
cortisol and, 399 Albumin (Alb), 14–16. See also
CT and, 378 Microalbumin
DHEAS and, 445 calcium and, 259–260
LDH and, 646 FEP and, 473
Adrenal gland scan (adrenal scintiscan), 4–7 protein fractions and, 925–926
Adrenal hyperplasia, 61, 348, 445, 906 zinc and, 1035
Adrenal insufficiency, 446, 544, 826 Albumin/globulin ration (A/G ratio), 14–16
Adrenergic tumors, 5, 445, 486 Alcaptonuria, amino acid urine screen and,
CT and, 348, 378 40
Adrenocortical hyperfunction, 36, 556 Alcohol. See Ethanol
Adrenocortical insufficiency, magnesium and, Alcohol toxicity, 786
689 Alcohol withdrawal, phosphorus and, 776
Adrenocortical tumors, 906 Alcoholic hepatitis, AMA and, 108
Adrenocorticoid insufficiency, 745 Alcoholic myopathy, muscle biopsy and, 204
Adrenocorticotropic hormone (ACTH) tests, Alcoholism, 447–448
7–11 acetaminophen and, 55
cortisol and, 398–400 AGAP and, 82
DHEAS and, 445 Alb, A/G ratio and, 15
Adrenogenital syndrome, cortisol and, 400 ALT levels in, 13
Adrenoleukodystrophy, VER and, 491 -aminolevulinic acid and, 43
Adult lymphoblastic (T-cell) leukemia, HTLV amylase levels and, 52–53
antibodies and, 603 bilirubin and, 174
Aerobic organisms calcium and, 261
blood culture for, 153–156 cholesterol and, 311, 315
sputum culture for, 157 CK and, 402
tissue culture for, 149–153 EMG and, 464
Aeromonas spp., stool culture for, 161 ferritin and, 502
AFB. See Acid-fast bacilli (AFB) folate and, 514
Afibrinogenemia, 765, 838 FSH and, 516
AFP. See 1-Fetoprotein (AFP) GGT and, 547
AGAP. See Anion gap (AGAP) GTT and, 544
1106 Index
Alcoholism (Continued ) A/a gradient, a/A ratio), 29–31

IgE and, 615 Alveolar gas exchange, 221
ketones and, 639 Alveolar hemorrhage, 94
LDH and, 646 Alveoli
lipoprotein electrophoresis and, 669 bronchoscopy for, 242
magnesium and, 689–690, 692 PFTs and, 844
potassium and, 812 Alzheimer disease (AD)
prealbumin and, 819 markers for, 32–34
RBCs and, 864, 869–870 PET and, 801–802
reticulocyte count and, 879 AMA. See Antimitochondrial antibody
sweat chloride and, 298 (AMA)
TG and, 932 Ambiguous sexual differentiation, 516
total protein and, 926 Amblyopia, VER and, 491
total testosterone and, 906 Ambulatory electrocardiography. See Holter
uric acid and, 993 monitor
urine urate and, 995 Amebiasis, 196, 752
vitamins and, 1012, 1021 Amebic abscess
WBC and, 1028 liver and spleen scan and, 671–672
Aldolase (ALD), 17–18 MRI and, 695
Aldosterone, 19–22, 147, 812, 870, 872 Amebic colitis, fecal analysis and, 497
Aldosterone-secreting adrenal adenoma, 873 Amebic meningitis, CSF analysis and, 284
Aldosteronism, adrenal gland scan for, 5 Amenorrhea, 236, 318, 655, 826
Alglucerase, PAP levels with, 3 American Cancer Society personal breast-care
Alkali ingestion, blood gases and, 221–222 plan, 717
Alkaline phosphatase and isoenzymes (Alk American Diabetes Association, diabetes
Phos, ALP), 22–26 diagnosing criteria from, 537–538, 543
peritoneal fluid analysis and, 774 Amikacin, 90–93
Alkalosis, 31 -Aminioiso-butyric acid, 35, 38
pH and, 218–222, 227 Amino acid(s)
potassium and, 812, 816 deamination of, 45
urine sodium and, 897 urine protein and, 834
Allen test, 31, 225 Amino acid metabolism errors, 48, 189
Allergen-specific immunoglobulin E (Allergen Amino acid screen(s)
profile, RAST), 27–29 blood, 34–38
Allergic reaction(s) urine, 38–42
IgE and, 615 Aminoaciduria(s), 40
insulin antibodies and, 627 -Amino adipic acid, 34, 38
latex and, 658–659 -Amino-butyric acid, 35, 38
PFTs and, 844, 846 Aminodiacetic acid compound(s), 582–583
total complement and, 339 Aminoglycosides, 90-93
Allergies, 470, 1028 toxicity of, 732
Allergic rhinitis, 28 -Amino-n-butyric acid, 34, 38
Alloimunization, 783 -Aminolevulinic acid (-ALA), 43–45, 798
ALP. See Alkaline phosphatase and Amitriptyline, 118–121
isoenzymes Ammonia (NH3), 45–47, 774
Alpha-antitrypsin. See 1-Antitrypsin Amniocentesis, 48, 50–51
Alpha-fetoprotein. See -Fetoprotein AFP and, 506
Alpha islet-cell neoplasm, 535 L/S ratio and, 662–664
Alpha lipoprotein cholesterol. See Amniotic fluid analysis, 47–51, 318, 506,
Alpha lipoprotein deficiency, 137, 499 Amphetamines, 447–449
Alpha tocopherol. See Vitamin E Ampulla of Vater, ERCP and, 307
ALT. See Alanine aminotransferase (ALT) Amylase, 51–53, 774, 795
Altitude, blood gases and, 221–222 Amyloid plaque, Alzheimer’s disease markers
Alveolar/arterial gradient and arterial/ alveolar and, 32
oxygen ratio (alveolar-arterial difference, Amyloidosis
Index 1107
C3 complement and, 337 Hgb and, 567–568

D-xylose tolerance test and, 442 IAT and, 394
fecal fat and, 499 iron and, 634, 637
gastric emptying scan and, 525 Kleihauer-Betke test and, 644
IFE and, 613 LDH and, 647
liver and spleen scan and, 672 lead and, 660
liver biopsy and, 196 platelet count and, 786
lung biopsy and, 199 pulse oximetry and, 849
2-M and, 732 pyruvate kinase and, 851
osmolality and, 745 RBCs, 860, 864, 869
urine protein and, 835 reticulocyte count and, 879
Amyloidosis infiltration, kidney biopsy and, thyroid antibodies and, 104
193 vitamin deficiency and, 1021
Amyotrophic lateral sclerosis, 1, 204 WBC and, 1028
EMG and, 464–465 zinc and, 1035
Amyotonia, 464 Anencephaly, 507
ANA. See Antinuclear antibodies (ANA) Anesthesia, blood gases and, 222
Anaerobic organisms Aneurysm
blood culture for, 153–156 abdominal angiography and, 57–58
sputum culture for, 157 arterial ultrasound and, 945
tissue culture for, 149–153 coronary angiography and, 65
Anal fissure, 497, 821 CT and, 348, 351–352, 354, 359, 371,
Anal tissue, bacterial culture for, 149–153 374–375, 378, 381, 385, 388–389
Analgesic and antipyretic drugs, MRI and, 698–699, 715
acetaminophen and acetysalicylic acid as, PET and, 801, 805
54–56 pulmonary angiography and, 71
Anaphylaxis, 28, 617, 1028 renal angiography and, 75
angiography and, 73, 77 TEE and, 454
Anastamoses, 171, 821 ANF. See Atrial natriuretic factor (ANF)
Ancyclostoma duodenale, O & P and, 752 Angelman syndrome, 318
Androgen levels, 3, 5, 445 Angiitis, 94
Androgen resistance, 906 Angina
Anemia(s). See also specific kinds of anemia, COHb and, 271
e.g. Pernicious anemia coronary angiography and, 65
ALD levels in, 17 D-dimer and, 439
ALP levels in, 25 myocardial perfusion heart scan and, 740
anticonvulsant toxicity and, 115 PET and, 805
Apo B and, 137 Angina pectoris, unstable, 938
BE and, 167 Angiocardiography, 64–68
bleeding time and, 214 Angiodysplasia, 532
blood gases and, 222 Angioedema, complement and, 337, 339
bone marrow biopsy and, 183 Angiography
CBC and, 345 abdominal, 56–60
chloride and, 294 adrenal, 60–64
cholesterol and, 312, 315 coronary, 64–68
colonoscopy and, 330 CT and, 351–354
complement and, 338–339 magnetic resonance, 68–71
copper and, 396 pulmonary, 71–74
creatinine clearance and, 408 renal, 74–78
DAT and, 391 Angioplasty, 57, 61, 65, 69, 75
differential diagnosis of, 502 myocardial perfusion heart scan and, 740
EPO and, 477 postoperative evaluation of, 695, 701
ESR and, 475 Angiotensin, 20, 147, 872
FEP and 473 Angiotensin-converting enzyme (ACE),
G6PD and, 541 78–80
Hct and, 563–564 Anion gap (AGAP), 81–83, 294
1108 Index
Anisocytosis, 864 antithyroglobulin and antithyroid

Ankylosing spondylitis, 396, 602 peroxidase, 103–104
Ankylosis, 142 cardiolipin, immunoglobulin G, and
Anomalous pulmonary venous drainage, immunoglobulin M, 105–106
pulmonary angiography and, 71 DAT and, 392
Anorchia, 682 gliadin (immunoglobulin G and
Anorectal infections, 420 immunoglobulin A), 106–108
Anorexia nervosa Jo-1, 111–112
ACE levels and, 79 IAT and, 393–394
Apo B and, 136 Antibody/human leukocyte antigen
bilirubin and, 174 reaction(s), 787
blood gases and, 222 Anticentromere antibodies, 97–98
cholesterol and, 312, 315 Anticoagulant(s)
digoxin toxicity and, 86 angiography and, 59, 62, 73
FSH and, 516 antiarrhythmic levels and, 88
gastric emptying scan and, 525 antidepressant toxicity and, 121
GH tests and, 555 APTT and, 765
LH and, 682 proteins and, 830, 833
potassium and, 812 PT and, 837
PRL and, 826 Anticonvulsant drugs, 112–116
TG and, 932 calcium and, 261
WBC and, 1028 Anticytoplasmic neutrophilic antibodies,
Anoscopy, 820 94–96
Anovulation, 445, 682, 906 Antideoxyribonuclease-B, streptococcal
Anoxia, 222, 270 (ADNase-B), 116–118
Antacids Antidepressant drugs, 118–121
excessive intake of, 260 Antidiabetic medications, 120
fecal analysis and, 497 Antidiuretic hormone (ADH), 122–124
metabolic alkalosis and, 221 excessive production of, 894
overuse of, 690 inappropriate secretion of, 295, 690, 692
Anterior pituitary hypofunction, 516 osmolality and, 745
Anti-DNA antibodies, 97 Antiestrogen therapy, 487
Anti-extractable nuclear antigens/antibodies, Antigens/antibodies
124–125 anti-extractable nuclear, 124–125
Antianginals, 494 blood groups and, 228
Antiarrhythmic drugs, 84–89 cold agglutinin titer and, 326
ECG and, 457 eosinophil count and, 470
exercise stress test and, 494 Antihormone therapy, 488
Holter monitor and, 590 Antihuman globulin, 393–394
Antibiotic drugs, 90–93 Antiglobulin, 228
enterocolitis from, 496 Anti-glomerular basement membrane
fecal analysis and, 497 antibodies (anti-GBM), 95–96
sensitivity testing for, 154, 157, 161, 163, Antihemophilic factor (AHF), 322
165 Antihistidyl transfer tRNA synthase, ASMA
vitamin deficiency and, 1019 and, 111
Antibodies Antimanic drugs, 126–128
anticytoplasmic neutrophilic, 94–96 Antimetabolite therapy, 864
anti-glomerular basement membrane (anti- Antimicrobial removal device (ARD),
GBM), 95–96 154–155
antimitochondrial (AMA), 108–109 Antimicrobial therapy, 149–150, 154, 156
antinuclear (ANA), anti-DNA, and Antineoplastic agents, 79, 272, 1028–1029
anticentromere, 97–99 Antinuclear antibodies (ANA), 97–98, 111
antiscleroderma, 99–100 Antiphospholipid antibody, 105
anti-smooth muscle (ASMA), 109–111 Antiphospholipid syndrome, 125
antisperm, 100–101 Antiplatelet antibody. See Platelet antibodies
antistreptolysin O (ASO), 102–103 Antipsychotic drugs, 126–128
Index 1109
Antipyretic drugs, 54–56 Arrhythmias. See also Atrial arrhythmias,

Antiretroviral therapy, 732 Ventricular arrhythmias
Antiscleroderma antibodies, 99–100 angiography and, 59, 63, 67, 73, 77
Antisperm antibodies, 100–101 antidepressant toxicity and, 121
Antistreptococcal DNase-B titer, 116–118 aspartate aminotranspeptidase levels and,
Antithyroglobulin antibodies, 103–104 144
Antithyroid peroxidase antibodies, 103–104 calcium and, 260
Antithrombin III (AT-III), 128–130, 764 cardiac glycoside toxicity and, 85–87
1-Antitrypsin and 1-Antitrypsin ECG of, 457–458
phenotyping, 130–133 Holter monitor and, 590
Anuria, 87 lithium toxicity and, 127
Anus, proctosigmoidoscopy of, 820–823 magnesium and, 689, 692
Anxiety, 122, 268 potassium and, 811
respiratory alkalosis and, 221–222 Arsenic intoxication, 870
RBC count and, 860–861 ART. See Automated reagin testing
Aortic aneurysm Arterial blood gases, 216–218, 223, 225
CT and, 348, 352, 355, 385, 388–389 PFTs and, 844
magnetic resonance angiography and, 69, pulse oximetry and, 848
695, 702 Arterial blood pressure, 78
Aortic disease Arterial blood oxygen saturation (SPO2),
coronary angiography and, 65 pulse oximetry and, 848
echocardiography and, 451, 454 Arterial hypertension, 876
MRI and, 701–702 Arterial hypoplasia, pulmonary angiography
Aortoduodenal fistula, 532 and, 71
Aplasia(s), 851 Arterial infarct, pulmonary angiography and,
Aplastic anemia 73
bone marrow biopsy and, 182–183 Arterial occlusion
CD4/CD8 enumeration and, 281 plethysmography and, 790–791
eosinophil count and, 471 renal angiography and, 75
Hgb electrophoresis and, 571 ultrasound and, 945, 967
iron and, 634 Arterial plethysmography, 789–792
LAP and, 665 Arterial puncture, 223, 225
MRI and, 705 Arterial stenosis
parvovirus B19 and, 767 abdominal angiography and, 57–58
platelet antibodies and, 783 adrenal angiography and, 61
platelet count and, 786 pulmonary angiography and, 71
RBC morphology and inclusions and, 869 renal angiography and, 75
reticulocyte count and, 879 Arterial thrombosis, 105, 439
WBC and, 1029 Arterial ultrasound. See Ultrasound, arterial
Apnea Doppler; Ultrasound, peripheral Doppler
bronchoscopy for, 242 Arteries
red blood cell cholinesterase and, 858 plethysmography and, 789–792
Appendicitis, 247, 652–653, 1028 ultrasound of, 942–946, 966–968
Appendix, 167–168, 695 Arteriosclerosis, 1035
ultrasound of, 963–966 Arteriovenous fistula, 876
Apolipoprotein A (Apo A), 133–135 angiography of, 57–58, 61, 75
Apolipoprotein B (Apo B), 136–138 Arteriovenous malformation(s), 71, 699
APTT. See Activated partial thromboplastin arterial ultrasound and, 945
time (APTT) CT and, 358–359
Arginine Arthralgia, Lyme disease and, 684
amino acid screens and, 35, 38 Arthritis
GH stimulation test and, 555 arthrogram and, 139
Arginine vasopressin hormone. See arthroscopy for, 141–142
Antidiuretic hormone (ADH) bone scan for, 239
Argonz-Del Castillo syndrome, 827 bone radiography and, 856
Arm, plethysmography and, 789 Jo-1 antibody and, 111
1110 Index
Arthritis (Continued ) WBC and, 1028

HP and, 559 Asymptomatic cardiac volume overload, 147
Lyme disease and, 684 Asystole, quinidine toxicity and, 87
MRI and, 705 Ataxia
myocardial perfusion heart scan and, 740 anticonvulsant toxicity and, 114–115
parvovirus B19 and, 768 antidepressant toxicity and, 120
white blood cell scanning for, 238, 1032 lithium toxicity and, 127
Arthrocentesis. See Synovial fluid analysis quinidine toxicity and, 87
Arthrogram, 138–140, 142 Ataxia-telangiectasia, 615, 618
Arthroscopy, 141–143 Atelectasis, 30, 222, 290
Artificial organs, platelet count and, 787 lung scanning and, 674–675, 677
ASA. See Antibody, anti-smooth muscle plethysmography and, 790–791
(ASA) Atherectomy, 57, 61, 75
Asbestosis, 846 Atherosclerosis
Ascariasis, 752 angiography and, 59, 63, 65, 77
Ascites C-reactive protein and, 247
abdominal laparoscopy and, 653 carotid ultrasound and, 943
KUB and, 642 COHb and, 271
liver and spleen scan and, 671 creatinine clearance and, 408
MRI and, 711 CT and, 352
peritoneal fluid analysis and, 773 homocysteine and, 593–594
Ascorbic acid. See Vitamin C plethysmography and, 789–790
Aseptic meningitis, mumps serology and, 735 RBC count and, 859
ASO. See Antistreptolysin O (ASO) renogram and, 876
Asparagine, 35, 38 TG and, 932
Aspartate aminotransferase (AST), Athletic injury, arthroscopy for, 141
acetaminophen intoxication and, 55 Atopic dermatitis, 28, 659
Aspartate aminotranspeptidase (AST), Atopic eczema, 27
143–146 ATP. See Adenosine triphosphate (ATP)
Aspartic acid, 35, 38 Atransferrinemia, 930
Aspergilloma, 72 Atrial arrhythmias, 85–86
Aspergillosis, 615 Atrial hypertrophy, 457–458
Aspergillus, 418, 607 Atrial natriuretic factor (ANF), 146–148
Aspiration Atrial tachycardia, 147
bone marrow biopsy and, 181–182, 184 Atrial thrombi, 451–452, 454–455
bronchoscopy for, 241–242 Atrial tumor(s), 451, 454
GE reflux scan and, 529 Atrial venous shunt(s), 30
lung biopsy and, 198 Atrophic changes
thyroid biopsy and, 211 colposcopy and, 334
ultrasound and, 952 CT and, 358
Aspiration scan, 529–531 Atypical depression, 120
Asplenia, 385, 748 Auditory brain stem response (ABR),
Asthma 490–492
blood gases and, 220–222 Auditory nerve, 358
carbon dioxide and, 268 Autoimmune disorders
chest x-ray for, 289 C-reactive protein and, 247
coronary angiography and, 67 CD4/CD8 enumeration and, 281
eosinophil count and, 471 complement and, 337–339
IgE and, 615 cryoglobulin and, 411
lung scanning and, 674–675, 677 CSF analysis and, 283–284
PFTs and, 846 DAT and, 391
plethysmography and, 790 ESR and, 475
potassium and, 812 IgG and, 618
RAST in, 27–28 insulin antibodies and, 627
sputum cytology and, 432 2-M and, 732
vitamin deficiency and, 1021 platelet antibodies and, 783
Index 1111
protein fractions and, 926 BAER. See Evoked brain potentials

Autoimmune hemolysis, HP and, 559 Baker’s cyst, 141
Autoimmune kidney disease, 96 Barbiturates, 447–448
Autoimmune liver disease, 94, 110 Bard BTA. See Bladder cancer markers
Autoimmune response, platelet antibodies Barium
and, 783 angiography and, 58, 62, 76
Autoimmune thyroid disorders, 104 fecal analysis and, 497
Automated reagin testing (ART), syphilis stool culture and, 161
serology and, 903 Barium enema (BE), 167–170, 365
Autonomic nervous system dysfunction, Barium swallow, 170–173, 191
catecholamines and, 275, 278 Bart’s hemoglobin, electrophoresis and, 571
Autosomal chromosome defects, 318–319 Bartter’s syndrome, 20, 692, 873
Autosomal-dominant trait(s), catecholamines Basal acid output (BAO), 522–523
and, 275, 278 Basal cell carcinoma, 209
Autosomal-recessive trait(s) Base deficit, blood gases and, 218–219
1-AT deficiency as, 131 Base excess, blood gases and, 218, 220, 223
sweat chloride and, 297 Basophils, 341–342, 346, 1025–1026
Tay-Sachs disease as, 588 Basophilic leukemia, 522
Avascular necrosis, 705 Basophilic strippling, 861, 870
Axillary lymph nodes, biopsy of, 202 BE. See Barium enema (BE)
Azoospermia, 889 Beckwith-Wiedemann syndrome, 318
Azotemia, 46, 745, 894, 897 Behavior problems, haloperidol for, 126
AZT. See Zidovudine (AZT) Bell’s palsy, 465
Bence Jones proteins, 835
Babesia, RBC morphology and inclusions Benign prostatic hypertrophy, 3, 829, 969
and, 870 Benign strictures, PTC and, 301
Bacillus cereus, 161 Benzene toxicity, 798
Bacterial abscess, liver and spleen scan and, Benzodiazepine derivatives, 118–121
671–672 Benzodiazepines, 447–448
Bacterial culture(s) Beriberi, 465, 1021
anal/genital, ear, eye, skin, and wound, Bernard-Soulier syndrome, 214, 786
148–153 Bernstein test. See Esophageal manometry
blood, 153–156 Beta-agonists, stress testing and, 493
gram stain of, 551–553 Beta-lipoprotein cholesterol. See Cholesterol,
sputum, 156–160 HDL, LDL
stool, 160–162 Beta2-Microglobulin. See 2-Microglobulin
throat or nasal pharyngeal, 162–164 (2-M)
urine, 164–167 Bethesda System, 756
Bacterial empyema, 795 BGP. See Osteocalcin
Bacterial endocarditis, 475 Bicarbonate (HCO3)
Bacterial infections antidepressant toxicity and, 121
Alb, A/G ratio and, 15 blood gases and, 218–220, 222–223
1-AT and, 131 carbon dioxide and, 268
C-reactive protein and, 248 ketones and, 639
complement and, 337–339 PTH and, 759
fecal analysis and, 497 salicylate intoxication and, 55
IgM and, 618 Biclonal gammopathies, 613
platelet count and, 787 Bicornate uterus, 609
urinalysis and, 1001 Bilateral adrenal hyperplasia, 61
Bacterial overgrowth, 442, 754, 1013 Bile duct(s)
Bacterial pericarditis, 770 cholangiography of, 302, 304, 306
Bacterial peritonitis, 773 CT and, 348, 378
Bacterial pneumonia, 156–157, 795 ERCP of, 307–310
Bacterial septicemia, 776 hepatobiliary scan of, 582–585
Bacteremia, 154–156 ultrasound of, 953–955
BAEP. See Evoked brain potentials Bile duct diseases, 110
1112 Index
Bile duct obstruction, 52, 302, 497 prostate, 206–208, 427

Bile salt deficiency, 499 skin, 208–210
Biliary atresia, 25, 1017 thyroid, 210–212
Biliary cirrhosis, 94, 287, 311, 396 tissue and, 821
Biliary disease, 174 Bipolar disease, 114
Biliary fistula, 221 Birth defects
Biliary sclerosis, 301 alcohol abuse and, 447
Biliary system chromosome analysis and, 317
cholangiography and, 301, 305 Bismuth, fecal analysis and, 497
CT of, 348, 354–357 Bladder
ultrasound of, 953–955 biopsy of, 176–178
Biliary tract disease, 754 CT of, 371, 378
Biliary tract obstruction cystometry of, 422–423
ALP levels and, 24–25 cystoscopy of, 425–426
ALT levels in, 12 IVP and, 628–631
aspartate aminotranspeptidase levels and, KUB and, 641–643
144 MRI and, 695, 711
bilirubin and, 174 perforation of, 774
cholangiography and, 301, 305 ultrasound of, 946–948
ERCP and, 307 voiding cystourethrography of, 428–431
GGT and, 547 Bladder calculi, 371, 629, 881
HP and, 559 Bladder cancer
PT and, 838 CK and, 403
ultrasound and, 954 cystoscopy and, 425
Biliary tract radionuclide scan. See IVP and, 629
Hepatobiliary scan ultrasound and, 947, 964
Bilirubin, 173–176 urine calcium and, 264
amniotic fluid analysis and, 47–49 urine markers of, 212–214
ERCP and, 307 voiding cystourethrography and, 429
FEP and, 473 Bladder distention, 642
urinalysis and, 998, 1000 Bladder tumor antigen (BTA), 213
Binocularity, VER and, 490 Blastocystis, 752
Biopsy Blastomyces, 199, 242
bladder, 176–178 Blebs, pulmonary angiography and, 71
bone, 179–181 Bleeding
bone marrow, 181–184 APTT and, 765
breast, 185–186 CSF analysis and, 283
bronchial tree, 241 fecal analysis for, 496
cervical, 187–188 FDP and, 509
chorionic villus, 189–190 platelet count and, 785–786
colonoscopy and, 330 proctosigmoidoscopy and, 821
CT and, 348, 354, 368, 371, 378, 381, PT and, 838
385 reticulocyte count and, 879
endometrium and, 824 vitamin K and, 1018
endoscopic, 561 Bleeding disorder(s)
gram stain and, 551–553 A/a gradient, a/A ratio and, 30–31
intestinal, 191–193, 482, 652 acetaminophen and, 54
kidney, 193–195, 952 angiography and, 62, 67, 72, 75
laparoscopy and, 652, 655–656 arthroscopy and, 142
liver, 196–198, 954 contrast medium and, 58, 66
lung, 198–201 coagulation factors and, 323
lymph node, 201–204 Bleeding sites
mammography for, 717 bronchoscopy for, 242
mediastinoscopy and, 722, 724 colonoscopy for, 330–331
muscle, 204–206 cystoscopy for, 426–427
PET and, 808 Bleeding time, 214–216
Index 1113
Blighted ovum, 959 A1c and, 549

Blind loop syndrome, 514 bone marrow biopsy and, 183
Bloating, LTT and, 650 CBC and, 345
Blood CK and, 403
amniotic fluid analysis and, 49 Hct and, 563–564
CA 125 in, 249 Hgb and, 567
calcium in, 254, 256, 259 iron and, 634
fungal culture of, 417 RBC count and, 860
gram stain of, 551–553 reticulocyte count and, 879
HBV testing of, 577 Blood pool imaging, 231–234
HCV antibody and, 579 Blood pressure
Hgb and, 566–570 aldosterone levels and, 19
homocysteine and, 592 ANF and, 147–148
iron-binding capacity of, 930 cardiac scoring and, 362
ketones and, 638–641 exercise stress test and, 493–494
lactate in, 648 renin and, 872
2-M and, 733–734 serum sodium and, 894
uric acid and, 992–994 Blood sugar. See Glucose
urine and, 629 Blood transfusion
viral culture of, 419 bilirubin and, 174
Blood amino acid screen, 34–38 blood gases and, 223
Blood ammonia, 45 blood groups and antibodies and, 228–230
Blood-brain barrier, CT and, 358 calcium and, 261
Blood clot(s) CBC and, 346
MRI and, 695, 711 CMV and, 437–438
removal of, 242, 426 DAT and, 391–393
venography and, 1009 EPO and, 478
Blood clotting HBV testing before, 577
magnesium and, 689, 692 HCV antibody and, 579
APTT and, 764 Hct and, 563
platelet count and, 786 hemosiderin and, 573
PT and, 838 Hgb and, 567–568
Blood culture, 153–156 HIV antibodies and, 600
Blood dyscrasias, 345, 563, 567, 860, 864, HP and, 559
869 HTLV antibodies and, 603
WBC and, 1027 IAT and, 394
Blood flow IgA and, 617
CT and, 357, 361, 369 iron and, 634
ECG of, 456 platelet antibodies and, 783
echocardiography and, 450–451, 454 platelet count and, 787
lung perfusion scan and, 674 potassium and, 812
MRA and, 68–69, 695, 698, 701, 704, reticulocyte count and, 879
708, 711, 714 Blood urea nitrogen (BUN), 405, 984–986
myocardial perfusion heart scan and, Blood vessels
739–740 antiscleroderma antibodies and, 99
PET and, 801, 805 coagulation factors and, 323
plethysmography and, 789–790 cryoglobulin and, 411
pulse oximetry and, 848 CT of, 354, 371, 375, 378, 381, 385,
renogram and, 875–876 388
ultrasound and, 943, 945, 966–967, 979 diabetes and, 537, 543, 549
Blood gases, 216–227 mediastinoscopy of, 722
A/a gradient, a/A ratio and, 29–30 MRA of, 695, 701, 704, 711
Blood glucose, 475, 535 plethysmography and, 789–792
Blood groups and antibodies, 227–231 Blood volume, 15, 19, 122, 147
Blood incompatibility, 392, 394 BMD. See Bone mineral densitometry
Blood loss (BMD)
1114 Index
Body fluid(s) Bowel resection, 653, 1015

gram stain of, 551–553 Bradycardia, 494, 812
severe loss of, 690 Brain
Body plethysmography, 789–793 aspartate aminotranspeptidase and, 144
PFTs and, 843–844 catecholamines and, 274
Bone(s) CK and, 402–403
calcium and, 254, 259–260 CT and, 357–361, 374
chest x-ray for, 289 EEG and, 460–463
MRI and, 704–707 evoked potentials and, 489–493
NTx and, 328 MRI and, 697–700
phosphorus and, 776, 779 PET and, 800–804
Bone cancer red blood cell cholinesterase and, 857
biopsy for, 179–181 Brain damage
ceruloplasmin and, 287 amino acid screen, blood, and, 36
MRI and, 705 bilirubin and, 174–175
osteocalcin and, 750 CSF analysis and, 284
PAP levels in, 3 Brain death, 461
phosphorus and, 776 Brain disesases, CSF analysis and, 283–284
scan for, 238–239 Brain infarct, 932
urine calcium and, 263–264 Brain injury, SER and, 490
Bone disease, 263, 750 Brain stem auditory evoked potentials
ALP and, 24–25 (BAEP). See Evoked brain potentials
scan for, 238–241 Brain stem auditory evoked responses
vitamin D and, 1015 (BAER). See Evoked brain potentials
Bone x-rays, 855–857 Brain stem lesions, ABR and, 490
Bone GLA protein (BGP). See Osteocalcin Brain tumor(s)
Bone marrow ADH levels in, 123
biopsy of, 181–184 carbon dioxide and, 268
EPO and, 477 EEG and, 461
fungal culture of, 417 MRI and, 698
Hct and, 564 PET and, 801–802
iron and, 637 Branch-chained ketonuria, 639
MRI and, 705 Breast, ultrasound of, 948–950
Mycobacterium culture and smear of, 413 Breast biopsy, 185–186
parvovirus B19 and, 767 Breast milk jaundice, 174
RBCs and, 860, 870 Breast neoplasms
replacement of, 786 ALD levels in, 17
reticulocyte count and, 879 CA 125 in, 249
transplantation of, 439, 620 CA 15-3 in, 250
WBCs and, 1026–1029 CEA in, 272–273
Bone metabolism, 749–750 calcitonin and calcitonin stimulation tests
Bone mineral densitometry (BMD), 234–237 for, 254
Bone scan, 238–241 estrogen and progesterone receptor assays
Bordetella, 163 and, 487–488
Borrelia burgdorferi, 684

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Copyright © 2003 F.A.

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F. A. DAVIS COMPANY • PHILADELPHIA

Copyright © 2003 by F. A. Davis Company

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Acquisitions Editor: Lisa B. Deitch

To my parents, James and Marceline, who always told me I could do or be anything I

ABOUT THIS BOOK

viii About This Book

About This Book ix

• Pretest section addresses the need to:

x About This Book

Information provided in the appendices includes a summary of specimen collection

This page intentionally left blank

ABOUT THIS BOOK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

SYSTEM TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1037

Patient Preparation Before Diagnostic and Laboratory Procedures 1053

Organ/Disease Panels (with CPT Codes) 1065

Potential Nursing Diagnoses Associated with Laboratory

Guidelines for Age-Specific Communication 1069

Effects of Natural Products on Laboratory Values 1073

Standard Precautions (CDC Isolation Precautions) 1076

This page intentionally left blank

DESCRIPTION: When present, acetyl- • Thymoma associated with MG

2 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications

procedures. For related tests, refer Intratest:

ACID PHOSPHATASE, PROSTATIC

SYNONYMS/ACRONYM: Prostatic acid phosphatase, o-phosphoric

SPECIMEN: Plasma (1 mL) collected in lavender-top (ethylenediaminetetra-

Swab with vaginal secretions may be submitted in the appropriate transfer

REFERENCE VALUE: (Method: Enzyme immunoassay)

Acid Phosphatase, Prostatic 3

Conventional Units SI Units (Conversion Factor: 1.0)

DESCRIPTION: Acid phosphatases are • Acute myelogenous leukemia

4 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications

➤ Observe standard precautions and

ADRENAL GLAND SCAN

SYNONYM/ACRONYM: Adrenal scintiscan.

Adrenal Gland Scan 5

AREA OF APPLICATION: Adrenal gland.

DESCRIPTION: This nuclear medicine • Differentiate between asymmetric

6 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications

of being pregnant, unless the potential ➤ Obtain a history of the patient’s

Adrenocorticotropic Hormone (and Challenge Tests) 7

SYNONYM/ACRONYM: Corticotropin, ACTH.

8 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications

REFERENCE VALUE: (Method: Immunoradiometric assay)

ACTH Challenge Tests

ACTH (Cosyntropin) SI Units

Adrenocorticotropic Hormone (and Challenge Tests) 9

Corticotropin- 2–4-fold increase 2–4-fold increase

DESCRIPTION: The anterior pituitary occurring during the morning hours

10 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications

from morning to evening is clinically stimulation by ACTH occurs after an

Adrenocorticotropic Hormone (and Challenge Tests) 11

• Recent radioactive scans or radiation men collection takes approximately

12 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications

SYNONYMS/ACRONYMS: Serum glutamic pyruvate transaminase

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

REFERENCE VALUE: (Method: Spectrophotometry)

DESCRIPTION: Alanine aminotrans- INDICATIONS:

• Burns (severe) levodopa, lincomycin, low-molecular-

14 Davis’s Comprehensive Laboratory and Diagnostic Handbook—with Nursing Implications

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