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15 – Diagnostic Testing

June 20, 2024

Diagnostic Testing. Assisting with Diagnostic Manipulations

Nursing Care of the Client

Diagnostic testing is a critical element of assessment. Assessment data are used to formulate nursing diagnoses, a plan of care, and outcome measures in collaboration with the client. Ongoing client assessment and evaluation of the client’s expected outcomes requires the incorporation of diagnostic findings.

Preparing a Client for Diagnostic Testing

The nurse plays a key role in scheduling and preparing the client for diagnostic testing. “The emphasis of pretest is on appropriate test selection, proper patient preparation, individualized patient education, and emotional support” (Fischbach, 2000, p. 9). When tests are not scheduled correctly, the client is inconvenienced. It may also delay interventions, which places the client’s health status at risk. The institution is also at risk to lose money. Table 28-1 presents a sample protocol of the nursing care to prepare a client for diagnostic testing.

Care of the Client During Diagnostic Testing

Although the care of the client needs to be individualized for a specific procedure, general guidelines for client care during a procedure are given in Table 28-2. Protocols are used to assist the nurse with client care. Standard Precautions are initiated when exposure to body fluids presents a threat to the safety of the caregiver. Protective barriers, such as gloves and a gown, should be used during invasive procedures. The nurse is responsible for labeling any specimen with the client’s name, room number (hospitalized clients), date, time, and source of the specimen. Some specimens may need to be taken immediately to the laboratory or placed on ice (e.g., arterial blood gases).

In order to promote the client’s comfort and cooperation during diagnostic tests, nurses must consider the management of procedural pain. Although not all procedures are painful, advances in diagnostic and therapeutic studies have placed clients at risk for painful procedures. Clients who are repeatedly subjected to painful procedures without adequate analgesia become anxious and anticipate pain; if pain is experienced during one procedure, the client is reluctant to return for the same procedure or other tests. “Unrelieved procedural pain also can have adverse physiologic effects, even if the pain is temporary” (Pasero, 1998, p. 18).

Recognizing that diagnostic procedures are performed in various settings, intravenous conscious sedation (conscious sedation) is often used to manage pain during diagnostic testing.

Conscious sedation is a minimally depressed level of consciousness during which the client retains the ability to maintain a continuously patent airway and respond appropriately to physical stimulation or verbal commands (Fischbach, 2000). The nurse managing conscious sedation is usually functioning in an expanded role that requires additional education and demonstrated ability beyond basic education.

See the accompanying display for some procedures that may require analgesia or sedation.

Ongoing assessment of the client’s status is required during the procedure. Always assess the patency of theclient’s airway, which may be compromised by the client’s position, anesthesia, or the procedure itself. During an invasive procedure the nurse needs to monitor for signs and symptoms of accidental perforation of an organ (e.g., sudden changes in vital signs). The nurse has additional responsibilities:

· Preparing the room (e.g., adequate lighting).

· Gathering and charging for supplies used during the procedure

· Testing the equipment to ensure it is functional and safe

· Securing proper containers for specimen collection

Practitioners usually have preference cards within the diagnostic testing area that specify the type of equipment to be used, the position to place the client, and the type of sedation or anesthesia.

Care of the Client After Diagnostic Testing

Nursing care postprocedure is directed toward restoring the client’s prediagnostic level of functioning (Table 28-3). Nursing assessment and interventions are based mainly on the nature of the test and whether or not the client received anesthesia. Anesthesia can be administered in one of three ways:

· Local anesthesia—client loses sensation to a localized body part—spraying the back of the throat with lidocaine to decrease the gag reflex

· Regional anesthesia—client loses sensation in an area of the body—laparoscope for a tubal sterilization

· General anesthesia—client loses all sensation and consciousness—major surgical procedures

The client is monitored closely for signs of respiratory distress and bleeding. Some diagnostic procedures require that the vital signs be measured every 15 minutes for the first hour, then gradually decreased in frequency until the client is stable (alert and vital signs within the client’s normal range).

Some diagnostic tests require the use of medications that are excreted through the kidneys; the nurse monitors the client’s intake and output for 24 hours. The client is taught how to monitor intake and output.

Instruct the client to report hematuria (presence of blood in the urine). Clients receiving radioactive iodine must have their urine collected and properly discarded in a special container, according to agency policy for handling radioactive medical wastes.

When clients are discharged after diagnostic tests, they should receive written instructions. Most agencies have discharge forms for the nurse to document teaching regarding medications, dietary and activity restrictions, and signs and symptoms to be reported immediately to the practitioner. Clients may also need to have follow-up appointments made for them.

LABORATORY TESTS

Common laboratory studies are usually simple measurements to determine how much or how many analytes, (a substance dissolved in a solution, also called a solute) are present in a specimen. Laboratory tests are ordered by practitioners to:

· Detect and quantify the risk of future disease

· Establish and exclude diagnoses

· Assess the severity of the disease process and determine the prognosis

· Guide the selection of interventions

· Monitor the progress of the disorder

· Monitor the effectiveness of the treatment

Specimen Collection

The scheduling and sequencing of laboratory tests is an important function of the nurse. All tests requiring venipuncture (the puncturing of a vein with a needle to aspirate blood) are grouped together so that the clientis subjected to only one venipuncture. Fasting laboratory and radiologic studies are scheduled on the same day so that the client has to fast for only one day. Appropriate scheduling increases the client’s comfort level and satisfaction. “Communication errors account for more incorrect results than do technical errors” (Fischbach, 2000, p. 13). Accuracy in laboratory testing requires that:

· The practitioner’s order is transcribed onto the correct requisition form.

· All information requested should be written onto the form (e.g., the client’s full name and medical number).

· Pertinent data that could influence the test’s results, such as medication taken, must be included.

· Collection of the specimen from the correct client is confirmed by the identification band.

· Laboratory results are placed on the correct client’s medical record.

The risk for errors increases when clients have the same last name. Always check the full name of the client and the medical record number before placing the laboratory results report onto a chart.

Point of care testing (POCT) is a common practice in critical care settings and is proving to be a cost-effective, quality intervention for both clients and agencies. With advances in POCT technology over the past two decades, critical care nurses can perform a blood analysis and within seconds to minutes have a measurement upon which to change or implement an intervention. Schallom (1999) suggests that nurses be involved in the implementation and evaluation process of POCT since accuracy of the test is contingent on correct calibration and correct usage by the test performer. The following advantages are inherent in POCT (McConnell, 1999; Schallom, 1999):

· Prompt client diagnosis, treatment, and monitoring by decreasing turnaround time (TAT)

· Decreasing the risk for error by eliminating many of the steps in conventional laboratory testing

· Decreasing prolonged hospital stays and avoiding unnecessary hospitalizations by facilitating appropriate triage from emergency departments and prehospital settings

· Decreasing delays or cancellations of surgical procedures due to unavailable laboratory results, and the actual time the client spends in surgery;

· Minimizing blood loss due to phlebotomy since POCT devices usually require only a few microliters or drops of blood versus 25 to 125 microliters per day for the critically ill client due to laboratory testing

Studies regarding POCT’s clinical and financial value have revealed positive results: improved overall day-stay unit operations and client services; and earlier therapeutic decision-making time that required blood test results for emergency room clients (McConnell, 1999).

Although studies have proven positive results in settings where the client’s condition is acute and unstable, critical care applications may be quite different from that on a general medical/surgical unit. Studies will need to document the usefulness of POCT as a quality intervention in nonacute care settings.

Venipuncture

Venipuncture can be performed by various members of the health care team. Laboratories employ a phlebotomist (an individual who performs venipuncture) to collect blood specimens; however, it is the responsibility of a nurse to know how to perform a venipuncture. Nurses routinely perform venipuncture in the home, long-term care settings, and hospital critical care units. Venipuncture can either be performed by using a sterile needle and syringe or a vacuum tube holder with a sterile two-sided needle. Test tubes are used to collect blood specimens. Test tubes have different colored stoppers to indicate the type of additive in the test tube.

Collecting tubes are universally color coded as follows:

· Red—no additive

· Lavender—EDTA (ethylenediaminotetraacetic acid)

· Light blue—sodium citrate

· Green—sodium heparin

· Gray—potassium oxalate

· Black—sodium oxalate

It occurs with increased capillary hydrostatic pressure that causes water to shift from the intravascular into the interstitial space. Hemoconcentration can be caused from prolonged standing or a prolonged time of application of a tourniquet during venipuncture. Alterations in the circulating blood volume can also cause hemoconcentration, such as occurs with dehydrated and burned clients.

Hemolysis is the breakdown of red blood cells and the release of hemoglobin. Hemolysis occurs with the rapid flow of blood through small-bore needles and exposure to large negative pressures. A negative pressure exists inside the collecting test tubes and syringe. To minimize the possibility of hemolysis use a large-bore needle, moderate flow rates, and moderate negative pressures.

The third source of variability occurs when a blood specimen is drawn from a site above an intravenous infusion. The specimen is contaminated with intravenous solutions. Blood should be drawn from the client’s other arm or below the infusion site.

Venipuncture is an invasive procedure. Health care providers performing venipuncture are at risk for the transmission of blood-borne organisms, such as human immunodeficiency virus (HIV) and hepatitis. HIV is the causative agent for acquired immunodeficiency syndrome (AIDS).

Correct selection and preparation of equipment and vein provides for a safe and efficient venipuncture (Procedure 28-1). Review of the client’s health history and physical assessment data will assist in identifying special client considerations. If the client has a bleeding disorder or is taking anticoagulant therapy, apply pressure to the puncture site for 3 to 5 minutes after the removal of the needle.

Arterial Puncture

Assessment of arterial blood gases (ABG) reveals the ability of the lungs to exchange gases by measuring the partial pressures of oxygen (PO2) carbon dioxide (PCO2) and evaluates the pH of arterial blood. Blood gases are ordered to evaluate:

• Oxygenation

• Ventilation and the effectiveness of respiratory therapy

• Acid-base level of the blood

Arterial blood samples are drawn from a peripheral artery (e.g., radial or femoral) or from an arterial line. The arterial blood sample is collected in a 5-ml heparinized syringe. The syringe is then rotated to mix the blood with the heparin to prevent clotting. The blood sample is placed on ice to reduce the rate of oxygen metabolism.

In some agencies it is within the scope of nursing practice to perform radial artery puncture; however, femoral artery puncture is usually performed only by an advanced practitioner. An increased risk of hemorrhage exists with a femoral puncture. Although it is not common practice for student nurses to draw ABG samples, students often have to assist with the procedure and care for the client after the procedure.

Arterial punctures should not be performed:

· If the client is hyperthermic

· Immediately after breathing and suctioning treatments

· If there have been changes on ventilator settings

Arterial samples are also contraindicated in the following conditions:

· Anticoagulant therapy

· Clotting disorders

· Symptomatic peripheral vascular disease

· Negative Allen test

An Allen test is performed to measure the collateral circulation to the radial artery. Regardless of who performs the arterial puncture, the nurse is responsible for assessing the client for symptoms of bleeding or occlusion postpuncture. Direct pressure must be applied to the puncture site until all bleeding has stopped, a minimum of 5 minutes. Ensure that all bleeding has stopped before releasing the pressure. Symptoms of impaired circulation include:

· Numbness and tingling

· Bluish color

· Absence of a peripheral pulse

Capillary Puncture

Skin punctures are performed when small quantities of capillary blood are needed for analysis or when the client has poor veins. Capillary puncture is also commonly performed for blood glucose analysis, discussed later in this chapter. The common sites for capillary punctures are the:

· Heel—most common site for neonates and infants

· Fingertip—the inner aspect of palmar fingertip used most commonly in children and adults

· Earlobe—when the client is in shock or the extremities are edematous

To perform a skin puncture, assemble the equip ment, prepare the client, and select the appropriate site (Procedure 28-2). Figure 28-3 shows a capillary puncture of a fingertip.

Urine Collection

The kidneys are responsible for maintaining homeostasis of the body’s buffering systems and the volume, and ionic and osmotic composition of its fluid compartments. “Although the results of kidney functions are reflected in analyses of blood, the mechanisms by which normalcy of body fluids is preserved can be understood only through studies of urine” (Kirschbaum, Sica, & Anderson, 1999, p. 597).

Urine can be collected for various studies. The type of testing determines the method of collection. The different methods of urine collection are:

· Random collection (routine analysis)

· Timed collection

· Collection from a closed urinary drainage system

· Clean-voided specimen

The urine from a closed urinary drainage system is a sterile specimen. Client teaching depends on the client’s age and the method of collection. Initiate the protocol for preparing the client for testing (see Table 28-1). The method of collection should be written on the laboratory requisition.

Random Collection

The practitioner usually writes the order for a UA (routine urine analysis), which is also called a random collection. It can be collected at any time using a clean cup. The urine does not have to be collected in a sterile container. Instruct the client to urinate into the specimen cup or into a clean bedpan or urinal. Wearing gloves, transfer the urine into a clean container. Seal the lid tightly, label, and place in a biohazard bag for transport to the laboratory. Submit the specimen immediately to the laboratory to prevent the growth of bacteria or changes in the urine’s analytes (substances).

Timed Collection

Timed collection is done over a 24-hour period. The urine is collected in a plastic gallon container that contains preservative(s), some of which are caustic. The laboratory usually adds the preservatives to the container. If the analyte to be studied is light sensitive, a dark plastic container is necessary. Provide the client with specific instructions. The client is told to void (the process of urine evacuation) and discard the specimen at the beginning of the collection. The 24-hour collection begins with the first discarded voiding. For example, if the client is instructed to void at 1000 hours (24-hour clock time frame), discard the urine, save all other voided specimens until 1000 hours the following day. The client can void throughout the test into a clean container, then pour the urine into the collection bottle. Toilet tissue should not be dropped into the container used to catch the urine.

The collection container should be refrigerated or kept on ice throughout the 24 hours. This retards bacterial growth and stabilizes the analytes. The last urine collection, 1000 hours, should be a complete, forced voiding at the exact timed period. Seal the labeled container tightly and take immediately to the lab.

Collection from a Closed Drainage System

A sterile specimen can be collected from a client with an indwelling Foley catheter with a closed drainage system. A sterile specimen is used to culture the urine. The urine specimen should not be obtained from the drainage bag. The analytes in the urine drainage bag change; this will cause inaccurate results. Bacteria grow quickly in the drainage bag. The catheter’s closed drainage tubing has an aspiration port that is used for a sterile specimen collection (Procedure 28-3).

Clean-Voided Specimen

Clean-voided (clean-catch, or midstream) specimen collection is done to secure a specimen uncontaminated by skin flora. A clean-voided specimen should be obtained on first voiding in the morning. Most adult clients are capable of following instructions to perform this test. Different aseptic techniques are used for women and men. Poor technique in cleaning the perineum can contaminate the specimen. Instruct the female client to cleanse from the front to the back (Procedure 28-4).

Instruct the male client to perform the same procedure except for the cleansing of the perineal area; men should cleanse from the tip of the penis downward. The Nursing Checklist describes the procedure for obtaining a clean-voided specimen from a man. When obtaining a clean-voided specimen from infants and small children, secure assistance. Follow the Nursing Checklist.

Stool Collection

Explain to the client why the stool specimen is being collected. Instruct the client to defecate into a clean bedpan or container, discarding tissue into the toilet. Stools can be collected for either a one-time defecation or over 24, 48, or 72 hours. If a specimen is needed over a prolonged period of time, all stools must be placed into a container and refrigerated. Once collected, label the container with the client’s name, date, time, and the test to be performed on the specimen. All stool specimens are placed in a biohazard bag before transport to the laboratory.

RADIOLOGIC STUDIES

Radiography (the study of x-rays or gamma ray-exposed film through the action of ionizing radiation) is used by the practitioner to study internal organ structure.

Fluoroscopy (the immediate, serial images of the body’s structure and function) is used to demonstrate the motion of organs when used with contrast medium (a radiopaque substance that facilitates roentgen imaging of the body’s internal structures). X-rays are valuable to the practitioner in either formulating a diagnosis (e.g., pneumonia) or as a tool to determine if other studies are necessary (e.g., lung lesion requiring biopsy to differentiate between a benign or malignant tumor).

Certain radiologic tests will require a contrast medium that could interfere with other diagnostic studies. Barium and iodine are commonly used contrast media. Laboratory blood samples measuring the thyroid function should be drawn before an intravenous pyelogram (IVP) where radioactive iodine dye is administered. If the client needs both an IVP and barium enema, the IVP is done first because the barium is likely to decrease the visualization of the kidneys.

Precautions need to be taken to ensure client safety. It is essential during history taking that the client is questioned about the possibility of pregnancy, asthma, and allergic reactions to contrast media (iodine) as well as to other foods and drugs. If the client has never received iodine, this should be noted on the requisition.

Chest X-Ray

The most common radiologic study is the noninvasive, noncontrasted chest x-ray. The best results are obtained when the films are taken in the radiology department; however, a portable chest x-ray can be performed at the bedside.

Radiographic projection positions of chest x-ray films are taken from various views (Figure 28-13). Multiple views of the chest are necesary for the practitioner to assess the entire lung field. To prepare the client for a chest x-ray, remove metal objects (jewelry) and all clothing from the waist up and replace with a gown. Metal will appear on the x-ray film thereby obscuring visualization of parts of the chest. Pregnant women are draped with a metal apron to protect the fetus. Chest films can indicate the following alterations and diseases:

· Lesions (tumors, cysts, masses) in the lung tissue, chest wall, bony thorax or heart

· Inflammation of lung tissue (pneumonia, atelectasis, abscesses, tuberculosis); pleura (pleuritis); and pericardium (pericarditis)

· Fluid accumulation in the lung tissue (pulmonary edema, hemothorax); pleura (pleural effusion); and pericardium (pericardial effusion)

· Bone deformities and fractures of the rib and sternum

· Air accumulation in the lungs (chronic obstructive pulmonary disease, emphysema), and pleura (pneumothorax)

· Diaphragmatic hernia

Kidney-Ureter-Bladder

A kidney-ureter-bladder, also known as a KUB (x-ray of the abdomen), is used to visualize the kidney, ureter, and bladder and sometimes the gallbladder, liver, and spleen. The results can reveal congenital abnormalities, enlarged organs, lesions, and obstructions.

Mammography

Mammography (a low-dose radiographic study of breast tissue) is used to reveal congenital abnormalities and lesions. The American Cancer Society (1997) recommends a baseline mammogram by age 40, followed by a mammogram every 2 years until age 50, and every year after age 50.

Skeletal X-Rays

Skeletal x-rays are taken of any bony processes to reveal congenital abnormalities, fractures, joint and spine abnormalities, and degeneration (arthritis).

Computed Tomography

Computed tomography (CT) is the radiologic scanning of the body with x-ray beams and radiation detectors that transmit data to a computer that transcribes the data into quantitative measurement and multidimensional images of the internal structures. Figure 28-14 demonstrates the directions of sagittal, transverse, and coronal planes taken during CT scanning.

This procedure requires the client’s written consent. Because the client will be positioned on the scanning table and told to remain motionless, the client’s cooperation is essential during the scanning. Prepare the client with an explanation and pictures of what to expect. Figure 28-15 shows the direction of CT scan waves. A simple drawing of this figure can be used in client teaching to increase understanding of the test.

Assess the client’s ability to relax and review imagery relaxation. Sedation can be administered with an order from the practitioner. Clients who will receive a contrast medium need to be kept NPO 2 to 4 hours before the test. The client should void before the test unless the pelvic area is to be studied. A full bladder enhances visualization of the pelvic area.

Barium Studies

Barium(a chalky white contrast medium) is an oral preparation that allows for roentgenographic visualization of the internal structures of the digestive tract. The results of barium studies can reveal: congenital abnormalities; lesions; spasm, reflux, stricture, and obstruction; inflammation and ulceration; varices; and fistula. General client preparation for barium studies should include:

· Placing the client on NPO status after midnight

· Administering a laxative the evening before and enemas the morning of the test

· Forcing fluid postprocedure

· Follow-up 2 to 3 days postprocedure to ensure the client has had a normal brown stool

Postprocedure barium will be expelled in the stool, making it milky white. Fluids are forced to help with the excretion of barium. If the barium is not completely excreted, it can cause an intestinal obstruction.

Barium Swallow

Barium swallow (also called esophography) is a fluoroscopic visualization of the esophagus following the ingestion of barium sulfate. Implement the nursing care discussed above for client having a barium study.

Upper Gastrointestinal Study

Upper gastrointestinal (UGI) study is a fluoroscopic visualization of the stomach and small bowel following the ingestion of barium sulfate. In addition to the general preparation of the client for a barium study, also instruct the client:

· Not to smoke 24 hours before the procedure (smoking causes an increased production of gastric juices)

· That during the procedure (which will last approximately 2 hours) pictures will be taken at 30-minute intervals with the client in different positions

Barium Enema

Barium enema (a rectal infusion of barium sulfate) is the roentgenographic study of the lower intestinal tract. The colon should be free of all fecal material to allow for maximum visualization. Instruct the client:

· To eat a low residue diet 2 days prior to the test

· That during the procedure various positions will need to be assumed on the table to facilitate movement of the barium in the intestines

· The test will take about 1 hour.

· The postprocedure cleansing enemas will be given to help remove the barium

ULTRASONOGRAPHY

Ultrasound (echogram) is a noninvasive study that uses high-frequency sound waves to visualize deep body structures. This test should be scheduled before any studies using a contrast medium or air to ensure accuracy because an ultrasound does not require any contrast medium. The client is instructed to lie still during the procedure.

Ultrasound is used to evaluate the brain, thyroid gland, heart, vascular structure, abdominal aorta, spleen, liver, gallbladder, pancreas, and pelvis. An ultrasound is commonly done during pregnancy to evaluate the size of the fetus and placenta; a full bladder is needed to ensure visualization. Instruct the mother to drink 6 to 8 glasses of water and to avoid urination before testing.

A coupling agent (lubricant) is placed on the surface of the body area to be studied to increase the contact between the skin and the transducer (instrument that converts electrical energy to sound waves). The transducer emits waves that travel through the body tissue and are reflected back to the transducer and recorded. The varying density of body tissues deflects the waves into a differentiated pattern on an oscilloscope. Photographs can be taken of the sound wave pattern on the oscilloscope.

Echocardiograms

An echocardiogram is an ultrasonographic procedure used to reveal abnormal structure or motion of the heart wall and thrombi. This test is also used after radiofrequency ablation (the delivery of low-voltage, high-frequency alternating electrical current to cauterize the abnormal myocardial tissue) to identify the potential complications of pericardial effusion.

Doppler Ultrasonography

Doppler (a hand-held transducer) transmits high frequency sound waves to the artery or vein being studied. The sound waves strike the moving RBCs and are reflected back to the transducer, which amplifies the sound and produces a graphic recording. Doppler ultrasonography reveals blood clots and peripheral vascular disease.

MAGNETIC RESONANCE IMAGING

Magnetic resonance imaging (MRI) is an imaging technique that uses radiowaves and a strong magnetic field to make continuous cross-sectional images of the body.

The client is instructed to wear earphones to decrease the discomfort from the machine’s clanging sound. A noniodine intravenous paramagnetic contrast agent may be used during the study. The study reveals lesions and changes in the body’s organs, tissues, vascular, and skeletal structures.

RADIOACTIVE STUDIES

Radionuclide imaging (nuclear scanning) uses radionuclides (or radiopharmaceuticals) to image the morphologic and functional changes in the body’s structure. A scintigraphic scanner is placed over the area of study to detect the radiation emission and to produce a visual image of the structure on film. Radiopharmaceutical agents are administered by various routes with consideration given to time delays of absorption. The results reveal congenital abnormalities, lesions, skeletal changes, infections, and gland and organ enlargement.

ELECTRODIAGNOSTIC STUDIES

These diagnostic tests use devices to measure the electrical activity of the heart, brain, and skeletal muscles.

Electrical sensors (electrodes) are placed at certain anatomic points to measure the tone, velocity, and direction of the impulses. The impulses are then transmitted to an oscilloscope or printed on graphic paper.

Electrocardiography

An electrocardiogram (ECG or EKG) is a graphic recording of the heart’s electrical activity. The client may be asked not to smoke or drink caffeinated beverages 24 hours before the test. Nicotine and caffeine can affect the heart rate. Electrodes are applied to the chest wall and extremities. A lubricating gel applied to the electrodes increases the conduction of electrical activity between the skin and electrode. The client is instructed to lie still during the pain-free test. The test can reveal abnormal transmission of impulses and electrical position of the heart’s axis.

A portable cardiac monitor (Holter monitor) is a device that records the heart’s electrical activity. It produces a continuous recording over a specified period of time (e.g., 24 hours). The portable unit allows the client to ambulate and perform regular activities. Clients are instructed to maintain a log of activities that occur when they feel their heart beating faster or irregularly. The practitioner reviews the ECG tracing in relation to the client’s log to determine if certain activities, such as walking, are associated with abnormal transmission of impulses.

Signal-Averaged Electrocardiography

Signal-averaged electrocardiography (SAECG) is a surface ECG that amplifies late potentials (the electrical activity that occurs after normal depolarization of the ventricles). The test requires a specialized ECG machine and small computer to detect the late potentials. It is performed on clients who have had a myocardial infarction. The test reveals the client’s risk for ventricular tachycardia.

Stress Test

A stress test measures the client’s cardiovascular response to exercise tolerance. It demonstrates the ability of the myocardium to respond to increased oxygen requirements (the result of exercise) by increasing the blood flow to the coronary arteries.

The client is connected to an ECG machine and asked to walk on a treadmill. Continuous ECG recordings are made of the client’s heart response (rate, electrical activity, and cardiac recovery time) to frequent changes in the treadmill’s speed and slope. The test is stopped immediately if the client experiences any symptoms of decreased cardiac output (chest pain, dyspnea, fatigue, or ischemic changes on the ECG monitor).

Thallium Test

Thallium (a radionuclide that is the physiological analogue of potassium) is normally absorbed into normal myocardial tissue from the circulating blood. During the test, thallium is administered intravenously to detect damaged myocardial tissue (necrotic or ischemic).

Because thallium is not absorbed by the damaged tissue, the degree of heart damage can be estimated. There are two types of thallium tests: resting imaging or stress imaging. Resting imaging is performed a few hours after myocardial infarction. The thallium is injected and an ECG tracing is performed. Stress imaging (thallium stress test) is performed while the client is on the treadmill with ECG monitoring. At peak stress the intravenous thallium is injected; scanning is done 3 to 5 minutes postinjection. The test is stopped immediately if the client becomes symptomatic for ischemia.

Electroencephalography

An electroencephalogram (EEG) is the graphic recording of the brain’s electrical activity. The procedure is painless and takes about an hour. The test is performed in a quiet, nonstimulating environment. It can reveal the presence and type of seizure disorder and intracranial lesion. The absence of brain’s electrical activity is used to confirm death.

During the procedure, electrodes are placed on the client’s scalp. The electrodes transmit the impulses from the brain to an EEG machine. The machine amplifies the brain’s impulses and makes a recording of the waves on strips of paper.

ENDOSCOPY

Endoscopy is the visualization of a body organ or cavity through a scope. The procedure is performed with an endoscope (a metal or fiberoptic tube) being inserted directly into the body structure to be studied (see Figure 28-16). A light at the end of the scope allows the practitioner to assess for lesions and structural problems. The endoscope has an opening at the distant tip that allows the practitioner to administer an anesthetic agent, lavage, suction, and biopsy tissue. Common endoscopic procedures are presented in Table 28-12.

General client preparation and positioning depend on the structure being studied as discussed in Table 28-12. As with all invasive procedures, the client needs to sign a consent form and the nurse needs to establish baseline vital signs before administering sedative agents.

Postprocedure the nurse monitors the vital signs, observes for bleeding, and assesses for procedural risks (e.g., return of the gag and swallowing reflexes following an esophagogastroduodenoscopy with local anesthesia).

ASPIRATION/BIOPSY

Aspiration is performed to withdraw fluid that has abnormally collected or to obtain a specimen. Aseptic technique and Standard Precautions are used during aspiration. Aspiration diagnostic studies are invasive; implement the protocols for diagnostic tests. A local anesthetic is administered in the area being studied to decrease the client’s discomfort when the skin is pierced by the needle.

A stylet needle with an outer, hollow-bore needle is used to pierce the skin. Once the needle is in place, the stylet is withdrawn, leaving only the outer needle to aspirate the fluid. A tissue biopsy (excision of a small amount of tissue) can be obtained during aspiration or with other diagnostic tests (e.g., bronchoscopy). A biopsy can be taken from most of the body’s tissue.

Bone Marrow Aspiration/Biopsy

The sternum and iliac crest are the common sites for bone marrow puncture. During a bone marrow puncture a fluid specimen (aspiration) or a core of marrow cells (biopsy) can be obtained. Both tests are commonly done concurrently to obtain the best marrow specimen.

The test can reveal anemias or cancer, such as leukemia, multiple myeloma, or Hodgkin’s disease, or the client’s response to chemotherapy.

There are no restrictions on fluids or food before the puncture. The nurse should explain the procedure to elicit the client’s support during the procedure. The client must lay perfectly still throughout the procedure. The client is usually fearful; allay the client’s fear with relaxation methods or sedation. Infants and small children are restrained by holding them throughout the procedure.

Client positioning is determined by the site to be used, supine (sternum) or side-lying (iliac crest). The site is prepped for puncture to decrease the skin’s normal flora. Explain to the client that pressure may be experienced as the specimen is withdrawn. The client should not move when the specimen is being withdrawn; a sudden movement may dislodge the needle.

Postprocedure the client should be on bed rest for an hour. The nurse monitors vital signs to assess for bleeding (rapid pulse rate, low blood pressure). Instruct the client to report to the practitioner any bleeding or signs of inflammation.

Paracentesis

Paracentesis is the aspiration of fluid from the abdominal cavity. This test can either be diagnostic, therapeutic, or both. For instance, with endtage liver or renal disease there is ascites (an accumulation of fluid in the abdomen). Pressure caused from the ascites can interfere with breathing and gastrointestinal functioning.

Aspiration in this instance is therapeutic. If a culture specimen is taken, it is also diagnostic.

Have the client void and obtain a body weight before the procedure. Place the client in a high Fowler’s position in a chair or sitting on the side of the bed. The skin is prepped, anesthetized, and punctured with a trocar (a large-bored abdominal paracentesis needle). The trocar is held perpendicular to the abdominal wall and advanced into the peritoneal cavity. When fluid appears, the trocar is removed, leaving the inner catheter in place to drain the fluid. Observe the client for pressure changes that can result from the rapid removal of fluid.

Postprocedure apply a sterile dressing to the puncture site. Monitor the client for changes in vital signs and electrolytes. Instruct the client to record the color, amount, and consistency of drainage on the dressing after discharge.

Thoracentesis

Thoracentesis is the aspiration of fluids from the pleural cavity. The pleural cavity normally contains a small amount of fluid to lubricate the lining between the lungs and pleura. Infection, inflammation, and trauma may cause an increased production of fluid, which can impair ventilation.

Position the client with arms crossed and resting on a bedside table to allow access to the rib cage (Figure 28-17). Instruct the client not to cough during insertion of the needle. The practitioner selects, preps, and anesthetizes the puncture site. The needle is usually inserted into the intercostal space at the location of maximum dullness to percussion. Posteriorly, the site should be above the ninth rib, and laterally, above the seventh rib During the procedure, monitor the client for symptoms of a pneumothorax (collection of air or gas in the pleural space causing the lungs to collapse), such as dyspnea, pallor, tachycardia, vertigo, and chest pain.

Postprocedure observe for cardiopulmonary changes and a mediastinum shift as assessed by vital signs and bloody sputum.

Cerebrospinal Fluid Aspiration

Lumbar puncture (“spinal tap”) is the aspiration of CSF from the subarachnoid space. The specimen is examined for organisms, blood, and tumor cells. A spinal tap is also performed:

· To obtain a pressure measurement when blockage is suspected

· During a myelogram, as discussed earlier

· To instill medications (anesthesia, antibiotics, or chemotherapy)

A spinal tap is contraindicated in clients with increased intracranial pressure, hemorrhagic diathesis, and an infection at the proposed puncture site. Place the client in a lateral recumbent position with the craniospinal axis parallel to the floor and flat of the back perpendicular to the procedure table. Have the client assume a flexed knee-chest position to bow the back. This position separates the vertebrae. Most clients will require assistance in maintaining this position throughout the procedure. To assist, the nurse stands facing the client with one hand across the client’s posterior shoulder blades and the other hand over the buttocks.

The practitioner selects, preps, and anesthetizes the puncture site (usually interspace L3-L4, L4-L5, or L5-S1). The needle and stylet are inserted into the midsagittal space and advanced through the longitudinal subarachnoid space (Figure 28-18).

Once in the subarachnoid space, the stylet is removed, leaving the needle in place. An initial CSF pressure reading is taken:

· A three-way stopcock with a manometer (calibrated column) is securely connected to the spinal needle.

· The stopcock is opened toward the manometer to allow the CSF to rise in the column. Under normal conditions, the CSF will fluctuate in the column with respirations.

· When the CSF stabilizes, a pressure reading is taken.

If the pressure reading is greater than 200 mm H2O or falls quickly, only 1 or 2 ml CSF is obtained for analysis. If the pressure is less than 200 mm H2O, an adequate specimen sampling is withdrawn slowly.

After the pressure reading is taken, the stopcock is turned to allow the CSF to slowly flow into a sterile test tube. A sterile cap is placed on the test tube, and the sample is transported to the laboratory for analysis. Rapid withdrawal of CSF can cause a transient postural headache. Throughout the procedure, monitor the client’s cardiorespiratory status.

Postprocedure, pressure is applied and then a sterile bandage. Assess the bandage for leakage of CSF and the client’s neurologic and cardiorespiratory status. A postural headache is the most common complication of a lumbar puncture; using a small-bore spinal needle minimizes the chances of a headache.

Assisting with Diagnostic Manipulations

Administering an Electrocardiogram

Assessment

1. Assess age, gender, and current medication history for any medications with possible cardiac or hemodynamic effects. Gather other data that may be required by unit/institution protocol (height, weight, recent blood pressure, operator identiﬁcation). Reference standards are tailored to age and gender. Some medications cause abnormalities in portions of the ECG complex that must be recognized as medication effect.

2. Determine that the client is able to tolerate a supine position and that adequate exposure of chest and limbs is possible for electrode placement. Correct siting of electrodes is enhanced by comfortable, stable position.

3. Determine presence of neck, arm, jaw, or other pain with possible cardiac origin. Chest or other pain may provide additional information useful in serial comparison of ECGs.

4. Assess client need for information about the procedure purpose and requirements and ability to cooperate: that client should lie still and refrain from talking, electrode attachment, procedure lasts only a few minutes and is painless. Anxiety may be relieved by simple explanation of intent, duration, and purpose.

Diagnosis

8.1.1 Knowledge Deﬁcit regarding the ECG procedure

9.3.1 Anxiety related to the procedure or to the diagnosis and treatment

1.4.2.1 Decreased Cardiac Output

Planning

Expected Outcomes:

1. The client will be able to cooperate with procedure.

2. The client will not be anxious.

3. The client will be able to describe the reason for the ECG.

Equipment Needed (see Figure 11-1-2):

• Twelve-lead ECG machine with charged battery, cables and leads, graph paper

• Disposable electrodes (12)

• Electrode paste or gel

• Alcohol wipes

• Pillows

• Sheet or drape

• Towel and washcloth

• Disposable razor

Client Education Needed:

1. Assure the client that no electrical current goes through the body from the machine.

2. Explain to the client that he will feel nothing during the procedure.

3. Instruct the client to report chest pain or other symptoms to the nurse or physician.

4. Explain to the client that he will need to be in the supine position and will need to lie still during this test.

5. Explain to client that he will need to breathe normally and refrain from talking.

6. Explain to client that it may be necessary to shave body hair at some sites where electrodes are to be placed to provide good contact.

7. Tell the client that he will have to remove his clothes from the waist up and expose his lower arms and legs but that he will be covered as much as possible during the procedure.

8. Assure the client that his privacy will be guarded.

Evaluation

• The client tolerated the ECG procedure.

• The client is able to state purpose of ECG.

• The client is free of chest pain or other cardiac complaints.

• An accurate tracing was obtained for analysis.

Documentation

Nurses’Notes

• Note the date and time of the ECG.

• Describe the reason for the ECG and any signiﬁcant ﬁndings.

• Record the time the tracing results were reported to the physician or qualiﬁed practitioner.

Medication Administration Record

• Note the date and time of any cardiac medication.

Magnetic Resonance Imaging (MRI)

Assessment

1. Assess the client’s knowledge of the purpose and plan of the procedure so he will cooperate and not be anxious.

2. Review the client’s signature on the informed consent form. It is a legal requirement of the institution.

3. Assess the client’s weight since the procedure is contraindicated in clients over 300 pounds.

4. Assess the client for cardiac pacemaker, aneurysm clips, and history of valve replacement or other metal objects in the body since the magnet may cause movement of metal or electronic objects.

5. Assess the client for claustrophobia since the electromagnet is a large tube that does not allow for any movement. Sedation may be necessary.

6. Asses the client for pregnancy. An MRI is contraindicated, especially in the ﬁrst trimester.

7. Assess the client’s ability to remain still for 30 to 90 minutes during the procedure.Movement may produce unreliable images.

8. Assess the client for allergies to dye or contrast medium to avoid an anaphylactic reaction.

9. Assess the client’s veins for adequate venous access for injection of the contrast medium.

Diagnosis

9.3.1 Anxiety

9.3.2 Fear

8.1.1 Knowledge Deﬁcit regarding the procedure

Planning

Expected Outcomes:

1. The client will tolerate the procedure without anxiety.

2. The client will remain still during the procedure.

3. Successful images will be obtained for diagnosis.

4. If contrast medium is used, the client will not experience a reaction to it.

Equipment Needed:

• Contrast medium ordered by physician or qualiﬁed practitioner

• Magnetic Resonance Imaging scanner

Client Education Needed:

1. The client should be taught the rationale for the procedure and how it will be performed.

2. Recommend that clients limit their ﬂuid intake so they will not have to urinate for 60 to 90 minutes during the test.

3. The client should void just prior to the procedure since he will not be able to move during the lengthy procedure.

4. Explain to the client that no metallic objects including make-up (contains metallic particles) should be worn.Metal may be affected by the strong magnet and can disrupt the images.

5. Even though the study is painless, there may be a slight discomfort if a contrast dye is injected intravenously.

6. Tell the client that the machine will make various humming and loud thumping noises.

7. Ask the client to verbalize his knowledge and feelings about the procedure.

8. The client will be able to return home after the procedure if not hospitalized.

Evaluation

• The client tolerated the procedure without anxiety.

• The client remained still during the procedure.

• Successful images were obtained for diagnosis.

• If contrast medium was used, the client did not experience a reaction to it.

Documentation

Nurses’Notes

• Note the date, time, length, and place the procedure was done.

• Describe the client’s tolerance of the procedure.

• If contrast medium was used, describe the client’s response.

• Document the client’s status after the procedure.

Medication Administration Record

• Record medications administered before or during the procedure, such as diazepam (Valium) or midazolam (Versed).

Assisting with Computed Tomography (CT) Scanning

Assessment

1. Conﬁrm client’s identity and his knowledge level concerning the procedure and purpose for the CT scan so that client teaching can be tailored to needs.

2. Determine the need for informed consent and witness the signing of the consent so that institutional and legal regulations are followed.

3. Determine the client’s ability to lie still, supine for up to 1 hour, since this position is necessary for the procedure.

4. Assess the client for feelings of claustrophobia since some clients feel conﬁned in the scanner during the procedure.

5. Assess the client for an allergy to iodine or other contrast agents if CT is to be an “enhanced” study or contrast agents will be used so an allergic reaction will be avoided.

6. Determine if the client has a history of compro mised renal function in order to avoid renal complication if contrast agents are used.

7. Assess the client’s need for sedation during procedure since anxiety or claustrophobia may prevent the client from being comfortable and able to lie still.

Diagnosis

7.2 Sensory/Perceptual Alterations related to conﬁnement in the CT tube

8.1.1 Knowledge Deﬁcit related to the CT procedure

9.3.1 Anxiety related to the procedure and conﬁnement in the CT tube

Planning

Expected Outcomes:

1. The client will cooperate during the procedure and will be free from anxiety.

2. The client will be comfortable during and after the procedure.

3. Satisfactory images will be obtained for diagnosis.

4. The client will understand the general nature of the information to be obtained and when and how he will be informed of the results of the CT scan.

Equipment Needed:

• Sterile needle and syringe for administering contrast dye if ordered

• CT scanner

Client Education Needed:

1. Reassure the client that the procedure will take 30 minutes to 1 hour.

2. Inform the client that a CT scan is a noninvasive procedure unless IV contrast dye is used.

3. If a contrast agent is used, tell the client he may feel warm or ﬂushed as injection is given and may experience a metallic or salty taste for a moment.

4. Instruct the client about the part of the body to be imaged and how long it will take.

5. Tell the client he will need to lie still in a supine position on a hard surface.

6. Stress the need for the client to lie still.

7. Tell the client that a restraint or belt will be used to hold his hips, abdomen, or head in place on the table.

8. Reassure the client that the amount of radiation used is similar to several chest x-rays.

9. Tell the client that while he is alone in the scanner, he can talk to a technician through an intercom (see Figure 11-3-2).

10. Reassure the client that his family can wait nearby.

11. Tell the client that the machine will make clicking and whirring noises.

12. Reassure the client that he will be made comfortable as soon as possible after the test.

Evaluation

• The client cooperated during the procedure and was free from anxiety.

• The client was comfortable during and after the procedure.

• Satisfactory images were obtained for diagnosis.

• The client understands the general nature of the information to be obtained and when and how he will be informed of the results of the CT scan.

Documentation

Nurses’Notes

• Document the date, time, and length of the procedure.

• Document the date and time the contrast dye was given.

• Describe the response of the client to the procedure.

Medication Administration Record

• Document the date and time sedation given.

• Document the date and time contrast dye given.

Assisting with a Liver Biopsy

Assessment

1. Assess the client’s knowledge of the purpose and plan of the procedure so he will cooperate and not be anxious.

2. Review the client’s signature on the informed consent form. It is a legal requirement of the institution.

3. Assess the client’s ability to remain still in either the supine position during the procedure and the right lateral position for 2 hours after the procedure. These positions are required in order to access the liver and control bleeding after the procedure.

4. Assess the client for his ability to cooperate and hold his breath for 15 seconds during the procedure since the liver can be accessed best while the client has exhaled.

5. Assess vital signs as baseline data in order to compare with postprocedural vital signs.

6. Review the medical record for the client’s risk of bleeding, including use of anticoagulants, prothrombin time, and platelet count. These factors may affect the risk of bleeding.

7. Review the medical record for a history of allergic reactions to antiseptic or anesthetic solutions in order to avoid an allergic reaction.

8. Assess the client for massive ascites since ﬂuid in the abdominal cavity increases the risk of laceration of the liver’s surface.

9. Assess the client for pneumonia since an infection in the right pleural space could contaminate the biopsy needle at it passes through to the liver.

10. Assess the client for bleeding tendencies to determine the risk of bleeding during or after the procedure.

Diagnosis

9.3.1 Anxiety

9.3.2 Fear

8.1.1 Knowledge Deficit regarding the procedure

9.1.1 Pain

1.2.1.1 Risk for Infection

1.6.1 Risk for Injury, speciﬁcally bleeding

Planning

Expected Outcomes:

1. The client will understand the rationale for the procedure and tolerate it without anxiety.

2. The client will assume the required position and remain still during and after the procedure.

3. The client will experience minimal pain.

4. There will be no bleeding or infectious complications.

5. The biopsy will be sufficient for diagnostic testing.

Equipment Needed (see Figure 11-4-2):

• Liver biopsy tray, including:

–Antiseptic solution (povidone-iodine)

–Gauze sponges (4 3 4)

–Sterile towels

–Local anesthetic solution (lidocaine)

–Sterile syringes: two 3-ml with 23- to 25-gauge needles for anesthetic and two 10-ml for biopsy

–Three 5-cc vials of normal saline

–One biopsy needle

–One number 11 scalpel

–Specimen containers with formalin

–Povidone-iodine ointment

–Sterile gauze and tape

–Gloves

• Sterile gloves

• Masks and goggles

• Pain medication or sedative as ordered (to be given before procedure)

• Absorbent pads to protect the bed

Client Education Needed:

1. The client should be taught the rationale for the procedure.

2. Assure the client that the actual biopsy takes only 5 to 10 seconds.

3. The client should be told about the need for sterile technique.

4. The client should be instructed on the position to be assumed and the importance of remaining still.

5. The client should be instructed and practice breathing and holding the breath for the procedure.

6. The client should be instructed to not eat or drink anything for 6 hours before the biopsy or for 2 hours after the biopsy.

7. Encourage the client to take slow deep breaths and use imagery to promote relaxation.

8. The client should be assured that a local anesthetic will be given to dull the pain.

9. The client should be encouraged to ask questions and verbalize his fears or anxiety.

10. The client should be told that he will need to remain in bed for 6 hours after the procedure; the ﬁrst 2 hours he will need to rest in the lateral position on the right side.

11. Instruct the client to report any severe pain, shortness of breath, or fever immediately.

12. The client should be instructed to refrain from coughing or straining for 4 hours after the procedure and to avoid lifting heavy objects or strenuous activities for 1 week.

Evaluation

• Assess the client for pain or bleeding.

• Inspect the dressing over the puncture site.

• Assess the puncture site for swelling, tenderness, or erythema.

• Monitor vital signs and notify physician or qualiﬁed practitioner if blood pressure decreases signiﬁcantly.

• Observe for severe pain and notify physician or qualiﬁed practitioner.

• Observe for internal bleeding by obtaining a blood sample for a hematocrit 6 hours after the biopsy.

• Observe for complications such as perforation of the portal or hepatic vein, laceration of the liver, pneumothorax, perforation of the gallbladder, bleeding into the biliary tract, bile peritonitis, bacteremia, or septic shock.

Documentation

Nurses’Notes

• Note date, time, and site of the liver biopsy.

• Describe how the client tolerated the procedure.

• Document laboratory tests ordered and when specimen was sent.

• Describe the type of dressing and ointment applied.

• Record vital signs before and after the procedure.

• Document the presence of any bleeding at the site.

Medication Administration Record

• Document the date and time of pain medication or sedative.

Assisting with a Thoracentesis

Assessment

1. Determine the necessary pretests needed and their purpose prior to the thoracentesis. To determine the proper positioning of the client and determination of the exact location of the pleural effusion.

2. Obtain client (or power of attorney) consent per institution policy. This protects the nurse, physician or qualiﬁed practitioner, and hospital against legal action and provides an opportunity to inform the client and family about the procedure.

3. Obtain baseline vital signs and medical history. Baseline vital signs are necessary to determine tolerance during and changes in health status following the procedure.

4. Determine client’s knowledge of and prior experience with thoracentesis. This helps determine their knowledge base to tailor their teaching.

They may have a special routine that they use to prepare themselves, such as relaxation, guided imagery, or the use of transdermal numbing medication.

5. Assess the need for sedation, premedications, or restraints. Some pediatric and adult clients may be unable to cooperate with a thoracentesis. Proper positioning and an immobile client is important to prevent complications or damage to the lungs or other internal organs or tissue.

Diagnosis

9.3.1 Anxiety related to the procedure

1.5.1.2 Ineffective Airway Clearance

1.5.1.3 Ineffective Breathing Pattern

1.5.1.1 Impaired Gas Exchange

8.1.1 Knowledge Deﬁcit related to the procedure and/or purpose

1.6.1 Risk for Injury (e.g., hemothorax, pneumothorax)

1.2.1.1 Risk for Infection

Planning

Expected Outcomes:

1. The client’s pain will decrease or cease.

2. Respirations will show no evidence of distress.

3. Arterial blood gases, pulse oximetry, and other diagnostic tests will improve.

4. There will be an absence of pleural effusion on follow-up diagnostic tests.

5. The client will experience minimal discomfort with the procedure.

6. The client will not experience any complicating injury or infection related to procedure.

Equipment Needed (see Figure 11-5-2):

• Thoracentesis tray (may be disposable kit, or reusable tray from central supply). In addition, there are speciﬁc trays available for infants and small children. If a thoracentesis tray is not available in one of these prepackaged forms, then the following equipment is necessary:

–Antiseptic solution

–Sterile gauze sponges (4 3 4 in. and 2 3 2 in.)

–Sterile towels and drapes

–Local anesthetic (e.g., lidocaine 1%)

–Sterile syringes and needles: two 3- to 5-ml with 23- to 25-gauge needles for administration of local anesthetic medication; two 20- to 50-ml syringes with 14- to 17-gauge needles 5 to 7 cm in length for ﬂuid drainage

–Three-way stopcock/two-way stopcock with extension tubing

–Hemostat

–Fluid receptacle

–Sterile specimen containers

• Items needed for universal precautions (mask/face shield, gown, gloves), as needed

• Sterile gloves in appropriate size for physician or qualiﬁed practitioner and anyone assisting in the sterile ﬁeld

• Laboratory specimen container with labels and requisitions (a specimen container with a preservative may be needed for biopsy purposes)

• Premedications (e.g., sedation, pain medication, cough suppressant)

Client Education Needed:

1. Explain the purpose and approximate length of the test.

2. Review the body position the client will need to assume as well as the need to remain immobile throughout the procedure.

3. Provide an opportunity for the client to practice the position required for the procedure.

4. Describe the sensations the client will experience with the local anesthesia as well as the pressure from the needle insertion.

5. Review all pre- and posttests required to assist the client in knowing what to expect.

6. Provide timeline to client for when to expect laboratory test results and who will communicate results.

7. Teaching relaxation or guided imagery can sometimes minimize the anxiety related to the procedure.

8. Instruct the client to void prior to the procedure.

9. Help the client determine the necessary supports needed (e.g., pillows) to assume the ideal body positioning for a thoracentesis.

10. Review need to remain immobile and not to move suddenly or cough during the thoracentesis as this could cause injury.

11. Describe routine tests (e.g., chest x-ray) and monitoring required postthoracentesis.

12. Review delayed complications of the procedure (e.g., spleen or liver perforation) and instruct client to report dyspnea, chest pain, or cough.

13. Review both early-onset and delayed complications of thoracentesis, and ask client to repeat information back to you prior to discharge from the hospital, clinic, or ofﬁce. Provide written information as well.

14. Instruct client that there is usually no need to remain NPO prior to or after the procedure. If anxiety usually makes the client queasy, he may wish to not eat or to eat lightly to reduce the risk of nausea, vomiting, and aspiration during the procedure.

Evaluation

• The client’s pain decreased or ceased.

• Respirations show no evidence of distress.

• Arterial blood gases, pulse oximetry, and other diagnostic tests improved.

• There is an absence of pleural effusion on follow-up diagnostic tests.

• The client experienced a minimal amount of discomfort during the procedure.

• The client has not experienced any complicating injury or infection related to the procedure.

Documentation

Nurses’Notes

• Record pre- and postassessments, including vital signs and other physiologic parameters.

• Document the length of and tolerance to the procedure.

• Describe the location of and dressing placed after the thoracentesis.

• Describe the color, quantity, and quality of ﬂuid obtained from the pleural cavity.

• Describe the color, quality, and quantity of ﬂuid on the postthoracentesis dressing.

• Document laboratory tests sent and pending.

• Record postprocedure evaluation and test completed with notation of results if known (e.g., chest x-ray).

• Record any adverse events that would indicate complications from procedure and reports given to physician or qualiﬁed practitioner and health care team members.

Medication Administration Record

• Record medications required pre, during, and postthoracentesis.

Kardex

• Record the location of and dressing required for thoracentesis.

• Document laboratory tests sent and pending.

Assisting with an Abdominal Paracentesis

Assessment

1. Identify the purpose for the abdominal paracentesis. This allows the nurse to anticipate effects of the abdominal paracentesis and to observe client’s response.

2. Check allergies to medications or anesthetic, bleeding problems, medications currently using, including aspirin, or if the client might be pregnant. This will decrease the chance of complication during the abdominal paracentesis.

3. Assess client’s knowledge regarding the abdominal paracentesis. Determines need for education and assists in identifying questions and concerns.

4. Assess the client for bleeding tendencies to determine the risk of bleeding during and after the procedure.

Diagnosis

9.1.1 Pain secondary to abdominal paracentesis

1.4.1.2.1 Fluid Volume Excess secondary to disease process

1.4.1.2.2 Fluid Volume Deﬁcit secondary to abdominal paracentesis

Planning

Expected Outcomes:

1. Client will experience minimal discomfort during abdominal paracentesis procedure.

2. Client will not suffer any adverse effects such as cardiovascular distress, shock, infection, or internal bleeding following the procedure.

3. Client will experience relief of symptoms of excessive abdominal ﬂuid, such as increased respiratory rate and decreased respiratory volume.

Equipment Needed (see Figures 11-6-2A and B):

• Disposable paracentesis tray or 16-gauge 3.5-inch aspiratioeedle

• Ampule of 1% lidocaine, 5 ml

• Needles for local anesthetic, 25 gauge, 5⁄8 inch

• Needle, 21 gauge 1.5 inches

• Syringe, 5 ml

• Syringe, 50 ml

• Prep tray

• Prep applicators

• Sterile drapes

• Sponges

• Two-way valve

• Specimen tubes

• Drainage bag or bottles

• Adhesive bandage

• Sterile gloves

• Masks (optional)

• Biohazard bag

Client Education Needed:

1. Explain purpose of abdominal paracentesis and risks. Reinforce verbal teaching with written instructions.

2. Instruct the client that there will be a stinging sensation from the anesthetic and a feeling of pressure as the needle is inserted.

3. Explain positioning during procedure and ensure that client understands.

4. Explain that if a large amount of fluid is withdrawn, the client may experience dizziness or lightheadedness.

5. Client understands the need to report any changes in symptoms, such as shortness of breath, dizziness, and increased perspiration.

6. Make sure client knows who to call if any complications arise after the procedure is completed.

Evaluation

• Client experienced minimal discomfort during abdominal paracentesis procedure.

• Client did not suffer any adverse effects such as cardiovascular distress, shock, infection, or internal bleeding following the procedure.

• Client experienced relief of symptoms of excessive abdominal ﬂuid, such as increased respiratory rate and decreased respiratory volume.

Documentation

Nurses’Notes:

• Note the time the abdominal paracentesis procedure took place.

• Record the anatomical site of puncture.

• Document laboratory analysis ordered for sample of ﬂuid.

• Document the client’s response to procedure.

• Ensure the signature of the nurse assisting with the procedure is included.

• Document the specimens collected and where they were sent.

• Record the vital signs during procedure and after procedure 4 times every 15 minutes.

• Describe the pressure dressing and assessment of drainage.

• Record urinary output (may be covered in the intake and output record).

• Record abdominal girth and weight pre- and postprocedure.

Intake and Output Record

• Record urinary output.

• Record the amount of ﬂuid removed from the abdominal cavity.

Kardex

• Record the amount of ﬂuid removed from the abdominal cavity.

• Record the anatomical site of puncture.

• Document laboratory analysis ordered for sample of ﬂuid.

Assisting with a Bone Marrow Biopsy/Aspiration

Assessment

1. Assess the client’s knowledge of the purpose and plan of the procedure so they will cooperate and not be anxious.

2. Review the client’s signature on the informed consent form. It is a legal requirement of the institution.

3. Assess the client’s ability to remain still in the supine, prone, or lateral position during the procedure. This procedure is required in order to assess the bone marrow.

4. Assess vital signs as baseline data in order to compare with postprocedural vital signs.

5. Review the medical record for the client’s risk of bleeding, including use of anticoagulants, prothrombin time, and platelet count. These factors may affect the risk of bleeding.

6. Review the medical record for a history of allergic reactions to antiseptic or anesthetic solutions in order to avoid an allergic reaction.

Diagnosis

9.3.1 Anxiety

8.1.1 Knowledge Deﬁcit regarding the procedure

9.1.1 Pain

1.6.1 Risk for Injury

Planning

Expected Outcomes:

1. The client will understand the rationale for the procedure and tolerate it without anxiety.

2. The client will assume the required position and remain still during the procedure.

3. The client will experience minimal pain.

4. There will be no extensive bleeding or infectious complications.

5. The aspiration or biopsy will be sufﬁcient for diagnostic testing.

Equipment Needed (see Figure 11-7-2):

• Bone marrow aspiration/biopsy tray, including:

–Antiseptic solution (povidone-iodine)

–Gauze sponges (4 3 4)

–Sterile towels

–Local anesthetic solution (lidocaine)

–Sterile syringes: two 3-ml with 23- to 25-gauge needles for anesthetic

–Two 10-ml syringes for marrow aspiration

–Two bone marrow needles with inner stylus

–One biopsy needle

–Test tubes and glass slides

–Povidone-iodine ointment

–Sterile gauze and tape or Band-Aid

• Sterile gloves

• Masks and goggles for physician or qualiﬁed practi–

tioner and nurse, if required

• Pain medication or sedative as ordered (to be given before procedure)

Client Education Needed:

1. The client should be taught the rationale for the procedure.

2. The client should be told about the need for sterile technique.

3. The client should be instructed on the position to be assumed and the importance of remaining still.

4. Encourage the client to verbalize their fears or anxiety.

5. The client should be encouraged to ask questions.

6. Assure the client that the actual aspiration takes only a minute or two.

7. Encourage the client to take slow deep breaths and use imagery to promote relaxation.

Evaluation

• The client understood the rationale for the procedure and tolerated it without anxiety.

• The client assumed the required position and remained still during the procedure.

• The client experienced minimal pain.

• There was no extensive bleeding or infectious complications.

• The aspiration or biopsy was sufﬁcient for diagnostic testing.

Documentation

Nurses’Notes

• Record the date, time, and site of the bone marrow aspiration or biopsy.

• Describe the amount and color of bone marrow aspirated.

• Document laboratory tests ordered and when specimens were sent.

• Document the type of dressing and ointment applied.

• Record vital signs before and after the procedure.

• Note complications or pain.

• Note the presence of any bleeding at the site.

• Describe the condition of the skin at the site.

Medication Administration Record

• Record the date and time of pain medication or sedative.

Assisting with a Gastrointestinal Endoscopy

Assessment

1. Assess the client’s knowledge of, preparation for, anxiety level concerning, and readiness to undergo the endoscopic procedure. Accurate assessment will allow the nurse to provide more information if needed about the endoscopic procedure. Proper preparation for the exam (i.e.,NPO status, laxatives, enemas) will inﬂuence whether the procedure can be performed as well as the quality of the exam.

2. Perform a brief health assessment, focusing on identifying whether a client has underlying heart, liver, or kidney disease. Speciﬁcally, it is helpful to know about implanted prosthetic devices, hepatitis, insulin-dependent and non–insulin-dependent diabetes mellitus (IDDM/NIDDM), hypertension, bleeding, seizure disorders, or pregnancy. Knowledge about the general health of the client, in addition to assessing for certain conditions, can better prepare the health practitioners to care for the client during endoscopic exam. Clients who have diabetes, for example, should have their blood sugars monitored and be observed for hypo- or hyperglycemic reactions. Clients with a history of pulmonary and coronary disease should be monitored closely for excessive sedation or dysrhythmias during medication administration. Extra caution must be taken with the electrosurgical equipment if the client has a pacemaker. Clients with liver or kidney disease should be carefully assessed regarding the extent of their illness because their tolerance of medications may be impaired.

3. Assess for substance abuse or chemical dependencies; include the types of drugs and the last time used. Use caution in administering medications to clients who have chemical dependencies. Avoid giving Valium to alcoholics or Narcan to drug abusers.

4. Check for allergies to drugs. During most endoscopic exams, IV medications are given, which may include fentanyl, morphine, meperdine, hydromorphone, midazolam, lorazepam, diazepam, hydroxyzine, and promethazine. Also, check for an allergy to the “caine” family if the client is undergoing an EGD because the back of the throat may be sprayed with cetacaine or other anesthetic prior to insertion of the scope.

5. Ask about current medications, speciﬁcally whether the client has taken Coumadin, aspirin, nonsteroidal anti-inﬂammatory drugs (NSAIDS), heparin, or other anticoagulants recently (within the last 5 days). These medications cause anticoagulation of the blood and can contribute to bleeding during the procedure, especially if biopsies are indicated.

6. Check for dentures, removable dental plates, and/or loose teeth if client is undergoing EGD and ERCP. Because the endoscope is inserted through the mouth, removal of the dentures and dental plates is essential prior to the procedure.

7. Verify plans for transportation home if client is an outpatient. For 24 hours after the completion of the procedure, it is recommended that the client does not operate moving machinery if conscious sedation was utilized.

Diagnosis

9.3.1 Anxiety related to pending procedure

9.1.1 Pain

1.6.1.4 Risk for Aspiration

1.4.1.2.2.1 Risk for Fluid Volume Deﬁcit related to dehydration or bleeding

1.6.1 Risk for Injury related to perforation from the scope insertion

8.1.1 Knowledge Deficit related to the procedure

7.2 Alteration in Sensory Response related to sedation for the procedure

Planning

Expected Outcomes:

1. Client will have no signs of bleeding or perforation.

2. Client will have a stable airway and respiratory status (respiratory rate and O2 saturation within 20% of the baseline).

3. Client will have stable cardiovascular status (blood pressure and heart rate within 20% of the baseline).

4. Client will be easily aroused and able to talk.

5. Gag reﬂex will be intact.

6. Client will be able to move with minimal assistance.

7. At the conclusion of the procedure, client will be either transferred back to the unit or discharged to home.

Equipment Needed (see Figure 11-11-2):

• Blood pressure monitoring equipment

• Continuous pulse oximeter and cardiac monitoring

• IV start equipment

• Suction

• Emergency equipment

• IV medications, properly labeled

• Oxygen

• Endoscope and related equipment

• Gloves

Client Education Needed:

1. Prior to the procedure, explain preparatioeeded (i.e., NPO from midnight or 8 hours prior to the procedure for most endoscopy procedures; laxatives and /or enemas for lower endoscopy).

2. Explain the procedure, including when the client will be asked to move or to swallow, what sounds he may hear, how the procedure will progress, how long the procedure will take, and what sensations he may feel.

3. Explain to the client that he will be connected to monitoring equipment during the procedure to observe vital signs. Reassure the client that this is a normal part of the procedure.

4. If used, explain the use of conscious sedation and what the client will experience.

5. After the procedure, discuss discharge instructions with the client and also provide written discharge instructions. It is important that the client clearly understands instructions.

6. Explain to the client undergoing a colonoscopy or sigmoidoscopy that feelings of mild abdominal fullness or cramping after the procedure are normal.

7. Instruct the client to report symptoms of acute abdominal pain, fever, chills, or bleeding immediately.

Evaluation

• Monitor vital signs, oxygenation, and heart rhythm during conscious sedation to assess client’s response to medications.

• Clients should meet discharge criteria:

–Return to baseline cardiovascular and respiratory status

–Is easily arousable; able to talk

–Gag reflex is intact if upper endoscopy performed

–Vital signs within 20% of the baseline recordings

• For a client who has undergone an ERCP, assess for the presence of the most common complication—acute pancreatitis. Symptoms include increasingly acute abdominal pain, nausea, vomiting, abdominal distention, and diminished or absent bowel tones.