Special Examinations

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Special ExaminationsTests

• Nursing Fundamentals
• Chapter 13

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Diagnostic Examination

• Is a procedure that involves physical inspection
  of body structures and evidence of their
  functions (making sure organs are working)
• Diagnostic exam is done with the use of equipment

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Equipment

• Radiography (x-rays)
• Endoscopy (optical scopes)
• Radionucleide imaging (radioactive chemicals)
• Ultrasonography (high frequency sound waves)
• Electrical graphic recordings

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Laboratory Tests

• Procedures that involve the examination of body
  fluids or specimens
• Laboratory tests involve comparing the components
  of a collected specimen with normal findings
• These are lab tests such as CBC or CMP or UA/CS

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Preprocedural Care

• Clarifying explanations
• It is important that pts understand what
  procedure they will be having
• Pts should not sign forms for procedures unless
  they completely know what will happen

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Informed Consent

• The consent given by a person after receiving
  full explanation including risks and benefits of
  a procedure that will take place

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Informed Consent Must Include

• 3 elements
• Capacity indicates that the pt has the ability
  to make a rational decision about what will
  happen and its outcome
• Comprehension indicates that the pt understands
  what was said about the procedure
• Voluntariness indicates that the pt is acting
  on his own free will.

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Preparing Clients For Tests

• Withholding food
• Nurse refers to written protocols for prep before
  tests
• Directions are provided to the pt, nursing staff
  and other depts in the hospital and others
  involved in the test
• Helping pt get into gowns and putting on ID
  bracelets and allergy bracelets, getting VS,
  telling pt to urinate
• The completetion of all forms before pt undergoes
  the procedure

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Obtaining Equipment Supplies

• Nurses do it all
• We prepare the pt, we prep the room, we have pt
  sign the forms
• We explain procedures
• We prepare the equipment
• We take care of the pt and their family

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Some equipment that may be needed

• Packaged kits like
• lumbar puncture kits, chest tube kits, foley
  kits, sterile equipment, canisters, tubes,
  syringes, evacuation bottles

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Arranging the Examination Area

• The nurse removes unnecessary articles from the
  exam or procedural area
• The nurse provides privacy by pulling the curtain
• The nurse makes sure all equipment is present and
  stocked
• The nurse covers the exam table with new paper or
  linens
• The nurse arranges the equipment to be used for
  easier access
• The nurse leaves sterile items wrapped or covered
  until just before their use

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Positioning of the Patient

• Dorsal recumbent position on back with knees
  bent
• Lithotomy position on back with feet in
  stirrups
• Sims position on belly with one leg sl. bent
• Knee-chest position on belly with knees bent
• Modified standing position standing up with
  upper body bent over a table

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Which position are they in?
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Assisting the Examiner

• The nurse must be familiar with all of the
  equipment
• The nurse anticipates what the examiner will need
  next and provides it to him
• The nurse holds supplies and containers for the
  examiner
• The nurse holds med containers so the examiner
  can see the label
• The nurse delegates to other nurses or assistants
  when help is needed
• The nurse keeps the room in control

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Providing Physical Emotional Support

• The nurse tends to the pts needs while awake and
  asleep
• If awake, nurse provides position changes,
  blankets, suctioning to mouth
• If asleep, nurse provides privacy and maintains
  safety of the pt

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Postprocedural Care

• Once all tests and exams are completed, the nurse
  attends to the pts needs for safety, comfort,
  cares for specimens, assesses VS, records and
  reports the findings

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Specimens

• Samples of tissue or body fluids
• The nurse
• Collects the specimen
• Labels the container with pt. Information
• Attaches the proper requisition form
• Places in refrig or on ice so it wont decompose
• Delivers the specimen to the proper place

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Recording Reporting

• The nurse records pertinent information about the
  pt during the exam or procedure
• She records
• Date time
• Pre-exam assessments, preparation and VS
• Type of test or exam the pt underwent
• Where it was performed on the body
• Response of the pt during and after the procedure
• Type of specimen if any, obtained
• Appearance, size or volume of specimen and where
  it was taken

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Common Diagnostic Examinations

• Pelvic examination
• Radiography
• Endoscopic examinations
• Radionuclide Imaging
• Ultrasonography
• Electrical Graphic Recordings

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Pelvic Exams

• Pelvic exams with pap smears
• This is the physical inspection of the vagina and
  cervix with palpation of the uterus and ovaries
• A physician, physicians assistant or NP performs
  this
• The pap smear (papanicolaou) is a specimen of
  cervical secretions for abnormal cervical cells,
  status of reproductive hormone activity and
  normal or infectious microorganisms within the
  vagina or uterus

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Radiography

• Procedures with x-rays such as
• MRI magnetic resonance imaging is a technique
  for producing an image by using atoms subjected
  to a strong electromagnetic fields. There are no
  rays of radiation. No metal objects may enter an
  MRI room such as metal implants, pacemakers and
  staples
• Contrast a substance that adds density to a
  body organ or cavity such as barium or iodine.
  These make hollow body areas appear more distant.
  Some people have an allergy to these. Allergies
  to shell fish may not have the contrast

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MRI
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Radiography

• CT computed tomography this type of scanning
  shows planes of tissue
• CT uses a contrast medium that is swallowed or
  injected IV that requires the use of fluoroscopy
  to view organs and structures. Contrast medium
  makes it possible to identify differences in
  tissue density when obtaining x-ray images from
  various angles and levels in the body

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CAT Scan (AV)
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Related Nursing Responsibilities

• For pts undergoing radiographic examination,
  nursing responsibilities include the following
• 1. Assess VS to get a baseline before the test
  starts to help detect changes in pts condition
  during and after the procedure
• 2. Remove any metal clips, bra clips, religious
  medals, these produce a dense image that may be
  confused with tissue abnormality

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Related Nursing Responsibilities

• 3. Application of a lead apron or collar to
  protect fetus and vulnerable body parts during
  x-ray
• 4. Ask the pt if he has allergies to seafood or
  iodine before the exam or procedure begins.
  Reactions of the dye range from N/V to shock and
  coma
• 5. Know the location of the emergency equip. if
  allergies or emergencies occur
• 6. Plan the schedule of pts carefully, schedule
  procedures with iodine before those that use
  barium

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Related Nursing Responsibilities

• 7. Instruct the pt to drink a large amount of
  water after the exam involving iodine to promote
  its secretion
• 8. Check on bowel elimination and stool
  characteristics for at least 2 days after
  administration of barium or other oral contrast
  medium. Barium retention can lead to
  constipation and bowel obstruction.
  Administration of laxative is often prescribed

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Endoscopic Examinations

• Endoscopy visual examination of internal
  structures, this is performed using optical
  scopes. Endoscopes have lighted mirror-lens
  systems attached to a tube and are quite flexible
  so that they can be advanced through curved
  structures
• If endoscopic exams will cause discomfort or
  anxiety, a light sedative is given such as
  conscious sedation. Pts end up having no memory
  of the procedure though they communicate and
  interact with staff during the procedure

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Examples of Endoscopic Examinations

• Bronchoscopy inspection of the bronchi
• Gastroscopy inspection of the stomach
• Colonoscopy inspection of the colon
• Laparoscopy inspection of the abd cavity
• Cystoscopy inspection of the bladder
• Anything with the wordscopy means the Dr. is
  using a scope, usually to investigate

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Nursing Responsibilities During Endoscopic
Procedures

• 1. Nurse prevents aspiration. Nurse tells pt to
  withhold fluid 6-8 hrs before procedure in preop
  visit. The scope is passed into the upper airway
  or upper GI tract
• 2. If conscious sedation is used, nurse assesses
  VS, O2 sats, cardiac rhythm and has resuscitation
  equip. ready

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Nursing Responsibilities During Endoscopic
Procedures

• 3. If topical anesthesia is used, nurse tells pt
  in preop visit to withhold fluids and food for 2
  hrs before procedure and cannot eat until
  swallow, cough and gag reflexes return
• 4. Relieve the pts sore throat with ice, fluids,
  or gargles when safe to do so
• 5. Confirms that bowel preps or laxatives and
  enemas have been used before procedure begins
• 6. Reports difficulty in arousing the pt, sharp
  pain, fever, bleeding, N/V or difficulty
  urinating after any type of endoscopic procedure

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Endoscope
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Endoscopy
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Radionucleide Imaging

• Radionuclides are elements whose molecular
  structure are altered to produce radiation
• Radionuclides are injected into the body by IV
  route, tissues or organs absorb them. The pt is
  then put into a scanning device that detects
  radiation which creates an image of the size,
  shape and concentration of the organ containing
  the radionuclide dye
• Hot spots where the radionuclide is intensely
  concentrated, shows up as a lit up spot

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• A radioisotope is introduced into the body
  (usually by injection). The radiation it emits,
  detected by a scanner and recorded, reflects its
  distribution in different tissues and can reveal
  the presence, size, and shape of abnormalities in
  various organs.
• The isotopes used have short half-lives and decay
  before radioactivity causes any damage.
• Different isotopes tend to concentrate in
  particular organs (e.g., iodine-131 in the
  thyroid). Radioactive substances are also
  implanted to treat small, early-stage cancers.
  This yields a slow, continuous dose that limits
  damage to normal cells while destroying tumour
  cells.
• Examples computerized axial tomography
  diagnostic imaging positron emission tomography
  radiation therapy radiology

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2 advantages of radionuclide imaging

• It visualizes areas within organs and tissue that
  are not possible with standard x-rays
• It involves less exposure to radiation than with
  standard x-rays
• Radionuclides are not recommended in pregnant or
  breastfeeding women d/t the energy being released
  is harmful to the rapidly growing cells of an
  infant or fetus

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Example of a radionuclide examination

• PET scan positron emission tomography
• Tomography is a radiographic technique that
  selects a level in the body and blurs out
  structures above and below that plane leaving a
  clear image of the selected anatomy
• This test combines the technology of radionuclide
  scanning with the layered analysis of tomography
• The images in PET scan are in color and indicate
  the degree of metabolism or blood flow

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PET SCAN
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Nursing Responsibilities r/t Radionuclide Imaging

• 1. Inquire about a womans menstrual and
  obstetric history, this type of imaging can be
  harmful to baby or fetus
• 2. Inquire about allergies esp. iodine
  (shellfish), this is in the dye
• 3. Be sure pt doesnt have any metal implants,
  these interfere with diagnostic findings

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Nursing Responsibilities r/t Radionuclide Imaging

• 4. Obtain an accurate weight because the dose of
  radionuclide is directly r/t weight
• 5. Inform the pt that he will be radioactive for
  lt 24hrs but urine and stool can be flushed away
  safely
• 6. Instruct premenopausal women to use effective
  birth control for a short period during which
  radiation continues to be present

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Ultrasonography

• This is a soft tissue exam that uses sound waves
  in ranges beyond human hearing
• A hand-held probe projects sound through the
  bodys surface, the sound waves cause vibrations
  within body tissues producing images as the waves
  are reflected back toward the machine

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What do we use ultrasound for

• To visualize
• The breast
• Abdomen and pelvic organs
• Male reproductive organs
• Structures in the head and neck
• Heart and valves
• Structures of the eyes
• Air-filled structures such as lungs or
  intestines, and dense structures do not image
  well

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Nursing Responsibilities r/t ultrasound

• Perform the ultrasound before any barium study in
  order to be able to see hollow structures
• Instruct pt to drink 5-6 glasses of water to fill
  the bladder so it can be seen (tell the pt not to
  urinate until after the test)
• Explain that gel is applied over the area where
  the tranducer will be placed to better conduct an
  image

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Ultrasound
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Electric Graphic Recordings

• These are machines that record electrical
  impulses from structures such as heart, brain and
  skeletal muscles
• Electrodes (wires) are attached to the skin. The
  electrodes transmit electrical activity to a
  machine that converts it into a series of
  waveforms

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Examples of Electric Graphic Recordings

• Electrocardiogram (ECG or EKG) heart waves
• Electroencephalography (EEG) brain waves
• Electromyography (EMG) this attaches a wire
  directly to a muscle(s) and examines the energy
  produced by stimulated muscles

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Nursing Responsibilities r/t EKG/ECG

• 1. The nurse must clean the skin and clip the
  hair in the area where the electrode tabs will be
  placed to ensure adherence and to reduce
  discomfort of removal
• 2. The nurse will attach adhesive tabs to the
  skin where the electrode wires will be fastened
  (avoid attaching the adhesive tabs over bones,
  scars, or breast tissue)

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EKG
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Electrocardiography
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Nursing Responsibilities r/t EEG

• Instruct pt to shampoo the hair the evening
  before the procedure to facilitate the firm
  attachment of the electrodes and shampoo the hair
  after the test is completed to remove the
  adhesive from the scalp
• Withhold coffee, tea and cola to avoid the need
  to urinate frequently for 8 hrs before the
  procedure
• If sleep deprived EEG is scheduled, instruct the
  pt to stay awake after midnight before the
  examination

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Electroencephalography
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Nursing Responsibilities r/t EMG

• Tell the pt that he will be instructed to
  contract and relax muscles during the examination
• Explain that electrical current is applied to
  muscles during an EMG and that the sensation can
  be painful, a muscle electrode is inserted with a
  small-gauge needle in 10 or more locations but
  the experience is painless unless it touches a
  terminal nerve in the area (pts I know state that
  this test hurts and they have begged Dr. to stop
  the test)

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Electromyography
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Diagnostic Laboratory Tests

• These are any tests where a specimen of some type
  is collected and sent to a lab for results
• Diagnostic lab tests include specimens such as
• Blood, urine, stool, sputum, intestinal
  secretions, spinal fluid and drainage from wounds
  or infected tissue
• Lab manuals are always referred to for normal
  values by many staff members

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Paracentesis

• This is a procedure for withdrawing fluid from
  the abdominal cavity to relieve pressure and to
  improve breathing which becomes labored when
  fluid crowds the lungs. At times, 1 liter or
  more may need to be removed. Specimen can be
  sent to the lab for microscopic examination
• A Physician is the only one to perform this with
  the assistance of a nurse

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Paracentesis
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Thoracentesis

• Needle is inserted into the thoracic cavity in
  order to remove fluid
• BIG CONCERN
• Placing the needle in the pleural space causing a
  hemo or pneumothorax

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Thoracentesis
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Lumbar Puncture

• This involves the insertion of a needle between
  the lumbar vertebrae in the spine but below the
  spinal cord itself to remove CSF to test for
  microorganisms such as meningitis
• Pressure of spinal fluid can also be measured to
  detect malfunctioning shunt, tumor or other brain
  dysfunction
• Fluid can be removed if contrast needs to be
  injected
• Medication can be instilled into the spinal fluid

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Nursing Responsibility r/t Lumbar Puncture

• The nurse prepares the pt by explaining the
  procedure
• The nurse prepares the area where the procedure
  will take place
• The nurse holds the pt in a side lying position
  with knees bent as far to the chest as possible
  and with chin to chest (in a ball)
• The nurse calms the pt throughout the procedure

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Post-Lumbar Puncture

• The nurse instructs the pt to lay flat for up to
  6-8 hrs to avoid the leakage of CSF which causes
  spinal headaches

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Throat Culture

• A culture is an incubation of microorganisms and
  it is performed by collecting body fluids or
  substances suspected of containing infectious
  microorganisms that can be seen with a microscope
• The most common cause of throat infection is d/t
  streptococcal bacteria

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Obtaining a Throat Culture

• The nurse obtains a specimen from the throat by
  either having the pt sit upright or having the pt
  lying down on their back
• A cotton swab stick is placed in the back of the
  throat towards the tonsillar area and the area is
  swabbed back and forth
• Rapid strep test is performed in an out-pt office
  and that same culture is sent off the to lab for
  further growth

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Cultures
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Measuring Capillary Blood Glucose

• A glucometer is the instrument that is used
• Pts finger is poked, a drop of blood is put onto
  the strip and the strip is placed into the
  machine. Within 30 secs to 1 minute, the machine
  deciphers a blood glucose amount
• Normal blood glucose is ???
• Pts can perform this test at home and on self
• Pts can then adjust their amount of insulin taken
  to better control blood glucose levels

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Tips on measuring blood glucose levels

• 1. Several glucose monitors are available. The
  nurse must become familiar with her facilitys
  meter. Allow pt to teach you about their
  glucometer for better learning
• Blood glucose should be measured up to 30 minutes
  before eating a meal
• Always wear gloves when assisting a pt with blood
  glucose monitoring, (BSI)

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Glucometer
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NANDA Diagnoses

• Pts that undergo exams have much anxiety and many
  questions, you may find the following issues
• Anxiety
• Fear
• Impaired adjustment
• Decisional conflict
• Powerlessness
• Spiritual distress

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Arteriogram

• An arteriogram is an imaging test that uses
  x-rays and a special dye to see inside the
  arteries. It can be used to see arteries in the
  heart, brain, kidney, and many other parts of the
  body.
• The procedure is often called angiography

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Arteriogram
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Arteriography (AV)
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Colonoscopy
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Sigmoidoscopy (AV)
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Bronchoscopy (AV)
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Cystoscopy
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IVP

• Intravenous pyelorogram dye
• is used to examine the kidney
• Pt must drink increased amount fluids after this
  test
• is completed

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Liver Biopsy (AV)
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The End