Clinician's Guide to Diagnostic Testing

Clinician's Role Overview

• Clinicians must understand modalities beyond their expertise, including diagnostic evaluation and services
• Test selection relies on clinical judgment, national recommendations, and evidence-based healthcare
• Clinical interventions span the pretest, intratest, and posttest phases
• Clinicians need basic knowledge to plan care, understand psychoneuroimmunology, make careful judgments, and gather patient information for appropriate diagnoses within professional standards

Pretest Interventions

• Understand test terminology and translate it for the patient
• Assess test indications, interferences, and contraindications, identifying and adjusting care for risk-prone patients
• Obtain informed consent
• Order tests correctly
• Prepare and educate the patient and family
• Consider ethical and legal aspects
• Support the patient and/or family
• Document, report, and maintain records

Intratest Interventions

• Adhere to regulatory standards and institutional policies
• Perform or assist with the procedure
• Collect and transport specimens
• Observe standard precautions
• Provide physical support and reassure the patient
• Offer comfort; medicate and sedate if necessary
• Facilitate family presence
• Monitor appropriately
• Prevent, and treat complications
• Report, document, and maintain records

Posttest Interventions

• Interpret test results, assessing pretest compliance if abnormal
• Know and treat critical sedation and complications
• Monitor for posttest sedation and complications
• Follow infection control guidelines
• Provide social support and counsel for unexpected outcomes
• Order follow-up tests and inform the patient
• Re-educate the patient for future testing
• Summarize diagnostic care
• Document, maintain records, and report results as mandated
• Help the patient integrate test results into their lifestyle

Basics of Informed Diagnostic Care

• Provide patient-centered care
• Manage the testing environment collaboratively
• Communicate effectively and clearly
• Prepare the patient properly
• Follow standards
• Consider culture, gender, and age diversity
• Perform and assist with diagnostic tests
• Measure and evaluate outcomes; modify treatment as necessary
• Manage effective diagnostic services using a team approach
• Interpret, treat, monitor, and counsel on test outcomes
• Identify clinical crises
• Maintain proper test records

Pretest Phase: Elements of Safe, Effective, Informed Care

• Emphasize appropriate test selection, obtaining consent, patient preparation, education, support, and effective communication

Basic Knowledge and Necessary Skills (Pretest)

• Know test terminology, purpose, process, procedure, and normal values
• Test value relates to its sensitivity, specificity, and disease incidence in the tested population

Specificity

• Refers to a test's ability to correctly identify individuals without the disease

Sensitivity

• Refers to a test's ability to correctly identify individuals with the disease

Incidence

• Refers to the number of new disease cases within a specified period and population

Prevalence

• Refers to the number of existing disease cases at a specific time in a given population

Testing Environments

• Testing occurs in various environments
• Point-of-care testing involves medical testing near the patient, decentralizing testing

History and Assessment (Pretest)

• Identify conditions that could influence testing, like pregnancy, diabetes, or altered mental state
• Perform a risk assessment for potential injury, adverse events, or noncompliance
• Identify contraindications, like allergies
• Assess coping styles and knowledge needs
• Assess fears and phobias and accommodate them
• Observe precautions with every patient, even if conditions aren't disclosed
• Document data and address patient concerns

Methodology of Testing

• Testing procedures should be followed accurately; verify and document orders
• Document all drugs the patient takes due to potential influence on test outcomes
• Ensure specimens are correctly obtained, handled, labeled, and delivered. Avoid drawing blood near infusing IV lines
• Observe precautions for patients in isolation, using standard or transmission-based precautions
• Healthcare personnel should use personal protective equipment (PPE)
• Coordinate patient activities with testing schedules
• Maintain NPO status when necessary
• Administer medications properly and schedule tests with contrast substances appropriately

Interfering Factors

• Minimize test outcome deviations by following protocols, including written instructions
• Reasons for deviations include incorrect collection, handling, storage, labeling, wrong preservative, delayed delivery, incomplete preparation, hemolyzed blood samples, incomplete or old samples
• Patient factors affecting results include incorrect diet, current drug therapy, illness, dehydration, time of day, pregnancy, knowledge, stress, noncompliance, undisclosed drug use, age, and gender

Avoiding Errors

• Know required equipment and test performance; communication errors are significant
• Properly identify and label every specimen immediately

Proper Preparation

• Begins at scheduling through testing
• Provide testing site information and directions
• Arrive 15 minutes early
• Identify the patient via two identifiers like name spelling and birth date, and confirm preprinted labels
• Review pretest instructions clearly, explaining fasting guidelines
• Be aware of special needs for those with limitations, disabilities, or cultural diversity
• Give simple, accurate instructions according to the patient's understanding, including specifics on eating, drinking, or fasting
• Encourage discussing fears and use relaxation techniques
• Assess the patient's ability to understand instructions, accommodating visual or hearing difficulties with clear, written instructions
• Assess for language and cultural barriers, valuing patient uniqueness
• Document each testing phase accurately

Patient Education

• Education patient and family regarding the testing process and expected outcomes
• Giving sensory and objective information is important
• Encourage questions and acknowledge feelings
• Emphasize waiting periods for results
• Offer support during anxious times
• Record test result information and the patient's response
• Document specific information

Testing Protocols

• Establish consistent teaching and testing protocols with comprehensive pretest, intratest, and posttest care
• Prepare patients based on common experiences and reactions from other patients

Patient Independence

• Allow the patient to maintain as much control as possible in decision making
• Validate understanding by having the patient repeat instructions
• Include and reinforce information about the diagnostic plan, procedure, time frames, and the patient's role

Test Results

• Understanding normal values is important since ranges vary by laboratory due to equipment differences
• Normal values can refer to ideal health, average values, or statistical distribution
• Reference ranges differ based on the lab, method, population, and specimen handling
• Most normal blood test values are determined by measuring fasting specimens
• Factors like posture affect results; plasma volume changes based on being supine
• Changing from supine alters hemoglobin, RBC count, hematocrit, calcium, potassium, phosphorus, AST, phosphatases, total protein, albumin, cholesterol, and triglycerides
• Laboratories must specify their own normal ranges since values are affected by age, gender, race, environment, posture, diurnal variations, foods, fasting state, drugs, and exercise
• Interpretation must be in the context of the patient's state including hydration, nutrition, mental status, and compliance

Laboratory Reports

• Clinical laboratory data values are changing from conventional units to Systeme International (SI) units
• The SI system uses seven dimensionally independent units of measurement for logical and consistent measurements
• Numerical values may differ or be the same between systems

Margins of Error

• Recognize that some tests may be abnormal due to chance, given the arbitrary setting of limits
• If a test is normal up to the 95th percentile, 5 out of 100 will show an abnormality without illness
• Each successive testing will produce a higher percentage of abnormal results

Ethics and the Law

• Consider legal and ethical implications, including the right to information, correct diagnosis, consent forms, and explanations of risks and benefits
• Chain of custody ensures specimen integrity from collection to storage
• Informed consent involves patient autonomy and the right to be free of procedures without consent and the right to determine what will be during to one's own person
• Risks, benefits, and alternatives are explained, and written consent is obtained in advance
• The patient must demonstrate cognitive faculties for valid consent; patients under sedation cannot legally consent
• Advance directives must be honored
• A collaborative team approach is essential for ethical patient-focused care
• The clinician who orders the test informs the patient about risks, results, and alternatives. Caregivers provide additional information and support
• The duty to maintain confidentiality, provide freedom of choice, and report infectious diseases may cause dilemmas, e.g., HIV screening
• Respect for the individual's dignity reflects ethical considerations
• Patients have a right to consent, question, request other opinions, and refuse tests. Caregivers have a right to know patient diagnoses to minimize risks

Patient's Bill of Rights and Patient Responsibilities

• Patients have a right to expect policies ensuring rights and responsibilities
• Rights include considerate, honest, respectful care, involvement in decision-making, informed consent, information on costs, refusal of testing, family support, standards of care, safe and skilled care, and education
• More rights include access to results, counseling on outcomes, pain control, confidentiality
• Responsibilities:. to comply with test requirements and inform clinicians if unable
• These include reporting conditions, keeping appointments, disclosing substance use and allergies, reporting adverse effects, providing their own specimens, reporting impairments, and informing tester of not understanding testing

Cultural Sensitivity

• Preserving cultural well-being promotes compliance and easier recovery
• Sensitive questioning may reveal cultural traditions related to health
• The Hmong believe the soul resides in the head, requiring permission to touch it
• Understanding cultural differences without judgment is important
• A translator is sometimes necessary for accurate communication
• Concerns about blood sampling or disposal of body fluids may require patience and tact
• Ethnographic interviewing helps access values and shows respect

Intratest Phase: Elements of Safe, Effective, Informed Care

• Focus on specimen collection, monitoring the environment, assisting with procedures, providing comfort, administering analgesics/sedatives, and monitoring vital parameters
• The clinician needs basic knowledge and skills
• Safe practices, proper collection, minimizing delays, providing support, preparing/administering drugs, monitoring, and being alert to side effects are integral
• Invasive procedures increase risks, requiring vigilance
• Monitoring fluids, temperature, and systems, and treating problems involves critical thinking

Infection Prevention

• Institute accepted infection prevention protocols, observe special measures and sterile techniques, identify at-risk patients, and initiate isolation as necessary
• Quality assurance requires proper collection, transport, and cleaned equipment
• Standard precautions assume body fluids are infectious, requiring protection
• Healthcare workers must adhere to standard precautions and strict infection control guidelines, including scrupulous hand hygiene

Collaborative Approaches

• A team approach is necessary for most procedures where clinicians must assist each other
• Invasive procedures require closer monitoring and may involve IV sedation
• Observation, critical thinking, and quick decision-making skills are necessary

Risk Management

• Assess for and provide a safe environment for the patient at all times
• Identify patients at risk of falling, cerebrovascular accident (CVA), neuromuscular disorders, loss of balance, and use of assistive devices are contributory risk factors
• Prevention of complications and management of risk factors are an important part of the intratest phase
• Observe standard precautions and infection control protocols as necessary
• Use caution during procedures that require iodine and barium contrasts, radiopharmaceuticals, latex products, sedation, and analgesia
• Remove jewelry, false teeth, and other prosthetic devices necessary
• Check for NPO or fasting status if appropriate

Specimens and Procedures

• Conduct or assist with diagnostic procedures
• Assisted procedures: endoscopy, lumbar puncture, and cardiac catheterization
• Procedures independently performed: Papanicolaou (pap) test, centrifugation, ECG, breathing tests, and pulse oximetry
• Pulse oximetry monitors oxygen saturation (Sp02) noninvasively; Sp02 refers to pulse oximetry, arterial saturation measured on an arterial blood sample
• Sensors are placed on fingers, nose, earlobe, toe, foot, or forehead
• Factors interfering with accuracy: patient movement, ambient light, electronic interference, artificial nails, anemia, edema, or poor circulation
• Collecting specimens and conducting procedures are the main interventions in the diagnostic pretest and intratest phases
• Procure, process, transport, and store specimens properly
• Thorough understanding is needed to ensure accurate results
• Determine specimen type needed and method of sample procurement. Special equipment and supplies may be necessary (e.g., sterile containers, special kits)
• Patient collection requires the patient's cooperation, understanding, and instruction
• Supervised collection requires that trained personnel be present when the specimen is collected
• Clinician collection requires that the clinician perform the entire collection
• Time of collection is also important (e.g. a sequence of samples for a cardiac panel)
• Peak drug level collection is when the highest concentration in the blood is expected (therapeutic drug management and dosing)
• Trough level collection is when the lowest concentration is expected (therapeutic drug monitoring, specimens collected and results reported before the next scheduled dose of medication)
• Legal and forensic specimens are collected as evidence in legal proceedings, for criminal investigations, and after death
• Factors such as chain-of-custody situations and witnessed collections may be involved

Stool and Urine Collection

• Requires clean, dry containers and kits
• Timed urine collection requires refrigeration or containers with special additives
• Sterile, dry containers and special kits are needed for midstream clean-catch urine specimens
• Oral, saliva, and sputum specimens require specific techniques and kits and, sometimes, special preservatives
• Blood collection equipment includes gloves, needles, collection tubes, syringes, tourniquets, needle disposal containers, lancets for skin puncture, cleansing agents or antimicrobial skin preparations, and adhesive bandages
• Color-coded stoppers and tubes indicate the type of additive present in the collection tube
• Additives preserve the specimen, prevent deterioration and coagulation, or block action of certain enzymes in blood cells
• Tubes with anticoagulants should be gently and completely inverted 7 to 10 times after collection, ensuring complete mixing
• Store specimens properly after collecting or transport them to the laboratory immediately for processing and analysis if possible
• STAT ordered tests should always be hand-delivered to the laboratory and then processed as STAT
• Unacceptable specimens lead to wasted costs and time
• Exposure to sunlight, air, or other substances and warming or cooling can alter specimen integrity

Equipment and Supplies

• Use required kits, equipment, and supplies
• Special kits are used for obtaining heel sticks and finger sticks, blood alcohol samples, saliva or oral fluid specimens, and urine specimens
• Do not use it if you notice a defect (e.g., moisture, pinholes, tears). In cases of sexual assault, special rape kits are required
• Operating special equipment such as video monitors for endoscope procedures may be required in some instances
• Use barrier drapes as directed
• Maintain aseptic technique during certain procedures (e.g., cystoscopy, bone marrow biopsy)

Family Presence

• Involving family members in the diagnostic care process has helped families by making them active participants.
• Facilitating family presence during invasive procedures may provide the opportunity to calm the patient, offer additional comfort, and reduce anxiety and fear
• Family presence should be documented in the health care record

Positioning for Procedures

• Body positioning involves placing the patient in the best possible position for the procedure and aligning the body correctly for optimal
• Respiratory and circulatory function and positions positions
• Positions include jackknife, prone, lithotomy, sitting, supine, and Trendelenburg
• Using positioning devices, arranging padding, and repositioning are important interventions to prevent skin pressure and skin breakdown
• The potential adverse effects of various positions, especially during lengthy procedures, include skin breakdown, venous compression, sciatic nerve injury, muscle injury, and low back strain
• Necessary positioning skills include ensuring that the patient's airway, IV lines, skin integrity, and monitoring devices are not compromised

Administration of Drugs and Solutions

• All drugs and solutions administered during diagnostic procedures are given according to accepted protocols given by mouth, inhalation, intubation or parenterally
• Be cognizant of the potential for adverse reactions to drugs
• Risks for injury are related to hypersensitivity, allergic or toxic reactions, impaired drug tolerance due to liver or kidney malfunction, extravasation of intravenous fluids, and absorption of irrigating fluids into the systemic circulation
• Required skills include managing airways and breathing patterns; monitoring fluid intake and loss; monitoring body, skin, and core temperature; and observing the effects of sedation and analgesia (e.g., vital signs, rashes, edema)

Management of Environment

• Goal is safe practice to ensure the patient is free from injury; be attentive to temperature and air quality, noise, radiation, latex, odors, sanitation, and cleanliness
• Eliminate or modify sensory stimuli (e.g., noise, odors, sounds)
• Post a PATIENT AWAKE or if the patient is awake or PATIENT ASLEEP for sleep studies
• Be sensitive to conversation among team members in the presence of the patient

Latex Sensitivity and Allergy

• Allergic reactions are caused by latex proteins retained in the finished products, which can show great variations in latex allergen levels
• The greatest environmental hazard exposure is produced by latex gloves and the powder from the gloves that becomes airborne
• Increased or continued exposure increases sensitivity to latex allergens and worsens allergic reactions
• Patients and health care workers can become sensitized to latex through repeated skin or mucous membrane contact or by inhaling aerosolized glove allergens
• Persons with latex allergies are more likely to react to certain foods that contain cross-reactive proteins, especially banana, avocado, chestnut, almond, kiwi fruit, raw potato, tomato, peach, plum, cherry, melon, celery, apple, pear, and papaya
• Besides latex allergies, other glove-associated reactions may occur

Pain Control, Comfort Measures, and Patient Monitoring

• Provide information, support, and reassurance to allay anxiety
• Administer sedatives, pain medication, or antiemetics
• Uphold the dignity of each patient, provide privacy, and minimize embarrassment
• Do not keep the patient disrobed longer than necessary, ensure privacy and allow personal clothing
• Accommodate persons with special needs
• Monitor and document vital signs, observe for problems, and ensure equipment is available
• Document the patient's response, significant events, and disposition of specimens

Sedation and Analgesia

• Increasing people are receiving short-term moderate sedation and analgesia for invasive diagnostic procedures because of short, rapid recovery; early ambulation; patient preference for light sleep and amnesia; cooperation; protective reflexes remain intact; stable vital signs; and infrequent complications
• Goals include diminishing discomfort and pain, and anxiety and immobilizing the patient for complex procedures
• Practitioners should be able to rescue patients whose sedation becomes deeper

Preadministration

• Explain the purpose of moderate sedation and analgesia before administering the medications
• Assess health status, allergies, medications, previous test results, understanding, orientation, and ability to cooperate
• Check the patient's health and identify those who are risk (lung or cardio disease)
• Explain the process and use, and ensure they are aware of side effects
• For adults, no food or liquid should be taken for 2 to 6 hours before the procedure to allow for gastric emptying
• Before beginning procedure, establish IV line
• Monitor ventilation oxygenation, electrocardiogram according to established guidelines before administering moderate sedation
• Vital signs should be documented (before, during, and after the procedure)
• A designated individual, other than the practitioner performing the procedure, should be present
• Have equipment readily available for emergency situations

Intra-Administration

• Continuously assess pain or discomfort and sedation levels at frequent established intervals
• Administer sedation and analgesics as ordered, often in incremental doses
• Monitor the IV site for infiltration and side effects (local anesthesia and sedation may cause adverse reactions)
• Assess level of consciousness—responses of patients to commands during the procedure serve as a guide to their level of consciousness
• Be cognizant that detecting changes in heart rate and blood pressure for hemodynamics reduces the risk for cardiovascular collapse and hypoedema
• Use oximetry to detect hypoxemia and decrease adverse outcomes such as cardiac arrest and death
• Many of these medications are respiratory depressants, mandating frequent respiratory assessments
• If oxygen saturation drops below acceptable levels, sedation may need to be held or reversed
• Have IV reversal agents such as naloxone (Narcan) and flumazenil (Romazicon) readily available
• Document carefully and completely all observations, including medications and dosages. Record unexpected outcomes and follow-up care

Post administration

• Monitor vital signs, ECG, saturation until baseline
• Provide verbal and written instructions to not complete the following: Drive or operate power machinery or tools for at least 24 hours; Consume alcoholic beverages or make legal decisions for 24 hours and Smoke
• Provide instructions for patients who unexpectedly become ill and require medications
• Evaluate the patient for readiness for discharge and that vital signs are stable- Provide a safe transport or discharge a post full recovery
• Allow sufficient time (up to 2 hours) to elapse after the last administration of reversal agents to ensure that patients do not become re-sedated after reversal effects have worn off

Posttest Phase: Elements of Safe, Effective, Informed Care

• The focus is on aftercare, monitoring, and prevention of complications
• Major components include evaluation of outcomes and effectiveness, follow-up counseling, discharge planning, and referrals

Abnormal Test Results

• Report and interpret test results, as patterns are more useful than single deviations
• Recognize abnormal results and consider implications both acutely and chronically
• Consider the role of drugs when tests are abnormal
• Evaluate age-related variables and test outcomes

Follow-Up Counseling

• Counsel the patient regarding test outcomes and their implications and provide time for the patient to ask questions
• Reassess interfering factors if results deviate
• Greater abnormality indicates a real disorder
• Notify the patient about test results after consultation with the clinician
• Help patients interpret the results of community-based testing
• When providing genetic counseling, the family needs support
• Be familiar with crisis intervention skills and recognize different stages of behavioral responses
• Monitor for complications and take measures to prevent them

Complication Monitoring

• Observe for complications or other risks, such as effects of sedation and analgesia, and take appropriate measures to prevent or deal with them in a safe patient environment
• The most common complications after invasive procedures are bleeding, infection (frequently a later complication), respiratory difficulties, perforation of organs, and adverse effects of conscious sedation and local anesthesia
• Watch for related signs and symptoms such as redness, swelling, skin irritation, pain or tenderness, dyspnea, abnormal breath sounds, cyanosis, decreased or increased pulse rate, blood pressure deviations (e.g., hypertension, hypotension), laryngospasm, agitation or combative behavior, pallor, and complaints of dizziness
• The above is for patient compliance, alteration in mental or physical state to prevent further issues
• Older patients and children may require closer, more lengthy monitoring and observation
• If patients are under certain medications certain protocols need to followed

Test Result Availability

• Collaborate with disciplines to ensure timely availability
• Properly use computers and wireless networks to expedite reporting data

Integration

• Promoting self-care, behavior change, and expression of grief or loss

Referral and Treatment

• Refer patients for testing and ensure that they have diet
• When being discharged tell the staff about patients and their condition for proper care

Follow-Up Care

• Post test care should be consistent, provide clear discharge instructions and specific protocols
• Ensure that information is understood and plan time for listeniSupport, discussion, and problem solving according to the patient's needs and requests
• Follow-up by phone may be done after discharge if indicated

Documentation, Record Keeping, and Reporting

• Record all phases of the diagnostic process in the patient's health care record for accuracy, clarity and organization
• Document purpose, side effects, risks, expected results/benefits, alternative methods, medications, IV sedation and allergic reactions
• Document the patient's reasons for refusing a test from the clinical
• Record information about testing, and results
• Ethical standards may be a source of conflict and anxiety when the professional clinician is acting in the role of patient advocate
• Make sure the patient has right to to be informed of test results
• In cases in which the patient brings family and significant others together to inform them about test results, communication becomes open and shared
• Document follow-up patient education and counseling and document that the patient or family has been notified regarding test results

Patient Responses to Diagnosis

• Develop crisis intervention skills to use when communicating with the patient who experiences difficulty dealing with abnormal test results or confirmation of disease or illness
• Monitor changes in patient affect, mood, behaviors, and motivation and do not assume a perception of a disorder will always be negative

Action Responses To Improve Well-being

• Offer appropriate comfort measures and provide patients with support
• Ensure proper health behavior through therapy and help make daily life activities easier

Expected and Unexpected Outcomes

• Compare normal values with abnormal results and apply these comparisons to the patient's situation
• Desired outcomes and recommendations may not be successful due to various restrictions a patient may endure
• Patients may refuse diagnostic testing because they fear the results may get worse
• Adverse events may occur as a result of diagnostic procedures
• Report unexpected abnormalities to health