Case Sharing on Diagnostic Tests PDF

CASE SHARING Presented to the Faculty of the School of Nursing Adventist Medical Center College Brgy. San Miguel, Iligan City In Partial Fulfillment to Care of Clients with Problems in Oxygenation, Fluid and Electrolyte...

CASE SHARING Presented to the Faculty of the School of Nursing Adventist Medical Center College Brgy. San Miguel, Iligan City In Partial Fulfillment to Care of Clients with Problems in Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations, Acute and Chronic Submitted by: De La Cruz, Jon Rusty Gutierrez, Cherry Mae Ibrahim, Al-fhaiz Jabutay, Mariah Cecille May Latuhan, Uziel Masbod, Sittie Hafsah Ollodo, Jhanna Mae Pagente, Lyrah Faith Submitted to: Shella G Dello, RN, MAN Raymond M. Salvador, RN, MN October 21, 2024  TABLE OF CONTENTS COVER PAGE TABLE OF CONTENTS……………………………………………………………………1 I. OBJECTIVES…………………………………………………………………………2 II. INTRODUCTION…………………………………………………………………….3 III. SERUM GLUTAMIC PYRUVIC TRANSAMINASE / ALANINE AMINOTRANSFERASE IV. SERUM GLUTAMIC OXALOACETIC TRANSAMINASE / ASPARTATE AMINOTRANSFERASE V. ARTHROSCOPY VI. ANTINUCLEAR ANTIBODIES VII. WESTERN BLOT VIII. BILIRUBIN TEST (DIRECT,INDIRECT,TOTAL) IX. ENZYME-LINKED IMMUNOSORBENT ASSAY X. VIRAL LOAD XI. ATRIAL NATRIURETIC PEPTIDE XII. BARIUM ENEMA / LOWER GI SERIES XIII. BARIUM SWALLOW / UPPER GI SERIES XIV. CHOLANGIOGRAPHY XV. CYSTOSCOPY XVI. ELECTROENCEPHALOGRAM (EEG) XVII. ELECTROMYOGRAPHY (EMG) XVIII. BONE SCAN XIX. PAP XX. RADIOALLERGOSORBENT TEST (RAST) XXI. SINGLE-PHOTON EMISSION COMPUTED TOMOGRAPHY (SPECT) XXII. VENEREAL DISEASE RESEARCH LABORATORY (VDRL) 1  I. OBJECTIVES General Objectives After 4 hours, the presenters will be able to deliver a comprehensive yet concise discussion of the 20 diagnostic tests. This case sharing will provide a structured overview, ensuring all relevant aspects are addressed effectively. Specific Objectives Presenters To explain the definition and purpose of various diagnostic tests, helping learners understand the indications for each test. To describe the interpretation of normal and abnormal findings in diagnostic tests, providing examples and case studies. To outline the nursing responsibilities before, during, and after diagnostic tests, emphasizing the importance of patient safety and comfort. To identify factors that can interfere with diagnostic test results and suggest strategies to minimize their impact. Learners To understand the definition, purpose, and indications of various diagnostic tests in clinical settings. To recognize the differences between normal and abnormal findings and their implications for patient care. To apply knowledge of nursing responsibilities before, during, and after diagnostic tests to ensure optimal patient outcomes. To identify factors that can interfere with test results and determine ways to address these in practice. 2  II. INTRODUCTION Diagnostic tests are fundamental components of the healthcare system, providing valuable information that aids in the assessment, diagnosis, and management of various health conditions. These tests help to identify potential health issues, confirm suspected diagnoses, and monitor the progression of diseases or the effectiveness of treatment plans. By offering objective data, diagnostic tests complement clinical evaluations, giving healthcare providers a clearer picture of a patient’s health status and guiding critical decision-making processes. The primary purpose of diagnostic tests is to support accurate and timely diagnosis, which is essential for effective treatment. They are used in a range of scenarios, from screening for conditions in asymptomatic individuals to confirming specific diagnoses in symptomatic patients. Additionally, they play a role in monitoring patients’ responses to therapies and detecting complications early. Each test is selected based on the clinical question it aims to answer, ensuring that it aligns with the patient’s needs and the overall goals of care. Accurate interpretation of diagnostic tests is crucial, as it directly impacts patient care. Understanding what constitutes normal and abnormal results allows healthcare professionals to distinguish between typical variations and those that may indicate a health concern. However, various factors can influence test results, including patient preparation, timing, and external variables that may interfere with accuracy. Awareness of these factors is vital to ensure the reliability of test outcomes and to avoid misinterpretation that could lead to unnecessary treatments or missed diagnoses. The role of healthcare professionals, particularly nurses, is integral throughout the diagnostic testing process. Their responsibilities include preparing patients for tests, ensuring adherence to necessary pre-test guidelines, and providing post-test care and support. They play a critical role in educating patients about the procedure, addressing concerns, and facilitating follow-up care. This comprehensive approach to managing diagnostic tests ensures patient safety, enhances the accuracy of results, and contributes to improved health outcomes through well-informed clinical decision. 3 4 1 III. SERUM GLUTAMIC PYRUVIC TRANSAMINASE / ALANINE AMINOTRANSFERASE INTRODUCTION SGPT (Serum Glutamic Pyruvic Transaminase), also known as ALT (Alanine Aminotransferase), is an enzyme found primarily in the liver. It plays a key role in converting proteins into energy for liver cells. The ALT test measures the level of this enzyme in the blood and is commonly used to assess liver health, as ALT is released into the bloodstream when liver cells are damaged. PURPOSE/INDICATION The SGPT/ALT test is indicated for detecting liver injury, diagnosing liver diseases, and monitoring liver conditions such as hepatitis, cirrhosis, and fatty liver disease. It also helps evaluate the liver's response to medications that may be hepatotoxic NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS 29 - 33 IU/L for males and 19 - 25 UI/L for Elevated Levels females (varies slightly by laboratory standards). Hepatitis (viral, alcoholic, autoimmune) leads to the release of ALT from damaged liver cells. Chronic liver damage often presents with elevated ALT. Non-alcoholic fatty liver disease (NAFLD) often causes mild to moderate ALT elevation. 5 1 Liver tumors can elevate ALT levels due to liver damage. NURSING RESPONSIBILITIES BEFORE: Inform the patient about the test procedure and its purpose. Verify if fasting is required (usually not). Review medications that might interfere with results and ensure they are appropriately withheld. DURING: Assist with venipuncture and ensure proper collection, labeling, and transport of the blood sample to the lab. AFTER: Monitor the venipuncture site for any bleeding or signs of infection. Inform the patient when results will be available. Reinforce the need for follow-up tests if necessary, depending on results. INTERFERING FACTORS FACTORS RATIONALE Recent strenuous exercise. Exercise can cause temporary ALT elevation due to muscle activity. Hemolysis of the blood sample. Hemolysis breaks open red blood cells, releasing intracellular enzymes that falsely elevate ALT levels. Medications like statins, aspirin, or Drugs metabolized by the liver or that are antibiotics. hepatotoxic can lead to elevated ALT levels. 6 1 VI. DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Statins Statins can cause mild to moderate increases in liver enzymes as part of their hepatic metabolism. Acetaminophen Acetaminophen at high doses can lead to acute liver failure due to its toxic metabolite. Antibiotics (e.g., tetracyclines, isoniazid) Certain antibiotics can be hepatotoxic, particularly with long-term or high-dose usage. 7 1 IV. SERUM GLUTAMIC OXALOACETIC TRANSAMINASE / ASPARTATE AMINOTRANSFERASE INTRODUCTION SGOT (Serum Glutamic Oxaloacetic Transaminase), also known as AST (Aspartate Aminotransferase), is an enzyme found primarily in the liver, heart, muscles, and other tissues. When these tissues are damaged, AST is released into the bloodstream. The test measures AST levels to evaluate the extent of tissue damage. It is commonly used in diagnosing and monitoring liver diseases like hepatitis, cirrhosis, fatty liver disease, and alcoholic liver disease. Elevated AST levels may also indicate heart conditions like myocardial infarction, and muscle disorders such as muscular dystrophy. PURPOSE/INDICATION To assess liver function, detect liver damage, monitor liver disease progression, or evaluate heart and muscle damage. NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS 8 - 33 U/L (may slightly vary depending on Elevated levels may indicate liver diseases the laboratory). (e.g., hepatitis, cirrhosis), heart damage (e.g., myocardial infarction), or muscle injuries. Low levels not typically clinically significant. NURSING RESPONSIBILITIES BEFORE: Educate the patient about the purpose of the test. Ensure the patient fasts for 8-12 hours if required. Verify any medications that need to be withheld before the test. DURING: Ensure proper blood sample collection via venipuncture. 8 1 Label the specimen accurately and transport it to the lab promptly. AFTER: Monitor the puncture site for bleeding or hematoma. Provide patient education on test results and follow-up care. INTERFERING FACTORS FACTORS RATIONALE Recent strenuous exercise Exercise can temporarily elevate AST levels due to muscle strain or damage. Hemolysis during blood draw Destruction of red blood cells may falsely increase AST levels. Alcohol consumption Chronic consumption can elevate AST due to liver damage.enzymes that falsely elevate ALT levels. Certain medications Some drugs can elevate AST by affecting liver or muscle function. VI. DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Acetaminophen Acetaminophen can harm the liver, leading to artificially elevated AST levels. Statins Statins are known to cause liver enzyme elevations due to potential liver or muscle damage.. Antibiotics (e.g., amoxicillin) Antibiotics may affect liver function, temporarily raising AST.. 9  V. ARTHROSCOPY INTRODUCTION (ahr-THROS-kuh-pee) is a procedure that uses a fiber-optic camera to diagnose and treat joint problems.minimally invasive surgical procedure used to diagnose and treat joint problems using an arthroscope, a small camera inserted into the joint through a small incision. A surgeon inserts a narrow tube attached to a fiber-optic video camera through a small incision — about the size of a buttonhole. This method is commonly performed on joints like the knee, shoulder, elbow, ankle, wrist, and hip issues, among others, and typically results in quicker recovery times compared to traditional open surgery. PURPOSE/INDICATION Arthroscopy helps diagnose and treat joint problems while minimizing damage. It's like peeking inside without fully opening the door, which means less pain, fewer complications, and faster recovery. It’s especially significant for athletes and active folks, allowing them to return to their routines quicker. This minimally invasive approach typically results in less pain, reduced recovery time, and fewer complications compared to open surgery NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS Healthy cartilage: Smooth, intact surfaces Cartilage damage: This can range from without any wear or tears. small defects to more extensive degeneration, such as in chondromalacia patellae. Normal ligaments: Firm and intact, Ligament tears: Tears in ligaments like the without any signs of stretching or tearing. ACL (anterior cruciate ligament) or meniscus are frequently observed. Clear synovium: The lining of the joint Synovitis: Inflammation of the synovial should not be inflamed or thickened membrane, which can cause joint swelling and pain. 10 No loose bodies: Absence of any fragments Loose bodies: Fragments of bone or or debris within the joint space. cartilage that have broken off and are floating within the joint space. Tendon damage: Issues with tendons, such as fraying or partial tears, can also be detected. NURSING RESPONSIBILITIES BEFORE: Preoperative Assessment: Conduct a thorough assessment of the patient's medical history, current medications, allergies, and any previous surgeries Patient Education: Explain the procedure to the patient, including what to expect before, during, and after the surgery Medication Management: Ensure the patient follows instructions regarding medication adjustments, especially blood thinners and NSAIDs, to minimize bleeding risks Fasting Instructions: Instruct the patient to fast (no food or drink) after midnight before the procedure to reduce the risk of aspiration during anesthesia Consent: verify that the patient has signed the informed consent form and understands the procedure and its potential risks. Preparation for Surgery: Help the patient get ready for surgery by assisting with changing into a hospital gown, starting an IV line, and administering preoperative medications as ordered. Emotional Support: provide emotional support to the patient and their family, addressing any concerns and offering reassurance DURING: Monitor vital sign: Keep a close watch on the patient's vital signs, such as heart rate, blood pressure, and oxygen levels, to ensure they remain stable after anaesthesia. Pain management: Administer prescribed pain medications and monitor their effectiveness. Make sure the patient is comfortable and address any pain concerns. Wound care: Check the surgical site for signs of infection or excessive bleeding. Change dressings as needed and keep the area clean and dry. 11  Encouraging Mobility: Assist the patient in getting up and moving as soon as it’s safe. Early mobility helps prevent complications like blood clots. Patient Education: Provide instructions on home care, including how to care for the surgical site, manage pain, and recognize signs of infection or complications. Follow-Up Appointments: Remind the patient about follow-up appointments and any physical therapy sessions they may need. Emotional Support: Offer reassurance and support to the patient and their family, addressing any concerns and helping them understand the recovery process. AFTER: Monitoring Vital Signs: Keep tabs on heart rate, blood pressure, and oxygen levels Pain management: Ensure pain relief with medications and make sure the patient is comfortable. Wound care: Regularly check the surgical site, change dressings, and watch for signs of infection. Patient education: Give clear instructions on home care, pain management, and recognizing complications. Follow up appointments: Make sure the patient knows about follow-ups and any required therapy. Emotional support: Provide support and reassurance to both the patient and their family. INTERFERING FACTORS FACTORS RATIONALE Allergic Reactions Some patients may have allergic reactions to anesthesia or other medications used during the procedure Blood clots There's a risk of developing blood clots, including deep vein thrombosis (DVT), especially if the patient is immobile for long periods. 12  Tissue or nerve damage There's a possibility of damaging surrounding tissues or nerves during the procedure. Excessive bleeding or swelling some patients may experience more bleeding or swelling than expected, which can complicate recovery Infection as with any surgical procedure, there’s a risk of infection at the incision site or within the joint DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Blood thinners (aspirin, Coumadin to reduce the risk of excessive bleeding (warfarin), Xarelto (rivaroxaban), or Eliquis during and after the procedure. Blood (apixaban) thinners impair the blood's ability to clot, which can lead to significant bleeding complications, both during surgery and in the recovery period. Nonsteroidal anti-inflammatory drugs increasing the risk of bleeding and (NSAIDs) ibuprofen (Advil, Motrin) and potentially interfering with the healing naproxen (Aleve) process. These medications inhibit platelet function and can prolong bleeding time, which is particularly important to consider before surgical procedures. 13  VI. ANTINUCLEAR ANTIBODIES (ANA) INTRODUCTION ANA stands for Antinuclear Antibodies. An ANA test is a blood test that detects the presence of antinuclear antibodies in your blood. These antibodies are produced by the immune system and target the nucleus (center) of your own cells. A high level of ANA can indicate an autoimmune disorder, where the immune system mistakenly attacks your body's own tissues. Examples of organs implicated in organ-specific autoimmune diseases are thyroid, liver, and lung. PURPOSE/INDICATION An ANA test is pivotal in diagnosing autoimmune disorders, where the body's immune system mistakenly attacks its own tissues. High levels of antinuclear antibodies can indicate conditions like lupus, rheumatoid arthritis, and Sjögren's syndrome. By detecting these antibodies, doctors can better understand the underlying issue, tailor treatment plans, and monitor disease progression. It's a crucial piece of the puzzle in managing autoimmune conditions. NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS An normal ANA (Antinuclear Antibody) Abnormal findings in an ANA (Antinuclear test result typically shows a negative or low Antibody) test typically indicate a positive titer. result, meaning higher levels of antinuclear antibodies are present in the blood Negative: Less than or equal to 1:40 High Titers: Indicative of or 1.0 U. autoimmune disorders such as lupus, Weakly Positive: 1:40 to 1:80 or rheumatoid arthritis, and 1.1-2.9 U. scleroderma. Positive: 1:80 to 1:160 or 3.0-5.9 U. Presence of Specific Antibody Strongly Positive: Greater than or Patterns: Certain patterns can equal to 1:160 or 6.0 U suggest specific diseases (e.g., homogeneous pattern for lupus) 14  Sjögren's Syndrome Mixed Connective Tissue Disease Autoimmune Hepatitis NURSING RESPONSIBILITIES BEFORE: Patient Assessment: Review the patient's medical history and current medications. Patient Education: Explain the procedure, purpose, and what to expect. Consent: Ensure informed consent is obtained. DURING: Preparation: Gather necessary supplies and equipment. Support: Provide emotional support and reassurance to the patient. Blood Collection: Perform or assist with the blood draw, ensuring proper technique to avoid complications. AFTER: Aftercare: Apply pressure to the puncture site and provide a bandage. Monitor for signs of bleeding or infection. Documentation: Record the procedure, patient response, and any observations. Follow-up Instructions: Inform the patient about when to expect results and any follow-up appointments. INTERFERING FACTORS FACTORS RATIONALE Laboratory Errors Mistakes in the testing process can lead to false-positive or false-negative results. Fluctuating Antibody Levels ANA levels can vary over time, which might result in different test outcomes on different occasions. 15 Medications Certain medications can affect the test results, causing inaccuracies. It's important to inform your healthcare provider about any medications you're taking. Infections Active infections can sometimes cause temporary increases in ANA levels, potentially leading to misleading results. DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Immunosuppressants These drugs weaken the immune system Cyclosporine (Neoral, Gengraf) and could potentially affect the production Tacrolimus (Prograf) of antinuclear antibodies Mycophenolate mofetil (CellCept) Azathioprine (Imuran) Methotrexate (Trexall) Hydroxychloroquine (Plaquenil) Antibodies Can interfere with protein synthesis, which Procainamide (Procan SR) could impact the results of the test. Hydralazine (Apresoline) Phenytoin (Dilantin) Hormones Can influence protein expression levels, Estrogen and progesterone potentially leading to inaccurate results. Thyroid hormones Drugs that affect protein expression Alters the production, modification or Methotrexate degradation of proteins might interfere with Hydroxychloroquine the ANA test cyclosporine 16  VII. WESTERN BLOT INTRODUCTION Also known as immunoblotting or protein blotting, is a laboratory technique used to detect specific proteins in a complex mixture of proteins extracted from cells or tissues. Here’s a simplified breakdown of the process: 1. Sample Preparation: Proteins are extracted from the cells or tissues., 2. Gel Electrophoresis: The protein mixture is separated based on size using gel electrophoresis., 3. Transfer: The separated proteins are transferred from the gel onto a membrane., 4. Detection: Specific antibodies are used to bind to the target protein, and a detection system is used to visualize the bound antibodies, indicating the presence of the target protein. PURPOSE/INDICATION Western blotting is crucial for detecting specific proteins, usually antibodies in a patient’s sample confirming the presence of an infection or disease. It’s a follow-up test to initial screenings and offers a high level of specificity including the HIV diagnosis, Lyme Disease, autoimmune disorders, and other infections. NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS Consistent Band Patterns: The High Background: Excessive noise presence of specific bands at or non-specific binding, making it expected molecular weights hard to distinguish the target protein. indicates the target protein is present. Control Proteins: Housekeeping Weak or No Signal: Indicates low proteins (like actin or GAPDH) protein expression, poor transfer, or should show consistent band issues with the detection antibodies intensity across all samples, serving as loading controls. 17  No Non-Specific Binding: Minimal Multiple Bands: Can suggest or no bands appearing in lanes protein degradation, non-specific where no target protein is expected, binding, or the presence of similar indicating the antibodies are specific proteins. to the target protein Smearing: Often caused by protein degradation or issues during electrophoresis. Uneven Staining: May result from inconsistent sample loading or uneven transfer. NURSING RESPONSIBILITIES BEFORE: Patient Assessment: Review medical history, current medications, and allergies. Patient Education: Explain the test purpose, process, and what to expect. Preparation: Ensure the patient is comfortable and has no contraindications for the blood draw. DURING: Sample Collection: Perform or assist with the blood draw using proper technique to avoid hemolysis. Support: Provide reassurance and address any anxiety the patient may have. AFTER: Aftercare: Apply pressure to the puncture site, bandage it, and monitor for bleeding or infection. Documentation: Record the procedure details, patient response, and any observations. Follow-Up Instructions: Inform the patient about when to expect results and any subsequent steps. 18 INTERFERING FACTORS FACTORS RATIONALE Protein Degradation Improper handling or storage of samples can lead to protein degradation, resulting in weak or smeared bands. Non-Specific Binding Antibodies binding to unintended proteins can cause high background noise. Inconsistent Sample Loading Uneven loading of samples can lead to variable band intensity across lanes. Transfer Issues Problems during the transfer process, such as air bubbles or incomplete transfer, can affect band clarity. Blocking Inefficiency Inadequate blocking can result in non-specific binding and high background. Contaminated Reagents Using contaminated buffers or antibodies can introduce artifacts into the results. Equipment Issues Dirty or malfunctioning equipment can cause unexpected results, such as dark spots or streaks DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Immunosuppressants to measure the levels of specific proteins in cells treated with immunosuppressants to Methotrexate (Trexall) understand how these drugs modulate the Hydroxychloroquine (Plaquenil) immune response. 19  Prednisone Antibiotics to measure the levels of specific bacterial proteins in response to antibiotic treatment, Penicillins or to study the host's immune response to cephalosporins infection and treatment. 20 5 21 22  VIII. BILIRUBIN TEST (DIRECT, INDIRECT, TOTAL) INTRODUCTION Bilirubin testing plays a vital role in evaluating liver function and diagnosing various hematologic and hepatic disorders. Bilirubin is a yellowish pigment produced during the breakdown of hemoglobin in old red blood cells. It exists in three forms: total bilirubin, direct (conjugated) bilirubin, and indirect (unconjugated) bilirubin. Total bilirubin represents the overall concentration of bilirubin in the bloodstream, while direct bilirubin indicates the fraction that has been conjugated in the liver, making it water-soluble and prepared for excretion. Indirect bilirubin is the unconjugated form that has not yet been processed by the liver. Elevated levels of total or direct bilirubin may indicate liver dysfunction, biliary obstruction, or hemolytic anemia, whereas increased indirect bilirubin often signals heightened red blood cell breakdown or liver disease. PURPOSE/INDICATION A bilirubin test may be recommended if you experience symptoms such as jaundice, dark urine, or stomach pain, as these can indicate liver conditions like hepatitis, cirrhosis, or other liver diseases. These symptoms may also be associated with gallbladder disease. Additionally, a bilirubin test can help determine if there is a blockage in the bile ducts, which are responsible for carrying bile from the liver to the intestines. This type of test is also used to monitor existing liver conditions, helping healthcare providers track the progression or improvement of liver diseases or disorders. Moreover, it can assist in diagnosing disorders related to the breakdown of red blood cells, such as hemolytic anemia, a condition where the body destroys red blood cells more quickly than it produces them, leading to elevated bilirubin levels in the bloodstream. NORMAL VALUES & ABNORMAL FINDINGS High bilirubin levels, known as hyperbilirubinemia, can occur for several reasons. One possibility is that the body is breaking down red blood cells too quickly, leading to an excess of bilirubin. Conditions like hemolytic anemia, where red blood cells are destroyed at a faster rate than usual, can cause this overproduction. Alternatively, a liver struggling to handle its normal workload due to chronic disease or toxin exposure might also lead to elevated bilirubin levels. Additionally, issues in the biliary system, such as blocked bile ducts, 23 can prevent bile from being cleared efficiently, causing bilirubin to accumulate in the bloodstream. On the other hand, low bilirubin levels, or hypobilirubinemia, are less common and often not a cause for concern. Certain medications, such as antibiotics, birth control pills, sleeping pills, and seizure medications, can reduce bilirubin levels. Typically, low bilirubin levels do not indicate a serious health issue and are often observed during routine checks without requiring further intervention. NORMAL VALUES ABNORMAL FINDINGS Adult/elderly/child : Elevated Total Bilirubin - liver issues, such as hepatitis, cirrhosis, or Total bilirubin: 0.3-1.0 mg/dL bile duct obstructions. It can also or 5.1-17 μmol/L (SI units) point to conditions like hemolytic Indirect bilirubin: 0.2-0.8 anemia, where red blood cells are mg/dL or 3.4-12.0 μmol/L (SI breaking down too quickly. units) High Direct Bilirubin - blockage in Direct bilirubin: 0.1-0.3 the bile ducts, preventing the liver mg/dL or 1.7-5.1 μmol/L (SI from properly excreting bilirubin. It units) can also indicate liver diseases like Newborn: cholestasis, where bile flow from the liver is reduced or blocked. Total bilirubin: 1.0-12.0 High Indirect Bilirubin - red blood mg/dL or 17.1-205 μmol/L (SI cells are breaking down at a faster units) rate than normal, overwhelming the liver’s ability to process them. Conditions such as hemolytic anemia or Gilbert’s syndrome, a mild liver condition, can lead to increased indirect bilirubin levels. NURSING RESPONSIBILITIES BEFORE: 24  Instruct the patient to fast for 4 hours as food intake can influence bilirubin metabolism. Review the patient’s medications, such as antibiotics, analgesics, anticonvulsants, and oral contraceptives as this can affect bilirubin conjugation and metabolism. Assess the patient’s history for liver disease, hemolytic anema, or recent surgeries. DURING: Use sterile gloves and antiseptic to clean the venipuncture site to prevent infection. Select an appropriate vein (antecubital fossa) and draw blood using a sterile needle to prevent complications like hematoma. Ensure the patient is comfortable and encourage deep breathing to reduce anxiety. Label the sample correctly with patient details to prevent diagnostic errors. AFTER: Apply pressure to the venipuncture site for 2-5 minutes to prevent excessive bleeding. Monitor the site for signs of infection or continued bleeding for early detection of complications. Advise the patient to resume normal activities but to report any persistent bleeding pain to enhance safety post-procedure. Document the procedure, including the site used and the patient’s response to ensure continuity and quality of care. INTERFERING FACTORS FACTORS RATIONALE Dietary intake Fatty meals can elevate bilirubin levels postprandially due to increased hepatic metabolism and changes in bile composition. Chronic alcohol abuse can lead to liver damage. Dehydration causes decreased plasma volume relative to red blood cells. Medications (antibiotics, analgesics, Antibiotics and anticonvulsants can induce anticonvulsants, oral contraceptives) liver enzymes leading to increased bilirubin 25  production. Analgesics like acetaminophen (high-dises) can cause liver injury, affecting bilirubin clearance. Oral contraceptives can cause cholestasis where bile cannot flow from the liver to the duodenum, resulting in elevated levels of both direct and indirect bilirubin. Hemolysis of the blood sample This can release free hemoglobin, leading to elevated indirect bilirubin levels which is detected by a color change in the serum. Pre-existing liver conditions (cirrhosis, This can impair bilirubin conjugation and hepatitis) excretion. Genetic conditions like Gilbert’s syndrome This can cause intermittent elevations as it affects the liver’s ability to break down red blood cells DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Anticonvulsants (e.g., Phenytoin, This can induce hepatic enzymes, potentially Carbamazapine) leading to decreased indirect bilirubin levels. Oral contraceptives (Estrogen-containing) Estrogen can cause cholestasis and impair bilirubin excretion from the liver, leading to elevated direct bilirubin levels. Antibiotics (Rifampin) This can induce liver enzymes and increase bilirubin production. Acetaminophen High doses can cause liver damage, affecting bilirubin metabolism and clearance. 26 Antipsychotic drugs (Penothiazines) This can lead to hepatic dysfunction and elevated bilirubin levels. Salicylates (Aspirin) High doses can affect bilirubin metabolism and liver function Certain muscle relaxants (Dantrolene) This can cause liver impairment. 27 7 28 7 IX. ENZYME-LINKED IMMUNOSORBENT ASSAY (ELISA) INTRODUCTION Enzyme-linked immunosorbent assay (ELISA) is a widely used laboratory technique designed to detect and quantify specific proteins, antibodies, or antigens in a sample. ELISA operates on the principle of antigen-antibody interaction, allowing researchers to measure the concentration of target molecules in various biological samples, such as serum, plasma, or tissue extracts. The assay is particularly valuable in immunology, clinical diagnostics, and research applications because of its sensitivity, specificity, and ability to process multiple samples simultaneously. PURPOSE/INDICATION The Enzyme-Linked Immunosorbent Assay (ELISA) is a versatile laboratory technique used in many medical tests. It is important to understand that laboratory results will not specifically mention an "ELISA test" since ELISA itself is a technique rather than a singular test. Numerous tests utilize this method, each tailored to detect different substances in a variety of clinical contexts. ELISA's adaptability allows it to be used in detecting and measuring various proteins, antibodies, antigens, and other molecules, depending on the test's purpose. One of the most common uses of ELISA is for the detection and measurement of antibodies. This includes antibodies targeting bacterial, viral, or fungal infections. For example, ELISA can identify antibodies in bacterial infections like Lyme disease, brucellosis, and syphilis, as well as in viral infections such as HIV and hepatitis types A, B, and C. Additionally, it can detect antibodies for fungal infections like yeast (Candida). ELISA is also widely employed in identifying autoantibodies, which are antibodies that mistakenly attack the body's own cells, a characteristic seen in autoimmune diseases. Type 1 diabetes is an example where autoantibodies target insulin-producing cells in the pancreas. Beyond antibody detection, ELISA has other significant applications. It is used for measuring hormone levels such as human chorionic gonadotropin (HCG), follicle-stimulating hormone (FSH), and testosterone. This technique is also instrumental in monitoring disease outbreaks within communities, such as tracking the spread of infections like chlamydia or influenza. In the realm of blood safety, ELISA is employed for screening blood donations to ensure they are free of viral contaminants, such as HIV. Additionally, it is used in toxicology to screen for nonmedical drug use, identifying substances like amphetamines or cocaine. 29 7 Though these tests are primarily used for initial screening, they play a critical role in early detection. ELISA is also utilized for detecting and measuring tumor markers, which are substances that provide information about the presence or progression of cancer. A well-known example is prostate-specific antigen (PSA), which is used in screening for prostate cancer. The technique can also identify allergies by detecting immune responses to dust, food, or other allergens. Furthermore, ELISA is valuable in determining whether a person has been vaccinated against certain diseases, such as mumps or rubella, by checking for the presence of vaccine-induced antibodies. This broad range of applications makes ELISA an essential tool in both clinical diagnostics and public health surveillance NORMAL VALUES & ABNORMAL FINDINGS In general, normal values in an ELISA test indicate that the target antigen or antibody is not present in significant quantities, suggesting an absence of the condition or infection being tested. For many ELISA tests, a normal result is defined as being below a certain cutoff value, which may be represented as an optical density (OD) measurement or as a concentration value (e.g., units per milliliter). A normal ELISA result typically indicates that a person's immune response has not produced a detectable amount of antibodies against a particular pathogen, or that the target antigen, such as a hormone or a protein marker, is present within the expected range for healthy individuals. This interpretation helps reassure patients and healthcare providers that no active infection or abnormal process is indicated by the test. Abnormal values in an ELISA test occur when the results exceed the predetermined cutoff point, suggesting a significant presence of the target antigen or antibody. This could indicate an active infection, an autoimmune response, or elevated levels of specific proteins or hormones. For example, a high antibody level in an ELISA test might suggest recent or current exposure to a pathogen, while an elevated antigen level could indicate an ongoing infection or inflammation. Similarly, abnormally high concentrations of tumor markers detected through ELISA could be a sign of malignancy or cancer progression. When results fall within an abnormal range, they often prompt further diagnostic testing or clinical evaluation to confirm the findings and guide appropriate medical management. NURSING RESPONSIBILITIES BEFORE: 30 7 Inform the patient about the purpose and procedure of the ELISA test, using simple and clear language to improve compliance with pre-test requirements leading to more reliable results. Confirm if any dietary restrictions, fasting, or medication withholding is required to help minimize test inaccuracies, as certain foods or medications can alter immune responses. Assess the patient’s medical history and current medications, as these can influence the test outcome to ensure that any interfering factors are considered when interpreting results. DURING: Follow proper aseptic technique during venipuncture to prevent contamination. Accurately label specimens with patient identifiers and handle them according to laboratory protocols for preventing sample mix-ups and ensuring test reliability. Observe for signs of discomfort, dizziness, or syncope during blood draw. AFTER: Instruct the patient to apply pressure to the venipuncture site and avoid strenuous activity for a few hours to minimize the risk of bleeding or hematoma formation. Emphasize the importance of follow-up appointments if results indicate further evaluation to ensure continuity of care and patient understanding. Record details of the sample collection, patient condition during the procedure, and any adverse reactions to ensure traceability and accountability, as well as compliance with legal and clinical guidelines. INTERFERING FACTORS FACTORS RATIONALE Sample Quality Poor-quality samples, such as hemolyzed or lipemic specimens, can interfere with the accuracy of ELISA results. Hemolysis can release hemoglobin and other cellular components, which may compete with the target antigen or antibody, leading to false positives or negatives. 31 7 Reagent Quality The quality and stability of reagents used in ELISA, including antibodies and substrates, are critical for accurate outcomes. Expired or improperly stored reagents can degrade, resulting in decreased sensitivity and specificity of the assay. Incubation time and temperature Deviations from the recommended incubation times and temperatures can lead to inconsistent binding of antibodies or antigens, affecting the assay's sensitivity. Interfering substances (Lipids, proteins, and Substances such as lipids, proteins, and medications) medications in the sample can bind to antibodies or interfere with enzyme-substrate reactions in the assay, causing nonspecific results. Cross-Reactivity Some antibodies used in ELISA may cross-react with other antigens, leading to false-positive results. This is particularly problematic when testing for closely related pathogens or proteins. Operator Technique Variability in the technique used by the operator during sample preparation, pipetting, and washing steps can introduce inconsistencies in the results. DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Immunosuppressants This can reduce or weaken the immune response, potentially leading to 32 7 false-negative results in tests designed to detect antibodies. Antibiotics This can disrupt the normal microbial flora and potentially modulate the immune response, leading to altered antibody production. Hormonal Treatments This can influence various biochemical pathways and immune responses, potentially affecting the binding of antibodies in the ELISA. Anticonvulsants Some anticonvulsants can alter metabolic pathways and immune functions, which may lead to decreased antibody production or altered immune responses, affecting the outcomes of ELISA tests. NSAIDS By modulating inflammatory responses, NSAIDs may affect the immune system's ability to produce antibodies, leading to inconsistent or misleading ELISA test results related to inflammation or infection. 33 8 X. VIRAL LOAD INTRODUCTION HIV viral load is a blood test that measures the amount of HIV in a sample of your blood. HIV stands for human immunodeficiency virus. The test looks for genetic material from the virus in your blood. These tests are called molecular tests or nucleic acid amplification tests (NAAT or NAT). There are several types of NAAT tests. A PCR test is one type of NAAT that may be used to find HIV. PURPOSE/INDICATION HIV viral load test measures the amount of HIV RNA in the blood to monitor the progression of the infection and the effectiveness of antiretroviral therapy (ART). This test helps determine whether the virus is being suppressed by the treatment, with lower or undetectable levels indicating successful management of HIV. It is especially useful in newly diagnosed patients to establish a baseline and for ongoing monitoring to detect potential treatment failure or the development of drug resistance. By tracking viral load levels, healthcare providers can adjust treatment plans as necessary to ensure optimal patient care. NORMAL VALUES & ABNORMAL FINDINGS HIV Viral Load (copies/mL) Interpretation Undetectable (< 20–50 copies/mL) Normal: Indicates effective ART treatment and successful viral suppression. Low risk of transmission. Low (< 200 copies/mL) Near Normal: Viral suppression is well-maintained. ART is effectively controlling the virus. Moderate (200–10,000 copies/mL) Abnormal: May indicate early signs of treatment failure or inconsistent adherence to ART. Further monitoring required. High (> 10,000 copies/mL) Abnormal: Suggests treatment failure, drug 34 8 resistance, or lack of adherence to ART. Requires immediate medical intervention to adjust treatment. NURSING RESPONSIBILITIES BEFORE: Educate the patient on the purpose and procedure of the test. Obtain informed consent if required. Review the patient’s HIV history and ART adherence. Prepare lab requisitions and materials. DURING: Ensure patient comfort and use standard precautions. Assist with or perform venipuncture, ensuring proper labelling. Monitor for any immediate complications during blood collection. AFTER: Provide post-test care, ensuring bleeding has stopped. Reinforce ART adherence and inform the patient of result timelines. Document the procedure and any patient reactions. Arrange follow-up for results and additional care if needed. INTERFERING FACTORS FACTORS RATIONALE Poor ART Adherence Irregular use of ART can cause fluctuations in viral load, affecting result reliability. Recent Vaccination or Infection Immune activation from vaccines or infections can temporarily increase viral load, skewing results. Blood Sample Handling Errors Improper collection, labeling, or delays in processing can degrade the sample, leading to inaccurate results. 35 8 Medications or Supplements Certain drugs or supplements may interact with ART or affect viral load, causing misleading results. Time of Testing After ART Initiation Testing too soon after starting or adjusting ART may not reflect true viral suppression. Co-infections (e.g., Hepatitis B or C) Co-infections can affect immune response and viral replication, increasing viral load independently. Technical Laboratory Errors Issues with lab equipment or techniques can result in erroneous viral load readings, requiring retesting. DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Corticosteroids Can suppress the immune system and affect viral replication, potentially altering viral load levels. Immunosuppressants May interfere with immune response and lead to fluctuations in viral load. Chemotherapy Agents Can impact immune function and affect viral replication, leading to misleading viral load results. Antibiotics (in case of infection) Active infections can influence viral load, and certain antibiotics may affect viral suppression. The test should ideally be delayed until after infection is resolved. Herbal Supplements Known to interact with ART and affect its efficacy, potentially altering viral load 36 8 measurements. Antiviral Drugs (for other infections) May interact with HIV treatment or affect viral replication, leading to altered test results. 37 8 XI. ATRIAL NATRIURETIC PEPTIDE (ANP) INTRODUCTION The atria and other mammalian tissues contain a family of three peptides with natriuretic, diuretic, vasorelaxant, and other properties. This peptide family consists of atrial natriuretic peptide, brain natriuretic peptide, and C-type natriuretic peptide. Atrial natriuretic peptide (ANP) is a polypeptide secreted by atrial muscle cells that acts as an endogenous antagonist of the renin-angiotensin-aldosterone system. It is believed to be involved in regulation of salt and fluid balance as well as blood pressure. Its main systemic effects include vasodilation, natriuresis, and diuresis PURPOSE/INDICATION Atrial natriuretic peptide (ANP) is a hormone produced by the heart’s atria in response to increased blood volume and pressure, particularly when the atrial walls are stretched. The primary purpose of ANP is to regulate blood pressure and fluid balance by promoting sodium and water excretion through the kidneys, thus reducing blood volume and decreasing blood pressure. ANP also inhibits the release of renin and aldosterone, which are hormones that normally promote water retention. Clinically, ANP levels are measured to assess heart function, particularly in conditions such as heart failure, where elevated levels indicate increased cardiac stress and fluid overload. It serves as a diagnostic tool for evaluating heart failure severity and guiding treatment decisions. NORMAL VALUES & ABNORMAL FINDINGS ANP Level (pg/mL) Interpretation Normal (20–77 pg/mL) Indicates normal blood volume and pressure regulation, with no excessive cardiac stress. Elevated (> 77 pg/mL) Abnormal: May indicate conditions such as heart failure, hypertension, or fluid overload, as the heart is under increased stress. Significantly Elevated (> 100–150 pg/mL) Abnormal: Often associated with more severe heart failure, chronic kidney disease, or other cardiovascular conditions requiring urgent medical evaluation. 38 8 NURSING RESPONSIBILITIES BEFORE THE TEST: Educate the patient on the test’s purpose (heart function assessment). Obtain informed consent if required. Review medications that may affect ANP levels. Ensure patient comfort and address any questions. DURING THE TEST: Assist with the blood draw, using standard precautions. Ensure proper labeling and prompt transport of the sample to the lab. AFTER THE TEST: Apply pressure to the puncture site and monitor for any reactions. Advise the patient on when to expect results and follow-up. Document the procedure and patient education. Arrange follow-up for discussing results and any further care. INTERFERING FACTORS INTERFERING FACTORS RATIONALE Diuretics Can lower blood volume, artificially decreasing ANP levels. Renal Impairment Reduced kidney function can cause elevated ANP levels independent of cardiac function. Acute Heart Failure Increases ANP levels, which may reflect temporary changes rather than chronic conditions. High-Sodium Diet Excessive sodium intake can increase blood volume, potentially raising ANP levels. Dehydration Decreases blood volume, potentially lowering ANP levels. Physical Exercise Exercise temporarily increases ANP due to increased cardiac output and blood 39 8 pressure. Recent Surgery or Trauma Physical stress can elevate ANP levels, unrelated to baseline cardiac function. DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Diuretics Can lower blood volume, artificially decreasing ANP levels. ACE Inhibitors May alter blood pressure and fluid balance, affecting ANP levels. Angiotensin II Receptor Blockers Can lower blood pressure, potentially affecting the accuracy of ANP results. Beta-blockers May affect heart function and influence ANP levels. Calcium Channel Blockers These drugs can alter blood pressure and heart function, influencing ANP levels. Corticosteroids Can cause fluid retention and increase blood volume, raising ANP levels. NSAIDs May affect kidney function and fluid balance, altering ANP results. 40 9 XII. BARIUM ENEMA / LOWER GI SERIES INTRODUCTION A barium enema, also known as a lower gastrointestinal (GI) examination, is a radiologic procedure used to visualize the large intestine, including the colon and rectum. During the test, a barium contrast material is introduced into the colon via a tube inserted into the anus, allowing for clear imaging on X-ray films. This contrast agent blocks X-rays, making the barium-filled colon distinctly visible, which helps radiologists identify abnormalities such as tumors, polyps, inflammatory conditions, and structural issues within the lower gastrointestinal tract. Barium enemas are often employed to investigate unexplained gastrointestinal symptoms and screen for colorectal cancer, making them a valuable diagnostic tool in clinical practice. PURPOSE / INDICATION A barium enema is indicated for a variety of clinical scenarios that necessitate detailed visualization of the lower gastrointestinal tract. One of the primary reasons for performing this procedure is to investigate unexplained gastrointestinal symptoms, such as abdominal pain, rectal bleeding, or persistent changes in bowel habits. In such cases, the barium enema can help identify underlying conditions that may be causing these symptoms. Additionally, barium enemas are commonly used as a screening tool for colorectal cancer, especially in individuals who are at an increased risk due to age, family history, or other risk factors. The procedure can detect abnormal growths, such as polyps or tumors, allowing for early intervention and treatment. Furthermore, barium enemas are helpful in assessing inflammatory bowel diseases like ulcerative colitis and Crohn's disease, where they can reveal patterns of inflammation, strictures, or ulceration within the colon. In cases of suspected intestinal obstructions or structural abnormalities, a barium enema provides critical information regarding the shape and condition of the colon. By filling the colon with barium, healthcare providers can visualize any irregularities or blockages that may not be apparent on conventional X-rays. Overall, the barium enema serves as an essential diagnostic tool, enabling healthcare professionals to accurately diagnose and manage various conditions affecting the lower gastrointestinal tract. 41 9 NORMAL VALUES & ABNORMAL FINDINGS FINDINGS INTERPRETATION Normal No abnormalities; smooth, well-defined contours of the colon and rectum. Diverticula Pouches or bulges in the colon wall, indicating diverticulosis. Polyps Abnormal growths, possibly indicating colorectal cancer or benign tumors. Tumors/Masses Abnormal growths, possibly indicating colorectal cancer or benign tumors. Strictures Narrowing of the colon, possibly due to Crohn’s disease or previous injury. Ulcerations Open sores in the colon lining, suggesting conditions like ulcerative colitis. Filling Defects Areas where barium does not fill, possibly indicating masses or polyps. Twisting (Volvulus) Abnormal twisting of the colon, which can cause obstruction.. Intussusception One part of the intestine slides into another, leading to obstruction. Inflammation/Colitis Swelling or inflammation of the colon walls, indicating colitis or infection. NURSING RESPONSIBILITIES BEFORE THE TEST: Instruct the patient on bowel prep (laxatives, clear liquids, or fasting as per protocol). Explain the procedure and ensure informed consent. Assess for any allergies (especially to barium or latex) and contraindications (e.g., bowel perforation). DURING THE TEST: Assist the patient in positioning and provide reassurance. Monitor for discomfort, especially during the insertion of the enema tube. Ensure privacy and maintain standard precautions. 42 9 AFTER THE TEST: Encourage fluid intake to help eliminate barium. Monitor for signs of bowel obstruction or constipation (inform the patient to expect white stools). Document the procedure and patient’s response, and schedule follow-up if necessary. INTERFERING FACTORS INTERFERING FACTOR RATIONALE Incomplete Bowel Preparation Residual stool can obstruct the view, making it difficult to interpret results accurately. Recent Barium Swallow or Upper GI Study Residual barium from a prior test can interfere with visualization of the lower GI tract. Medications (e.g., Opioids, These drugs can slow bowel motility, Anticholinergics) leading to incomplete bowel emptying. Dehydration Can cause thickening of the barium, leading to poor distribution and visualization. Active Inflammation or Perforation Conditions like colitis or perforation may increase the risk of complications during the test. Excessive Gas or Air in the Colon May obscure images and prevent accurate assessment of the colon's structure. Patient Non-Cooperation Inability to hold still or follow breathing instructions may result in poor-quality images. 43 9 DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Opioids (e.g., Morphine, Oxycodone) Slow bowel motility, leading to incomplete bowel emptying and poor visualization. Anticholinergics (e.g., Atropine, Decrease bowel movement, potentially Scopolamine) affecting the clarity of the images. Iron Supplements Can cause stool discoloration and constipation, hindering bowel prep and image quality. Laxatives (in certain cases) May need to be withheld after bowel prep is completed to avoid excess bowel irritation. Antidiarrheals (e.g., Loperamide) May prevent complete bowel emptying, impacting the effectiveness of the test. NSAIDs (e.g., Ibuprofen, Naproxen) May increase the risk of bowel irritation or bleeding, especially in patients with GI issues. Bismuth-containing Medications (e.g., Can coat the GI tract and interfere with Pepto-Bismol) barium coating and imaging. 44 9 XIII. BARIUM SWALLOW / UPPER GI SERIES INTRODUCTION A Barium Swallow, also known as an esophagogram, is an imaging test that evaluates the upper gastrointestinal (GI) tract, including the mouth, esophagus, stomach, and duodenum. It involves swallowing a barium solution that coats the GI tract to allow clear visualization on fluoroscopy (a special X-ray technique). The test assesses real-time movement in the upper GI tract. PURPOSE/SIGNIFICANCE The test is used to diagnose swallowing difficulties, esophageal disorders, structural abnormalities (such as diverticula, polyps, or tumors), hiatal hernia, gastroesophageal reflux disease (GERD), ulcers, and to investigate symptoms such as abdominal pain, bloating, vomiting, or dysphagia. NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS Normal esophageal motility and smooth Esophageal stricture, achalasia, or motility passage of barium through the esophagus, disorders affecting swallowing. stomach, and duodenum without any delays or obstructions. No reflux of barium from the stomach into Gastroesophageal reflux disease (GERD), the esophagus. with backflow of barium into the esophagus. Clear visualization of normal anatomical Hiatal hernia, diverticula, polyps, ulcers, or structures (esophagus, stomach, duodenum) tumors along the upper GI tract. without irregularities or growths. No evidence of barium leakage or abnormal Fistulas or perforations in the upper GI tract. flow patterns. 45 9 NURSING RESPONSIBILITIES BEFORE: Ensure the patient is NPO (nothing by mouth) for at least 8 hours before the test. Assess for any known allergies to barium or contrast agents. Instruct the patient to avoid smoking, chewing gum, or sucking on hard candy before the test. Explain the procedure to the patient, including the taste and texture of the barium solution. DURING: Assist with patient positioning as required (sitting, standing, or lying down). Instruct the patient on how to follow the radiologist's directions, such as when to hold their breath. Monitor the patient for any signs of discomfort or difficulty swallowing the barium. Ensure the patient remains still during the imaging process for clear X-ray results. AFTER: Encourage the patient to drink plenty of fluids to help eliminate the barium. Monitor for bowel movements, and inform the patient about possible white or light-colored stools. Advise the patient to report any symptoms of constipation or abdominal discomfort. Document the procedure and any immediate patient concerns. INTERFERING FACTORS FACTORS RATIONALE Eating or drinking before the test May obscure imaging and reduce the effectiveness of the barium in outlining the GI structures. Inadequate barium intake An insufficient amount of barium ingested can lead to poor imaging results. 46 9 DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Antacids May alter the appearance of the stomach lining and interfere with imaging results. Laxatives Can cause excessive clearing of the GI tract, affecting the test accuracy. Medications for GERD May suppress symptoms, masking the findings of reflux or other esophageal disorders. 47 9 XIV. CHOLANGIOGRAPHY INTRODUCTION Cholangiography is an imaging test that provides visualization of the bile ducts (biliary tree) and gallbladder using a contrast medium and X-ray or fluoroscopic imaging. This procedure is crucial for identifying obstructions, tumors, or other abnormalities within the biliary system. By injecting contrast dye into the bile ducts, healthcare providers can assess conditions such as bile duct cancer and gallbladder cancer, as well as determine the extent of tumors and their potential spread. Cholangiography can be performed using several methods, including Percutaneous Transhepatic Cholangiography (PTC), Endoscopic Retrograde Cholangiopancreatography (ERCP), and Magnetic Resonance Cholangiopancreatography (MRCP), allowing for both diagnostic and therapeutic interventions. PURPOSE/INDICATION Cholangiography is indicated for several clinical purposes, primarily focusing on evaluating biliary obstructions or blockages, which can lead to complications such as jaundice or cholangitis. It provides essential anatomical details of the bile ducts, assisting healthcare providers in assessing the biliary anatomy before surgical procedures to ensure safe interventions. Additionally, cholangiography aids in diagnosing various conditions, including bile duct stones, strictures, or tumors, thereby offering critical information for the identification and management of biliary disorders. The procedure is also valuable in assessing postoperative complications, such as bile leaks following surgical interventions, and guiding therapeutic interventions, such as stent placements, to relieve obstructions and effectively manage jaundice symptoms. NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS Common bile duct diameter: 4–8 mm. Dilation of the common bile duct (>8 mm), Normal anatomy with unobstructed passage indicating obstruction. of contrast dye. 48 9 Bile flow: Normal flow of contrast dye into Blockages indicated by areas of incomplete the duodenum without delay or backflow. contrast filling. No leakage of contrast dye. Clear visualization of the gallbladder, Presence of filling defects suggesting hepatic ducts, and pancreatic ducts. tumors, stones, or strictures. Normal bile duct pressure: Typically 5–15 Increased bile duct pressure indicating mmHg. Normal-sized CBD, typically 4–8 obstruction or cholestasis. mm in diameter, with no narrowing. Normal flow of contrast dye into the Signs of infection or inflammation, such as duodenum, indicating proper drainage and thickened walls or fluid collection. function of the biliary system. NURSING RESPONSIBILITIES BEFORE: Ensure the patient is NPO (nothing by mouth) for 6 to 8 hours prior to the procedure, allowing for adequate preparation. Assess for any allergies to contrast dye or iodine. Verify any prescribed medications that need to be withheld (e.g., blood thinners). Obtain a blood test if ordered to check clotting function. Educate the patient about the procedure, including the potential for abdominal discomfort during the injection of contrast, and ensure they understand consent forms and instructions. DURING: Assist in positioning the patient as needed (e.g., prone position for endoscopic approaches). Monitor the patient’s vital signs throughout the procedure. Observe for any signs of allergic reactions to the contrast dye (e.g., rash, difficulty breathing). Provide emotional support to the patient, as they may feel pressure or discomfort during the injection of the dye. AFTER: 49 9 Monitor for any signs of infection, bleeding, or pancreatitis (especially after ERCP). Encourage the patient to report any symptoms of abdominal pain, fever, or jaundice post-procedure. Ensure the patient rests for about 4 hours post-procedure, lying on the side where the injection was made to minimize the risk of bleeding. Instruct the patient to drink plenty of fluids to help eliminate the contrast dye from the body. Document the procedure and any immediate patient concerns. INTERFERING FACTORS FACTORS RATIONALE Recent surgery on the biliary system May alter normal anatomy and biliary function. Use of certain medications (e.g., blood Can increase the risk of complications. thinners) Failure to fast before the test Eating or drinking may interfere with bile duct imaging and affect the accuracy of results. DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE Anticoagulants (e.g., Warfarin, Apixaban, These medications increase the risk of Rivaroxaban, Dabigatran) bleeding during and after the procedure. Withholding them reduces the risk of complications. Metformin Risk of lactic acidosis if contrast media are used, especially in patients with kidney issues. 50 9 NSAIDs NSAIDs can affect platelet function and prolong bleeding time, warranting their discontinuation before the procedure. Antiplatelet agents (e.g., Aspirin, Similar to anticoagulants, these drugs can Clopidogrel) prolong bleeding time, increasing the risk of hemorrhage during the procedure. 51 10 52 11 53 12 54 13 XV. CYSTOSCOPY INTRODUCTION Also known as cystourethrography or prostatography. It is an invasive diagnostic procedure that allows direct visualization of the urethra, urinary bladder, and ureteral orifices through the transurethral insertion of a cystoscope into the bladder. There are two types of cystoscopy: Rigid and Flexible. Rigid cystoscopy uses a thin, lighted tube that consists of an obturator and a telescope with a lens and light system. It is done under general or spinal anesthesia. Flexible cystoscopy uses a flexible fiber-optic telescope to provide a diagnosis of urinary abnormalities and to evaluate the effectiveness of a treatment. It is performed under local anesthesia. PURPOSE/INDICATION Cystoscopy is a diagnostic procedure used to examine the bladder and urethra. Its primary purposes include diagnosing conditions such as urinary tract infections, bladder stones, and tumors, as well as guiding treatments like biopsies or removing obstructions. The significance lies in its ability to provide direct visualization of the urinary tract, facilitating accurate diagnosis and effective management of various urological issues NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS Normal size, shape, and position of the Bladder cancer urethra, bladder, and urethral stricture. Diverticulum of the bladder, fistula, stones, and strictures Foreign body Infection or inflammation Obstruction Polyps Prostatic hyperplasia Prostatitis Renal calculi Tumors 55 13 Ureteral calculi Ureteral reflux Ureteral or urethral strictures Ureterocele Urinary fistula Urinary tract malformation and congenital anomalies NURSING RESPONSIBILITIES BEFORE: Assess the patient's understanding of the procedure and answer any queries. The procedure is usually performed in a urology clinic and it takes about 30-45 minutes. Inform the patient who will perform the test, where it will take place, and other health team members involved in the care. Obtain informed consent. A written and informed consent is signed prior to the procedure and before the administration of medications. Withhold blood thinning medications. Some examples are aspirin, warfarin (Coumadin), enoxaparin (Lovenox), heparin, clopidogrel (Plavix), and dabigatran (Pradaxa). Provide instruction for fasting and non-fasting preparation. Unless a general anesthetic has been ordered, inform the patient that he doesn’t need to restrict food and fluids. If a general anesthetic will be administered, instruct the patient to fast for at least 6 to 8 hours prior to the test. Establish an IV line. To allow infusion of fluids, anesthetics, sedatives or emergency medications. Prepare the patient. Instruct the patient to empty the bladder prior to the procedure and to change into the hospital gown provided. Administer sedation and other medications as ordered. Preoperative medications are given 1 hour before the test. Sedative decreases the spasm of the bladder sphincter, reducing the patient’s discomfort. AFTER: 56 13 Monitor and record vital signs. An increase in pulse (tachycardia) and a decrease in blood pressure (hypotension) may indicate a sign of hemorrhage. Assess the patient’s ability to void at least 24 hours after the procedure. Urinary retention may be secondary to edema as a result of instrumentation. Observe the color of urine. Pink-tinged urine and burning or mild discomfort when urinating may be experienced for a few voidings after the procedure. This usually resolves within two or three days. Encourage increased fluid intake as indicated. Fluids will help flush the bladder to decrease the amount of bleeding and reduce the risk of infection. Encourage deep breathing exercises. These exercises may relieve the patient from bladder spasms. Provide warm sitz baths and administer mild analgesics as ordered. These may relieve urinary discomfort and promote muscle relaxation. Watch out for signs of serious complications (sepsis, bladder perforation, hematuria). Persistent, severe flank pain, elevated temperature over 101° F, chills, bright red blood or clots in the urine, painful urination, or urinary retention must be reported immediately to the HCP. INTERFERING FACTORS FACTORS RATIONALE Inability to cooperate or remain still during A patient who can't cooperate might the procedure due to age, significant pain, or endanger themselves or the medical team mental status during the procedure. Failure to follow dietary restrictions prior Not following dietary restrictions can lead may lead to the cancellation or repetition of to complications during or after the the procedure procedure, necessitating cancellation or repetition. DRUGS WITHHOLD PRIOR TO THE TEST DRUGS RATIONALE 57 13 1. Anticoagulants(e.g., warfarin, aspirin) to minimize bleeding risk. 2. Antiplatelet agents similar concerns regarding bleeding. 3. Nonsteroidal anti-inflammatory drugs can affect bleeding tendencies. (NSAIDs) 4. Diuretics may need to be adjusted based on fluid intake prior to the procedure. 58 13 XVI. ELECTROENCEPHALOGRAM (EEG) INTRODUCTION An electroencephalogram (EEG) is a test that measures electrical activity in the brain. This test also is called an EEG. The test uses small, metal discs called electrodes that attach to the scalp. Brain cells communicate via electrical impulses, and this activity shows up as wavy lines on an EEG recording. Brain cells are active all the time, even during sleep. PURPOSE/INDICATION The primary purpose is to diagnose conditions like epilepsy, sleep disorders, and brain injuries. Used to evaluate the electrical activity in your brain. It can help detect potential problems with brain cell communication. NORMAL VALUES & ABNORMAL FINDINGS NORMAL VALUES ABNORMAL FINDINGS Electrical activity in the brain appears in an epilepsy or another seizure disorder EEG as a pattern of waves. Different levels abnormal bleeding or hemorrhage of consciousness, like sleeping and waking, sleep disorder have a specific range of frequencies of encephalitis (swelling of the brain) waves per second that are considered tumor normal. For example, the wave patterns dead tissue due to a blockage of move faster when you’re awake than when blood flow you’re asleep. The EEG will show if the migraine frequency of waves or patterns is normal. excessive alcohol or drug use head injury NURSING RESPONSIBILITIES BEFORE: Ask your doctor if you should stop taking any medications before the test. You should also make a list of your medications and give it to the technician performing the EEG. Wash your hair the night before the EEG. Don’t put any products like sprays or gels on the day of the test. 59 13 Avoid eating or drinking anything containing caffeine for at least 8 hours before the test. Your doctor may ask you to sleep as little as possible the night before the test if you have to sleep during the EEG. You may also be given a sedative to help you relax and sleep before the test begins. In some cases, you may need to be given a sedative during the procedure. If so, your doctor will ask you to bring someone who can drive you home afterward. DURING: The test usually takes roughly 30 to 60 minutesTrusted Source to complete and involves the following steps: You’ll lie down on your back in a reclining chair or on a bed. A technician will measure your head and mark where to place the electrodes. These spots are scrubbed with a special cream that helps the electrodes get a high-quality reading. The technician will put a sticky gel adhesive on 16 to 25 electrodes and attach them to spots on your scalp. Once the test begins, the electrodes send electrical impulse data from your brain to the recording machine. This machine converts the electrical impulses into visual patterns that appear on a screen. A computer saves these patterns. The technician may instruct you to do certain things while the test is in progress. They may ask you to lie still, close your eyes, breathe deeply, or look at stimuli (such as a flashing light or a picture). During the test, very little electricity passes between the electrodes and your skin, so you’ll feel very little to no discomfort. AFTER: After the test is complete, the technician will remove the electrodes from your scalp. You can continue with your regular routine. However, if you were given a sedative, the medication will remain in your system for a little while. This means that you may need to have someone with you to take you home after the test. You’ll need to rest and avoid driving until the medication wears off. 60 13 INTERFERING FACTORS