Diagnostic Assessment in Medical Imaging, Cheat Sheet of Nursing

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Exam I – Diagnostic Assessment Diagnostic Assessment NUR  Objectives o Discusses the rationale for and reliability of diagnostic and laboratory testing o Examines the types of diagnostic imaging o Analyzes laboratory results to determine findings requiring additional assessment o Demonstrates knowledge of the nurse’s role in caring for the adult/geriatric client undergoing diagnostic assessment  Patient Safety: Rationale & Reliability o It is the responsibility of all healthcare workers to ensure tests are appropriately & safely completed specific to each diagnostic test including necessary radiation exposure. o Always use two patient identifiers (name & DOB), correct time, correct test, correct labeling per facility policy to avoid wrong patient events. o Nurses have a duty to inform HCP’s of existing contraindications, potential complications, and interfering factors that may exist. o Make sure test is ordered  Patient Safety: Lab Value Reporting o Normal values are dictated by test and facility where test is being performed. Normal values are reported with results reported. o Critical values are outliers, or extreme abnormal values, and must be reported to healthcare provider (HCP) per facility policy and the Joint Commission’s (TJC) patient safety goals. Time frames exist per organizational policy.  Labs calls nurse  Nurse verifies with pt name and lab value, reads it back to lab and notify the provider o Depending on what the lab value is can be considered low normal or high normal  Imaging o X-Ray o Computed Tomography (CT) o Magnetic Resonance Imaging (MRI) o Positron Emission Tomography (PET) o Angiography (Arteriography) o Ultrasound (U/S) o Radionuclide Imaging  X-Ray o Short procedure (<5 min) providing valuable picture of body structures. o Radiation; black coloring is air, dark gray coloring is fat, whitish coloring is bone. o Types: bone, chest, KUB (kidneys, ureter, bladder) o Soft tissue not shown well o Differentiates soft tissue, air, and fluid o Pre-procedure  Explain why getting it  No need to fast  Remove clothing with metal  Gown has metal snaps. Make sure not laying over chest  Shield is placed over ovaries and testicles

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Exam I – Diagnostic Assessment o Intra-procedure  May need to take deep breaths, hold a certain position o Post-procedure  Nothing special o Special considerations  Pregnancy  Computed Tomography (CT) o Short (<30 min) noninvasive procedure to enhance anatomical structures o Radiation beams as client moves on a motorized table, digital images of up to 500 images in one scan o Without contrast dye or with contrast dye (Oral or IV) o Better for soft tissues o IV contrast usually iodine  Allergy to iodine or shellfish? o Oral Contrast  Barium or galvalium  Drink at a specific time prior to test o Metformin  Can cause lactic acidosis when given with IV contrast  Hold 1 day prior to test and 2 days after test o Pre-procedure  Explain why getting  Table moves in and out of tube  Need to lie flat – back issues?  NPO with oral contrast 4 hours prior  IV Contrast  Warm sensation in body and may feel like urinating on self o Intra-procedure  Hold breath o Post-procedure  IV contrast excreted by kidneys  Push fluids to remove contrast  Monitor for reaction to dye  Oral contrast may cause loose stool or diarrhea o Special considerations  Pregnant o Pt with kidney issues – may not be able to have CT done o Claustrophobia  May need anti anxiety med o Pt weight  Usually holds up to 400 lbs  Able to fit in hole?  Magnetic Resonance Imaging (MRI) o Longer (45 - 90 min) noninvasive procedure to enhance anatomical structures, muscles, joints o Does not use radiation, uses magnets and radio waves o https://www.youtube.com/watch?v=DZTXa4qerI o Depending on what is being looked at can be better than CT o Ligaments, spine and brain god

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Exam I – Diagnostic Assessment  Angiography (Arteriography) o Visualization of blood vessels for diagnostic purposes o Catheter is thread under fluoroscopic visualization to site o Sedated for procedure, length is approx. 60 min. o https://www.medstarhealth.org/services/angiogram o Contrast used o See where blood flows o Visualization of blood vessels o Done in cath lab or interventional radiology o Pre-procedure  What to expect  Informed consent  Witness signature  Pt has questions call provider back  NPO  Peripheral pulses site marked below insertion site  Will feel flushness with IV dye o Intra-procedure  Area of entry shaved  Lie flat – back issues? o Post-procedure  Pressure bandage  Usually done at wrist  Monitor distal pulses to insertion site  Monitor for hemorrhage  Monitor VS  If done in groin needs to lay flat 8 hours  Compare temp and color with other side  Report any numbness, tingling, or loss of function o Special considerations  May need to use blood thinners  Empty bladder prior to procedure o Dx: arterial or venous occlusions, stenosis, emboli, thromboses, aneurysms, tumors, congenital malformations, or trauma to the brain, heart, lung, kidney, or lower extremities  Ultrasound (U/S) o Harmless sound waves converted to pictures o Technique is rapid with little or no prep, visualize pelvis, abdomen, heart, pregnancy, gallbladder o Venous doppler – blood clots o Fluid vs. solid o All soft tissues o Portal vein thrombosis o Can be uncomfortable o Pre-procedure  explain o Intra-procedure  Gel on skin  probe

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Exam I – Diagnostic Assessment o Post-procedure  Wipe off gel o Special considerations  Pelvic US – need full bladder  Gallbladder - NPO  Radionuclide Imaging o Radionuclide (isotope) given via IV which lights up the specific area of study o Non-invasive with low amount of radiation scanning bones, organs, or other parts of the body o Takes 1-4 hours depending on the study o HIDA o Nuclear Stress Test o Pre-procedure  Length of time – radioisotopes need to circulate o Intra-procedure  Lay still  Meds after done – Lasix to help flush out isotopes faster o Post-procedure o Special considerations  Pregnancy  Invasive Procedures o Endoscopy  Endo- means ‘within, inner, or containing’  -scopy means ‘viewing, observing or examination’ o Exemplars  Arthroscopy  Bronchoscopy  Colonoscopy  Endoscopic Retrograde Cholangiopancreatography (ERCP)  Aspiration Procedures  Arthroscopy o Endoscopy procedure of joint space for diagnosis of inflammation versus injury o Local or general anesthesia is used o Takes approximately 1 hour o Can be used diagnostically o Mostly used for corrective procedures o arthrocentesis o Pre-procedure  Explain  Inform consent  NPO after Midnight  Shave site  May need crutches or sling o Intra-procedure  Will be sedated  Laying supine  Incision with sutures NIFTY'm ask (^) Po to^ not empty beer for Pelvic US

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 Changes in diet if diverticulitis is present  Clear liquids 24 hours prior to test  Avoid red, purple, orange and blue foods/drinks o Intra-procedure o Post-procedure  Evacuate air  Will have more gas than usual  Monitor for bowel perforation  Distended abdomen  Chills, fever  Rectum for blood  Oral fluids  Signs and symptoms to contact provider  Unable to pass gas  BM with blood  Weakness, dizziness, increased heart rate o Special considerations o Same probe used as an endoscopy o Camera, light source o Risks  Intestinal perforation, hemorrhage, peritonitis, aspiration, respiratory depression, and/or MI due to vasovagal response  Endoscopic Retrograde Cholangiopancreatography (ERCP) o Scope inserted orally to visualize gastro/hepatic tracts. Includes biliary and pancreatic ducts. o Stents and biopsies can be completed during procedure o Pre-procedure  Explain procedure  NPO after midnight  Lay on back supine, or left side  Spray for throat to suppress gag reflex  Glucagon  IV to minimize spasms in duodenum o Intra-procedure o Post-procedure  No food or drink until gag reflex returns  Monitor for N/V/D, abdominal pain  Monitor for pancreatitis will show above symptoms  Monitor for intestinal perforation  Sore throat/hoarseness  Cool fluids and gargle o Special considerations  Aspiration Procedures o Used to obtain a specimen for diagnostic purposes o Examples:  Bone Marrow  Removal of liquid material in the medullary canals of selected bones  Adults

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o Most used: sternum or iliac crest  Bone marrow cultures o Differentiate infectious disease or histoplasmosis  Takes 20 minutes  Complications o Bleeding, infections, organ puncture o Tenderness or erythema at site  Lumbar Puncture  Needle into subarachnoid space of spinal column  Purpose o Measure pressure in the subarachnoid space o Obtain cerebral spinal fluid o Inject anesthetic, diagnostic, or therapeutic agents  Contraindications o Increased intracranial pressure  Will cause release of pressure and possible brain herniation  Herniation compresses the brainstem = sudden death  Unexpected Outcomes o Post procedure HA: HA, blurred vision, tinnitus o Excessive loss of CSF: decreased LOC, hearing loss, dilated pupils, decreased ICP  Abdominal Paracentesis  Aspiration of peritoneal fluid to determine presence of bacteria, blood, glucose, and protein to dx the cause  Can be for palliative reasons  Lavage Paracentesis o Lavage of solution instilled and then withdrawn to detect presence of bleeding  Caution o Coagulopathies o Portal hypertension with abdominal collateral circulation o Pregnancy  Takes about 30 minutes  Unexpected outcomes o Leaking fluids from site o Acute Abdominal pain  Thoracentesis  Analyze or remove pleural fluid or instill meds  Therapeutically relieves pain, dyspnea, and signs of pleural pressure  Takes about 30 minutes  Unexpected Outcomes o Pneumothorax: sudden dyspnea, tachypnea, asymmetrical chest excursion  Breast Biopsy  Liver Biopsy o Sterile procedure

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o PT/INR  Prothrombin time (PT)  International normalized ratio (INR) o PTT/aPTT  Partial Thromboplastin Time (PTT)  Activated Partial Thromboplastin Time(aPTT) o D-Dimer o Magnesium* o Phosphorus* o Basic Metabolic Panel (BMP)  Glucose  BUN  Creatinine  eGFR  Sodium*  Potassium*  Chloride  Carbon Dioxide*  Calcium* o Complete Metabolic Panel (CMP)  BMP labs, plus:  Protein, total  Albumin  Globulin, total  A/G ratio  Bilirubin, total  Alkaline phosphate  AST (SGOT)  ALT (SGPT)  White Blood Cells (WBC) o WBC: 5,000 to 10,000 cells per microliter o Function: fight infection and react against foreign bodies o WBCs are ‘leukocytes’ that are further broken down into 5 types which is called a ‘differential count’  Neutrophils aid in acute bacterial infections  Lymphocytes aid in chronic bacterial and acute viral infections  Monocytes aid in acute bacterial infections  Eosinophils aid in allergic reactions and parasitic infections  Basophils aid in allergic reactions and parasitic infections  White Blood Cells (WBC) o Increased WBC  Leukocytosis (all WBC’s elevated) is caused by:  Infection  Inflammation % Absolute Neutrophils 55 – 70 2500 – 8000 Lymphocytes 20 – 40 1000 – 4000 Monocytes 2 – 8 100 – 700 Eosinophils 1 – 4 50 – 500 Basophils 0.5 – 1 25 – 100

 Tissue necrosis  Trauma/stress  Leukemia  Neutrophilia  Lymphocytosis  Monocytosis  Eosinophilia  Basophilia  if just that WBC is elevated is called the above o Decreased WBC  Leukopenia is caused by:  Bone marrow failure  Drug toxicity  Autoimmune disease  Neutropenia  Lymphocytopenia  Monocytopenia  Eosinopenia  Basopenia  Red Blood Cells (RBC) o Male: 4.7-6.1, Female: 4.2-5. o Pregnancy dilutes RBCs because normal body fluid increases o High altitudes cause increased RBC o Hydration status dramatically affects RBC. Dehydration causes a false high and overhydration causes a false low level. o Certain drugs can increase or decrease RBC counts o Erythropoietin – produced by kidneys to produce RBC’s in marrow o Iron, B12, folate – needed to produce RBC’s o Polycythemia – increased RBC’s  Hemoglobin (Hgb)/Hematocrit (HCT) o Hgb: Male: 14-18 g/dL, Female: 12-16 g/dL o Iron-rich protein that binds oxygen while it is carried to cells in the body o Makes blood red o Hct: Male: 42%-52%, Female: 37%-47% o Amount of space in the blood that is occupied by RBCs o Usually is 3 times Hgb in a normal shaped RBC  Platelets (PLT) o PLT: 150,000-400,000/mm^3 o Platelet activity is essential for clotting o Thrombocytopenia: <100,000/mm o Thrombocytosis: > 400,000/mm o What is a major safety consideration if a client has a severely low level of platelets?  Blood in stool/urine  Bleeding gums  Blood in mucous when coughing  Brusing  Petechiae

 Glomerular Filtration Rate (GFR) o Normal Value: >60 mL/min/1.73 m o Measure kidney function and stage of kidney disease o Flow rate of fluid in milliliters per minute through the kidney o Creatinine test is used to determine GFR; may be called creatinine clearance o Best test to determine kidney disease  Protein, total o Total Protein: 6.4-8.3 g/dL o Albumin: 3.5-5 g/dL o Globulin: 2.3-3.4 g/dL  What is Protein?  Necessary building block for cell growth and development  Albumin and Globulin are the main components of protein and are measured as ‘total protein’  Albumin keeps fluid from leaking out of blood vessels into extracellular space  Globulin play a role in the immune system  Bilirubin o Total Bilirubin: 0.3-1.0 mg/dL o What is bilirubin?  Byproduct of broken-down RBCs (normal process)  Processed by liver and put into bile  Elevated levels are indicative of liver disorders  Bilirubin >2.5 will cause yellowing of the skin (Jaundice)  Liver Enzymes o AST (Aspartate aminotransferase) 0 – 35 units/L o ALT (Alanine aminotransferase) 4 – 36 units/L o ALP (Alkaline phosphate) 30 / 120 units/L o Exist within liver cells o Diseases of the hepatocytes will cause a rise in enzymes  Coagulation Studies o Prothrombin Time (PT) - 11-12.5 seconds o International normalized ratio (INR) - 0.8-1. o Patients receiving anticoagulants - 1.5-2.5 times control value o Patients receiving anticoagulants - 60-70 seconds o Partial thromboplastin time, activated (APPT) - 30-40 seconds o Patients receiving anticoagulants - 1.5-2.5 times control value  Coagulation Studies o D-Dimer Normal Value: < 0.4 mcg/mL o What is D-Dimer?  Assesses thrombin and plasmin activity  Promote clotting of blood o Pulmonary Embolism  Disseminated intravascular coagulation  Deep Vein Thrombosis (DVT)  Urinalysis (UA) o What is a urinalysis? o Why/when would a urinalysis be ordered? o What would an abnormality in the urine represent?

 Urinalysis (UA) o Results from a UA:  Appearance (Color, Clarity)  Odor  pH  Specific gravity  Blood  Protein  Glucose  Ketones  Nitrites (bacteria)  Leukocyte Esterase  UA Results  Turbid = unable to see through o pH: 4.6 to 8 (average 6)  Relation to acidic or alkalotic state of body  7 = neutral o Specific gravity: 1.005 – 1.  Concentration of water & electrolytes in body  1.005 - = less concentrated o Blood: Negative  Indicates damage to kidneys  Infection, trauma, kidney stones o Protein: < 8 mg/dL  Indicator of renal function  If increased = infection or kidney issues  UA Results o Glucose: Negative  Indicator of serum glucose control o Ketones: Negative  Indicator of fat metabolism o Nitrites: Negative  Indicator of bacteria o Leukocytes: Negative  Indication of inflammation/infection  UA: Culture & Sensitivity (C&S) o Bacterial count >100,000 indicates infection o Mixed bacterial count <10,000 indicates possible contamination o What considerations should we take when collecting a urine specimen?  Dirty – pediatric where bag is stuck on skin  Clean Catch  Sterile o What antibiotic its sensitive to o Done prior to starting antibiotics o 24 hrs preliminary o 72 hrs final Find some quit less concentrate