Competency Appraisal 1 Group 6-4NU02 Macaraig, Kristel Cammil T. Magaling, Frances Rexjean C. Manapol, Paola Mae S.

Mape, Shannon Monique M. Marao, Rodelen C.

Diagnostic Exam for Bones, Joints and Muscles

1. Bone Density test for Osteoporosis Background A bone density test determines if you have osteoporosis a disease that causes bones to become more fragile and more likely to break. In the past, osteoporosis could be detected only after you broke a bone. By that time, however, your bones could be quite weak. A bone density test makes it possible to know your risk of breaking bones before the fact. A bone density test uses X-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone. The bones that are most commonly tested are located in the spine, hip and forearm. Preparation of the patient On the day of the exam the patient may eat normally. Inform the patient not to take calcium supplements for at least 24 hours before your exam. Tell the patient to wear loose, comfortable clothing, avoiding garments that have zippers, belts or buttons made of metal on the day of the exam. Ask the patient if he/she recently had a barium examination or have been injected with a contrast material for computed tomography (CT) scan or radioisotope (Nuclear Medicine) scan 10 to 14 days before undergoing the DXA test. Ask the patient if there is any possibility that they are pregnant. Many imaging test are not performed during pregnancy so as not to expose the fetus to radiation. Procedure

A bone density scan or DEXA scan takes approximately 15 minutes. You will be asked to lie down on a table. A small X-ray will scan your lumbar spine and both hips. From the images the doctor will be able to evaluate bone mineral (calcium) content of the bone. The amount of calcium correlates with bony content and with bone strength. Bone density testing can be done several different ways. The most common and accurate way uses a dual-energy x-ray absorptiometry (DEXA) scan. It uses low-dose x-rays. (You receive more radiation with a chest x-ray.) There are two different types of DEXA scans: Central DEXA. You lay on a soft table, and the scanner passes over your lower spine and hip. Usually, you do not need to undress. This scan is the best test to predict your risk of fractures. Peripheral DEXA (p-DEXA). These smaller machines measure the bone density in your wrist, fingers, leg, or heel. Nursing Care after procedure Inform the client that she could continue to eat normally without any complications. Results interpretation The results of your test are usually reported as a T-score and Z-score. T-score compares your bone density with that of healthy young women. Z-score compares your bone density with that of other people of your age, gender, and race. With either score, a negative number means you have thinner bones than the standard. The more negative the number, the higher your risk of a bone fracture. A T-score is within the normal range if it is -1.0 or above. Bone mineral density testing does not diagnose fractures. Along with other risk factors you may have, it helps predict your risk of having a bone fracture in the future. Your doctor will help you understand the results. T-score between -1 and -2.5 indicates the beginning of bone loss (osteopenia). T-score below -2.5 indicates osteoporosis. Treatment recommendation depends on your total fracture risk. This risk can be calculated using the FRAX score.

2.

Bone Scan Background A bone scan involves injecting a radioactive material (radiotracer) into a vein. The substance travels through your blood to the bones and organs. As it wears off, it gives off a little bit of radiation. This radiation is detected by a camera that slowly scans your body. The camera takes pictures of how much radiotracer collects in the bones. If a bone scan is done to see if you have a bone infection, images may be taken shortly after the radioactive material is injected and again 3 to 4 hours later, when it has collected in the bones. This is called a 3-phase bone scan. To evaluate metastatic bone disease, images are taken only after the 3 to 4 hour delay. The scanning part of the test will last about 1 hour. The scanner's camera may move above and around you. You may need to change positions. You will probably be asked to drink extra water after you receive the radiotracer to keep the material from collecting in your bladder. Reasons for bone scan: To assess for bone trauma in situations where ordinary X-rays do not reveal trauma To detect fractures that are difficult to locate To determine the age of fractures To detect and/or assess bone infections (osteomyelitis) To assess unexplained bone pain To detect conditions such as arthritis, benign bone tumors, Paget's disease (a bone disorder, usually occurring in people over age 50, in which there is chronic inflammation of the bones, leading to thickening and softening of the bones, and curving of the long bones), and avascular necrosis (death of bone tissue not due to infection) Preparation of the patient General, no special preparations will be needed before bone scan. Get consent of the patient in doing the procedure.

Ask the patient for any medications that are being taken as well as allergies or any medical conditions. Medicines that contain barium or bismuth. Make sure if the patient is a female if she is breast feeding or pregnant Procedure Inform the patient to remove any metal materials and jewelries to avoid from getting false results Nursing Care after procedure Inform the client that she could continue to eat normally without any complications. Results Interpretation Normal Results Test results are considered normal if the radiotracer moves evenly throughout all the bones in your body. Abnormal Results The images should show that the radioactive material has been evenly distributed throughout the body. There should be no areas of increased or decreased distribution. "Hot spots" are areas where there is an increased accumulation of the radioactive material. "Cold spots" are areas that have taken up less of the radioactive material.

3. CT Scan for the back Background A CT scan uses X-rays to make detailed pictures of the spine and vertebrae. During the test, you will lie on a table that is attached to the CT scanner, which is a large doughnut-shaped machine. The CT scanner sends X-rays through the body. Each rotation of the scanner takes a second and provides a picture of a thin slice of the organ or area being studied. One part of the scanning machine can tilt to follow the curve of your spine. All of the pictures are saved as a group on a computer. They also can be printed. In some cases, a dye called contrast material may be put in a vein (IV) in your arm or into the spinal canal. The dye makes structures and organs easier to see on the CT pictures. The dye may be used to check blood flow and look for tumors, areas of inflammation, or nerve damage.

Preparation of the patient Inform the patient to wear comfortable, loose-fitting clothing to your exam. You may be given a gown to wear during the procedure. Metal objects, including jewelry, eyeglasses, dentures and hairpins, may affect the CT images and should be left at home or removed prior to your exam. You may also be asked to remove hearing aids and removable dental work. Women will be asked to remove bras containing metal underwire. You may be asked to remove any piercings, if possible. You should inform the technologist if you have a pacemaker. Pacemakers do not hinder the use of CT as in MRI as long as the scanner will not be taking images repeatedly over the area of the pacemaker device in the upper chest. You may be asked not to eat or drink anything for a few hours beforehand, especially if a contrast material will be used in your exam. You should inform your physician of all medications you are taking and if you have any allergies. If you have a known allergy to contrast material, or "dye," your doctor may prescribe medications (usually a steroid) to reduce the risk of an allergic reaction. These medications generally need to be taken 12 hours prior to administration of contrast material. To avoid unnecessary delays, contact your doctor before the exact time of your exam. Also inform your doctor of any recent illnesses or other medical conditions and whether you have a history of heart disease, asthma, diabetes, kidney disease or thyroid problems. Any of these conditions may increase the risk of an unusual adverse effect. Women should always inform their physician and the CT technologist if there is any possibility that they may be pregnant. If your infant or young child is having a spinal CT, there are measures that can be taken to ensure that the test will not be a cause of anxiety for either the child or parent.

Procedure The technologist begins by positioning you on the CT examination table, usually lying flat on your back or less commonly, on your side or on your stomach. Straps and pillows may be used to help you maintain the correct position and to help you remain still during the exam. Depending on the part of the body being scanned, you may be asked to raise your arms over your head.

Many scanners are fast enough that children can be scanned without sedation. In special cases, sedation may be needed for children who cannot hold still. Motion will degrade the quality of the examination the same way that it affects photographs. If a contrast material is used, it will be injected through an intravenous line (IV) into an arm vein during the procedure. A scan of the spine may also be done after injecting contrast material into the spinal canal (usually well below the bottom of the spinal cord) during a lumbar puncture, also known as a myelogram. This will help to detect tumors or locate areas of inflammation or nerve compression. Next, the table will move quickly through the scanner to determine the correct starting position for the scans. Then, the table will move slowly through the machine as the actual CT scanning is performed. Depending on the type of CT scan, the machine may make several passes. You may be asked to hold your breath during the scanning. Any motion, whether breathing or body movements, can lead to artifacts on the images. This loss of image quality can resemble the blurring seen on a photograph taken of a moving object. When the examination is completed, you will be asked to wait until the technologist verifies that the images are of high enough quality for accurate interpretation. The CT scanning is usually completed within 30 minutes.

Nursing Care after procedure If contrast dye was used during the procedure, the patient may be monitored for a period of time for any side effects or reactions to the contrast dye, such as itching, swelling, rash, or difficulty breathing. Tell the patient to notify if they experience any of these symptoms. If the patient notices any pain, redness, and/or swelling at the IV site after he/she returns home following his/her procedure, he/she should notify as this could indicate an infection or other type of reaction. Otherwise, there is no special type of care required after a CT scan of the spine. The patient may resume his/her usual diet and activities unless physician advises differently. Results interpretation Normal Result vs Abnormal Result CT scan of the spine

Normal: Spinal bones (vertebrae) are normal in shape, number, and alignment. The discs and joints that support the spine are normal. The spinal canal is normal in size and shape. If contrast material is used, it flows evenly through the spinal canal. No narrowing or blockage of the spinal canal is present. None of the nerves leaving the spinal cord are compressed or pinched. No growths or bulges are present. Abnormal: Spinal bones (vertebrae) are missing, damaged, or out of alignment. One or more discs may be damaged. One or more herniated discs are found. The flow of contrast material through the spinal canal is restricted or blocked, indicating narrowing of the canal (spinal stenosis). The vertebrae show signs of arthritis or bone problems caused byosteoporosis. A condition that has been present from birth (congenital condition) is present in the spine or the vertebrae. An abscess or spinal tumor is found. 4. Myelography

Background A myelogram is a special spinal X-ray examination used to help determine the cause of pain, numbness and/or weakness in the back, arms or legs. During the test, a contrast medium (also referred to as contrast material) is injected into the spinal canal under X-ray guidance to provide an outline of the spinal cord and nerve roots. A series of X-ray films are taken. Preparation of the patient Patients should be well-hydrated at the time they are undergoing a myelogram. Increasing fluids the day before the study is usually recommended. All food and fluid intake should be stopped approximately four hours before the procedure. Certain medications may need to be stopped for one to two days before myelography is performed. These include some antipsychotics, antidepressants, blood thinners, and diabetic medications. Patients should discuss this with their physician or the staff at the facility where the study is to be done.

Patients who smoke may be asked to stop the day before the test. This helps decrease the chance of nausea or headaches after the myelogram. Immediately before the examination, patients should empty their bowels and bladder. Procedure

You will wear a hospital gown during the examination. You will be asked to lie on your abdomen or side during the procedure. After cleaning your back with an antiseptic, a local anesthetic will be administered. When the area is numb, a contrast material is injected into the spinal canal. This sometimes causes pressure. During the X-rays, you may be asked to assume different positions, or tilt your head downward. You may also be tilted downward by the table, which may be uncomfortable. You may feel some discomfort or have a minor headache. The needle is removed once the contrast material has been injected. Nursing Care after procedure After the examination is complete, the patient usually rests for several hours, with the head elevated. Extra fluids are encouraged, to help eliminate the contrast material and prevent headaches. A regular diet and routine medications may be resumed. Strenuous physical activities, especially those that involve bending over, may be discouraged for one or two days. The physician should be notified if the patient develops a fever, excessive nausea and vomiting, severe headache, or a stiff neck.

Results interpretation A normal myelogram shows nerves that appear normal, and a spinal canal of normal width, with no areas of constriction or obstruction. Abnormal results A myelogram may reveal a herniated disk, tumor, bone spurs, or narrowing of the spinal canal (spinal stenosis). 5. Spine x-rays Background Spinal X-rays are pictures of the spine. They may be taken to find injuries or diseases that affect the discs or joints in your spine. These problems may include spinal fractures, infections, dislocations, tumors, bone spurs, or disc disease. Spinal X-rays are also done to check the curve of your spine (scoliosis) or for spinal defects. X-rays are a form of radiation, like light or radio waves, that are focused into a beam, much like a flashlight beam. X-rays can pass through most objects, including the human body. Dense tissues in the body, such as bones, block (absorb) many of the X-rays and look white on an X-ray picture. Less dense tissues, such as muscles and organs, block fewer of the Xrays (more of the X-rays pass through) and look like shades of gray on an X-ray. X-rays that pass only through air look black on the picture. The most common spinal X-rays are of the cervical vertebrae (C-spine films) and lumbosacral vertebrae (LS-spine films). Preparation of the patient Explain the procedure to the patient Generally, no prior preparation, such as fasting or sedation, is required. Ask the patient if he/she recently had a barium examination or have been injected with a contrast material for computed tomography (CT) scan or radioisotope (Nuclear Medicine) scan 10 to 14 days before undergoing the DXA test. Ask the patient if there is any possibility that they are pregnant. Many imaging test are not performed during pregnancy so as not to expose the fetus to radiation. Procedure

A spinal X-ray is taken by a radiology technologist. The X-ray pictures are usually read by a doctor who specializes in reading X-rays (radiologist). Patient will need to remove any jewelry that may be in the way of the X-ray picture. He may need to take off some of your clothes, depending on which area is examined and will be given a cloth or paper gown to use during the test. During the X-ray test, patient will lie on an X-ray table. If the X-ray is being taken because of a possibly serious injury to the neck or back, to prevent causing more injury a radiologist will look at the first X-ray pictures before taking others. If patient has a neck brace (cervical collar) in place, X-ray pictures may be taken and a physical exam done to see whether the brace can be taken off without hurting the spine. Usually 3 to 5 X-ray pictures are taken. Patient need to lie very still to avoid blurring the pictures. A spinal X-ray usually takes about 15 minutes. Patient will wait about 5 minutes until the X-rays are processed in case more pictures need to be taken. In some clinics and hospitals, X-ray pictures can be shown right away on a computer screen. Nursing Care after procedure Inform the client that she could continue to eat normally without any complications. Results Interpretation Spinal X-ray Normal: The bones of the spine (vertebrae) are normal in number, size, shape, appearance, and how they are lined up. No broken bones, dislocations, or foreign objects are present. The soft tissues around the vertebrae look normal. The spine is not abnormally curved. Abnormal: Broken bones, dislocations, or foreign objects are present. The spine is abnormally curved, such as from scoliosis. Diseases that affect the spine, such as thin bones (osteoporosis) or arthritis, are present. One or more bones in the spine may be abnormal because of a condition you were born with or because of cancer, infection, or trauma.

Disc disease, which is fairly common, can sometimes be seen on a spinal X-ray as a narrowed space between the bones of the spine. Bone spurs can also be seen. 6. ESR Background The erythrocyte sedimentation rate (ESR) is an easy, inexpensive, nonspecific test that has been used for many years to help detect conditions associated with acute and chronic inflammation, including infections, cancers, and autoimmune diseases. ESR is said to be nonspecific because increased results do not tell the doctor exactly where the inflammation is in the body or what is causing it, and also because it can be affected by other conditions besides inflammation. For this reason, the ESR is typically used in conjunction with other tests. ESR is helpful in diagnosing two specific inflammatory diseases, temporal arteritis and polymyalgia rheumatica. A high ESR is one of the main test results used to support the diagnosis. It is also used to monitor disease activity and response to therapy in both of these diseases. Combined use of ESR and CRP is useful in assessing the severity of acute pelvic inflammatory disease. Men aged 45-64 years with ESR in the upper quintile have more than twice the risk of coronary heart disease death of men with ESR in the lowest quintile after adjusting for other risk factors. Preparation of the patient No special preparations are needed for this test. Procedure A nurse or medical assistant will use a needle to draw blood from a vein, most likely a vein in your arm. When anticoagulated whole blood is allowed to stand in a narrow vertical tube for a period of time, the RBCs under the influence of gravity - settle out from the plasma. The rate at which they settle is measured as the number of millimeters of clear plasma present at the top of the column after one hour (mm/hr). There are two main methods used to measure the ESR: the Westergren method and the Wintrobe Method. Each method produces slightly different results. Most laboratories use the Westergren method. Westergren method: The Westergren method requires collecting 2 ml of venous blood into a tube containing 0 .5 ml of sodium citrate. It should be stored no longer than 2 hours at room temperature or 6 hours at 4 C. The blood is drawn into a Westergren-Katz tube to the 200 mm mark. The tube is placed in a rack in a

strictly vertical position for 1 hour at room temperature, at which time the distance from the lowest point of the surface meniscus to the upper limit of the red cell sediment is measured. The distance of fall of erythrocytes, expressed as millimeters in 1 hour, is the ESR. Wintrobe method: The Wintrobe method is performed similarly except that the Wintrobe tube is smaller in diameter than the Westergren tube and only 100 mm long. EDTA anticoagulated blood without extra diluent is drawn into the tube, and the rate of fall of red blood cells is measured in millimeters after 1 hour. The shorter column makes this method less sensitive than the Westergren method because the maximal possible abnormal value is lower. However, this method is more practical for demonstration purposes. Nursing Care after procedure After drawing the blood, tell the patient to apply pressure on the part where blood was drawn from for about 5 mins to prevent bleeding. Results interpretation Average values in healthy men are: <15mm/hr; in healthy females, they are somewhat higher: <20mm. The values are slightly higher in old age, in both genders. High ESR: any inflammatory disorder (eg infection, rheumatoid), tuberculosis, myocardial infarction (early response), anaemia, polymyalgia rheumatica/temporal arteritis. Low ESR: polycythaemia, hypofibrinogenaemia, congestive cardiac failure, spherocytosis, sickle cells. 7. Arthrocentesis Background A procedure where synovial fluid is drained from a joint using a needle and syringe. Arthrocentesis may also be used as a treatment to relieve joint pain by removing excessive or infected fluid from a joint. Arthrocentesis is only one method used to diagnose or treat a variety of joint conditions, most often of the knee.

Preparation of the patient Obtain Consent

A numbing anesthetic cream might be placed on the skin over the joint, usually 30 minutes to an hour before the procedure. If sedation is used, NPO is required hours before the procedure

Procedure
Clothing will be removed from the affected joint or you may be asked to dress in a patient gown. Patient will lie on the examination table to allow access to the joint. The doctor will insert a needle into the joint space and withdraw a portion of synovial fluid into a syringe. If medication will be injected into the joint, your physician will detach the syringe full of synovial fluid from the needle and replace it with a syringe of medication (corticosteroid). The medication can then be injected into the joint. The synovial fluid will be sent to the laboratory for evaluation.

Nursing Care after procedure For the first 24 hours, ice the joint every 3-4 hours. Do this for 20 minutes at a time. To reduce discomfort, take a pain reliever. Advise that normal activities may resume after 2-3 days Results Interpretation Normal results - Normal joint fluid is viscous (sticky) and appears clear to light yellow. Abnormal results - Cloudy joint fluid is abnormal and suggestive of inflammation or an infection. Bloody joint fluid is also abnormal and may be caused by trauma to the joint.