Laboratory/Diagnostic Exams: WORKSHEET ON Endocrine System Disorders

DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING
2nd semester S.Y. 2019-2020
WORKSHEET ON endocrine system disorders
LABORATORY/DIAGNOSTIC EXAMS
CAPILLARY BLOOD GLUCOSE TEST (CBG)
THYROID STIMULATINGHORMONE TEST (TSH) THYROID SCAN
SEMEN ANALYSIS
ORAL GLUCOSE TOLERANCE TEST
FIVE – DAY GLUCOSE SENSOR TEST FOR DIABETES FINE– NEEDLE ASPIRATION BIOPSY
DEXAMETHASONE SUPPRESSION TEST CRH STIMULATION TEST
BONE DENSITY TEST ACTH STIMULATION TEST
24 – HOUR URINE COLLECTION TEST
T3 & T4 DIAGNOSTIC EXAM
CAPILLARY BLOOD GLUCOSE TEST (CBG)

A.) Definition/Description
•The level of circulating blood glucose as measured by glucometer analysis of a fingerstick sample. Regular
measurements of CBG allow diabetic patients to make frequent adjustments in their caloric intake, exercise levels, and
use of antidiabetic medications, esp. insulin.
•Capillary blood glucose (CBG) testing was developed to replace home urine glucose testing by patients or by the staff in
physician offices. CBG testing can also be applied in the hospital laboratory as a cost-effective method to rapidly test
blood glucose levels.
•Blood glucose monitoring is a method of assessing the concentration of glucose in the blood. Tests are performed rapidly
and easily by using a reagent strip (e.g. Glucostix) where a minute drop of capillary blood is obtained from the client’s
digits (finger or toe), earlobe or heel. On the condition where the patient has all the equipments this test can be performed
at home, office, hospitals, clinics and even when travelling
B.) Purposes
•Determine if blood glucose levels are in a normal range
•Monitor patients with diabetes or risk for diabetes (i.e., familyhistory of diabetes, overweight, high blood pressure, has
heart disease)
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C.) Indications
This test is indicated for patients who:
•Controls their diabetes with insulin (with or without other agents)
•Are poorly controlled and are being considered for insulin treatment
•Are treated with gliclazide, glimepiride, glipizide, tolbutamide, glibenclamide, repaglinide and nateglinide since they can
be at an increased risk of hypoglycaemia (blood glucose below 4 mmol/l).
•Are treated with exenatide plus gliclazide, glimepiride, glipizide, tolbutamide and glibenclamide as they can be at an
increased risk of hypoglycaemia (blood glucose below 4 mmol/l).
D.) Contraindications/Precautions/Interfering Factors INTERFERING FACTORS
•Many forms of stress (e.g., trauma, general anesthesia, infection, burns, myocardial infarction [MI]) can cause increased
serum glucose levels.
•Caffeine may cause increased levels.
•Many pregnant women experience some degree of glucose intolerance. If significant, it is called gestational diabetes.
•Most intravenous (IV) fluids contain dextrose, which is quickly converted to glucose. Most patients receiving IV fluids
will have increased glucose levels.
•Drugs that may cause increased levels include antidepressants (tricyclics), antipsychotics, beta-adrenergic blocking
agents, corticosteroids, cyclosporins, IV dextrose infusion, dextrothyroxine, diazoxide, diuretics,
epinephrine, estrogens, glucagon, isoniazid, lithium, niacin, phenothiazines, phenytoin, salicylates (acute
toxicity), and triamterene.
• Drugs that may cause decreased levels include acetaminophen, alcohol, alpha-glucosidase inhibitors, anabolic
steroids, biguanides, clofibrate, disopyramide, gemfibrozil, incretin mimetics, insulin, monoamine oxidase
inhibitors, meglitinides, pentamidine, propranolol, sulfonylureas, and thiazolidinediones.
E.) Equipment/Patient Preparation EQUIPMENT
• Reagent strip
• disposable gloves
• lancet or automatic lancing device
• paper towels
• alcohol wipes
• 2x2 gauze
• cotton ball
• blood glucose meter
PATIENT PREPARATION
• Identify the patient by asking the patient to state his/her name. Also check the client’s identification band. (
confirm patient’s identity using two patient identifiers, based on the hospital protocol)
• Explain the procedure to the patient or parents (if patient is a child) to gain cooperation

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F.) Normal Values
• Cord: 45-96 mg/dL or 2.5-5.3 mmo1/L (SI units)
• Premature infant: 20-60 mg/dL or 1.1-3.3 mmo1/L
• Neonate: 30-60 mg/dL or 1.7-3.3 mmo1/L
• Infant: 40-90 mg/dL or 2.2-5.0 mmo1/L
• Child <2 years: 60-100 mg/dL or 3.3-5.5 mmo1/L
• Child >2 years to adult:
• Fasting: 70-110 mg/dL or <6.1 mmol/L (Fasting is defined as no caloric intake for at least 8 hours.)
• Casual: ≤200 mg/dL or <11.1 mmol/L (Casual is defined as any time of day.)
• Elderly: increase in normal range after age 50 years
G.) Procedure to include with Important Nursing Responsibilities, Before, During, and After the
Procedure
• Explain the procedure to the patient or parents (if patient is a child) to gain cooperation.
• Choose the puncture site. For adults and children fingertips and earlobe can be use. For infants, the tip of the
great toe or heel can be the site of puncture.
• Wash hands and don clean gloves.
• If glucometer is used, load the strip into the device beforehand.
• Swab alcohol pad to the chosen puncture site. Use sterile/clean gauze to dry it thoroughly. Piecing the skin with a
wet skin (alcohol) allows the chemical to pass through the outer layer of the skin thus, causing the procedure
more painful and uncomfortable.
• To collect a blood sample, position the lancet (pricking needle) at the side of the site. To minimize pain and
patient’s anxiety pierce the skin sharply and briefly. This technique also increases blood flow. For better results,
some agencies are using a lancing device (mechanical blood-letting device) wherein the lancets are simply
loaded in the spring of the equipment. (It’s like using a spring-loaded pen, once you click the button the spring
releases the lancet and immediately retracts it after piercing the skin). However, be sure to load an unused lancet
before using to prevent spread of blood-transmitted diseases.
• Don’t squeeze the puncture site to prevent diluting the sample with fluids from tissues.
• Cover the entire patch of strip with blood.
• Place gauze over the punctured area and briefly apply pressure until the bleeding stops. Ask the parents of a child
to do this.
• If using a reagent strip, leave the blood on the strip for 1 minute (60 seconds). And watch the color change on the
strip while comparing it to the standardized color chart of the product container.
• If glucometer is used, simply followthe manufacturer’s instruction.
• Apply an adhesive bandage once the bleeding on the puncture site has stopped.
• Remove gloves and record the resulting glucose level from the digital display for glucometer or from the color of
reagent strip to the standardized chart.
H.) Implications of Abnormal Results INCREASED LEVELS

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• Diabetes mellitus (DM): This disease is defined by glucose intolerance and hyperglycemia. A discussion of the
many possible etiologies is beyond the scope of this manual.
• Acute stress response: Severe stress, including infection, burns, and surgery, stimulates catecholamine release.
This in turn stimulates glucagon secretion, which causes hyperglycemia.
• Cushing syndrome: Blood cortisol levels are high. This in turn causes hyperglycemia.
• Pheochromocytoma: Catecholamine stimulates glucagon secretion, which causes hyperglycemia.
• Chronic renal failure: Glucagon is metabolized by the kidney. With loss of that function, glucagon and glucose
levels rise.
• Glucagonoma: Glucagon is autonomously secreted, causing hyperglycemia.
• Acute pancreatitis: The contents of the pancreatic cells (including glucagon) are spilled into the bloodstream as
the cells are injured during the inflammation. The glucagon causes hyperglycemia.
• Diuretic therapy: Certain diuretics cause hyperglycemia.
• Corticosteroid therapy: Cortisol causes hyperglycemia.
• Acromegaly: Growth hormone stimulates glucagon, which causes hyperglycemia.
DECREASED LEVELS
• Insulinoma: Insulin is autonomously produced without regard to biofeedback mechanisms.
• Hypothyroidism: Thyroid hormones affect glucose metabolism. With diminished levels of this hormone, glucose
levels fall.
• Hypopituitarism: Many pituitary hormones (adrenocorticotropic hormone [ACTH], growth hormone) affect
glucose metabolism. With diminished levels of these hormones, glucose levels fall.
• Addison disease: Cortisol affects glucose metabolism. With diminished levels of this hormone, glucose levels fall.
• Extensive liver disease: Most glucose metabolism occurs in the liver. With decreased liver function, glucose
levels decrease.
• Insulin overdose: This is the most common cause of hypoglycemia. Insulin is admini stered at too high of a dose
(especially in brittle diabetes) and glucose levels fall.
• Starvation: With decreased carbohydrate ingestion, glucose levels diminish.
THYROID STIMULATING HORMONE TEST (TSH)

• Thyroid-stimulating hormone (TSH) promotes increases in the size, number, and activity of thyroid cells and
stimulates the release of triiodothyronine and thyroxine. These hormones affect total body metabolism and are
essential for normal growth and development.
• This test measures serum TSH levels by radioimmunoassay. It can detect primary hypothyroidism and determine
whether the hypothyroidism results from thyroid gland failure or from pituitary or hypothalamic dysfunction.
Normal serum TSH levels rule out primary hypothyroidism. This test may not distinguish between low-normal
and subnormal levels, especially in secondary hypothyroidism.
B.) Purposes
• To confirm or rule out primary hypothyroidism and distinguish it from secondary hypothyroidism
• To monitor drug therapy in the patient with primary hypothyroidism

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C.) Indications
• Low or undetectable serum TSH levels, hypothyroidism, or hyperthyroidism of unknown etiology or type, or low
serum TSH levels combined with hypothyroidism or hyperthyroidism:
o A normal or delayed TSH response in persons with low baseline TSH levels and signs of hypothyroidism
indicates hypothalamic dysfunction or disruption of the hypothalamic–hypophyseal portal circulation and confirms
the diagnosis of tertiary hypothyroidism.
o A decreased or absent TSH response in persons with low baseline TSH levels and signs of
hypothyroidism indicates hypopituitarism and confirms the diagnosis of secondary hypothyroidism.
o A normal or increased TSH response in clients with elevated baseline TSH levels and signs of
hypothyroidism, with persistently decreased thyroid gland hormone levels, confirms the diagnosis of primary
hypothyroidism.
o A decreased or absent TSH response in persons with low baseline TSH levels and signs of
hyperthyroidism, with persistently elevated thyroid gland hormone levels, indicates that thyroid hormone production
is occurring autonomouslyand confirms the diagnosis of primary hyperthyroidism.
D.) Contraindications/Precautions/Interfering Factors
• Aspirin, steroid, or thyroid hormone use (possible alteration in test results)
E.) Equipment’s/Patient Preparation EQUIPMENT
• Red-top tube or serum separator tube; needle and syringe or vacutainer; alcohol swab
PATIENT PREPARATION
•Explain that this test helps assess thyroid gland function.
•Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.
•Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture.
•Withhold steroids, thyroid hormones, aspirin, and other medications that may influence test results as ordered. If they must
be continued, note this on the laboratory request.
•Advise the patient to lie down and relax for 30 minutes before the test.
F.) Normal Values
•TSH level is undetectable to 15 µIU/ml (SI, 15 mU/L).
G.) Procedure to include with Important Nursing Responsibilities, Before, During, and After the Procedure
BEFORE THE TEST
•Confirm the patient’s identity using two patient identifiers according to facility policy.
•Explain to the patient that the serum thyroid-stimulating hormone test helps assess thyroid gland function.
•Advise the patient that the test requires a blood sample. Explain that he may experience slight discomfort from the
tourniquet and the needle puncture.
•Withhold steroids, thyroid hormones, aspirin, and other medications that may influence test results, as ordered. If they must
be continued, note this on the laboratory request.
•Keep the patient relaxed and recumbent for 30 minutes before the test.

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DURING THE TEST
•Between 6 a.m. and 8 a.m., perform a venipuncture, and collect the blood sample i n a 5-ml clot-activator tube.
•Apply direct pressure to the venipuncture site until bleeding stops.
AFTER THE TEST
•If a hematoma develops at the venipuncture site, apply warm soaks.
•Tell the patient to resume medications that were stopped before the test as ordered.
H.) Implications of Abnormal Results
•TSH levels may be slightly elevated in euthyroid patients with thyroid cancer.
•TSH levels that exceed 20 µIU/ml (SI, 20 mU/L) suggest primary hypothyroidism or, possibly, endemic goiter.
•Low or undetectable TSH levels may be normal but occasionally indicate secondary hypothyroidism (with inadequate
secretion of TSH or thyrotropinreleasing hormone [TRH]).
•Low TSH levels may also result from hyperthyroidism (Graves’ disease) and thyroiditis; both are marked by hypersecretion
of thyroid hormones, which suppresses TSH release. Provocative testing with TRH is necess ary to confirm the diagnosis.
THYROID SCAN
• The thyroid scan is a nuclear medicine study performed to assess thyroid size, shape, position, and function. It
is useful for evaluating thyroid nodules, multinodular goiter, and thyroiditis; assisting in the differential
diagnosis of masses in the neck, base of the tongue, and mediastinum; and ruling out possible ectopic thyroid
tissue in these areas. Thyroid scanning is performed after oral administration of radioactive iodine- 123 (I-123)
or I-131 or IV injection of technetium-99m (Tc-99m).
• Thyroid scanning allows the size, shape, position, and physiologic function of the thyroid gland to be
determined with the use of radionuclear scanning. A radioactive substance such as technetium-99m (99mTc) or
Iodine131 is given to the patient to visualize the thyroid gland. A scintigraphy camera is passed over the neck
area, and an image is recorded.
B.) Purposes
•To assess thyroid gland size, structure, function, and shape toward diagnosing disorders such as tumor, inflammation,
cancer, and bleeding.
•To evaluate thyroid function (in conjunction with other thyroid tests)
C.) Indications
•Assess palpable nodules and differentiate between a benign tumor or cyst and a malignant tumor.
•Assess the presence of a thyroid nodule or enlarged thyroid gland.
•Detect benign or malignant thyroid tumors.
•Detect causes of neck or substernal masses.
•Detect forms of thyroiditis (e.g., acute, chronic, Hashimoto disease).
•Detect thyroid dysfunction.
•Differentiate between Graves’ disease and Plummer disease, both of which cause hyperthyroidism.
•Evaluate thyroid function in hyperthyroidism and hypothyroidism (analysis combined with interpretation of laboratory
tests, thyroid function panel including thyroxine and triiodothyronine, and thyroid uptake tests).

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D.) Contraindications/Precautions/Interfering Factors CONTRAINDICATIONS
•Patients who are pregnant or suspected of being pregnant, unless the potential benefits of a procedure using radiation far
outweigh the risk of radiation exposure to the fetus and mother.
INTERFERING FACTORS
•Ingestion of foods containing iodine (iodized salt) or medications containing iodine (cough syrup, potassium iodide,
vitamins, Lugol solution, thyroid replacement medications), which can decrease the uptake of the radionuclide.
•Antihistamines, antithyroid medications (propylthiouracil), corticosteroids, isoniazid, nitrates, sulfonamides, thyroid
hormones, and warfarin, which can decrease the uptake of the radionuclide.
•Increased uptake of iodine in persons with an iodine-deficient diet or who are on phenothiazine therapy.
•Vomiting and severe diarrhea, which can affect absorption of orally administered radionuclide.
•Gastroenteritis, which can interfere with absorption of orally administered radionuclide.
•Metallic objects (e.g., jewelry, body rings) within the examination field, other nuclear scans done within the previous 24
to 48 hr, or iodinated contrast from a previous radiological procedure, which may inhibit organ visualization and cause
unclear images.
•Improper injection of the radionuclide that allows the tracer to seep deep into the muscle tissue can produce erroneous
hot spots.
•Inability of the patient to cooperate or remain still during the procedure because movement can produce blurred or
otherwise unclear images.
•Nuclear scanning equipment
PATIENT PREPARATION
•Explain that this procedure helps determine the cause of thyroid dysfunction.
•If 123I or 131I will be used, tell the patient to fast after midnight the night before the test. Fasting isn’t required if an I.V.
injection of 99mTc pertechnetate is used.
•Explain to the patient that after he receives the radiopharmaceutical, a gamma camera will be used to produce an image
of his thyroid. Tell him that the imaging procedure will take about 30 minutes, and assure him that his exposure to
radiation is minimal.
•Ask the patient if he has undergone tests that used radiographic contrast media within the past 60 days. Note previous
radiographic contrast media exposure on the X-ray request.
•Check the patient’s diet and medication history. Medications such as thyroid hormones, thyroid hormone antagonists, and
iodine preparations (Lugol’s solution, some multivitamins, and cough syrups) should be
stopped 2 to 3 weeks before the test as ordered. Phenothiazines, corticosteroids, salicylates, anticoagulants, and
antihistamines should be stopped 1 week before the test as ordered. Instruct the patient to stop consuming iodized salt,
iodinated salt substitutes, and seafood for 14 to 21 days as ordered. Liothyronine, propylthiouracil, and methimazole
should be stopped 3 days before the test, and T4 should be stopped 10 days before the test as ordered. ▪ Just before the
test, tell the patient to remove dentures, jewelry, and other materials that may interfere with the imaging process.
•Make sure the patient or a responsible family member has signed an informed consent form, if required.
•The patient receives 123I or 131I (oral) or 99mTc pertechnetate (I.V.). Record the date and the time of
administration. ▪ The patient receiving an oral radioisotope should fast for another 2 hours after administration.
•There are no activity or medication restrictions unless by medical direction.

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•Instruct the patient to fast for 8 to 12 hr prior to the procedure.
•Protocols may vary among facilities.
•Ensure that this procedure is performed before other radiographic procedures using iodinated contrast medium.
F.) Normal Values
•The thyroid gland is about 2” (5 cm) long and 1” (2.5 cm) wide, with a uniform uptake of the radioisotope and without
tumors.
•The gland is butterfly-shaped, with the isthmus located at the midline. Occasionally, a third lobe called the pyramidal
lobe may be present; this is a normal variant.
BEFORE TEST:
•Explain the test procedure and the purpose of the test.
•Assess the client’s knowledge of the test.
•Educate client on need to remain still during scan.
•Reassure client no pain will be experienced during the test. Instruct cl ient to void before the procedure.
• Assess if client is pregnant or nursing.

• Have client remove all jewelry or metal objects.
• Administer sedatives as ordered.
• Ensure any specified pretest requirements have been met (e.g., fasting).
• Obtain a recent weight for purposes of determining radionuclide dosage.
DURING TEST:
• Adhere to standard precautions.
• Unlike x-ray procedures, it is not necessary for the client to be left alone, so a staff or family member may stay
with them.
AFTER TEST:
• Instruct client and caregivers to wash hands after voiding or bowel movements because the radionuclide is
excreted in urine and feces.
• Encourage client to drink fluids to assist in flushing isotopes from the body.

• Hyperfunctioning nodules (areas of excessive iodine uptake) appear as black regions called hot spots. The
presence of hot spots requires a follow-up T3 thyroid suppression test to determine if the hyperfunctioning areas
are autonomous.

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• Hypofunctioning nodules (areas of little or no iodine uptake) appear as white or light gray regions called cold
spots. If a cold spot appears, thyroid ultrasonography may be performed to rule out cysts, and fine -needle
aspiration and biopsy of the nodules may be performed to rule out malignancy
SEMEN ANALYSIS
• Semen analysis is a simple, inexpensive, and reasonably definitive test that’s used in many applications, including
evaluating a man’s fertility. Fertility analysis usually includes measuring seminal fluid volume, performing sperm
counts, and microscopic examination of spermatozoa. Sperm are counted in much the same way that white blood
cells, red blood cells, and platelets are counted in a blood sample. Motilityand morphology are studied
microscopically after staining a drop of semen.
• If analysis detects an abnormality, additional tests (for example, liver, thyroid, pituitary, or adrenal function tests)
may be performed to identify the underlying cause and to screen for metabolic abnormalities (such as diabetes
mellitus). Significant abnormalities—such as greatly decreased sperm count or motility or a marked increase in
morphologically abnormal forms—may require testicular biopsy.
• Semen analysis can also be used to detect semen on a rape victim, to identify the blood group of an alleged rapist,
or to prove sterility in a paternity suit.
B.) Purposes
• To evaluate male fertility in an infertile couple
• To substantiate the effectiveness of a vasectomy
• To detect semen on the body or clothing of a suspected rape victim orelsewhere at the crime scene
• To identify blood group substances to exonerate or incriminate a criminal suspect
• To rule out paternity on grounds of complete sterility
C.) Indications
• Evaluates for possible causes of infertility.
• Sperm count and semen volume levels increase up to 7 days during abstinence
D.) Contraindications/Precautions/Interfering Factors PRECAUTIONS
• If the patient prefers to collect the specimen during coitus interruptus, tell him he must prevent any loss of semen
during ejaculation.
• Deliver all specimens, regardless of the source or method of collection, to the laboratory within 1 hour.
• Protect semen specimens for fertility studies from extremes of temperature and direct sunlight during delivery to
the laboratory.
• Never lubricate the vaginal speculum. Oil or grease hinders examination of spermatozoa by interfering with
smear preparation and staining and by inhibiting sperm motility through toxic ingredients. Instead, moisten the
speculum with water or physiologic saline solution.
• Use extreme caution in securing, labeling, and delivering all specimens to be used for medicolegal purposes. You
may be asked to testify as to when, where, and from whom the specimen was obtained; the specimen’s general
appearance and identifying features; steps taken to ensure the specimen’s integrity; and when, where, and to

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whom the specimen was delivered for analysis. If your facility or clinic uses routing requests for such specimens,
fill them out carefully and place them in the permanent medicolegal file.
INTERFERING FACTORS
• Intercourse less than 72 hr pretest can reduce the number of sperm for analysis.
• Citrate (possible abnormal postcoital test results due to changes in cervical mucus
• Specimen container; microscope; aspiration syringe; glass slides
PATIENT PREPARATION
• Provide written instructions, and inform the patient that the most desirable specimen requires masturbation,
ideally in a physician’s office or laboratory.
• Tell the patient to follow the instructions given to him regarding the period of sexual continence before the test
because this may increase his sperm count. Some physicians specify a fixed number of days, usually between 2
and 5; others advise a period of continence equal to the usual interval between episodes of sexual intercourse.
• If the patient prefers to collect the specimen at home, emphasize the importance of delivering the specimen to the
laboratory within 1 hour after collection. Warn him not to expose the specimen to extreme tempe ratures or to
direct sunlight (which can also increase its temperature). Ideally, the specimen should remain at body temperature
until liquefaction is complete (about 20 minutes). To deliver a semen specimen during cold weather, suggest that
the patient keep the specimen container in a coat pocket on the way to the laboratory to protect the specimen
from exposure to cold.
• Alternatives to collection by masturbation include coitus interruptus or the use of a condom. For collection by
coitus interruptus, instruct the patient to withdraw immediately before ejaculation and to deposit the ejaculate in
a suitable specimen container. For collection by condom, tell the patient to first wash the condom with soap and
water, rinse it thoroughly, and allow it to dry completely. (Powders or lubricants applied to the condom may be
spermicidal.) Special sheaths that don’t contain spermicide are also available for semen collection. After
collection, instruct him to tie the condom, place it in a glass jar, and promptly deliver it to the laboratory.
• Fertility may also be determined by collecting semen from the woman after coitus to assess the ability of the
spermatozoa to penetrate the cervical mucus and remain active. For the postcoital cervical mucus test, instruct
the patient to report for examination 1 to 2 days before ovulation as determined by basal temperature records. A
urine luteinizing hormone-releasing hormone test may help predict ovulation in the patient with an irregular
cycle. Instruct the couple to abstain from intercourse for 2 days and then to have sexual intercourse 2 to 8 hours
before the examination. Remind them to avoid using lubricants. Explain to the patient scheduled for this test
that the procedure takes only a few minutes. Tell her that she’ll be placed in the lithotomy position and that a
speculum will be inserted into the vagina to collect the specimen. She may feel some pressure, but no pain.
F.) Normal Values
• The volume of semen ranges from 0.7 to 6.5 ml.
• The semen volume of many men in infertile couples is increased.
• Abstinence for 1 week or more results in progressively increased semen volume. (With abstinence of up to 10
days, sperm counts increase, sperm motility progressively decreases, and sperm morphology stays the same.)
• Liquefied semen is generally highly viscid, translucent, and gray-white, with a musty or acrid odor. After
liquefaction, specimens of normal viscosity can be poured in drops.

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• Semen is slightly alkaline with a pH of 7.3 to 7.9.
• It coagulates immediately and liquefies within 20 minutes.
• The normal sperm count is 20 million/ml to 150 million/ml and can be greater.
• Forty percent of spermatozoa have normal morphology, and 20% or more of spermatozoa show progressive
motility within 4 hours of collection.
• The normal postcoital cervical mucus test shows 10 to 20 motile spermatozoa per microscopic high-power field
and spinnbarkeit (a measurement of the tenacity of the mucus) of at least 4A (10 cm). These findings indicate
adequate spermatozoa and receptivity of the cervical mucus. Shaking or dead sperm may indicate antisperm
antibodies.
BEFORE TEST:
• Explain the test procedure and the purpose of the test.
• Assess the client’s knowledge of the test.
• Clients require support and sensitivity about the nature of the test (Note: many clients will find the test invasive
and embarrassing).
• Advise female client not to wash her perineal area before or after intercourse as perfumed soaps or deodorants
can be spermicidal.
• Instruct clients to abstain from intercourse for 72 hr before the test.

DURING TEST:
AFTER TEST:
• Inform client that more than one sperm test may become necessary.
• Sperm maturity takes 30–90 days.
• Abnormal semen isn’t synonymous with infertility.
• Only one viable spermatozoon is needed to fertilize an ovum. Although a normal sperm count is 20 million/ml or
more, many men with sperm counts below 1 million/ml have fathered normal children. Only men who can’t
deliver any viable spermatozoa in their ejaculate during sexual intercourse are absolutely sterile.
• Subnormal sperm counts, decreased sperm motility, and abnormal morphology are usually associated with
decreased fertility.
ORAL GLUCOSE TOLERANCE TEST

• The oral glucose tolerance test (OGTT) is the most sensitive method of evaluating borderline cases of diabetes
mellitus. Plasma and urine glucose levels are monitored for 3 hours after ingestion of a challenge dose of glucose

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to assess insulin secretion and the body’s ability to metabolize glucose.
• The OGTT isn’t usually used in patients with fasting plasma glucose values greater than 140 mg/dl (SI, > 7.7
mmol/ L) or postprandial plasma glucose values greater than 200 mg/dl (SI, > 11 mmol/ L
B.) Purposes
• To confirm diabetes mellitus in selected patients
• To help diagnose hypoglycemia and malabsorption syndrome
C.) Indications
• Diabetes mellitus, gestational diabetes, Cushing’s syndrome, pheochromocytomas, primary aldosteronism,
hyperthyroidism, acromegaly, acute pancreatitis, chronic renal disease with azotemia, liver disease, burns, stress,
and infections.
• Addison’s disease, hypoparathyroidism, hypothyroidism, alcoholism, and hyperinsulinism.
• Urine contaminated with feces; spillage or inaccurate collection of the specimen, including nonrefrigeration or
placing on ice; heavy bleeding during menstruation; medications that alter results are glucagon, corti-costeroids,
oral contraceptives, estrogens, thyroid hormones, thiazide, loop diuretics, and niacin
• Arginine, benzodiazepines, caffeine, chlorthalidone, hormonal contraceptives, corticosteroids, dextrothyroxine,
diazoxide, thiazide diuretics, epinephrine, furosemide, recent I.V. glucose infusions lithium, large doses of
nicotinic acid, phenolphthalein, phenothiazines, phenytoin, and triamterene (possible increase); amphetamines,
oral antidiabetic drugs, betaadrenergic blockers, clofibrate, ethanol, insulin, and monoamine oxidase inhibitors
(possible decrease)
PRECAUTIONS
• Send blood and urine samples to the laboratory immediately or refrigerate them.
• Specify when the patient last ate and the blood and urine sample collection times on the laboratory request.
• As appropriate, record the time the patient received his last pretest dose of insulin or oral antidiabetic drug.
• If the patient develops severe hypoglycemia, notify the practitioner. Draw a blood sample, record the time on the
laboratory request, and stop the test. Have the patient drink a glass of orange juice with sugar added, or administer
I.V. glucose to reverse the reaction.
• Green-top tube or serum separator tube; needle and syringe or vacutainer; alcohol swab (Note: urine collection
containers if needed)
PATIENT PREPARATION
• Explain that the OGTT is used to evaluate glucose metabolism.
• Instruct the patient to maintain a high carbohydrate diet for 3 days and then to fast for 10 to 16 hours before the
test.
• Advise the patient not to smoke, drink coffee or alcohol, or exercise strenuously for 8 hours before or during the
test.

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• Tell the patient that this test requires five blood samples and usually five urine samples. Explain who will perform
the venipunctures and when and that the patient may experience slight discomfort from the tourniquet and needle
punctures.
• Suggest to the patient that he bring a book or other quiet diversion with him to the test. The procedure usually
takes 3 hours but can last as long as 6 hours.
• Notify the laboratory and practitioner of medications the patient is taking that may affect test results; these
medications may need to be restricted.
• Alert the patient to the symptoms of hypoglycemia (weakness, restlessness, nervousness, hunger, and sweating)
and tell him to report such symptoms immediately.
F.) Normal Values
• Plasma glucose levels peak at 160 to 180 mg/dl (SI, 8.8 to 9.9 mmol/L) within 30 minutes to 1 hour after
administration of an oral glucose test dose and return to fasting levels or lower within 2 to 3 hours.
• Urine glucose test results remain negative throughout; no glucose is found in the urine
BEFORE TEST:
• Instruct client to eat adequate amounts of carbohydrates at least 3 days before the test.
• Inform the client to fast from food after midnight the day before the test and to refrain from smoking and
strenuous exercise after midnight until the test is completed.
• If a double-voided urine specimen is ordered, the second void is collected 30 min after the first void. A glass of
water is advised before each urine sample is collected to ensure adequate output.
DURING TEST:
• Adhere to required times for blood and urine collection.
AFTER TEST:
• Apply pressure to venipuncture site.
• Explain that some bruising, discomfort, and swelling may appear at the site and that warm, moist compresses can
alleviate this.
• Monitor for signs of infection.
• Decreased glucose tolerance, in which glucose levels peak sharply before falling slowly to fasting levels, may
confirm diabetes mellitus or may result from Cushing’s disease, hemochromatosis, pheochromocytoma, or
central nervous system lesions.
• Increased glucose tolerance, in which levels may peak at less than normal levels, may indicate insulinoma,
malabsorption syndrome, adrenocortical insufficiency (Addison’s disease), hypothyroidism, or hypopituitarism.
FIVE – DAY GLUCOSE SENSOR TEST FOR DIABETES


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• A five-day glucose sensor test uses a small sensor and an electronic recorder to monitor a diabetes patient's blood
sugar (glucose) levels. The test allows a doctor to find patterns in a patient's blood sugar levels, and discover
ways to prevent episodes of hypoglycemia (low blood sugar).
B.) Purposes
• A five-day glucose sensor test can show blood sugar trends over an extended time. A special sensor painlessly
measures blood sugar levels every five minutes, and sends the data to an electronic recorder worn on the belt.
This allows a doctor to fine-tune a patient's insulin type or dosage, and make changes to a patient's diet.
• A doctor most often recommends a five-day glucose sensor test if he or she suspects that a patient has episodes of
dangerously low blood sugar levels (hypoglycemia). The test can measure blood sugar levels at night, when a
patient is unable to do manual tests.
C.) Indications
• Situations that require detailed information about blood glucose fluctuations that only continuous monitoring can
provide include when adjusting therapy, quantifying the response in a trial of a diabetes therapy, assessing the
impact of lifestyle modifications on glycemic control, monitoring conditions where tighter control without
hypoglycemia is sought (e.g., gestational diabetes, pediatric diabetes, in the intensive care unit), diagnosing and
then preventing hypoglycemia (e.g., during sleep, with hypoglycemia unawareness), and diagnosing and
preventing postprandial hypoglycemia.
• No contraindications noted
E.) Equipment/Patient Preparation Equipment

•Tiny Sensor And Small Electronic Recorder
Patient Preparation
•Identify the patient by asking the patient to state his/her name. Also check the client’s identification band. ( confirm
patient’s identity using two patient identifiers, based on the hospital protocol)
•Explain the procedure to the patient or parents (if patient is a child) to gain cooperation
F.) Normal Values
•Between 70 and 130 mg/dL before meals
•Less than 180 mg/dL after meals
BEFORE TEST:
DURING TEST:
•Adhere to standard precautions.
•Elevated levels are found with diabetes mellitus, hyperthyroidism, Cushing’s syndrome, pancreatitis, pregnancy
(gestational diabetes), severe liver disease, shock, trauma, and drugs such as glucagon, adrenal corticosteroids, oral

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contraceptives, and some diuretics.
•Decreased levels are found with Addison’s disease, insulinoma, hypopituitarism, insulin-producing tumors, acute alcohol
ingestion, myxedema, and drugs such as insulin, salicylates, sulfonamides, and MAO inhibitors.
FINE – NEEDLE ASPIRATION BIOPSY

•A fine needle aspiration (FNA) or biopsy of a thyroid nodule is a simple test to check a thyroid nodule or mass for cancer
cells. A very fine, small needle is used to remove fluid and cells from the nodule or mass. The fluid and cells are then sent
to the lab for review.
•In FNAB, samples of thyroid tissue are obtained by placing a very thin (23 to 27 gauge) needle into the thyroid nodule
and aspirating small pieces of thyroid tissue that are then examined microscopically. he Bethesda System for Reporting
thyroid Cytopathology is used to provide the results of the biopsy. Results are indicated as the following: nondiagnostic
(insuicient tissue for evaluation); benign; atypia of undetermined significance; suspicious for a follicular neoplasm;
suspicious for malignancy; or malignant nodules (even if serum
triiodothyronine [T3] and thyroxine [T4] levels are normal), breathing and swallowing difficulties, vocal cord paralysis,
weight loss, hemoptysis, and a sensation of fullness in the neck. It’s commonly performed when
noninvasive tests, such as thyroid ultrasonography and scans, are abnormal or inconclusive. Coagulation studies should
always precede thyroid biopsy.
•Thyroid tissue may be obtained with a hollow needle under local anesthesia or during open (surgical) biopsy under
general anesthesia. Fine-needle aspiration with a cytologic smear examination can aid in diagnosis and replace an open
biopsy. Open biopsy, performed in the operating room, provides more information than needle biopsy; it also permits
direct examination and immediate excision of suspicious tissue.
•In FNAB, samples of thyroid tissue are obtained by placing a very thin (23 to 27 gauge) needle into the thyroid nodule
and aspirating small pieces of thyroid tissue that are then examined microscopically. he Bethesda System for Reporting
hyroid Cytopathology is used to provide the results of the biopsy. Results are indicated as the following: nondiagnostic
(insuicient tissue for evaluation); benign; atypia of undetermined signiicance; suspicious for a follicular neoplasm;
suspicious for malignancy; or malignant
B.) Purposes
•To differentiate between benign and malignant thyroid disease
•To help diagnose Hashimoto’s disease, hyperthyroidism, and nontoxic nodular goiter
C.) Indications
•Abnormal thyroid scan
•Thyroid gland enlargement of unknown etiology
•Signs and symptoms of thyroiditis or hyperthyroidism
•Presence of thyroid nodules of unknown etiology to differentiate between benign and malignant nodules
•Differentiation between thyroid cysts and solid tumors
•Differentiation between inflammatory thyroid diseases (Hashimoto’s thyroiditis versus granulomatous thyroiditis)
•Confirmation of the diagnoses of hyperthyroidism and nontoxic nodular goiter

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•Patients with coagulation disorders because of the risk of excessive bleeding
•Patients with hyperthyroidism, because the needle insertion may instigate thyroid storm and toxic nodular goiters are not
malignant
•Bleeding disorders
E.) Equipment/Patient Preparation
•Describe the procedure to the patient and answer his questions.
•Explain that this test permits microscopic examination of a thyroid tissue specimen.
•Inform the patient that he doesn’t need to restrict food and fluids (unless he’ll receive a general anesthetic).
•Tell the patient who will perform the biopsy and where it will be done.
•Make sure the patient or a responsible family member has signed an informed consent form.
•Check the patient’s history for hypersensitivity to anesthetics or analgesics.
•Tell the patient that he’ll receive a local anesthetic to minimize pain during the procedure but may experience some
pressure when the tissue specimen is procured.
•Check the results of the patient’s coagulation studies and make sure they’re in his chart.
•Advise the patient that he may have a sore throat the day after the test.
•Give the patient a sedative 15 minutes before biopsy.
F.) Normal Values
•Fibrous networks divide the gland into pseudolobules that are made up of follicles and capillaries.
•Cuboidal epithelium lines the follicle walls and contains the protein thyroglobulin, which stores T4 and T3. G.)
Procedure to include with Important Nursing Responsibilities, Before, During, and After the Procedure BEFORE
PROCEDURE
•Explain the procedure to the patient.
•Ensure that the physician obtains informed consent for this procedure.
•Inform the patient that no abstinence from food or drink is required.
•Tell the patient that no sedative is required.
•Note that the procedure may be done at the bedside.
•If ultrasound guidance is to be used, note that the aspiration is performed in the radiology or ultrasonography department.
DURING PROCEDURE
•Note the following procedural steps:
o The patient is placed in a supine position with a sandbag or pillow under the shoulder to hyperextend the
neck.
o Under sterile conditions, the skin overlying the thyroid is infiltrated with a local anesthetic (lidocaine).
o If the nodule can be felt, a biopsy can be performed in the doctor’s voice. When the nodule is not
palpable, ultrasound is used to help guide the biopsy.
o The patient holds his breath while the needle is rocked gently to obtain as much tissue as possible.
o The needle is then withdrawn and tissue is placed on a glass slide.
AFTER PROCEDURE
•Pressure is applied over the thyroid area to minimize bleeding.

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•Note that a physician performs this procedure in approximately 10 minutes.
•Malignant tumors appear as wellencapsulated, solitary nodules of uniform but abnormal structure.
•Benign tumors, such as nontoxic nodular goiter, demonstrate hypertrophy, hyperplasia, and hypervascularity.
•Distinct histologic patterns characterize subacute granulomatous thyroiditis, Hashimoto’s thyroiditis, and
hyperthyroidism.
DEXAMETHASONE SUPPRESSION TEST

•The dexamethasone suppression test requires administration of dexamethasone, an oral steroid. Dexamethasone
suppresses levels of circulating adrenal steroid hormones in normal people but fails to suppress them in patients with
Cushing’s syndrome and some forms of clinical depression.
•Dexamethasone suppression testing examines both blood and urine for the presence of cortisol. The test is performed by
administering dexamethasone (a synthetic glucocorticoid) to evaluate the production of cortisol. The dexamethasone is
given in high or low doses and blood samples are obtained to determine if cortisol is at normal levels in the blood. The
low dose is given for screening, and a high-dose test is administered to
determine the cause of Cushing’s disease (Cushing’s disease has no suppression of ACTH).
B.) Purposes
•To diagnose Cushing’s syndrome
•To help diagnose clinical depression
C.) Indications
•Suspected adrenal hyperfunction (Cushing’s syndrome) from a variety of causes, as indicated by elevated levels that do
not vary diurnally
•Evaluation of effects of disorders associated with elevated cortisol levels (e.g., hyperthyroidism, obesity, and diabetic
ketoacidosis)
•Suspected adrenal hypofunction (Addison’s disease) from a variety of causes, as indicated by decreased levels
•Monitoring for response to therapy with adrenocorticosteroids:
o Elevated levels are seen in clients receiving adrenocorticosteroid therapy.
o Decreased levels may occur for months after therapy is discontinued, resulting from druginduced
atrophy of the adrenal glands.
•Evaluates diurnal suppression of cortisol to confirm Cushing’s syndrome.
•Diagnoses endogenous depression (Note: cortisol is depressed in 50% of the cases).
•Elevated levels of cortisol after dexamethasone administration are found with adrenal hyperplasia, adrenal tumors, and
oat cell cancer of the lung.

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•The time of day when the test is performed may alter results because cortisol levels vary diurnally, with highest levels
being seen on awakening and lowest levels occurring late in the day.
•Stress and excessive physical activity may produce elevated levels.
•Pregnancy, therapy with estrogen-containing drugs, lithium carbonate, methadone, and ethyl alcohol may lead to
elevated cortisol levels.
•Therapy with levodopa, barbiturates, phenytoin (Dilantin), and androgens may produce decreased levels.
•Failure to follow dietary restrictions, if ordered, may alter test results.
•Urine contaminated with feces; spillage or inaccurate collection of the 24-hr specimen, including nonrefrigeration or
placing on ice; heavy bleeding during menstruation; failure to ingest dexamethasone; nuclear scan within previous 24 hr;
false positives will occur with alcoholism, anorexia nervosa, severe depression, malnutrition, fever, obesity, pregnancy,
and high stress levels; false negatives will occur with Addison’s disease and hypopituitarism; medications that increase
results are barbiturates, carbamazepine, estrogens, meprobamate, oral contraceptives, phenytoin, reserpine, and
spironolactone; medications that decrease results are benzodiazapines, corticosteroids, and cyproheptadine.
•Certain drugs, particularly barbiturates or phenytoin, within 3 weeks of the test (possible false-positive); corticosteroids,
hormonal contraceptives, lithium, methadone.
PRECAUTIONS
•Many medications, including corticosteroids, oral contraceptives, lithium, methadone, aspirin, diuretics,
morphine, and monoamine oxidase (MAO) inhibitors, can affect the accuracy of test results. If possible, don’t give any
of these medications for 24 to 48 hours before the test, as ordered.
•Diabetes mellitus, pregnancy, and severe stress, such as trauma, severe weight loss, dehydration, and acute alcohol
withdrawal can cause a falsepositive.
•Blood: red-top tube or serum separator tube; needle and syringe or vacutainer
•Urine: sterile plastic container; ice
PATIENT PREPARATION
•Explain the purpose of the dexamethasone suppression test.
•Inform the patient that the test requires two blood samples drawn after administration of dexamethasone. Explain who
will perform the venipunctures and when they’ll be done.
•Explain to the patient that he may experience discomfort from the tourniquet and needle punctures.
•Restrict food and fluids for 10 to 12 hours before the test.
F.) Normal Values
•A cortisol level of 5 g/dl (140 nmol/L) or greater indicates failure of dexamethasone suppression. G.) Procedure to
include with Important Nursing Responsibilities, Before, During, and After the Procedure BEFORE TEST:
•Instruct client not to discard any urine over the 24-hr time period.

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DURING TEST:
•On the first day, give the patient 1 mg of dexamethasone at 11 p.m. On the next day, collect blood samples at 4
p.m. and 11 p.m. More frequent sampling may increase the likelihood of measuring a nonsuppressed cortisol peak.
•If any urine is accidentally discarded or contaminated with feces, discard entire specimen and be gin test again the
following morning.
AFTER TEST:
•Apply pressure to venipuncture site.
•Explain that some bruising, discomfort, and swelling may appear at the site and that warm, moist compresses can
alleviate this.
•If a hematoma develops at the venipuncture site, apply warm soaks.
•Monitor for signs of infection.
•Document urine quantity, date, and exact hours of collection on requisition.
•Failure of suppression occurs in the patient with Cushing’s syndrome, severe stress, and depression that’s likely to
respond to treatment with antidepressants.
CRH STIMULATION TEST

•The corticotropin test measures plasma levels of corticotropin by radioimmunoassay. Corticotropin stimulates the
adrenal cortex to secrete cortisol and, to a lesser degree, androgens and aldosterone. It also has some
melanocytestimulating activity, increases the uptake of amino acids by muscle cells, promotes lipolysis by fat cells,
stimulates pancreatic beta cells to secrete insulin, and may contribute to the release of growth hormone. Corticotropin
levels vary diurnally, peaking between 6 a.m. and 8 a.m. and ebbing between 6 p.m. and 11 p.m. Through a negative
feedback mechanism, plasma cortisol levels control corticotropin secre tion—for example, high cortisol levels suppress
corticotropin secretion. Emotional and physical stress (pain, surgery, insulininduced hypoglycemia) stimulate secretion
and can override the effects of plasma cortisol levels.
•The corticotropin test may be ordered for a patient with signs of adrenal hypofunction (insufficiency) or hyperfunction
(Cushing’s syndrome). Corticotropin suppression or stimulation testing is usually necessary to confirm diagnosis. The
instability and unavailability of corticotropin greatly limit this test’s diagnostic significance and reliability.
B.) Purposes
•To aid in the differential diagnosis of primary and secondary adrenal hypofunction
•To aid in the differential diagnosis of Cushing’s syndrome
C.) Indications
•Signs and symptoms of adrenocortical dysfunction:
o Elevated ACTH levels with low cortisol levels indicate adrenocortical hypoactivity (Addison’s disease).
o Low ACTH levels with high cortisol levels indicate adrenocortical hyperactivity (Cushing’s syndrome)
caused by benign or malignant adrenal tumors.
o High ACTH levels, without diurnal variation, combined with high cortisol levels indicate adrenocortical

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hyperfunction caused by excessive ACTH production (e.g., resulting from pituitary adenoma and nonendocrine malignant
tumors in which there is ectopic ACTH production).
o Decreased ACTH levels are associated with panhypopituitarism, hypothalamic dysfunction, and long-
term adrenocorticosteroid therapy.
•Failure to observe pretest restrictions
•Corticosteroids, including cortisone and its analogues (decrease)
•Drugs that increase endogenous cortisol secretion, such as estrogens, calcium gluconate, amphetamines, spironolactone,
and ethanol (decrease)
•Lithium carbonate (decreases cortisol levels and may interfere with corticotropin secretion)
•Menstrual cycle and pregnancy
•Radioactive scan performed within 1 week before the test
•Acute stress (including hospitalization and surgery) and depression (increase)
PRECAUTIONS
•Proteolytic enzymes in plasma degrade corticotropin. A 39.2° F (4° C) temperature is necessary to retard enzyme
activity.

•Red-top tube or serum separator tube; needle and syringe or vacutainer.
PATIENT PREPARATION
•Explain that this test helps determine if the patient’s hormonal secretion is normal.
•Advise the patient to fast and limit his physical activity for 10 to 12 hours before the test.
•Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.
•Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture.
•Check the patient’s history for medications that may affect the accuracy of test results as ordered. Withhold these
medications for 48 hours or longer before the test. If they must be continued, note this on the laboratory request.
•Arrange with the dietary department to provide a low-carbohydrate diet for 2 days before the test. This requirement may
vary, depending on the laboratory.
F.) Normal Values
•Mayo Medical Laboratories sets baseline values at less than 120 pg/ml (SI, < 26.4 pmol/L at 6 a.m. to 8 a.m.), but these
values may vary, depending on the laboratory.
BEFORE THE TEST
•Explain to the patient that this test helps determine whether his hormonal secretion is normal.

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•Advise the patient that he must fast and limit his physical activity for 10 to 12 hours before the test.
•Tell the patient that the test requires a blood sample.
•Explain that the patient may experience slight discomfort from the tourniquet and the needle puncture.
•Check the patient’s history for medications that may affect test result accuracy. Withhold these medications for 48 hours
or longer before the test. If the patient must continue them, note this on the laboratory request.
DURING THE TEST
•For a patient with suspected adrenal hypofunction, perform the venip uncture for a baseline level between 6 AM and 8
AM (peak secretion).
•For a patient with suspected Cushing’s syndrome, perform the venipuncture between 6 PM and 11 PM (low secretion).
•Collect the sample in a plastic EDTA tube (corticotropin may adhere to glass). The tube must be full, because excess
anticoagulant will affect results.
•Pack the sample in ice and send it to the laboratory immediately, where plasma must be rapidly separated from blood
cells at 39.2° F (4° C). The collection technique may vary, depending on the laboratory.
AFTER THE TEST
•Apply direct pressure to the venipuncture site until bleeding stops.
•Tell the patient he may resume his usual diet, activities, and medications that were stopped before the test.
•Assess the venipuncture site for hematoma development; apply pressure if one develops.
H.) Implications of Abnormal Results ELEVATED LEVELS
•Primary adrenal hypofunction (Addison’s disease caused by idiopathic atrophy or partial gland destruction by
granuloma, neoplasm, amyloidosis, or inflammatory necrosis)
•Cushing’s syndrome
•Pituitary-dependent adrenal hyperplasia and non-adrenal tumors such as oat cell carcinoma of the lungs (moderately
elevated)
DECREASED LEVELS
•Secondary adrenal hypofunction resulting from pituitary or hypothalamic dysfunction
•Adrenal hyperfunction caused by adrenocortical tumor or hyperplasia
BONE DENSITY TEST

•Bone densitometry assesses bone mass quantitatively. This noninvasive technique, also known as dual energy X- ray
absorptiometry or DEXA, uses an X-ray tube to measure bone mineral density, but exposes the patient to only minimal
radiation. The images detected are computer analyzed to determine bone mineral status. The computer calculates the size
and thickness of the bone as well as its volumetric density to determine its potential resistance to mechanical stress. It
may be performed in the radiology department of a health care facility, a practitioner’s office, or a clinic.

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• The test involves positioning the patient on a table under the scanning device, with the radiation source below and
the detector above. The detector then measures the bone’s radiation absorption and produces a digital readout.
B.) Purposes
• Bone densitometry systems determine bone mineral content and density to diagnose osteoporosis.
• Monitor patients who are undergoing treatment for osteoporosis.
C.) Indications
• Early premenopausal oophorectomy or estrogen-deficiency syndromes (e.g., amenorrhea)
• Plain films indicating osteopenia
• Endocrinopathies known to be associated with osteopenia (e.g., hyperparathyroidism, prolactinoma, Cushing
syndrome, male hypogonadism, hyperthyroidism)
• Unexplained or multiple fractures
• Anorexia
• Multiple myeloma
• Prolonged immobility
• Gastrointestinal (GI) malabsorption (proteins and calcium)
• Chronic renal diseases (secondary and tertiary hyperparathyroidism)
• Treatment-related osteopenia (e.g., long-term heparin, breast cancer antihormone therapy, or steroid therapy)
• Monitoring of treatment of osteoporosis (e.g., selective estrogen receptor modulators, bisphosphonates,
calcitonins)
• Barium may falsely increase the density of the lumbar spine. Bone density measurements should not be
performed within about 10 days after barium studies.
• Posterior vertebral calcific arthritic sclerosis can falsely increase bone density of the spine.
• Calcified abdominal aortic aneurysm can falsely increase bone density of the spine.
• Internal fixation devices of the hip or radius will falsely increase bone density of those bones.
• Overlying metal jewelry or other objects can falsely increase bone density.
• Previous fractures or severe arthritic changes of the bone to be studied can falsely increase its bone density.
• Metallic clips placed in the plane of the vertebra in patients who have had previous abdominal surgery can falsely
increase bone density.
• Previous bone scans can falsely decrease bone density because the photons generated from the bone as a result of
the previously administered radionuclide will be detected by the scintillator counter.
• Explain the procedure to the patient or parents (if patient is a child) to gain cooperation
• Encourage client to wear comfortable, cotton garments that are free of metal or plastic zippers or buttons
F.) Normal Values
• Normal: <1 SD below normal (>–1.0)
• Osteopenia: 1.0-2.5 SD below normal (–1 to –2.5)

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• Osteoporosis: >2.5 SD below normal (<–2.5)
BEFORE TEST:
DURING TEST:
• Osteopenia (low bone mass), Osteoporosis: Osteopenia precedes osteoporosis. The most common cause of
osteoporosis is lack of sexual hormones (estrogen in the female, testosterone in the male). Osteopenia may result
from primary ovarian failure secondary to menopause or oophorectomy, or pituitary disease. In male patients,
osteopenia usually occurs in children with congenital hormone deficiencies.
• Hyperparathyroidism: Excess parathyroid hormone mobilizes calcium from the bone, causing demineralization
and bone weakening.
• Chronic renal insufficiency: Excess phosphates that accumulate as a result of reduced glomerular filtration
decrease the calcium in the blood. Parahormone is stimulated to increase calcium levels. Excess parathyroid
hormone mobilizes calcium from the bone, causing demineralization and weakening of the bones (secondary
hyperparathyroidism). If after persistent parathyroid stimulation the parathyroid glands become autonomous
and secrete elevated parahormone despite normal calcium levels, tertiary hyperparathyroidism develops. The
bone changes are the same as described above.
• GI malabsorption: Calcium and protein cannot be absorbed. The bones are depleted of their minerals, and bone
density is reduced.
• Cushing syndrome, Chronic steroid therapy: Glucocorticosteroids inhibit bone mineralization and decrease bone
density.
• Chronic heparin therapy: Heparin binds calcium and other minerals. These minerals are therefore not available for
bone growth. Further, these minerals are mobilized from their bone stores. Bone density diminishes.
• Chronic immobility: The pathophysiology of bone demineralization in the immobilized patient is not clearly
understood.
ACTH STIMULATION TEST

• The rapid corticotropin test is gradually replacing the 8-hour corticotropin stimulation test as the most effective
diagnostic tool for evaluating adrenal hypofunction. Using cosyntropin, the rapid corticotropin test provides
faster results and causes fewer allergic reactions than the 8-hour test, which uses natural corticotropin from
animal sources.
• Baseline cortisol levels must be determined before this test to evaluate the effect of cosyntropin administration on

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cortisol secretion. An unequivocally high morning cortisol level rules out adrenal hypofunction and makes further
testing unnecessary.
B.) Purposes
• To help identify primary and secondary adrenal hypofunction
C.) Indications
• Signs and symptoms of adrenocortical dysfunction:
o Elevated ACTH levels with low cortisol levels indicate adrenocortical hypoactivity (Addison’s disease).
o Low ACTH levels with high cortisol levels indicate adrenocortical hyperactivity (Cushing’s syndrome)
caused by benign or malignant adrenal tumors.
o High ACTH levels, without diurnal variation, combined with high cortisol levels indicate adrenocortical
hyperfunction caused by excessive ACTH production (e.g., resulting from pituitary adenoma and nonendocrine
malignant tumors in which there is ectopic ACTH production).
o Decreased ACTH levels are associated with panhypopituitarism, hypothalamic dysfunction, and long-
term adrenocorticosteroid therapy.
• Pregnancy: Pregnancy will affect ACTH levels and may obscure interpretation.
• Pediatric: Infants and children will need assistance in remaining still during the venipuncture and age- appropriate
comfort measures following the test
• Medications that alter results are adrenocorticosteroids (e.g., prednisone, dexamethasone, estrogens, androgens,
calcium gluconate, amphetamines, alcohol, spironolactone.
• Exercise
• Stress
• Blood Glucose
• ACTH levels vary diurnally; highest levels occur upon awakening, decrease throughout the day, and then begin to
rise again a few hours before awakening.
E.) Equipment’s/Patient Preparation
EQUIPMENT
• Lavender-top or green-top tube; needle and syringe or vacutainer; alcohol swab
PATIENT PREPARATION
• Explain that this test helps determine if the patient’s condition is due to a hormonal deficiency.
• Inform the patient that he may have to fast for 10 to 12 hours before the test and that he must be relaxed and
resting quietly for 30 minutes before the test.
• Tell him that the test takes at least 1 hour to perform.
• For an inpatient, withhold corticotropin and all steroid medications as ordered. For an outpatient, tell him to
refrain from taking these drugs as ordered. If the drugs must be continued, note this on the laboratory request.
• Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture.
F.) Normal Values
• Cortisol levels rise after 30 to 60 minutes to a peak of 18 mg/dl (SI, 500 mmol/L) or more after the cosyntropin
injection.

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• A normal response is usually double the baseline level; normal results rule out adrenal hypofunction
(insufficiency).
BEFORE TEST:
• Instruct client to be NPO after midnight prior to test.
DURING TEST:
AFTER TEST:
• Apply pressure to venipuncture site.
• Explain that some bruising, discomfort, and swelling may appear at the site and that warm, moist compresses can
alleviate this.
• Monitor for signs of infection.
• Cortisol levels that remain low may indicate primary adrenal hypofunction (Addison’s disease).
• Subnormal increases in cortisol levels may require prolonged stimulation of the adrenal cortex to distinguish
between primary and secondary adrenal hypofunction.
24 – HOUR URINE COLLECTION TEST

• A 24-hour urine collection is a simple lab test that measures what's in your urine. The test is used to check kidney
function. A 24-hour urine collection is done by collecting your urine in a special container over a full 24- hour
period. The container must be kept cool until the urine is returned to the lab.
• Because hormones, proteins, and electrolytes are excreted in small, variable amounts in urine, specimens for
measuring these substances must typically be collected over an extended period to yield quantities of diagnostic
value.
• A 24-hour specimen is used most commonly because it provides an average excretion rate for substances
eliminated during this period. Timed specimens may also be collected for shorter periods, such as 2 or 12 hours,
depending on the specific information needed.
B.) Purposes
• To screen the patient’s urine for renal or urinary tract disease
• To help detect metabolic or systemic disease unrelated to renal disorders
• To detect substances (drugs)
• Provides an average excretion rate for substances eliminated during this period
• Usually collected as part of the physical examination or during hospitalization
C.) Indications
• Detection of uncontrolled diabetes mellitus as indicated by the presence of glucose and ketones (seen primarily in
insulin-dependent diabetes mellitus) and by urine with low specific gravity

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• Detection of gestational diabetes during pregnancy
D.) Contraindications/Precautions/Interfering Factors PRECAUTIONS

• Keep the patient well hydrated before and during the test to ensure adequate urine flow.
• Before collection of a timed specimen, make sure the laboratory will be open when the collection period ends to
help ensure prompt, accurate results.
• Never store a specimen in a refrigerator containing food or medication to avoid contamination.
• If the patient has an indwelling catheter in place, put the collection bag in an ice-filled container at his bedside.
• Instruct the patient to avoid exercise and ingestion of coffee, tea, or any drugs (unless directed otherwise by the
practitioner) before the test to avoid altering test results.
• If you accidentally discard a specimen during the collection period, you’ll need to restart the collection. This may
result in an additional day of hospitalization, which may cause the patient personal and financial hardship.
Therefore, emphasize the need to save all the patient’s urine during the collection period to everyone involved in
his care as well as to his family and other visitors.
• If the patient must continue collecting urine at home, provide written instructions for the appropriate method.
• Tell the patient he can keep the collection container in a brown bag in his refrigerator at home, separate from
other refrigerator contents.

•Large collection container with a cap or stopper, or a commercial plastic container
•Preservative (if necessary)
•Gloves
•Bedpan or urinal (if patient doesn’t have an indwelling catheter)
•graduated container (if patient requires intake and output measurement)
•Gloves
•Ice-filled container (if a refrigerator isn’t available)
•Label
•laboratory request form
•Four patientcare reminders
•Check with the laboratory to see what preservatives may be needed in the urine specimen or if a dark collection
container is required.
PATIENT PREPARATION
•Explain the procedure to the patient and his family, as necessary, to enlist their cooperation and to prevent accidental
disposal of urine during the collection period. Emphasize that failure to collect even one specimen during the collection

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period invalidates the test and requires that it begin again.
•Place patient-care reminders over the patient’s bed, in his bathroom, on the bedpan hopper in the utility room, and on the
urinal or indwelling cathEter collection bag. Include the patient’s name and room number, the date, and the collection
interval.
•Instruct the patient to save all urine during the collection period, to notify you after each voiding, and to avoid
contaminating the urine with stool or toilet tissue.
•Explain any dietary or drug restrictions, and make sure he understands and is willing to comply with them.
F.) Normal Values
•The normal range for 24-hour urine volume is 800 to 2,000 milliliters per day (with a normal fluid intake of about 2 liters
per day).
Components Normal Range
Creatinine • In males, the level is 14 to 26 mg/kg body weight/24 hours (SI, 124 to 230 µmol/kg body weight/d).
• In females, the level is 11 to 20 mg/ kg body weight/24 hours (SI, 97 to 177 µmol/kg body weight/d).
Urea Nitrogen • BUN levels are 8 to 20 mg/dl (SI, 2.9 to 7.5 mmol/L).
• BUN levels are slightly higher in elderly patients.
Sodium • Urine sodium excretion in adults’ ranges from 40 to 220 mEq/L/24 hours (SI, 40 to 220 mmol/d)
• In infants and children, from 41 to 115 mEq/L/24 hours (SI, 41 to 115 mmol/d).
Chloride • Urine chloride excretion in adults’ ranges from 110 to 250 nmol/24 hours (SI, 110 to 250 mmol/d)
• In children, from 15 to 40 nmol/24 hours (SI, 15 to 40 mmol/d)
• In infants, from 2 to 10 mmol/24 hours (SI, 2 to 10 mmol/d).
Calcium • Normal values depend on dietary intake.
• In a normal diet, urine calcium levels range from 100 to 300 mg/24 hours (SI, 2.5 to 7.5 mmol/d).
Total • Dopamine: 65 to 400 mcg/24 hours (SI, 425–2610 nmol/24 hours)

Catecholamine • Epinephrine: 0 to 20 mcg/24 hours (SI, 0–109 nmol/24 hours)
• Norepinephrine: 15 to 80 mcg/24 hours (SI, 89–473 nmol/24 hours)
Protein • 50 to 80 mg/24 hours (SI, 50–80 mg/ day) (at rest)
G.) Procedure to include with Important Nursing Responsibilities, Before, During, and After the
Procedure BEFORE THE TEST
•Explain the procedure to the patient.
•Inform the patient if food or fluid restrictions are needed
DURING THE TEST
•Begin the 24-hour collection by discarding the first specimen.

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• Collect all urine voided during the next 24 hours.
• Show the patient where to store the urine.
• Keep the urine on ice or refrigerated during the collection period. Foley bags are kept in a basin of ice. Some
collections require a preservative. Check with the laboratory.
• Post the hours for the urine collection in a prominent place to prevent accidentally discarding a specimen.
• Instruct the patient to void before defecating so that urine is not contaminated by stool.
• Remind the patient not to put toilet paper in the urine collection container.
• Collect the last specimen as close as possible to the end of the 24-hour period. Add this urine to the collection.
AFTER THE TEST
• Transport the specimen promptly to the laboratory.
• Disorders that cause reduced urine volume include dehydration, not enough fluid intake, or some types of
chronic kidney disease.
• Some of the conditions that cause increased urine volume include:
o Diabetes insipidus - renal
o Diabetes insipidus - central
o Diabetes
o High fluid intake
o Some forms of kidney disease
o Use of diuretic medicines
Components Significance of Abnormal Findings
Creatinine • Low urine creatinine levels may result from impaired renal perfusion (associated with shock, for example), renal disease due
to urinary tract obstruction, chronic bilateral pyelonephritis, acute or chronic
glomerulonephritis, or polycystic kidney disease.
• High urine creatinine levels usually have little diagnostic significance.
Urea Nitrogen • High BUN levels occur in renal disease, reduced renal blood flow (from dehydration, for example), urinary tract obstruction,
GI bleed, congestive heart failure, and increased protein catabolism (possibly from burns).
• Low BUN levels indicate severe hepatic damage, malnutrition, low protein diets, and overhydration.
Sodium • High urine sodium levels may reflect increased salt intake, adrenal failure, salicylate toxicity, diabetic acidosis, saltlosing
nephritis, and water-deficient dehydration.
• Low urine sodium levels suggest decreased salt intake, primary aldosteronism, acute renal failure, and heart failure.
Chloride • High urine chloride levels may result from water-deficient dehydration, salicylate toxicity, diabetic
ketoacidosis, adrenocortical insufficiency (Addison’s disease), or salt-losing renal disease.
• Low urine chloride levels may result from excessive diaphoresis, heart failure, hypochloremic metabolic alkalosis, or
prolonged vomiting or gastric suctioning.
Calcium ELEVATED LEVELS
• Hyperparathyroidism

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• Vitamin D intoxication
• Metastatic carcinoma
• Sarcoidosis
• Renal tubular acidosis
• Multiple myeloma DECREASED LEVELS
• Milk-alkali syndrome
• Hypoparathyroidism
• Acute nephrosis
• Chronic nephrosis
• Acute nephritis
• Renal insufficiency
• Osteomalacia
• Steatorrhea
Total ELEVEATED LEVELS
Catecholamine
• Pheochromocytoma (in the patient with undiagnosed hypertension following a hypertensive episode)
• Neuroblastoma or a ganglioneuroma (elevated levels without marked hypertens ion)
• Severe systemic situations (burns, peritonitis, shock, and septicemia), cor pulmonale, manic depressive disorders, or
depressive neurosis
• Myasthenia gravis and progressive muscular dystrophy (test rarely used to diagnose these disorders)
DECREASED LEVELS
• Dysautonomia (malfunction of the autonomic nervous system) marked by orthostatic hypotension (consistently low–normal
catecholamine levels)
Protein • Presence of protein in urine, indicating chronic pyelonephritis, acute or chronic glomerulonephritis ,
amyloidosis, or toxic nephro p athies in diseases where renal failure typically develops as a late complication (such as
diabetes or heart failure), nephrotic syndrome, urinary tract infection (when accompanied by an
elevated white blood cell count), benign proteinuria (resulting from changes in body position), or functional proteinuria
(usually transient and associated with exercise or emotional or physiologic stress)
T3 & T4 DIAGNOSTIC EXAM

A.) Definition/Description T3
•The triiodothyronine (T3) test is a highly specific radioimmunoassay that measures total (bound and free) serum content
of T3 to investigate clinical indications of thyroid dysfunction. T3, the more potent thyroid hormone, is
an amine derived primarily from thyroxine (T4) by the process of monodeiodination. At least 50% and as much as 90% of
T3 is thought to be derived from T4 as a result of this pivotal transformation, during which T4 loses one of its iodine
atoms to become T3. The remaining 10% or more is secreted directly by the thyroid gland. Like
T4 secretion, T3 secretion occurs in response to thyroidstimulating hormone (TSH) and, secondarily, thyrotropin-

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releasing hormone (TRH).
•Although T3 is present in the bloodstream in minute quantities and is metabolically active only briefly , its impact on
body metabolism is greater than that of T4. Another significant difference between the two major thyroid hormones is that
T3 binds less firmly to thyroxinebinding globulin (TBG). Consequently, T3 persists in the bloodstream for a short time;
half disappears in about 1 day, whereas half of T4 disappears in 6 days.
•Serum T3 and T4 levels usually rise and fall in tandem. Generally, T3 levels are a more accurate diagnostic indicator of
hyperthyroidism. Although T3 and T4 levels are increased in about 90% of patients with hyperthyroidism, there’s a
disproportionate increase in T3.
T4
•Thyroxine (T4) is an amine secreted by the thyroid gland in response to thyroidstimulating hormone (TSH) and,
indirectly, thyrotropin-releasing hormone. The rate of secretion is normally regulated by a complex system of negative
and positive feedback involving the thyroid, anterior pituitary, and hypothalamus. The suspected precursor, or
prohormone, of triiodothyronine (T3), T4 is believed to convert to T3 by monodeiodination, which occurs mainly in the
liver and kidneys.
•Only a fraction of T4 (about 0.05%) circulates freely in the blood; the rest binds strongly to plasma proteins, primarily
thyroxine-binding globulin (TBG). This minute fraction is responsible for the clinical effects of thyroid hormone. TBG
binds so tenaciously that T4 survives in the plasma for a relatively long time, with a half -life of about 6 days. This
immunoassay, one of the most common thyroid diagnostic tools, measures the total circulating T4 level when TBG is
normal. An alternative test is the T4 (D), based on competitive protein binding.
B.) Purposes T3
•To help diagnose T3 toxicosis
•To help diagnose hypothyroidism and hyperthyroidism
•To monitor the patient’s response to thyroid replacement therapy in hypothyroidism
T4
•To evaluate thyroid function
•To help diagnose hyperthyroidism and hypothyroidism
•To monitor the patient’s response to antithyroid medication in hyperthyroidism or to thyroid replacement therapy in
hypothyroidism (TSH estimates needed to confirm hypothyroidism)
C.) Indications T3
• Support for diagnosing hyperthyroidism in clients with normal T4 levels, with early hyperthyroidism and T3
thyrotoxicosis indicated by elevated T3 levels in the presence of normal T4 levels
• Support for diagnosing “euthyroid sick” syndrome in severely ill clients with protein deficiency, as indicated by
low T3 levels, normal FT3 levels, and elevated rT3 levels
T
•4 Signs of hypothyroidism, hyperthyroidism, or neonatal screening for congenital hypothyroidism (required in
many states), or hypothyroidism or hyperthyroidism combined with neonatal screening:
o Decreased T4 and FT4 levels indicate hypothyroid states and also may be seen in early thyroiditis.
o Elevated T4 and FT4 levels indicate hyperthyroid states.

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o Normal T4 and FT4 levels in clients with signs of hyperthyroidism may indicate T3 thyrotoxicosis.
o Normal FT4 levels are seen in pregnancy, whereas T4 and TBG are usually elevated.
• Monitoring of response to therapy for hypothyroidism or hyperthyroidism:
o Elevated T4 and FT4 levels indicate response to treatment for hypothyroidism.
o Decreased T4 and FT4 levels indicate response to treatment for hyperthyroidism.
• Evaluation of thyroid response to protein deficiency associated with severe illnesses (e.g. , metastatic
cancer, liver disease, renal disease, diabetes mellitus, cardiovascular disorders, burns, and trauma):
o T4 is decreased in such disorders because of a deficiency of TBG, a protein.
o FT4 index is normal, if thyroid function is normal, because FT4 index is not dependent on TBG levels
D.) Contraindications/Precautions/Interfering Factors T3
PRECAUTIONS
• If the patient must receive thyroid preparations, such as T3 (liothyronine), note the administration time on
the laboratory request. Otherwise, T3 test results aren’t reliable.
INTERFERING FACTORS
• Pregnancy: Triiodothyronine levels are increased during pregnancy.
• Pediatric: Infants and children will need assistance in remaining still during the venipuncture and age -
appropriate comfort measures following the test.
• Fasting decreases levels
T4
INTERFERING FACTORS
• Estrogens, progestins, levothyroxine, and methadone (increase); free fatty acids, heparin, iodides,
liothyronine sodium, lithium, methylthiouracil, phenylbutazone, phenytoin, propylthiouracil, salicylates
(high doses), steroids, sulfonamides, and sulfonylureas (decrease); clofibrate (possible increase or
decrease)
• Pregnancy: Pregnancy will affect ACTH levels and may obscure interpretation.
• Pediatric: Infants and children will need assistance in remaining still during the venipuncture and age-
appropriate comfort measures following the test
• Increased in infants; values are decreased in adolescents; heparin will falsely elevate values; radioisotopes
interfere with the test; clients with severe or chronic illness may have fluctuation of thyroxine levels.
• Results of T4 D may be altered by circulating iodinated substances; T4 RIA is not similarly affected.
• Pregnancy, estrogen therapy, or estrogen-secreting tumors may produce elevated T4 levels.
• Ingestion of thyroxine will elevate T4 levels.
• Heroin and methadone may produce elevated T4 levels.
• Androgens, glucocorticoids, heparin, salicylates, phenytoin anticonvulsants, sulfonamides, and antithyroid
drugs such as propylthiouracil may lead to decreased T4 levels.
• Red-top tube or serum separator tube; needle and syringe or vacutainer; alcohol swab
PATIENT PREPARATION T3
• Explain that this test helps to evaluate thyroid gland function and determine the cause of his symptoms.

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• Withhold medications, such as steroids, propranolol, and cholestyramine, which may influence thyroid
function as ordered. If they must be continued, record this information on the laboratory request.
• Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and
when.
T4
• Explain that this test helps evaluate thyroid gland function.
• Inform the patient that he doesn’t need to fast or restrict activity.
• Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and
when.
• Withhold medications that may interfere with test results as ordered. If they must be continued, note this
on the laboratory request. If this test is being performed to monitor thyroid therapy, the patient should
continue to receive daily thyroid supplements.
F.) Normal Values T3
• Serum T3 levels are 80 to 200 ng/dl (SI, 1.2 to 3 nmol/L).
• In some patients with hypothyroidism, T3 levels may fall within the normal range and not be
diagnostically significant
T4
•Circulating T4 level is 5 to 13.5 mcg/dl (SI, 60 to 165 mmol/L). Normal T4 levels don’t guarantee euthyroidism; for
example, normal levels occur in T3 toxicosis.
G.) Procedure to include with Important Nursing Responsibilities, Before, During, and After the Procedure T3
BEFORE TEST:
DURING TEST:
AFTER TEST:
alleviate this.
T4
BEFORE TEST:

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•Instruct client not to take any thyroid medications for 6 weeks prior to the test.
DURING TEST:
AFTER TEST:
alleviate this.
•Resume prescribed thyroid medications.
H.) Implications of Abnormal Results T3
•▪ High T3 levels with normal T4 levels indicates T3 toxicosis, which occurs in Graves’ disease, toxic adenoma, and toxic
nodular goiter.
•T3 levels elevated higher than T4 levels are seen in patients receiving thyroid replacement therapy that contains more T3
than T4.
•T3 levels may be higher than T4 levels also in iodine-deficient areas, where the thyroid produces more cellularly active
T3 than T4 to try to maintain the euthyroid state.
•High T3 levels normally occur in pregnancy.
•Low T3 levels may appear in the euthyroid patient with systemic illness (especially hepatic or renal disease), severe
acute illness, or malnutrition and after trauma or major surgery
T4
•High T4 levels are consistent with primary and secondary hyperthyroidism, including excessive T4 (levothyroxine)
replacement therapy (factitious or iatrogenic hyperthyroidism).
•Subnormal levels suggest primary or secondary hypothyroidism or T4 suppression by normal, elevated, or replacement
T3 levels.
•In doubtful cases of hypothyroidism, measurement of TSH levels may be indicated. Overt signs of hyperthyroidism
require further testing.

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WORKSHEET ON newborn screening
I. Laboratory Exams
Newborn screening includes tests for:
• METABOLIC PROBLEMS. Metabolism is the process that converts food into energy the body can use to move,
think, and grow. Enzymes are special proteins that help with metabolism by speeding up the chemical reactions
in cells. Most metabolic problems happen when certain enzymes are missing or not working as they should.
Metabolic disorders in newborn screening include:
o phenylketonuria (PKU)
o methylmalonic acidemia
o maple syrup urine disease (MSUD)
o tyrosinemia
o citrullinema
o medium chain acyl CoA dehydrogenase (MCAD) deficiency
• HORMONE PROBLEMS. Hormones are chemical messengers made by glands. Hormone problems happen when
glands make too much or not enough hormones. Hormone problems in newborn screening include:
o congenital hypothyroidism
o congenital adrenal hyperplasia
• HEMOGLOBIN PROBLEMS: Hemoglobin is a protein in red blood cells that carries oxygen throughout the
body. Some of the hemoglobin problems included in newborn screening are:
o sickle cell disease
o hemoglobin SC disease
o beta thalassemia
• OTHER PROBLEMS. Other rare but serious medical problems included in newborn screening are:
o galactosemia
o biotidinase deficiency
o cystic fibrosis
o severe combined immunodeficiency (SCID)
o Pompe disease (glycogen storage disease type II)
o mucopolysaccharidosis type 1
o X-linked adrenoleukodystropy
o spinal muscle atrophy (SMA)
THERE ARE THREE PARTS TO NEWBORN SCREENING:

2. Blood Test:
• Blood tests. A few drops of blood are taken from the baby's heel. The blood is sent to a lab for analysis.

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• First, a physician, nurse, midwife, or other trained member of the hospital staff will fill out a newborn screening
card. One part of this card is the filter paper to collect the baby’s blood sample. The other part is for important
information for the lab performing the screen, such as the baby’s name, sex, weight, date/time of birth, date/time
of heel stick collection, and date/time of first feeding. It will also include the contact information of
the parents and the baby’s primary care provider for the follow-up results.
• During the blood test, which is sometimes called a heel stick, the baby’s heel will be pricked to collect a small
sample of blood. Parents are welcome to be a part of this process by holding their baby while the heel stick is
performed. Studies show that when mothers or health professionals comfort babies during this process, the
babies are less likely to cry. The health professional will put drops of blood onto the filter paper card to create
several “dried blood spots.” The newborn screening card is then sent to the state laboratory for analysis.
• Families can make requests for additional screening, also known as supplemental screening. Additional screening
refers to extra testing that can be performed after participating in your state’s newborn screening program. This is
sometimes done if there is family history of certain conditions or other health concerns. While each state screens
for many conditions, there are more conditions that can be detected at birth. We recommend discussing additional
screening and any concerns you might have with a health care professional. Make sure to ask what conditions are
covered in your state and what information additional screening could provide. It is also important to contact
your insurance company to determine their policy regarding additional screening coverage, since state programs
do not pay for additional screening or the follow-up treatment.
•Hearing Screen:
• Hearing test. A health care provider will place a tiny earpiece or microphone in the infant's ear. Another method
uses electrodes that are put on the baby's head while the baby is quiet or asleep
• Two different tests can be used to screen for hearing loss in babies. Both tests are quick (5-10 minutes), safe and
comfortable with no activity required from your child. In fact, these tests are often performed w hile a baby is
asleep. One or both tests may be used.
• Otoacoustic Emissions (OAE) Test: This test is used to determine if certain parts of the baby’s ear respond to
sound. During the test, a miniature earphone and microphone are placed in the ear and sounds are played. When
a baby has normal hearing, an echo is reflected back into the ear canal, which can be measured by the
microphone. If no echo is detected, it can indicate hearing loss.
• Auditory Brain Stem Response (ABR) Test: This test is used to evaluate the auditory brain stem (the part of the
nerve that carries sound from the ear to the brain) and the brain’s response to sound. During this test, miniature
earphones are placed in the ear and sounds are played. Band-Aid-like electrodes are placed along the baby’s head
to detect the brain’s response to the sounds. If the baby’s brain does not respond consistently to the sounds, there
may be a hearing problem.
1. Pulse Oximetry Testing:
• Pulse oximetry, or pulse ox, is a non-invasive test that measures how much oxygen is in the blood. Infants with
heart problems may have low blood oxygen levels, and therefore, the pulse ox test can help identify babies that
may have Critical Congenital Heart Disease (CCHD). The test is done using a machine called a pulse oximeter,
using a painless sensor placed on the baby’s skin. The pulse ox test only takes a couple of minutes and is
performed after the baby is 24 hours old and before he or she leaves the newborn nursery.

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• CCHD screen. A provider will place a small soft sensor on the baby's skin and attach it to a machine called an
oximeter for a few minutes. The oximeter will measure the baby's oxygen levels in the hand and foot.
1.) NEWBORN SCREENING TEST LAW (LEGAL BASIS FOR NEWBORN

SCREENING IN THE PHILIPPINES)
• The Comprehensive Newborn Screening (NBS) Program was integrated as part of the country’s public health
delivery system with the enactment of the Republic Act no. 9288 otherwise known as Newborn Screening A ct of
2004. The Department of Health (DOH) acts as the lead agency in the implementation of the law and collaborates
with other National Government Agencies (NGA) and key stakeholders to ensure early detection and
management of several congenital metabolic disorders, which if left untreated, may lead to mental retardation
and/or death. Early diagnosis and initiation of treatment, along with appropriate long-term care help ensure
normal growth and development of the affected individual. It has been an integral part of routine newborn care in
most developed countries for five decades, either as a health directive or mandated by law. It is also a service that
has been available in the Philippines since 1996. Under the DOH, NBS is part of the Child Development and
Disability Prevention Program at the Disease Prevention and Control Bureau.
• Republic Act No. 9288 or "Newborn Screening Act of 2004." AN ACT PROMULGATING A
COMPREHENSIVE POLICY AND A NATIONAL SYSTEM FOR ENSURING NEWBORN SCREENING.
• It is the policy of the State to protect and promote the right to health of the people, including the rights of children
to survival and full and healthy development as normal individuals. In pursuit of such policy, the State shall
institutionalize a national newborn screening system that is comprehensive, integrative and sustainable, and will
facilitate collaboration among government and non-government agencies at the national and local levels, the
private sector, families and communities, professional health organizations, academic institutions, and non-
governmental organizations. The National Newborn Screening System shall ensure that every baby born in the
Philippines is offered the opportunity to undergo newborn screening and thus be spared from heritable conditions
that can lead to mental retardation and death if undetected and untreated.
• The objective of the National Newborn Screening System are:
1) To ensure that every newborn has access to newborn screening for certain heritable conditions that can
result in mental retardation, serious health complications or death if left undetected and untreated;
2) To establish and integrate a sustainable newborn screening system within the public health delivery
system;
3) To ensure that all health practitioners are aware of the advantages of newborn screening and of their
respective responsibilities in offering newborns the opportunity to undergo newborn screening; and
4) To ensure that parents recognize their responsibility in promoting their child's right to health and full
development, within the context of responsible parenthood, by protecting their child from preventable causes
of disability and death through newborn screening.
DEFINITION/DESCRIPTION:
• Newborn screening is the practice of testing all babies in their first days of life for certain disorders and
conditions that can hinder their normal development. This testing is required in every state and is typically
performed before the baby leaves the hospital. The conditions included in newborn screening can cause serious

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health problems starting in infancy or childhood. Early detection and treatment can help prevent intellectual and
physical disabilities and life-threatening illnesses.
• Every newborn is tested for a group of health disorders that aren't otherwise found at birth. With a simple blood
test, doctors can check for rare genetic, hormone-related, and metabolic conditions that can cause serious health
problems. Newborn screening lets doctors diagnose babies quickly and start treatment as soon as possible.
• A heel-prick is used to sample the baby's blood. The blood drops are collected in a small vial or on a special
paper. The blood is then sent for testing. The baby's heel may have some redness at the pricked site, and some
babies may have bruising, but this usually disappears in a few days.
• Newborn screening (NBS) is a simple procedure to find out if your baby has a congenital metabolic disorder that
may lead to mental retardation and even death if left untreated.
PURPOSES/IMPORTANCE:
• The purpose of newborn screening is to detect potentially fatal or disabling conditions in newborns as early as
possible, often before the infant displays any signs or symptoms of a disease or condition.
• Such early detection allows treatment to begin immediately, which reduces or even eliminates the ef fects of the
condition. Many of the conditions detectable in newborn screening, if left untreated, have serious symptoms and
effects, such as lifelong nervous system damage; intellectual, developmental, and physical disabilities; and even
death.
• This test can identify rare disorders that cause brain damage or death if not treated early.
• Check for serious conditions in your baby.
• The tests will look for certain genetic and metabolic conditions, hearing loss, and specific heart problem.
• Newborn screening helps us find babies who have certain serious medical conditions so that they can begin
treatment right away. In most cases, these babies look normal and healthy at birth. They usually do not begin
showing symptoms until a few weeks or months later. Newborn screening helps to diagnose these babies before
they start showing symptoms. By starting treatment early, serious problems like illness, intellectual disabilities,
or death can often be prevented.
• Newborn screening allows health professionals to identify and treat certain conditions before theymake a baby
sick. Most babies with these conditions who are identified at birth and treated early are able to grow up healthy
with normal development
• To evaluate newborns for congenital abnormalities, which may include hearing loss
• Identification of hemoglobin variants such as thalassemias and sickle cell anemia
• Presence of antibodies that would indicate an HIV infection; or metabolic disorders such as homocystinuria,
maple syrup urine disease (MSUD), phenylketonuria (PKU), tyrosinuria, and unexplained physical or intellectual
disabilities.

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ASSESSMENT:
(What are the genetic diseases included in the NBS panel?

Please include Maple Syrup Urine Disease)
EFFECT if SCREENED
DISORDER SCREENED EFFECT if NOT SCREENED and TREATED
• Most babies do not have symptoms right away • Children with CH who start treatment
because they are protected by their mother’s soon after birth, usually have normal
CH thyroid hormone for a few weeks after birth.
growth and intelligence
After about three to four weeks of age, babies
(Congenital must rely solely on their own thyroid hormone. If and can live typical and healthy
Hypothyroidism) they don’t make enough, symptoms will show up lives. Some children, even when treated,
at that time. A small number of babies with CH do have problems with school work and
show effects at birth, however.
• Some babies have a yellow color to their skin or may need extra help.
the whites of their eyes. This is called jaundice. Some may have delayed growth

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Other s igns that may occur in early infancy include: compared to other children their age.
• Low activity level - babies s leep more • If treatment is not started until several
than usual and don’t move as much
• Poor feeding and poor suck
months after birth, delays or learning
• Fewer bowel movements or constipation
problems may occur. The level of
• Floppy muscle tone (hypotonia) delay varies from child to child.
• Swelling around the eyes and a puffy face
• Large swollen tongue
• Cool, pale, dry skin
• Large soft spot on the skull (the fontanel)
that closes late
• Large belly with protruding navel
(‘umbilical hernia’)
• If left untreated, babies may develop some or all
of the following effects over time:
• Coarse, swollen facial features
• Breathing problems
• Hoarse-sounding cry
• Delays in sitting, crawling, walking,
talking (delayed milestones)
• Wide, short hands
• Poor weight gain and growth
• Goiter (enlarged thyroid gland causing a
lump in the neck)
• Anemia
• Slow heart rate
• Fluid build-up under the skin (called
myxedema)
• Hearing loss
• Children who remain untreated usually develop
intellectual disabilities and are much shorter than
average. They may have spasticity and an
unsteady gait. Most have speech delay and
some have behavior problems.AT IS THE
• The effects of CAH can vary greatly from person • Children with CAH who start treatment soon
to person. There are a number of after birth usually have normal growth and
CAH different types of CAH which are described below. development. In most treated children,
• Most babies found to have CAH during puberty occurs at the normal age, although some
(Congenital Adrenal newborn screening have ‘classic CAH.’ One still have early changes. Even when treated,
Hyperplasia) type of classic CAH i s called ‘salt-wasting’ which i some adults are shorter than
s a serious condition needing immediate average.
treatment. The other type of classic CAH is
called ‘simple virilizing.’ Children with this type do
• Girls on medication usually have normal
not have immediate risks to their health but s ti ll menstrual periods. Pregnancy is possible,
need treatment. although fertility may be lessened in some
• Classic CAH – Salt-wasting type women.
About 75% of babies with classic CAH have the
salt-wasting type. Salt-wasting CAH occurs when • Children with salt-wasting CAH who remain on
the adrenal glands make lower amounts treatment usually do not have further salt-

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of both cortisol and aldosterone and too wasting adrenal crises or other associated health
much androgen. Babies who do not make problems.
enough aldosterone will start losing too much
water and salt in their urine. This can quickly• Pregnant women with classic salt-wasting CAH
cause dehydration and very low blood should be followed carefully by
pressure. This can be life-threatening i f not an endocrinologist during pregnancy.
treated right away. Medications may need to be increased during
• Infants with salt-wasting CAH usually show pregnancy to prevent problems with fetal
some of the following features within the first
growth.
few weeks of l ife:
• Poor feeding
• Lis tlessness and drowsiness
• Vomiting
• Diarrhea
• Dehydration
• Weight loss
• Low blood pressure
• Low blood salt (low blood s odium level)
• Too much acid in the blood, called
metabolic acidosis
• If not treated, severe dehydration leads to shock,
a serious situation in which not
enough blood is getting to the brain and other
organs. In babies with salt-wasting CAH, this is
also called an adrenal crisis. The signs of an
adrenal crisis include:
• Confusion
• Irritability
• Rapid heart rate
• Coma
• Periods of adrenal crisis due to too little
aldosterone can occur as early as one week to
one month of age. If a child in shock is not
treated, there i s a risk of death.
• All babies with salt-wasting CAH have the other
features of classic CAH l isted below. Girls with
salt-wasting CAH usually have more male-like
changes to their genitalsthan girls with simple
viri l izing CAH.
• Classic CAH – Simple virilizing type
About 25% of babies with CAH have the simple
viri l izing type. The adrenal glands make
enough aldosterone but not enough cortisol;
they also make too much androgen.
• Classic CAH starts its effects before birth.
Excess androgen hormones are made by the
fetus. This causes the genitals of female
fetuses to develop male-like features. Baby
girls born with classic CAH often have an

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enlarged clitoris. In some girls this is not very
noticeable, but in others it may look like a
small penis. Baby girls may also
have labiawhich are fused together, may be
wrinkled, and may look more l ike a
male scrotum. Some baby girls have fewer
genital changes than others. The high level of
androgen hormones does not affect the uterus
and ovaries, which develop normally.
• Girls who are not treated may develop other
male-like traits and behaviors as they grow.
Some of these changes may include:
• Deep, husky voice
• Excess hair on the face and body
• Lack of menstrual periods or very l ight or
i rregular periods
• Early puberty changes such as hair in the
armpits and pubic area
• Severe acne
• Male-pattern baldness (loss of hair near
the temples)
• Boys who are not treated may have some of the
following traits:
• Muscle growth at an early age
• Pubic hair and underarm hair during
childhood
• Enlargement of the penis during
childhood
• Early deepening of the voice
• Early beard
• Smaller than normal testicles
• Severe acne
• Sometimes the changes of early puberty
happen in boys and girls as young as two
to four years
old. Both boys and girls may have rapid
growth during childhood but end up
being short as
adults. Excess androgen hormones in
childhood
cause the rapid growth. The androgens
also
cause shorter adult height by closing the
growth plates too soon.
• Some untreated adults also have problems
with infertility and may have difficulty
achieving

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pregnancy.
• Children with s imple virilizing CAH are
at risk for adrenal crises, though typically
less severe than seen in children with the
salt-wasting type.
Acute i llness or stress increases the
body’s need for cortisol. If children with
CAH do not receive increased amounts
of medication during illness or stress,
they are at risk for health problems.
• Nonclassic CAH / Late-onset CAH
Nonclassic CAH, also called late-onset,
usually causes milder effects than classic
CAH.
However, symptoms can be quite variable
from
person to person. Many people with
nonclassic CAH often start showing signs
during childhood, adolescence, or early
adulthood. Some people never develop
symptoms. Newborn screening can detect
some, though not all, babies with the
nonclassic type of CAH.
• Children and adults with nonclassic CAH
have
adrenal glands that make near-normal
amounts
of cortisol and normal amounts of
aldosterone.
However, they have too much 17-OH
progesterone (17-OHP), a chemical used
to
make cortisol, in their blood. They also
may make too much of the androgen
hormones.
• Some of the traits that are sometimes seen
in both males and females with
nonclassic CAH
include:
• Rapid growth in childhood and early
teens with short adult height
• Severe acne
• Early puberty with development of pubic
hair, underarm hair, and body odor
during childhood
• Excess hair on the face and other parts of
the body
• Male-pattern baldness (hair loss near the
temples)
• Girls and women may have:
• Male-like changes in physical appearance
and behavior
• Irregular menstrual periods or early-
onset of periods
• Infertility
• Polycystic ovary syndrome

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• Boys may have:
• Early beard growth
• Excess galactose in the blood affects many parts • Because the body also makes some galactose,
of the body. Some of the organs that may be symptoms cannot be completely avoided by
GAL (Galactosemia) affected include the brain, eyes, l iver, and removing all lactose and galactose from the
kidneys. diet. Researchers are working on finding a
• Infants with galactosemia usually have diarrhea treatment to lower the amount of galactose
and vomiting within a few days of drinking milk made by the body, but there is no effective
or formula containing lactose. method to do so at this time.
• Some of the other early effects of untreated • When treatment starts before a baby is 10 days
galactosemia i nclude: old, there i s a much better chance for normal
• Failure to gain weight or grow in length growth, development, and
• Poor feeding and poor suck intelligence. Some children who receive early
• Lethargy treatment may have delays in growth, but most
• Irritability attain normal adult heights.
• Even with careful treatment from an early
• If treatment is not started, other symptoms are l
ikely to follow: age, some children with classic galactosemia show
delays in learning and development and
• Low blood sugar, called hypoglycemia
may need extra help in school. Some children
• Seizures develop speech and language delays. Some
• Enlarged liver that does not work properly have delays in motor skills such as walking and
• Jaundice (yellow color to the skin or coordination and balance problems.
whites of the eyes) • Even when carefully treated, girls with
• Bleeding galactosemia have a higher chance of having
• Serious blood infections that could lead to delayed periods and having premature
shock and death ovarian failure.
• Early cataracts which occur in about 10% • If treatment is started after 10 days of life,
of children delays or learning problems are more likely.
• Some untreated babies have high levels The level of delay varies from child to child.
of ammonia, a toxic substance, in their blood.
Treatment is still important, even if started late,
High ammonia levels and hypoglycemia can both
lead to coma and, i f not treated, can cause death. because i t can help prevent further
• Most untreated children eventually die of liver delays and symptoms.
failure. Surviving babies who remain untreated
may have intellectual disabilities and other
damage to the brain and nervous system.
• Even with adequate treatment, individuals with
galactosemia may develop one or more of the
following:
• Early cataracts
• Mild intellectual disabilities or learning
delays
• Ataxia (unsteady gait)
• Delays in growth
• Speech problems and delays
• Most girls with galactosemia will have delayed
periods or do not get their periods at all. Some
women with galactosemia start menopause
early or have ‘premature ovarian failure’ in
which the ovaries stop releasing eggs earlier than
normal menopause.

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• Babies with PKU seem perfectly normal at birth. • Children with PKU who start treatment soon
The fi rst symptoms are usually seen around 6 after birth and keep their Phe levels within the
months of age. Untreated infants may be late in suggested range usually have normal growth and
learning to sit, crawl and stand. They may pay intelligence. Some children, even when treated,
PKU (Phenylketonuria) less attention to things around them. Without have problems with schoolwork and may need
treatment, a child with PKU will have intellectual extra help.
disabilities. • If treatment is not started until several weeks
• Some of the effects of untreated PKU include: after birth, delays or learning problems may
• intellectual disabilities occur. The level of delay varies from child to
child.
• behavior problems
• Children who start treatment after 6 months of
• hyperactivity age often have intellectual disabilities.
• restlessness or irritability Treatment is still important, even if started
• seizures late, because i t can help control behavior and
mood problems and can prevent further
• a skin condition called eczema damage to the brain.
• a “mus ty” or “mousy” body odor
• fair hair and skin
• As stated above, most G6PD-deficient persons are • If your baby’s newborn screening result for
asymptomatic most of the time; however, any one glucose-6-phosphate dehydrogenase deficiency
G6PD Deficiency of them, when exposed to certain (G6PD deficiency) was out of the normal range,
triggering factors, can develop acute hemolytic your baby’s doctor or the state screening
anemia (AHA), which may be life-threatening program will contact you to arrange for your child
especially in children. Triggers for AHA in G6PD to have additional testing. It is important to
deficient persons include: (a) certain drugs (see remember that an out-of-range screening
Causes section), (b) certain infectious diseases, result does not necessarily mean that your child
(c) ingestion of fava beans. The onset of has the condition. An out-of-range result may
symptoms is within 2-3 days after exposure to the occur because the initial blood sample was too
trigger (even less with fava beans). small or the test was performed too early.
• A hemolytic anemia episode may be preceded by However, as a few babies do have the
behavioral changes such as irritability or condition, i t is very important that you go to
lethargy. Most episodes, even severe ones, are your follow-up appointment for a confirmatory
usually self-limiting and resolve on their own. The test. Because the harmful effects of untreated
severity of episodes can vary greatly. G6PD deficiency can occur soon after
Symptoms can include fatigue, pale color, birth, follow-up testing must be completed as
soon as possible to determine whether or not
shortness of breath, rapid heartbeat, dark urine, a
sudden ri se in body temperature, lower back pain, your baby has the condition.
and an enlarged spleen (splenomegaly). • Follow-up testing will involve looking at the red
Yellowing of the eyes, mucous membranes and blood cells in a sample of your baby’s blood. If
skin (jaundice) is common. Gastrointestinal your baby has G6PD deficiency, they may have
a reduced amount of the enzyme, glucose-6-
symptoms such as diarrhea, nausea or
phosphate dehydrogenase, in the red blood cells.
abdominal discomfort or pain may also occur.
• Most individuals with glucose-6-phosphate
• G6PD deficiency can cause neonatal jaundice,
dehydrogenase (G6PD) deficiency do not need
which is one of the most common conditions
treatment. However, they should be taught to
requiring medical attention in newborns.
avoid drugs and chemicals that can cause
Jaundice is caused by excess levels of bilirubin in
oxidant stress.

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the blood. Bilirubin i s an orange-yellow bile • Infants with G6PD deficiency may be at
pigment that i s a byproduct of the natural increased risk for pathological newborn
breakdown of hemoglobin in red blood cells. In jaundice and may warrant close monitoring for
rare cases in certain populations, i f untreated, associated complications during the newborn
neonatal jaundice can progress to cause period. Otherwise, treatment of G6PD
neurological issues such as kernicterus, a deficiency is avoidance. For the infant, this
condition characterized by the accumulation of means avoidance of several medications
toxic levels of bilirubin in the brain, which cause routinely prescribed for infections and illness.
lack of energy, poor feeding, fever, and Strict attention to the ingredients of prepared
vomiting. foods and restaurant meals is required as fava
beans are a frequent addition to prepared
foodstuffs. Patients should not be exposed to
moth balls containing naphthalene. The
adverse effects of infection on patients with
G6PD Deficiency can be acute and life
threatening. Over exertion from exercise and
work leading to dehydration and hypoglycemia
can precipitate clinical symptoms. As
mentioned above, patients mindful of these
l imitations can lead a normal life of exercise and
choice of vocation.
• Because the diagnosis and therapy of this
disorder is complex, the pediatrician is advised to
manage the patient in close collaboration with a
consulting pediatric hematology
specialist. It is recommended that parents
travel with a letter of treatment guidelines from
the patient’s physician.
• There are a number of different types of MSUD. • With prompt and l ifelong treatment, children
The most common type, “classic MSUD,” can be with MSUD often have healthy l ives with
l i fe-threatening and must be treated promptly to typical growth and development. Early
prevent serious health problems. Other types, treatment can help prevent brain damage and
Maple Syrup Urine including ‘intermediate’ and ‘intermittent’ forms intellectual disabilities.
Disease of MSUD, are less severe. These milder types are • However, children with MSUD are at
less common. This fact sheet contains increased risk to have attention deficit
information on classic MSUD. hyperactivity disorder (ADHD), anxiety and
• Classic MSUD depression even if they have had a liver
Symptoms start as soon as a baby i s fed protein, transplant. The reasons for this are not well
usually shortly after birth. Some of the first understood at this time.
symptoms are: • Even with treatment, some children still
• poor appetite develop swelling of the brain or have episodes of
metabolic crisis. Children who have
• weak suck repeated metabolic crises may develop permanent
• weight loss brain damage. This can cause l i felong learning
• high-pitched cry problems, intellectual
• urine that smells like maple syrup or burnt
sugar

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• Babies with MSUD have episodes of illness called disabilities, or spasticity.
metabolic crisis. Some of the first
symptoms of a metabolic crisis are:
• extreme sleepiness
• s luggishness
• i rritable mood
• vomiting
• If not treated, other symptoms can follow:
• episodes where muscle tone alternates
between being rigid and floppy
• swelling of the brain
• seizures
• high levels of acidic substances in the
blood, called metabolic acidosis
• coma, sometimes leading to death
• Symptoms of a metabolic crisis often happen:
• after going too long without food
• during illness or i nfection
• during stressful events such as surgery
• Without treatment, brain damage can occur.
This can cause intellectual disabilities
or spasticity. Some babies become blind. If not
treated, most babies with classic MSUD die
within a few months
EQUIPMENTS/PATIENT PREPARATION:
EQUIPMENT
•BLOOD TEST: Filter paper to collect the baby’s blood sample; sterile lancet or heel incision device; gauze pad
•HEARING SCREEN: Miniature earphones and Microphones; Band-Aid like electrodes
•PULSE OXIMETRY TESTING: pulse oximeter
PATIENT PREPARATION
•There is no preparation necessary for newborn screening tests. The tests are performed when the baby is between 24
hours and 7 days old, typically before the baby goes home from the hospital.
•There are no food, fluid, activity, or medication restrictions unless by medical direction.
PROCEDURE:
a.) When is Newborn Screening done?
•The blood test is generally performed when a baby is 24 to 48 hours old. This timing is important because certain
conditions may go undetected if the blood sample is drawn before 24 hours of age. If the blood is drawn after 48 hours of
age, there could be a life-threatening delay in providing care to an infant that has the condition. Some states require
babies to undergo a second newborn screen when they are two weeks old. This
precaution ensures that parents and health professionals have the most accurate results.

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•Ideally, the newborn hearing screen should be performed before the baby leaves the hospital.
•Newborn screening is ideally done on the 48th hour or at least 24 hours from birth. Some disorders are not detected if the
test is done earlier than 24 hours.
b.) How is Newborn Screening done?
•Newborn screening is a simple procedure. Using the heel prick method, a few drops of blood are taken from the baby's
heel and blotted on a special absorbent filter card. The blood is dried for 4 hours and sent to the
Newborn Screening Laboratory (NBS Lab).
•A small blood sample taken by pricking the baby's heel is tested. This happens before the baby leaves the hospital,
usually at 1 or 2 days of age. Talk to your doctor about newborn screening if your baby was not born in a hospital.
•The blood sample should be taken after the first 24 hours of life. Some babies are tested within the first 24 hours, though,
because sometimes moms and newborns are discharged within 1 day. If this happens, experts recommend taking a repeat
sample no more than 1 to 2 weeks later. Some states routinely do two tests on all infants.
THERE ARE THREE DIFFERENT PARTS TO NEWBORN SCREENING:
1) Heel Stick
When a baby is between 12-48 hours old, a few drops of blood is taken from the baby’s heel. This is called a heel
stick. The blood is usually placed on a small card. The card is sent to a laboratory where it is screened for different
metabolic and genetic conditions.
1) Pulse Oximetry
After a baby is at least 24 hours old, a small sensor is placed on the baby’s skin. This sensor is called a pulse
oximeter. It does not hurt the baby and is painless. The pulse oximeter measures how much oxygen is in the baby’s
blood. Babies who do not have enough oxygen in their blood could have a type of heart problem called Critical
Congenital Heart Defects.
2) Hearing Screen
Hearing screening can be done any time after a baby is about 12 hours old. There are two di fferent ways that the
hearing screen can be done. Both measure how well the baby responds to sound, and both are quick and
painless. Most of the time, the hearing screen can even be done while the baby is sleeping
c.) Who will collect the sample for Newborn Screening?
• Newborn screening can be done by a physician, a nurse, a midwife or medical technologist.
• Blood spot collection can be performed by trained personnel such as hospital nursery staff, laboratory staff, or
out-of-hospital birth providers.
d.) How much is the fee for Newborn Screening?
• P550. The DOH Advisory Committee on Newborn Screening has approved a maximum allowable fee of P50 for
the collection of the sample.

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e.) Where is the Newborn Screening available?
• Newborn screening is available in participating health institutions (hospitals, lying-ins, Rural Health Units and
Health Centers). If babies are delivered at home, babies may be brought to the nearest institution offering
newborn screening. Newborn Screening, specifically sample collection, i s expected to be present in all hospitals and
lying-in clinics following the order requiring these institutions to offer NBS for licensing purposes.
f.) When are Newborn Screening results available?
• Newborn screening results are available within seven to fourteen (7 - 14) working days after the newborn
screening samples are received in the NBS laboratory.
IMPLICATIONS OF ABNORMAL RESULTS:

• A negative screen means that the result of the test indicates extremely low risk of having any of the disorders
being screened.
• A positive screen means that the baby is at increased risk of having one of the disorders being screened.
(What should be done when a baby is tested a positive NBS result?)

• Babies with positive results should be referred at once to the nearest hospital or specialist for confirmatory
testing and further management. Should there be no specialist in the area, the NBS secretariat office will assist
its attending physician.
IMPORTANT NURSING RESPONSIBILITIES BEFORE (Pre), DURING, AFTER

(Post)
PROCEDURE: (Name as much as you can.)
BEFORE THE PRECEDURE
• Newborn screening education should start during the prenatal period and be reinforced during preadmission
testing. Many facilities provide educational brochures to the parents.
• A physician or delegate is responsible to inform parents of the newborn screening process before discharge.
• These procedures can assist in evaluating a number of congenital conditions, including hearing loss, thyroid
function, adrenal gland function, and other metabolic enzyme disorders.
• Evaluation may also include HIV antibody testing if not performed prenatally or if otherwise clinically indicated.
• Explain that a blood sample is needed for some of the tests.
• Nursing staff on each shift are responsible for checking that screening is performed or has been performed on
infants in their care.
• Nursing staff need to obtain written informed consent from a parent/guardian prior to performing the test.
• Note: if parent/guardian not available to provide written consent - writing ‘verbal consent by phone’ is only
acceptable with written explanation as to why no parent/guardian signature obtainable. Written or verbal
consent is only applicable for the first card sample. For subsequent samples, parents should know it has been
taken, but are not required to sign each subsequent card.
• Parent information leaflet (Newborn Bloodspot Screening – for the health of your baby) informs parents about
the screening program and should be given to the parents and discussed prior to obtaining written consent
DURING THE PRECEDURE
• Ensure all details are filled out correctly on the newborn screening card including:

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o Date and time of birth
o Gestation of birth
o Current weight
o Tick box if currently being breastfed or formula fed
o Alternativelytick box if baby is receiving TPN nutrition at time of sample
o Relevant clinical/family history – refers to the metabolic conditions we are testing for and if the baby has
a past medical history of relevant conditions such as; meconium ileus, severe jaundice or maternal
hypothyroidism. If the infant has received any blood products, this needs to be noted in the Relevant
Clinical/Family History section on the newborn screen card.
• Ensure all documentation has been filled out correctly.
• Occasionally, stored newborn bloodspot screening cards get used for research. Some examples are the
development of new tests or determining normal levels of a biomarker. This research is de -identified (i.e.
no personal details are released to the researchers) and must be approved by an ethics committee. Parents
can tick the “No Secondary Research Use” box if they do not wish their child’s card to be available for
such research.
Blood Test (Filter Paper Tests)
• Review the procedure with the parents or caregiver. Explain that blood specimens from neonates are
collected by heelstick and applied to filter paper spots on the birth state’s specific screening program card.
• Most regulations require screening specimens to be collected between 24 and 48 hr after birth to allow
sufficient time after protein intake for abnormal metabolites to be detected and preferablybefore blood
product transfusion or physical transfer to another facility.
• Prior to the heelstick, the site is cleansed with an antiseptic.
• When the heelstick is performed, the infant’s heel is gently squeezed and the filter paper touched to the
puncture site.
• When collecting samples for newborn screening, it is important to apply each blood drop to the correct
side of the filter paper card and fill each circle with a single application of blood.
• Overfilling or underfilling the circles causes the specimen card to be rejected by the testing facility.
Additional information is required on newborn screening cards and may vary by testing location.
• Newborn screening cards should be allowed to air dry for several hours on a level, nonabsorbent,
unenclosed area. If multiple patients are tested, cards should not be stacked.
• The puncture site should be assessed for bleeding or hematoma formation, and secured with gauze and an
adhesive bandage.
Hearing Test
• Review the procedure with the parents or caregiver. Address concerns about pain and explain that no
discomfort will be experienced during the test.
AFTER THE PROCEDURE
• Actively participate in the social contract of a nurse-client relationship through health promotion, disease
prevention, and patient advocacy for families affected by NBS remain current in their knowledge of NBS

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procedures, policies, and implications;
• Ensure that parents receive accurate information about NBS (e.g., purpose, meaning, risks, advantages,
their rights of enrollment depending on their locale, specimen collection and retention) prior to testing;
• Ensure that parents of infants with positive results are offered counseling about the interpretation and
implications of their infants’ NBS results; and
• If it is known that specimens will be used for research purposes, inform parents that such usage would
probably not benefit their own infants but may benefit future generations/populations.
• In addition to the above, it is the position of ISONG that nurse educators have a responsibility to include
information about NBS in the curricula of newborn care. Finally, nurses who are prepared at an advanced level
are encouraged to engage in policy-making and generate research to advance evidence-based clinical
practices and enhance patient outcomes associated with NBS.
Treatment Considerations
• Receiving a diagnosis for any of these conditions can be very fearful for a parent. Provide access to social
services, including culturallyappropriate education. Facilitate a safe environment to discuss fear and
explore cultural influences that may enhance fear.
• Identify concerns about the child’s diagnosed disease or disability and provide information related to
genetic counseling and support group information on caring for a disabled child. Disease- or disability-
specific education and treatment options should be discussed.
• Be supportive of the perceived loss of impaired activity or independence related to hearing loss or physical
limitations and parents’ fear of shortened life expectancy for the newborn.
• Offer support to victims of sexual assault in a nonjudgmental, nonthreatening atmosphere for a discussion
where the risks of sexually transmitted infections to the newborn are explained.
• Provide information related to access to genetic or other support counseling services.
Nutritional Considerations
• Provide education in special dietary modifications to treat deficiencies and references to the appropriate resource
for dietary consultation.
• Amino acids are classified as essential (i.e., must be present simultaneously in sufficient quantities), conditionally
or acquired essential (i.e., under certain stressful conditions, they become essential), and nonessential (i.e., can be
produced by the body, when needed, if diet does not provide them).
• Essential amino acids include lysine, threonine, histidine, isoleucine, methionine, phenylalanine, tryptophan, and
valine.
• Conditionally essential amino acids include cysteine, tyrosine, arginine, citrulline, taurine, and carnitine.
• Nonessential amino acids include alanine, glutamic acid, aspartic acid, glycine, serine, proline, glutamine, and
asparagine.
• A high intake of specific amino acids can cause other amino acids to become essential.
Follow-Up Evaluation and Desired Outcomes
• Acknowledges contact information provided regarding guidelines on sexually transmitted infections (www.cdc

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.gov/DiseasesConditions) and vaccine- preventable diseases (e.g., diphtheria, hepatitis B, measles, mumps, pertussis,
polio, rotavirus, rubella, varicella), as indicated (www.cdc.gov/vaccines/ vpd/vaccines- diseases.html).
• Accepts that positive neonatal HIV findings must be reported to local health department officials.
• Recognizes the importance of facilitating alternative language training (sign language) for an infant with hearing
loss to enhance growth and development.
• Understands that failure to refrain from feeding the child prohibited foods can result in severe disability and
death.
Refusal of Consent
If parents refuse to have the test the following steps should be followed:
• Confirm the parents/guardian have received the Newborn Bloodspot Screening information brochure (Newborn
Bloodspot Screening - for the health of your baby), and that staff have discussed the test with them.
• A medical staff member of the treating team must then meet with the parents and clearly outline the benefits &
risks of the NBS and the risks of not completing the test. This is to ensure the parents have a good understanding of
the possible consequences.
• Medical staff should document clearly in the Progress Notes refusal of consent and the nature of the discussion.
The refusal for consent form should be completed and countersigned by the parents.
• The newborn screening card should be filled out with relevant infant details with ‘NO’ ticked on the Newborn
Screening Consent section.
• The card can then be sent as normal to the laboratory.
• Document the refusal for the test in Child Health Record Book.
• Inform the parents/guardian that if the infant becomes unwell, they should inform their GP/paediatrician that their
infant has not had a newborn screening test.
• Parents/guardian can change their mind at any stage but it should be explained to them that some disorders will
not be detected if newborn screening is not performed at the correct time. Parents/guardian must be offered
the opportunity to meet with a newborn bloodspot screening counsellor.
Sampling
Collection • Refer to RCH Policy for Patient Identification Procedure.
• Refer to RCH Policy Aseptic Techniqueand adhere to Standard Aseptic
Technique principles for this procedure.
• Refer to VCGS Newborn Bloodspot Screening Sample Collection
Guidelines PDF for all information on sampling.
Procedural Pain
• Refer to Clinical Practice Guidelines regarding the use of Sucrose (oral) for
Management procedural pain management in infants.
• Refer to Clinical Practice Guidelines regarding Procedural pain
management.
Arterial Sample
• For arterial line sampling, ensure that the sample does not contain
heparinised fluid. A discard of 2-3mls is recommended before using a new
syringe to take the sample.

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Venous Sample• For venous sampling, refer to the blood sampling section of the RCH
Policy Central Venous Access Device Management. Ensure that the sample
does not contain heparinised fluid. A discard of 2-3mls is recommended before
using a new syringe to take the sample.
• A venous sample can also be collected via peripheral venous access. Refer to
Intravenous Access – Peripheral for sampling technique.
Documentation
•Record
date and time of sample taken in:
Electronic Medical Record • Progress Notes – for Ward patients.
(EMR) • Flowsheets: NICU Shift Checks: Neonatal Screening Tests
or ADT Navigators: Admission: Admission Information – for Butterfly/NICU
patients
*Download a Sample of Newborn Screening Test form from the Philippines, USA,
and Germany for comparison purposes. Use as many resources you can gather online
and offline, books or brochures.
Reference: https://sites.google.com/site/vylhphilippines/vylhadvocacies/newborn
screening-promotion/basic-information-on-newborn-screening

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Newborn Screening Test Form From
Philippines
Newborn Screening Test Form From

USA

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Newborn Screening Test Form From Germany

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WORKSHEET ON EYES
VISUAL ACUITY TESTS
COLOR VISION TESTS REFRACTION
EXOPHTHALMOMETRY TONOMETRY OPHTHALMOSCOPY FLUORESCEIN ANGIGRAPHY ORBITAL
RADIOGRAPHY
ORBITAL COMPUTED TOMOGRAPHY OCULAR ULTRASONOGRAPHY
VISUAL ACUITY
TESTS
•The visual acuity test evaluates the patient’s ability to distinguish the form and detail of an object. The patient is asked to
read letters on a standardized visual chart, commonly called the Snellen chart, from a distance of 20”
(6.1 m). A chart showing the letter “E” in various positions and sizes—the Lea symbol chart— are used for young
children and other people who can’t read. The smaller the symbol the patient can identify, the sharper his visual acuity. A
patient’s near (reading) vision may be tested as well, using a standardized chart such as the Jaeger card (a card with print
in graded sizes).
•The Snellen chart test should be performed on all patients with eye complaints. The near-vision test is routine for those
complaining of eyestrain or reading difficulty and for everyone over age 40. Results serve as a baseline
for treatments, follow-up examinations, and referrals.
B.) Purposes
•To test distance and near visual acuity
•To identify refractive errors in vision
C.) Indications
•Screening for impaired visual acuity in children with no complaints and determination of the need for a referral to an
ophthalmologist
•Screening for presbyopia and near vision impairment in clients over 40 years of age, with or without complaints,
to determine the need for a referral
•Eye strain, blurring, difficulty in reading, or other complaints to determine whether the cause is related to visual acuity
•Determination of the type of visual impairment, distance or near visual acuity deficit, and the need for corrective lenses
•Evaluation of existing visual correction for change in prescription lenses

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•Inabilityof client to cooperate and participate in the tests
•Inabilityof client to recognize and identify the letters or words on the chart or card
•Failure of client to bring corrective lenses to be used for testing the corrected vision during the test
•Snellen chart (standardized vision chart); E chart for children and illiterate; Jaeger card for near vision; hand-held vision
occluder; space with distance of 20 ft.
PATIENT PREPARATION
Explain to the Client:
•That the tests are performed by a physician, technician, or nurse and that they take 5 to 10 minutes
•That the client should bring corrective glasses or contact lenses to the test for evaluation
•That there are no food or fluid restrictions before the tests
•That each eye is tested separately with and without the corrective lenses
•That the client is requested to read letters or symbols of different sizes on a chart or words of different-sized print on a
card to test vision
•That no pain is associated with the tests
Prepare for the procedure:
•Obtain a history of known or suspected visual impairment and cause, use of corrective lenses, and age of client.
F.) Normal Values

•Distance visual acuity is 20/20, which means that the smallest symbol the patient can identify at 20” (6.1 m) is the same
symbol a patient with normal vision can identify from the same distance.
•Normal near visual acuity is usually recorded as 14/14 because standard testing charts, such as the Jaeger card,
are generally held 14” (35.6 cm) from the patient’s eyes.
•Normal or better-than-normal visual acuity doesn’t necessarily indicate normal vision. For example, a visual field defect
may be present if the patient consistently misses the letters on one side of all the lines.
BEFORE THE TEST
DURING THE TEST
Distance Visual Acuity
•Have the patient sit 20” (6.1 m) away from the eye chart. If he’s wearing glasses, tell him to remove them so his
uncorrected vision can be tested first.
•Begin with the right eye, unless vision in the left eye is known to be more acute. Have the patient occlude the left eye;
then ask him to read the smallest line of letters he can see on the chart. Encourage him to try to read lines he can’t see

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clearly because intelligent guesses usuallyindicate that the patient can recognize some of the symbols’ details.
•Instruct the patient not to place pressure on the occluded eye to avoid blurry vision during the examination.
•Record the number of the smallest line the patient can read. This number is expressed as a fraction. The
numerator is the distance between the patient and the chart; the denominator is the distance from which a patient with
normal vision can read the line. The greater the denominator, the poorer the vision.
•If the patient makes an error on a line, record the results with a minus number. For example, if the patient reads
the 20/40 line but makes one error, record his vision as 20/40 –1. If the patient reads the 20/40 line and one symbol on the
next line, record his vision as 20/40 +1.
•Have the patient occlude the right eye; then repeat the test for the left eye. To minimize recall, use a different set of
symbols, or have the patient read the lines backward.
•If the patient can’t read the largest letter on the chart, further testing is necessary.
•In recording the patient’s responses, indicate which eye was tested and whether it was tested with or without corrective
lenses.
•If the patient wears glasses, test his corrected vision using the same procedure. If he normally wears glasses but
doesn’t have them with him, note this on the test results.
•Use the Lea symbol chart when testing preschool children or others who can’t read.
Near visual acuity
•Have the patient remove his glasses and occlude the left eye. Ask him to read the Jaeger card at his customary reading
distance. Both eyes are tested with and without corrective lenses.
•In reporting near visual acuity, specify the size of the smallest print legible to the patie nt and the nearest
distance at which reading is possible
•If the denominator is more than 20 (for example, 40), the patient’s visual acuity is less than normal. In this
case, it means he reads at 20” what a person with normal vision can read at 40” (12.2 m). A person with visual
acuity of 20/200 in the better corrected eye is considered legally blind.
•Similarly, if the denominator is less than 20, the patient’s distance visual acuity is better than normal.
For example, 20/15 vision means that the patient can read at 20” what a person with normal visual acuity can
see at 15” (4.6 m).
•Decreased near visual acuity is indicated by a larger denominator. For example, 14/20 near vision
means that the patient can read at 14” what a person
•If the denominator is more than 20 (for example, 40), the patient’s visual acuity is less than normal. In
this case, it means he reads at 20” what a person with normal vision can read at 40” (12.2 m). A person with
visual acuity of 20/200 in the better corrected eye is considered legally blind.
•Similarly, if the denominator is less than 20, the patient’s distance visual acuity is better than normal. For
example, 20/15 vision means that the patient can read at 20A what a person with normal visual acuity can see at
15” (4.6 m).
•Decreased near visual acuity is indicated by a larger denominator. For example, 14/20 near vision means that
the patient can read at 14” what a person

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COLOR VISION
TESTS
•Color vision tests assess the ability to recognize differences in color. They’re commonly used to evaluate patients
with suspected retinal disease or with a family history of color vision deficiency. These tests are also used to screen
applicants for jobs in which accurate color perception is vital, as in the military and electronics fields.
•The most common color vision tests use pseudo isochromatic plates made up of dot patterns of the primary
colors superimposed on backgrounds of randomly mixed colors. A patient with normal color vision can identify the dot
pattern; a patient with a color vision deficiency can’t distinguish between the pattern and the background. Basic color
vision tests merely indicate the presence of deficiency; more sophisticated tests can determine the degree of deficiency.
B.) Purposes
•To detect color vision deficiency
C.) Indications
•Detect deficiencies in color perception
•Evaluate because of family history of color visual defects
•Investigate suspected retinal pathology affecting the cones D.) Contraindications/Precautions/Interfering Factors
Precautions
•To prevent discoloration of the plates, keep the test book closed when it isn’t being used, and turn the pages by their
edges.
•Don’t allow too much time for a response, as that may alter the test results.
Interfering Factors
•Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or mental status
•Inability of the patient to read
•Poor visual acuity or poor lighting
•Failure of the patient to wear corrective lenses (glasses or contact lenses)
•Damaged or discolored test plates
•Isihara book, pen, patient’s chart, proper lighting.
Patient Preparation
•Explain that this test evaluates color perception, takes only a few minutes, and causes no pain.
•If the patient normally wears glasses or contact lenses, tell him to wear them during the test.
F.) Normal Values
•A person with normal color vision—a trichromat—can identify all the patterns or symbols.
G.) Procedure to include with Important Nursing Responsibilities, Before, During, and After the Procedure Before
the procedure:
•Inform the patient that the procedure detects color vision impairment.
•Obtain a history of the patient’s complaints, including a list of known allergens.
•Obtain a history of the patient’s known or suspected vision loss, changes in visual acuity, including type and cause; use of
glasses or contact lenses; eye conditions with treatment regimens; eye surgery; and other tests and procedures to assess

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and diagnose visual deficit.
•Obtain a history of results of previously performed laboratory tests, surgical procedures, and other diagnostic procedures.
•Obtain a list of the medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals.
•Review the procedure with the patient. Ask the patient if he or she wears corrective lenses; also inquire about the
importance of color discrimination in his or her work, as applicable. Address concerns about pain related to the procedure.
•There are no food, fluid, or medication restrictions unless by medical direction.
During the procedure:
•Instruct the patient to cooperate fully and to follow directions.
•Seat the patient comfortably. Occlude one eye and hold test booklet 12 to 14 inches in front of the e xposed eye.
•Ask the patient to identify the numbers or letters buried in the maze of dots or to trace the objects with a handheld
pointed object.
•Repeat on the other eye.
•The results are recorded manually for recall and post-procedure interpretation by the appropriate health care practitioner.
After the procedure:
• Record the responses according to the instructions included in the test kit.
• Recognize anxiety related to test results and be supportive of impaired activity related to color vision loss.
• Depending on the results of this procedure, additional testing may be performed to evaluate or monitor
progression of the disease process and determine the need for a change in therapy.
• A patient with deficit color vision—an anomalous trichromat—can’t identify all the patterns or symbols. The
deficit is diagnosed more precisely by noting the combinations of colors that elicit incorrect responses.
• A patient with protanopia, a deficiency of the retinal pigment sensitive to red, can’t distinguish between red -
green and blue-green.
• A patient with deuteranopia, a deficiency of the retinal pigment sensitive to green, can’t distinguish between
greenpurple and red-purple.
• A patient with tritanopia, a deficiency of the retinal pigment sensitive to blue, can’t distinguish between blue -
green and yellow-green.
• Achromatopsia—true color blindness— is a rare disease inherited as a Mendelian autosomal dominant or
autosomal recessive trait. Patients with achromatopsia, called monochromats, see all colors as shades of gray. These
patients may also have impaired visual acuity, nystagmus, and photophobia from reduced or absent cone
function.

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• ▪ Inherited color deficiency affects both eyes; acquired deficiency may affect only one eye. The patient with an
acquired deficiency may complain of an inability to recognize colors that were formerly recognizable.
• Abnormalities of the ocular media, retina, or optic nerve can cause deficient color vision. For this reason, a patient
with an acquired or inherited color vision deficiency accompanied by a loss of visual acuity should be referred for
a complete ophthalmologic examination to determine the source of the deficiency.
REFRACTI
ON
•Refraction—the bending of light rays by the cornea, aqueous humor, lens, and vitreous humor in the eye —
enables images to focus on the retina and directly affects visual acuity. The refraction test, done routinely during a complete eye
examination or whenever a patient complains of a change in vision, defines the refractive error and determines the degree of
correction required to improve visual acuity with corrective lenses. The ophthalmologist generally performs a refraction objectively,
by using a retinoscope, and subjectively, by asking the patient about his visual acuity while placing trial lenses before his eyes.
B.) Purposes
•To diagnose refractive error and prescribe corrective lenses, if necessary
C.) Indications
•Diagnosing refractive errors in vision
•Determining whether an optical defect is present and whether light rays entering the eye focus correctly on the
retina (emmetropia),whether the point of focus is behind the retina (hyperopia or farsightedness), whether the point of focus is in
front of the retina (myopia or nearsightedness),or whether a non-uniform curvature of the horizontal plane is in contrast with the
vertical plane (astigmatism)
•Determining the type of corrective lenses needed for refractive errors, that is, biconvex or plus lenses for hyperopia, biconcave or
minus lenses for myopia, or compensatory lenses for astigmatism
D.) Contraindications/Precautions/Interfering Factors Interfering Factors
•Improper pupil dilation, which prevents adequate examination for refractive error
•Inability of client to remain still and cooperate during the test
Contraindicated in:
•Patients with narrow-angle glaucoma if pupil dilation is performed, as dilation can initiate a severe and sight - threatening open-
angle attack.
•Patients with allergies to mydriatics if pupil dilation using mydriatics is performed.
Precaution:
•For follow-up examinations, set the calibrated bar at the baseline reading.
E.) Equipment/Patient Preparation Equipment:
•Test is performed in examination room with special equipment; mydriatic eyedrops (per prescription order).
Patient preparation:
•Explain that the test helps determine whether the patient needs corrective lenses.
•Tell the patient that eye drops may be instilled to dilate his pupils and that the test takes 10 to 20 minutes.
•Reassure him that the test is painless and safe.

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• Don’t give dilating eye drops to a patient who has angle-closure glaucoma or a history of hypersensitivity
reactions to these drops.
F.) Normal Values
• Refractive power, measured in diopters, is greatest at the cornea (about 44 diopters) because of its curvature. The
aqueous humor has the same refractive power as the cornea and is considered to be the same medium.
• The lens, normally a convex structure, has a refractive power of about 10 to 14 diopters but can alter this power
by changing its shape. This phenomenon is known as accommodation and occurs when the eye views objects
closer than 20” (6.1 m).
• The vitreous humor, a gelatinous medium, has little refractive power and mainly transmits light.
• In the absence of accommodation, the average refractive power of the human eye is 58 diopters.
• Ideally, the eyes have no refractive error (emmetropia). Parallel light rays emanating from a point source can be
focused directly on the retina to produce a clear image.
Before the procedure:
• Inform the patient that the procedure evaluates visual acuity.
• Obtain a history of the patient’s complaints, including a list of known allergens, especially mydratics if dilation is
to be performed.
• Obtain a history of the patient’s known or suspected vision loss, changes in visual acuity, including type and
cause; use of glasses or contact lenses; eye conditions with treatment regimens; eye surgery; and other tests and
procedures to assess and diagnose visual deficit.
• Obtain a history of results of previously performed laboratory tests, surgical procedures, and other diagnostic
procedures.
• Obtain a list of the medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals.
• Instruct the patient to remove contact lenses or glasses, as appropriate. Instruct the patient regarding the
importance of keeping the eyes open for the test.
• Review the procedure with the patient. Address concerns about pain related to the procedure.
• There are no food or fluid restrictions, unless by medical direction.
• The patient should withhold eye medications (particularly mydriatic eye drops if the patient has glaucoma) for at
least 1 day prior to the test.
• Ensure that the patient understands that he or she must refrain from driving until the pupils return to normal
(about 4 hours) after the test and has made arrangements to have someone else be responsible for transportation
after the test.
• Ensure that the patient has complied with medication restrictions and pretesting preparations; assure that eye
medications, especially mydriatics, have been restricted for at least 1 day prior to the procedure.
• Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still during the procedure
because movement produces unreliable results.
• If dilation is to be performed, administer the ordered mydriatic to each eye and repeat in 5 to 15 minutes.
• Ask the patient to place the chin in the chin rest and gently press the forehead against the support bar. The
examiner will sit about 2 feet away at eye level with the patient.
• Request that the patient look straight ahead while the eyes are examined with the instrument and while different

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lenses are tried to provide the best corrective lenses to be prescribed.
• The results are recorded manually or on a paper strip from the automated equipment for recall and post-
procedure interpretation by the appropriate healthcare practitioner.
• Instruct the patient to resume usual medications, as directed by the health care practitioner.
• A written report of the examination will be completed by a health care practitioner specializing in this branch of
medicine.
• Recognize anxiety related to test results, and be supportive of impaired activity related to vision loss, perceived
loss of driving privileges, or the possibility of requiring corrective lenses (self -image).
• Most patients show some degree of refractive error (ametropia). Hyperopia, or farsightedness, occurs when the
eyeball is too short and parallel light rays focus behind the retina. Retinoscopic examination shows a red reflex
moving in the same direction as the retinoscope’s light. A patient with hyperopia sees clearly at a distance but
experiences blurring of near objects.
• Myopia, or nearsightedness, occurs when the eyeball is too long and parallel light rays focus in front of the
retina. Retinoscopic examination shows a reflex motion opposite to the movement of the retinoscope’s light. A patient
with myopia sees near objects clearly but experiences blurring of distant images.
• When light rays entering the eye aren’t refracted uniformly and a clear focal point on the retina isn’t attained,
the patient has astigmatism. This disorder is usuallycaused by unequal curvature of the cornea and is typically
associated with some degree of hyperopia or myopia.
EXOPHTHALMOM
ETRY
•Exophthalmometry determines the relative forward protrusion of the eye from its orbit by using an
exophthalmometer to measure the distance from the apex of the cornea to the lateral orbital margin. The
exophthalmometer is a horizontal calibrated bar with movable carriers on both sides. These carriers hold mirrors inclined
at a 45-degree angle that reflect the scale readings and the corneal apex in profile.
•This test provides information that’s useful in detecting and evaluating thyroid disease, eye tumors, and any condition
that displaces the eye in the orbit.
B.) Purposes
•To measure the amount of forward eye protrusion
•To evaluate the progression or regression of exophthalmos
C.) Indications
•Evaluates and monitors cellulitis of the eye, hyperthyroidism, tumors of the eyes, endophthalmos, exophthalmos,

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periostitis, and retinoblastoma.
•Steroid therapy causes exophthalmic condition.
D.) Contraindications/Precautions/Interfering Factors Interfering factors:
•Failure to set calibrated bar at baseline.
Precaution:
•Avoid excessive or prolonged pressure on the lateral orbital rim
•For follow-up examinations, set the calibrated bar at the baseline reading.
•Exophthalmometer
•Make sure that the patient has signed an appropriate consent form.
•Note and report all allergies
•Explain that this test determines the degree of eye protrusion
F.) Normal Values
•Readings range from 12 to 20 mm.
•Measurements for each eye are similar, usually differing by 1.5 mm or less and rarely by more than 3 mm.
the procedure:
•Explain the test procedure and the purpose of the test. Assess the client’s knowledge of the test. Inform cl ient that
procedure is painless.
•The patient sits upright facing the examiner with his eyes on the same level.
•The horizontal bar of the exophthalmometer is held in front of the patient’s eyes, parallel to the floor.
•The device’s two small concave mirrors are moved against the lateral orbital margins at its deepest angle.
•The calibrated bar reading is recorded for a baseline reading.
•The patient fixates his right eye on the examiner’s left eye.
•Using the inclined mirrors, the apex of the right cornea is superimposed on the millimetre scale.
•Left eye, right eye, and binocular readings are obtained, representing the eye’s relative forward displace ment from its
orbit.
•The patient fixates his left eye on the examiner’s right eye and procedure is repeated.
•Refer the patient to an appropriate specialist as needed.
•A difference between the eyes of more than 3 mm may indicate exophthalmos (outward displacement) or enophthalmos
(inward displacement).
•Readings under 12 mm may indicate enophthalmos.
•A single reading that exceeds 20 mm may indicate exophthalmos.
•Bilateral exophthalmos suggests a possible systemic disorder such as thyroid disease as well as xanthomatosis or a blood
dyscrasia.

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TONOMET
RY
•Tonometry allows indirect measurement of intraocular pressure (IOP) and serves as an effective screen for early
detection of glaucoma, which occurs in 2% of people over age 40 and is a common cause of blindness. Indentation
tonometry measures this resistance by observing how deeply a known weight depresses the cornea; applanation
tonometry provides the same information by measuring the amount of force required to flatten a known area of the
cornea. Both procedures necessitate corneal anesthetization and careful examination technique. Patients with IOP
problems can now monitor their pressure at home with a portable tonometer. If
the IOP is elevated, other tests, such as applanation tonometry, visual field testing, and ophthalmoscopy, must confirm the
diagnosis.
B.) Purposes
•To measure IOP
•To aid in the diagnosis and follow-up evaluation of glaucoma
C.) Indications
•Screening for glaucoma in clients over the age of 40
•Measuring intraocular pressure to assist in the diagnosis of glaucoma or determining whether other tests should be
performed to confirm the diagnosis
•Monitoring the progression of glaucoma and effectiveness of the treatment regimen
•Pressure greater than 20 mm Hg indicates the need for further testing for glaucoma.
•Corneal surface that inhibits correct placement of the tonometer footplate, which can alter measurement
•Flaccid or rigid cornea that prevents proper indentation of the tonometer footplate, which can affect correct measurement
•Inability of client to cooperate and remain quiet during the test
•Improper technique in the use of the tonometer in performing the measurement
Contraindications
•Corneal ulceration or infection that could cause further damage
Precautions
•Tonometry should never be performed on a patient with a corneal ulcer or infection, except by a skilled practitioner and
only in an emergency such as suspected acute angle-closure glaucoma.
•Avoid resting your fingers on the cornea or pressing on the cornea because this increases IOP.
•Don’t touch the patient’s lashes; this could trigger a blink response or Bell’s phenomenon (upward movement of the eyes
with forced closure of the lids), which can cause the footplate to move and scratch the cornea.
•Tonometer
•Explain that this test measures the pressure in the patient’s eyes.
•Tell the patient that the test takes only a few minutes and requires that his eyes be anesthetized, but reassure him that the
procedure is painless.

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•If he wears contact lenses, instruct him to remove them before the test or until the ane sthetic wears off completely.
•Ask the patient to assume a supine position. Make sure he’s relaxed, and have him loosen restrictive clothing around his
neck. Instruct him not to cough or squeeze his eyelids together.
•Place the patient in a darkenened oom to help decrease ocular pain.
•Place the patient in a supine or semi-recumbent position. For the Tono-Pen X, the patient can be in any position that
permits the tonometer to be applied perpendicular to the corneal surface.
•Instruct the patient not to blink or touch the eyes during the procedure.
•Instill topical anesthetics or cycloplegics as prescribed. Anesthetics should be administered before cycloplegics.
F.) Normal Values
•An IOP of 12 to 20 mm Hg, with diurnal variations is normal. The highest point is reached at the t ime of waking; the
lowest point, in the evening.
Before the procedure:
•Inform the patient that the procedure measures the intraocular pressure of the eye.
•Obtain a history of the patient’s complaints, including a list of known allergens, especially allergies or sensitivities to
topical anesthetic eyedrops.
• Obtain a history of the patient’s known or suspected vision loss, changes in visual acuity, including type and
cause; use of glasses or contact lenses; eye conditions with treatment regimens; eye surgery; and other tests and
procedures to assess and diagnose visual deficit.
procedures.
• Obtain a list of the medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals.
• Review the procedure with the patient. Explain that the patient will be requested to fixate the eyes during the
procedure.
• Instruct the patient to remove contact lenses or glasses, as appropriate. Instruct the patient regarding the
importance of keeping the eyes open for the test.
• There are no food, fluid, or medication restrictions, unless by medical direction.
• Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still during the
procedure because any movement, such as coughing, breath holding, or wandering eye movements, produces
unreliable results.
• Seat the patient comfortably. Instruct the patient to look at directed target while the eyes are examined.
• Instill ordered topical anesthetic in each eye, as ordered, and allow time for it to work.
• Instruct the patient to look straight ahead, keeping the eyes open and unblinking.

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• A number of techniques are used to measure intraocular pressure. Intraocular pressure can be measured at the slit
lamp or with a miniaturized, handheld applanation tonometer or an airpuff tonometer.
• When the applanation tonometer is positioned on the patient’s cornea, place the instrument’s headrestmagainst
the patient’s forehead.
• When the tip is properly aligned and in contact with the fluoresceinstained tear film, force is applied to the tip
using an adjustment control to the desired endpoint. The tonometer is removed from the eye. The reading is
taken a second time and, if the pressure is elevated, a third reading is taken. The procedure is repeated on the
other eye.
• With the airpuff tonometer, an air pump blows air onto the cornea, and the time it takes for the air puff to flatten
the cornea is detected by infrared light and photoelectric cells. This time is directly related to the intraocular
pressure.
• The results are recorded manually, taking care to denote left and right readings, for recall and postprocedure
interpretation by the appropriate health care practitioner.
medicine.
• Recognize anxiety related to test results, and be supportive of impaired activity related to vision loss or
perceived loss of driving privileges
• Instruct the patient in the use of any ordered medications, usually eyedrops that are intended to decrease
intraocular pressure.
• Elevated IOP requires further testing for glaucoma.
• Because IOP varies diurnally, findings must be supplemented with serial measurements obtained at different
times on different days.
OPHTHALMOSC
OPY
•Ophthalmoscopy allows magnified examination of the vascular and nerve tissue of the fundus, including the optic disk,
retinal vessels, macula, and retina. This test is conducted with either a direct or an indirect
ophthalmoscope— one of the most important diagnostic tools in ophthalmology. Generally, examiners use the direct
ophthalmoscope, a small, handheld instrument consisting of a light source, a viewing device, a reflecting device to
channel light into the patient’s eyes, and spherical lenses to correct refractive error of the patient or examiner. The
practitioner may also use the ophthalmoscope to examine the patient’s cornea, iris, and lens.
•If an abnormality of the retina is suspected, further testing, such as fluorescein angiography, may be necessary.
B.) Purposes
•To detect and evaluate eye disorders as well as ocular manifestations of systemic disease
C.) Indications
•Detection of cataracts, vitreous opacities, corneal scars.
•Close examination for the pathologic changes in retinal blood vessels that may occur with diabetes or hypertension.
•Examination of the choroid for tumors or inflammation.
•Examination of the retina for retinal detachment, scars, or exudates and hemorrhages of diabetes.

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D.) Contraindications/Precautions/Interfering Factors Precautions
•Don’t give dilating eyedrops to a patient who has angle-closure glaucoma or a history of hypersensitivity reactions to
these drops.
•Make sure the patient maintains fixation throughout the procedure.
Contraindications
•Patients with recent head injury or trauma
•Patients with intraocular pressure.
•Ophthalmoscope
•Explain that this test permits examination of the back of the eye.
•Describe the test, including who will perform it, where it will take place, and how long it will last.
•Advise the patient that eyedrops may be used to dilate the pupils for a clearer examination, but reassure him that he’ll
experience no discomfort during the test.
•Don’t give dilating eyedrops to a patient who has angle-closure glaucoma or a history of hypersensitivity reactions to
these drops.
•Before conducting an ophthalmoscopy, your eye doctor may use eye drops to dilate your pupils. This makes them larger
and easier to look through.
•Inform doctor if you are allergic to any medication.
•It’s important to tell your eye doctor about any medications that you take, including over-the-counter medications,
prescription medications, and dietary supplements.
•Tell your eye doctor if you have glaucoma or a family history of glaucoma.
F.) Normal Values
•The red reflex should be visible through the aperture.
•The slightly oval optic disk lies to the nasal side of the fundus center. Although its color varies widely, it’s usually pink
with darker edges at its nasal border.
•The physiologic cup, a pale depression in the center of the optic disk, varies widely in size; it tends to be larger in the
patient with myopia and smaller in one with hyperopia.
•The semitransparent retina surrounds the optic disk.
•Branching out from the disk are the retinal vessels, including the venules and the slightly smaller arterioles.
•Vessel diameter progressively decreases with distance from the optic disk.
•Retinal arterioles generally have a medium red color; venules appear dark red or blue.
•The macula is the most darkly pigmented area of the retina. In its center lies a small, even darker spot—the fovea.
•A tiny light reflex can be seen at the center of the fovea, caused by reflection of the ophthalmoscopic light from the
concave inner surface of the area.
Procedure:
•Introduce self, and identify the patient.
•Gain consent for the procedure, explain indications and check for contraindications or allergies.

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•Ensure bare below the elbows and wash hands.
During Procedure:
•Position patient in a chair.
•Administer dilating eye drops, if required, and allow time for these to take effect.
•Ask the patient to fix their gaze at a distant object, and dim the lights.
•First check the red reflex: shine the ophthalmoscope in each eye in turn from an arm’s length away.
•Check and comment on the anterior structures of the eye.
•Check the retina. You should use your right eye to examine the patient’s right eye and your left eye to examine the
patient’s left. It may help if you place your hand on the patient’s forehead.
•Try to examine the optic disc and the four quadrants of the eye around it.
•Finish by examining the macula and fovea.
•Check each eye in turn.
After Procedure:
•Thank the patient and ensure that they are comfortable and have no adverse effect.
•Wash hands.
•Document findings in patient’s notes.
• An absent or a diminished red reflex may be due to gross corneal lesions, dense opacities of the aqueous or
vitreous (such as from blood after hemorrhage), cataracts, or a detached retina.
• A cloudy vitreous that obscures the fundus may be caused by inflammatory disease of the optic disk, retina, or
uvea. Fundal lesions should be sketched or photographed for further study.
• Optic neuritis causes the optic disk to become elevated and more vascular; small hemorrhages may also occur.
Optic nerve atrophy causes the disk to appear white.
• Papilledema, which may result from increased intracranial pressure, causes an abnormal elevation of the disk,
blurring of disk margins, engorged vessels, and hemorrhages.
• In glaucoma, the physiologic cup may appear enlarged and gray with white edges.
• A milky white retina characterizes the acute phase of a central retinal artery occlusion; the fovea, in contrast to
the ischemic macula, appears as a bright red spot.
• Central retinal vein occlusion is marked by widespread retinal hemorrhaging, patches of white exudate, and disk
elevation.
• Retinal detachments appear as gray elevated areas, possibly with areas of red vascular choroid exposed by retinal
tears.
• A choroidal tumor appears as a dark lesion.

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FLUORESCEIN
ANGIGRAPHY
•In fluorescein angiography, a special camera takes rapid-sequence photographs of the fundus following I.V. injection of
sodium fluorescein (a contrast medium), thereby recording the appearance of blood vessels within the eye. This technique
provides enhanced visibility of the microvascular structures of the retina and choroid, which permits the evaluation of the
entire retinal vascular bed, including retinal circulation.
B.) Purposes
•To document retinal circulation when evaluating intraocular abnormalities, such as retinopathy, tumors, and circulatory or
inflammatory disorders
C.) Indications
•Detecting vascular disorders that affect visual acuity
•Detecting tumors, retinal edema, or inflammation by the degree or patterns of fluorescence during the study
•Diagnosing past reduced flow or patency of the vascular circulation of the retina by presence of neovascularization
•Diagnosing macular degeneration in elderly persons and any associated hemorrhage that might be present
•Diagnosing diabetic retinopathy caused by long-term diabetes mellitus
•Detecting microaneurysms caused by hypertensive retinopathy
•Detecting collateral circulation resulting from arterial or venous occlusion caused by stenosis with a reduced, delayed, or
absent flow of the dye through the vessels or possible leakage of the dye from the vessel
Interfering Factors
•Inability of client to keep eyelids open and eyes in a fixed position
•Presence of cataracts
•Improper dilation of pupils
Contraindications
•Allergy to iodinated contrast medium, unless medications are administered before the study
•Patients with narrow-angle glaucoma if pupil dilation is performed as dilation can initiate a severe and sight- threatening
open-angle attack.
•Patients with allergies to mydriatics if pupil dilation using mydriatics is performed.
Precautions
•Don’t leave the patient unattended because he may experience mild adverse reactions, such as nausea, vomiting,
sneezing, paresthesia of the tongue, and dizziness.
•Keep in mind that the needle must be placed in the vein correctly; extravasation of dye around the injection site is painful
Equipment:
•X-ray machine and related equipment from radiologyor special studies; IV equipment (heparin lock)
•Explain that fluorescein angiography takes about 30 minutes and evaluates the small blood vessels in the eyes.
•Make sure the patient or a responsible family member has signed an informed consent form.

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• Check the patient’s history for glaucoma and hypersensitivity reactions or allergies, especially to contrast media
and dilating eyedrops. If necessary, tell a patient with glaucoma not to use miotic eyedrops on the day of the test.
• Explain that eyedrops will be instilled to dilate his pupils and that a dye will be injected into his arm. Tell him that
his eyes will be photographed with a special camera before and after the injection. Stress that these are
photographs, not X-rays.
• Warn the patient that his skin may be discolored and his urine may appear orange for 24 to 48 hours after the
procedure.
• Have the patient arrange for transportation after the test as his vision may be blurred for up to 12 hours.
F.) Normal Values
• After rapid injection into the antecubital vein, sodium fluorescein reaches the retina in 12 to 15 seconds (filling
phase).
• As the choroidal vessels and choriocapillaries fill, the background of the retina fluoresces, taking on an evenly
mottled appearance known as the choroidal flush.
• The dye fills the arteries (arterial phase).
• There is no leakage from the retinal vessels.
Before Procedure:
• Confirm the patient’s identity using two patient identifiers according to facility policy.
• Explain that fluorescein angiography takes about 30 minutes and evaluates the small blood vessels in the eyes.
• Make sure the patient or a responsible family member has signed an informed consent form.
• Check the patient’s history for glaucoma and hypersensitivity reactions or allergies, especially to contrast media
and dilating eyedrops. If necessary, tell the patient with glaucoma not to use miotic eyedrops on the day of the
test.
• Explain to the patient that eyedrops will be instilled to dilate his pupils. The drops may cause a stinging or
burning sensation. A dye will be injected into his arm, which may cause nausea. Tell him that his eyes will be
photo graphed with a special camera before and after the injection. Stress that these are photo graphs, not X-
rays.
• Warn the patient that his skin may be discolored and that his urine may appear orange for 24 to 48 hours after the
procedure.
During Procedure:
• Administer mydriatic eyedrops. Usually, two instillations are necessary to achieve maximum mydriasis within 15
to 40 minutes.
• Following mydriasis, seat the patient comfortably in the examination chair facing the camera.
• Have the patient loosen or remove any restrictive clothing around his neck.
• Tell the patient to place his chin in the chin rest and his forehead against the bar. Tell him to open his eyes wide
and stare straight ahead, while keeping his teeth together and maintaining normal breathing and blinking.
• Provide support and reassurance during the venipuncture for dye instillation. Keep in mind that the needle must
be placed in the vein correctly; extravasation of dye around the injection site is painful.
• Warn the patient that the dye will be injected rapidly. Remind him to maintain his position and to continue to stare
straight ahead while the dye is injected.

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• Don’t leave the patient unattended because he may experience mild adverse reactions, such as nausea, vomiting,
sneezing, paresthesia of the tongue, and dizziness.
• Monitor the patient for evidence of hypersensitivityreactions.
After Procedure:
• Remind the patient that his skin and urine will be slightly discoloured for 24 to 48 hours after the test. Encourage
the patient to drink increased amounts of fluids to help excrete the dye.
• Explain to the patient that his near vision will be blurred for up to 12 hours and that he should avoid direct
sunlight and refrain from driving during this time.
• Abnormalities detected in the early filling phase may include microaneurysms, AV shunts, and
neovascularization.
• The test may identify arterial occlusion by showing delayed or absent flow of the dye through the arteries,
stenosis, and prolonged venous drainage.
• Venous occlusion may be associated with vessel dilation and fluorescein leakage.
• Chronic obstruction may produce recanalization and collateral circulation.
• In hypertensive retinopathy, abnormalities may include areas of increased vascular tortuosity, microaneurysms
around zones of capillary nonperfusion, and generalized suffusion of the dye in the retina.
• Aneurysms and capillary hemangiomas may leak fluorescein and are typically surrounded by hard yellow
exudate.
• Tumors exhibit variable fluorescein patterns, depending on the histologic type.
• Retinal edema or inflammation and fibrous tissue may show variable degrees of fluorescence.
• Papilledema produces vascular leakage in the disk area.
ORBITAL
RADIOGRAPHY
•Orbital radiography evaluates the orbit, the bony cavity that houses the eye and the lacrimal glands, as well as blood
vessels, nerves, muscles, and fat. Because portions of the orbit are composed of thin bone that fractures
easily, X-rays are commonly taken following facial trauma. They’re also useful in diagnosing ocular and orbital
pathologies. Special radiographic techniques can reveal foreign bodies in the orbit or eye that are invisible to an
ophthalmoscope. In some cases, radiography is used in conjunction with computed tomography scans and
ultrasonography to better define an abnormality.
B.) Purposes
•To help diagnose orbital fractures and diseases
•To help locate intraorbital or intraocular foreign bodies
C.) Indications
•Identification of fractures after known or suspected trauma to the eyes or face

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•Suspected tumor involving the orbit, hypophysis, retina, or optic nerve revealed by alterations in the size of the orbit
•Suspected foreign body in the eye or in the orbit itself
•Suspected Paget’s disease revealed by an increased density of the bone
•Suspected congenital microphthalmia or other craniofacial anomalies revealed by alterations in the size of the orbit
D.) Contraindications/Precautions/Interfering Factors Contraindications
•Pregnancy, unless benefits of performing the procedure greatly outweigh the risks to the fetus
Interfering Factors
•Improper positioning of the client to obtain the desired views
•Metal objects such as eyeglasses, eye prosthesis, dentures, or jewelry within the x -ray field
•X-ray machine and related equipment from radiology
Patient Preparation
•Explain that orbital radiography involves taking several X-rays to assess the condition of the bones around the eye.
•Describe the test, including who will perform it and where it will take place.
•Reassure the patient that the procedure is usually painless unless he has suffered facial trauma, in which case positioning
may cause some discomfort. Explain that he’ll be asked to turn his head from side to side and to flex or extend his neck.
•Instruct the patient to remove all jewelry and other metallic objects from the X-ray field.
F.) Normal Values
•Each orbit is composed of a roof, a floor, and medial and lateral walls.
•The bones of the roof and floor are very thin (the floor can be less than 1 mm thick).
•The medial walls, which parallel each other, are slightly thicker, except for the portion formed by the ethmoid bone.
•The lateral walls are the thickest part of the orbit and are strongest at the orbital rim.
•The superior orbital fissure, at the back of the orbit between the lateral wall and the roof, is actually a gap between the
greater and lesser wings of the sphenoid bone.
Test:
•Instruct the client that during the procedure it may be uncomfortable to sit on the hard table or achieve some of the
necessary positions; it is important to remain as still as possible during the test; there are no dietary
restrictions prior to the test; and it is necessary to remove dental prosthesis, jewelry, eyeglasses, or other metal objects
like hair clips before the procedure.
During Test:
•Adhere to standard precautions. Instruct client to reposition head or flex or extend neck during the x -rays.
•Instruct the client to take a deep breath and hold it or to exhale and not to breathe as the x -ray is taken.

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•Orbit enlargement indicates the presence of a lesion that has caused proptosis due to increased intraorbital pressure.
•Superior orbital fissure enlargement can result from orbital meningioma, from intracranial conditions such as
pituitary tumors or, more characteristically, from vascular anomalies.
•Optic canal enlargement may result from extraocular extension of a retinoblastoma or, in children, from an optic nerve
glioma.
•In adults, only prolonged pathology can increase orbital size; but in children, even a rapidly growing lesion can cause
orbital enlargement because orbital bones aren’t fully developed.
•A decrease in the size of the orbit may follow childhood enucleation of the eye or conditions such as congenital
microphthalmia.
•Destruction of the orbital walls may indicate a malignant neoplasm or an infection.
•A benign tumor or cyst produces a clear-cut local indentation of the orbital wall.
•Lesions of adjacent structures may also produce radiographic changes due to enlargement and erosion of the orbit.
•Increased bone density may be seen in such conditions as osteoblastic metastasis, sphenoid ridge meningioma, or Paget’s
disease.
•To confirm orbital disease, radiographic findings must be supplemented with results from other appropriate tests and
procedures.
ORBITAL COMPUTED
TOMOGRAPHY
•Orbitalcomputed tomography (CT) allows visualization of abnormalities not readily seen on standard radiographs,
delineating their size, position, and relationship to adjoining structures. A series of tomograms reconstructed by a
computer and displayed as anatomic slices on a monitor, the orbital CT scan identifies space - occupying lesions earlier
and more accurately than other radiographic techniques and provides three- dimensional images of orbital structures,
especially the ocular muscles and the optic nerve .
B.) Purposes
•To evaluate pathologies of the orbit and eye—especially expanding lesions and bone destruction
•To evaluate fractures of the orbit and adjoining structures
•To determine the cause of unilateral exophthalmos
C.) Indications
•An orbit CT scan may also be used to detect:
o Abscess (infection) of the eye area
o Broken eye socket bone
o Foreign object in the eye socket
•Use of contrast enhancement is contraindicated in the patient with hypersensitivity reactions to iodine, shellfish, or

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contrast media used in other tests, and in patients with severe renal or hepatic disease.
Interfering factors:
•Head movement
•Failure to remove metallic objects from examination field (possible poor imaging).
Equipment
•CT scan machine
Patient Preparation
•Describe the procedure to the patient, and explain that the orbital CT scan visualizes the anatomy of the eye and its
surrounding structures.
•If contrast enhancement isn’t scheduled, tell the patient that he doesn’t need to restrict food and fluids. If
contrast enhancement is scheduled, withhold food and fluids from the patient for 4 hours before the test.
•Tell the patient that a series of X-rays will be taken of his eye, and explain who will perform the test and where it will
take place.
•Reassure the patient that the test will cause him no discomfort.
•Tell the patient that he’ll be positioned on an X-ray table and that the head of the table will be moved into the scanner,
which will rotate around his head and make loud clacking sounds.
•If a contrast medium will be used for the procedure, tell the patient that he may feel flushed and warm and may
experience a transient headache, a salty or metallic taste, and nausea or vomiting after the contrast medium is injected.
Reassure him that these reactions are normal.
• Make sure that the patient or a responsible family member has signed an informed consent form, if required.
• Check the patient’s history for hypersensitivity reactions to iodine, shellfish, or contrast media, and notify the
practitioner of the sensitivities.
• Instruct the patient to remove jewelry, hairpins, or other metal objects in the X-ray field to allow for precise
imaging of the orbital structures.
F.) Normal Values
• Dense orbital bone provides a marked contrast to less-dense periocular fat.
• The optic nerve and the medial and lateral rectus muscles are clearly defined.
• The rectus muscles appear as thin dense bands on each side, behind the eye.
• The optic canals should be equal in size.
Before Procedure:
• Notify the radiology department if your patient has a peripheral inserted central catheter (PICC) line. PowerPICC
is indicated for power injection of contrast media.
• Make sure that the patient or a responsible family member has signed an informed consent form.
• Explain that the orbital CT scan visualizes the anatomy of the eye and its surrounding structures.
• Tell the patient that a series of X-ray films will be taken of his eye.

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• If contrast enhancement isn’t scheduled, inform the patient that he need not restrict food and fluids. If contrast
enhancement is scheduled, withhold food and fluids from the patient for 4 hours before the test.
• For women of childbearing age, assess pregnancy status (i.e., determine last menstrual period [LMP]) for possible
pregnancy and notify radiologyas needed.
• Explain who will perform the test, and when and where it will take place.
• Assure the patient that the procedure is painless, but that having to remain still for a prolonged period of time
may be uncomfortable.
• Tell the patient that he’ll be positioned on an X-ray table and that the head of the table will be moved into the
scanner, which will rotate around his head and make loud clacking sounds.
• If a contrast medium is being used, tell the patient that he may feel f lushed and warm, and he may experience a
transient headache, a salty or metallic taste, and nausea or vomiting after the contrast medium is injected. Assure him
that these reactions are normal.
• Instruct the patient to remove body piercings, jewellery, hairpins, or other metal objects in the X-ray field to allow
for precise imaging of the orbital structures.
• Make sure that the patient or a responsible family member has signed an informed consent form if required.
• Check the patient’s history for hypersensitivity reactions to iodine, shellfish, or contrast media. If such reactions
have occurred, note them in the patient’s chart and notify the practitioner, who may order prophylactic
medications or choose not to use contrast enhancement.
After Procedure:
• If a contrast medium was used, watch for its residual adverse effects, including headache, nausea, or vomiting.
Encourage fluids to assist in eliminating the contrast medium.
• Inform the patient that he may resume his usual diet as ordered.
• Intraorbital and extraorbital spaceoccupying lesions are present that obscure the normal structures or cause orbital
enlargement, indentation of the orbital walls, or bone destruction.
• Infiltrative lesions, such as lymphomas and metastatic carcinomas, appear as irregular areas of density.
• Encapsulated tumors, such as benign hemangiomas and meningiomas, appear as clearly defined masses of
consistent density.
• CT scans can also visualize intracranial tumors that invade the orbit, thickening of the optic nerve that may occur
with gliomas, meningiomas, and secondary tumors that may cause enlargement of the optic canal.
• CT scans can show early erosion or expansion of the medial orbital wall that may arise from lesions in the
ethmoidal cells.
• CT scans can also detect space-occupying lesions in the orbit or paranasal sinuses that cause exophthalmos.
• Thickening of the medial and lateral rectus muscles in proptosis results from Graves’ disease.
• Enhancement with a contrast medium may provide information about the circulation through abnormal ocular
tissues
OCULAR
ULTRASONOGRAPHY
•Ocular ultrasonography involves the transmission of high-frequency sound waves through the eye and the
measurement of their reflection from ocular structures. An A-scan converts the resulting echoes into waveforms whose
crests represent the positions of different structures, providing a linear dimensional picture. The B-scan

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converts the echoes into patterns of dots that form a two-dimensional, cross-sectional image of the ocular
structure.
• Because the B-scan is easier to interpret than the A-scan, it’s used more commonly to evaluate the structures of
the eye and to diagnose abnormalities. However, the A-scan is more valuable in measuring the eye’s axial length
and characterizing the tissue texture of abnormal lesions. Thus, a combination of A- and B-scans produces the
most useful test results.
• Illustrating the eyes’ structures through ultrasound is especially helpful in evaluating a fundus clouded by an
opaque medium such as a cataract. In such a patient, this test can identify pathologies that are normally
undetectable through ophthalmoscopy.
• Ophthalmologists may also perform this test before surgery—for example, cataract removal—to ensure the
integrity of the retina. If an intraocular lens is to be implanted, ultrasound may be used preoperatively to
measure the length of the eye and the curvature of the cornea as a guide for the surgeon.
• In addition to its diagnostic capabilities, ocular ultrasonography can identify intraocular foreign bodies and
determine their position in relation to ocular structures as well as assess the severity of resulting ocular damage.
B.) Purposes
• To help evaluate the fundus in an eye with an opaque medium such as a cataract
• To help diagnose vitreous disorders and retinal detachment
• To diagnose and differentiate between intraocular and orbital lesions and to follow their progression through
serial examinations
• To locate intraocular foreign bodies
C.) Indications
• Diagnosing and identifying type, size, shape, texture, and location of tumors such as melanoma, hemangioma,
glioma, neurofibroma, meningioma, metastic lymphoma
• Detecting cystic conditions such as mucoid or dermoid tumors and differentiating these from solid tumors
• Determining the effect of thyroid disease (Graves’ disease) on eye tissues revealed by inflammatory changes and
extraocular thickening
• Diagnosing orbital lesions and differentiating these from intraocular lesions Identifying and locating intraocular
foreign bodies
• Diagnosing the extent of retinal or choroidal detachment
• Determining vitreous abnormalities such as opacities, vitreous bands, or hemorrhage revealed by density in image
appearance
• Evaluating the fundus that is clouded by a cataract and measuring the length of the eye before surgery for
insertion of a lens implant after removal of a cataract
• Evaluating the eyes for keratoprosthesis Evaluating the vitreous cavity for abnormalities before vitrectomy
• Inability of client to remain still during the procedure, which can result in an injury
• Vitreous humor that has been replaced by gas
• Incorrect placement of the transducer on the eye

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• Ocular ultrasound should be performed with the high-frequency linear probe, and many ultrasound machines have
an ocular setting.
• Describe the procedure to the patient, and explain that ocular ultrasonographyevaluates the eye’s structures.
• Tell the patient that he doesn’t need to restrict food and fluids.
• Tell the patient who will be performing the test and where it will be done.
• Reassure him that it’s safe and painless and takes about 5 to 10 minutes to perform.
• Tell the patient that a small transducer will be placed on his closed eyelid and that the transducer transmits high-
frequency sound waves that are reflected by the structures in the eye.
• Explain that he may be asked to move his eyes or change his gaze during the procedure and that his cooperation
is required for accurate test results.
F.) Normal Values
• The optic nerve and the posterior lens capsule produce echoes that take on characteristic f orms on A- and B- scan
images.
• The posterior wall of the eye appears as a smooth, concave curve; retrobulbar fat can also be identified.
• The lens and vitreous humor, which don’t produce echoes, can also be identified.
• Normal orbital echo patterns depend on the position of the transducer and the position of the patient’s gaze during
the procedure.
Procedure:
•Obtain a history that includes known or suspected eye trauma or abnormalities and therapy or surgery for an eye
disorder.
•Inform the client that eyedrops will be instilled to anesthetize the eye for examination and that some temporary eye
blurring will be experienced after the procedure.
During Procedure:
•The client is placed on the examination table in a supine position.
•Drops to anesthetize the eye are instilled according to ordered dosage and frequency before the study.
•The client is requested to close the eye and a conductive gel is applied to the eyelid. The transducer is placed on the gel,
and sound waves are transmitted into the eye.
•The waves produce echoes that are viewed on a screen and photographed for future comparison and evaluation. This
provides a B scan to diagnose eye abnormalities.
•An A scan is performed by placing a cup over the eyeball, applying gel to the cup, and gently moving the
transducer over the cup or gently manipulating the transducer directly on the corneal surface. The A scan measures the
axial length of the eye and assists in diagnosing abnormal lesions.
•The client can be requested to change the gaze of the eye being examined to obtain orbital echo patterns that can be
differentiated from abnormal patterns.

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•When the study is completed, the gel and cup are removed from the eye or eyelid.
After Procedure:
•Remind the client that vision may be blurred for a short period and that rubbing the eye should be avoided until the
anesthetic has worn off (about 3 to 4 hours) to prevent injury to the eye.
•In eyes clouded by a vitreous hemorrhage, the organization of the hemorrhage can be identified by the degree of density
that appears on the image. In some instances, the cause of the hemorrhage, the prognosis, and associated abnormalities
can also be determined.
•Massive vitreous organization and vitreous bands may also be detected by ultrasonography.
•Retinal detachment, commonly found in a patient with an opaque medium, characteristically produces a dense, sheetlike
echo on a B-scan. The extent of retinal or choroidal detachment can be defined by transmitting
ultrasound waves through the quadrants of the patient’s eye.
•Ocular ultrasonography can be used to diagnose and differentiate intraocular tumors according to size, shape, location,
and texture.
•Hemangiomas and cystic lesions produce characteristic ultrasound patterns.
•Other orbital lesions detectable by ultrasound include meningiomas, neurofibromas, gliomas, neurilemomas, and the
inflammatory changes associated with Graves’ disease.

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WORKSHEET ON EARS
OTOSCOPY
TUNINGFORK TESTS PURE TONE AUDIOMETRY
ACOUSTIC IMMITANCE TESTS WORD RECOGNITION TESTS SITE OF LESION TESTS
ELECTRONYSTAGMOGRAPHY
OTOSCO
PY
•Otoscopy is the direct visualization of the external auditory canal and the tympanic membrane through an
otoscope. It’s a basic part of physical examination of the ear and should be performed before other auditory or vestibular
tests. Otoscopy indirectly provides information about the eustachian tube and the middle ear cavity.
B.) Purposes
•To visualize inner ear structures
•To detect foreign bodies, cerumen, or stenosis in the external canal
•To detect external or middle ear disease, such as an infection or a tympanic membrane perforation
C.) Indications
•Detect causes of deafness, obstruction, stenosis, or swelling of the pinna or canal causing a narrowing or closure that
prevents sound from entering
•Detect ear abnormalities during routine physical examination
•Diagnose cause of ear pain
•Remove impacted cerumen (with a dull ring curette) or foreign bodies (with a forceps) that are obstructing the entrance
of sound waves into the ear
•Evaluate acute or chronic otitis media and effectiveness of therapy in controlling infections.
Precautions:
•The otoscope should be advanced slowly and gently through the medial portion of the ear canal to avoid irritation of the
canal lining, especially if an infection is suspected.
•Continuing to insert an otoscope against resistance may cause the tympanic membrane to perforate.
Interfering factors:
•Obstruction of the auditory canal with cerumen, dried drainage, or foreign bodies that prevent introduction of the
otoscope.
Contraindications:

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•The insufflation portion of the examination is avoided for persons with upper respiratory infection since it may result in
movement of infectious material into the middle ear.
Equipment:
•Otoscope; speculum
•Describe the procedure to the patient, and explain that this test permits visualization of the ear canal and eardrum.
•Reassure the patient that the examination is usually painless.
•Tell the patient that his ear will be pulled upward and backward to straighten the canal to ease insertion of the otoscope.
•If the patient will undergo pneumatic otoscopy, tell him that he may experience dizziness with nystagmus, a positive
fistula sign.
•There are no food, fluid, activity, or medication restrictions unless by medical direction.
F.) Normal Values
•The tympanic membrane is thin, translucent, shiny, and slightly concave. It appears as a pearl gray or pale pink disk that
reflects light in its inferior portion.
•The short process, manubrium mallei, and umbo should be visible but not prominent.
•Light reflex extends inferiorly and anteriorly from the umbo.
Procedure:
•Inform the patient that the procedure is performed to investigate suspected ear disorders.
• Obtain a history of the patient’s complaints, including a list of known allergens.

• Obtain a history of the patient’s known or suspected hearing loss, including type and cause; ear conditions with
treatment regimens; ear surgery; and other tests and procedures to assess and diagnose auditory deficit.
procedures.
• Obtain a list of the medications the patient is taking, especially antibiotic regimen, as well as herbs, nutritional
supplements, and nutraceuticals.
• Review the procedure with the patient. Inform the caregiver that he or she may need to restrain a child in order to
prevent damage to the ear if the child cannot remain still. Address concerns about pain related to the procedure.
Explain to the patient that no discomfort will be experienced during the test.
• Ensure that the external auditory canal is clear of impacted cerumen.
During Procedure:
• Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still during the procedure
because movement produces unreliable results.
• Administer ear drops or irrigation to prepare for cerumen removal, if ordered.
• Place adult patient in a sitting position; place a child in a supine position on the caregiver’s lap. Request that the
patient remain very still during the examination; a child can be restrained by the caregiver if needed.
• Assemble the otoscope with the correct-size speculum to fit the size of the patient’s ear and check the light

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source. For the adult, tilt the head slightly away and, with the nondominant hand, pull the pinna upward and
backward. For a child, hold the head steady or have the caregiver hold the child’s head steady, depending on the
age, and pull the pinna downward. Gently and slowlyinsert the speculum into the ear canal downward and forward
with the handle of the otoscope held downward. For the child, hold the handle upward while placing the edge of
the hand holding the otoscope on the head to steady it during insertion. If the speculum resists insertion,
withdraw and attach a smaller one.
• Place an eye to the lens of the otoscope, turn on the light source, and advance the speculum into the ear canal
until the tympanic membrane is visible. Examine the posterior and anterior membrane, cone of light, outer rim
(annulus), umbo, handle of the malleus, folds, and pars tensa.
• Culture any effusion with a sterile swab and culture tube.
• Pneumatic otoscopy can be done to determine tympanic membrane flexibility. This test permits the introduction
of air into the canal that reveals a reduction in movement of the membrane in otitis media and absence of
movement in chronic otitis media.
• The results are recorded manually for recall and postprocedure interpretation by a health care professional
specializing in this field.
After Procedure:
• Administer ear drops of a soothing oil, and as ordered, if the canal is irritated by removal of cerumen or foreign
bodies.
medicine.
• Scarring, discoloration, or retraction or bulging of the tympanic membrane indicates a pathologic condition.
• Movement of the tympanic membrane in tandem with respiration suggests abnormal patency of the eustachian
tube.
• An altered or absent light reflex isn’t a reliable indicator of disease because there can be many normal variations
of the tympanic membrane and posterior bony ear canal.
TUNING FORK
TESTS
•The Weber, Rinne, and Schwabach tuning fork tests are quick, valuable screening tools for detecting hearing loss and
obtaining preliminary information as to its type. The Weber test determines whether a patient lateralizes
the tone of the tuning fork to one ear. The Rinne test compares air and bone conduction in both ears. The Schwabach test
compares the patient’s bone conduction response with that of the examiner, who’s assumed to have normal hearing.
•Test results are most reliable when a low-frequency tuning fork is used; results aren’t definitive because they depend on
subjective factors, such as the examiner’s ability to strike the fork with equal force each time and the patient’s ability to
report audible tones correctly.
•Results of the Weber test may be misleading, and the Rinne test commonly doesn’t detect a mild conductive hearing loss
(10 to 35 dB). Thus, abnormal test results require confirmation by pure tone audiometry.
B.) Purposes
•To screen for or confirm hearing loss
•To help distinguish conductive from sensorineural hearing loss

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C.) Indications
•Screening for hearing loss as part of a routine physical examination and determining the need for a referral to an
audiologist
•Obtaining information about the type of hearing loss (conductive or sensorineural) as revealed by a tone heard
on one side, indicating a conductive loss on that side or sensorineural loss on the other side in the Weber test;
bone conduction tone heard louder or for a longer time than air conduction tone, indicating a conductive loss; or air
conduction tone heard louder, indicating a sensorineural loss in the Rinne test; tone that is heard longer by the client than
by the examiner, indicating a conductive loss, and heard for a shorter time, indicating a sensorineural loss in the
Schwabach test
•Failure to strike the tuning fork with equal force or to hold it correctly during the procedure
•Striking the tuning fork on a hard surface rather than on the elbow or knee
•Failure to use either the 512-Hz frequency tuning fork or the more sensitive 256-Hz tuning fork
•Inaccurate patient response due to poor understanding of his task
•Undetected hearing loss in the examiner
•Tuning Fork
Patient Preparation
•Describe the procedure to the patient, and explain that the tuning fork tests help detect and assess hearing loss. Tell him
who will conduct the tests, and reassure him that they’re painless.
•Explain to the patient that concentration and prompt responses are essential for accurate testing. Have him use
hand signals to indicate whether a tone is louder in his right ear or left ear and when he stops hearing the tone.
•Inform the patient that tuning fork tests aren’t definitive and that further testing may be necessary to confirm abnormal
results.
F.) Normal Values
•In the Weber test, hearing the same tone equally loudly in both ears (Weber midline result) is normal.
•In the Rinne test, hearing the airconducted tone louder or longer than the bone-conducted tone (Rinnepositive result) is
normal.
•In the Schwabach test, hearing the tone for the same duration as the examiner is normal.
the Procedure
•Explain to the client:
o That the test is conducted in a quiet room by the nurse or the physician during a physical or hearing
examination and that it takes less than 5 minutes
o That there are no restrictions or special preparations before the tests
o That the client will be requested to respond verbally or by pushing a button to indicate the tones heard in
each ear

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o That no pain is associated with these tests
o Obtain a history of known or suspected hearing loss and cause, use of hearing aid, changes in auditory
acuity, and other hearing tests and procedures performed and the results.
During the Procedure
•The client is placed in a comfortable sitting position facing the examiner in a chair or on the examining table in a quiet
environment. A tuning fork of 1024 Hz is used because it tests within the range of human speech (400 to
5000 Hz).
•Weber Test. Tap the tuning fork on the handle against the hand to start a light vibration. Hold the base of the vibrating
tuning fork with the thumb and forefinger of the dominant hand, and place it on the middle of the
forehead or at the vertex of the head. Ask the client to determine whether the sound is heard better and longer on one side
than on the other. Record as Weber right or left or, if the sound is heard equally, as Weber negative.
•Rinne Test. Tap the tuning fork on the handle against the hand to start a light vibration. Have the client move a
finger in and out of the canal of the ear not being tested (masking). Hold the base of the vibrating tuning fork with the
thumb and forefinger of the dominant hand and place it in contact with the mastoid process. Ask the client to indicate
when he or she can no longer hear the sound. Then place the same vibrating tuning fork in front of the ear canal without
touching the external part of the ear. Ask the client which of the two has the louder or longer tone. Repeat the test in the
other ear. Record as Rinne positive if air conduction is heard longer and as Rinne negative if bone conduction is heard
longer.
• Schwabach Test. Tap the tuning fork on the handle against the hand to start a light vibration. Hold the base of
the tuning fork against the client’s mastoid process and ask whether the tone is heard. Have the client mask the
other ear by moving a finger in and out of the ear not being tested. Then place the same tuning fork against your own
mastoid process of the same side and listen for the tone. Continue to alternate the tuning fork until the sound is no
longer heard, and determine whether both cease to hear the tone at the same time. Repeat the procedure on the
other ear. If the client hears the tone for a longer or shorter time, count and note this in seconds.
• Abnormal test results require further testing by audiometry to confirm findings and detect the type and exte nt of
hearing loss with more specificity.
After the Procedure
• No special aftercare is required for this test.
• Refer the client to an audiologist if a hearing loss is detected.
H.) Implications of Abnormal Results Weber Test
• Lateralization of the tone to one ear suggests a conductive loss on that side or a sensorineural loss on the other
side.
• Lateralization results if the tone is louder in one ear (Stenger effect) or reaches one ear sooner (phase effect).
• If one ear has a sensorineural loss, the Stenger effect causes lateralization to the unaffected ear; if one ear has a

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conductive loss, either the Stenger or the phase effect produces lateralization to that ear.
• If a patient’s hearing loss is unilateral, the Weber test may suggest the type of loss.
Rinne Test
• Hearing the bone-conducted tone louder or longer than the air-conducted tone indicates a conductive loss.
• In unilateral hearing loss, the tone may be heard louder when conducted by bone, but in the opposite ear; this is a
false-negative Rinne test result.
• A sensorineural loss is indicated when the sound is heard louder by air conduction.
Schwabach Test
• Hearing the tone longer than the examiner hears it suggests a conductive loss; conversely, a shorter
duration indicates a sensorineural loss.
• A conductive loss attenuates (decreases the energy of) air-conducted sound in a room with ambient
noise, enabling the patient with this type of loss to hear bone-conducted sound longer than the
examiner can hear it.
PURE TONE
AUDIOMETRY
•Pure tone audiometry, performed with an audiometer, provides a record of the thresholds (the lowest intensity
levels) at which a patient can hear a set of test tones introduced through earphones or a bone conduction (sound) vibrator.
The energy of these pure tones is concentrated at discrete frequencies. The octave frequencies between 125 and 8,000 Hz
are used to obtain air conduction thresholds; frequencies between 250 and 4,000 Hz are used to obtain bone conduction
thresholds.
•Comparison of air and bone conduction thresholds can suggest a conductive, sensorineural, or mixed hearing loss but
doesn’t indicate the cause of the loss; further audiologic and vestibular tests and X-rays may be needed. Pure tone
audiometry results may also suggest a need to consult an audiologist to evaluate communication difficulties.
B.) Purposes
•To determine the presence, type, and degree of hearing loss
•To assess communication abilities and rehabilitation needs
•To accurately determine pure tone and speech reception threshold
C.) Indications
•Pure tone audiometry is indicated for any patient who requires a quantitative hearing assessment.
•Screening for hearing loss in infants and children and determining the need for a referral to an audiologist
•Determining the type and extent of hearing loss (conductive as revealed by a reduced air threshold and
unchanged bone threshold, sensorineural as revealed by a reduced air and bone threshold, or mixed as evidenced by
abnormal air and bone thresholds) and determining whether further radiologic, audiologic, or vestibular procedures are
needed to identify the cause
•Evaluating the degree and extent of preoperative and postoperative hearing loss after stapedectomy in clients with
otosclerosis
•Evaluating communication disabilities and planning for rehabilitation interventions
•Determining the need for and type of hearing aid and evaluating its effectiveness

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•There are no contraindications; however, results depend on the patient’s cooperation.
Precautions
•Any modifications of standard testing procedure—such as inserting a plastic tube to prevent ear canal collapse— must be
recorded on the audiogram.
•Be on the alert for false responses; they can be misleading and influence interpretation of test results. False responses
include failure to indicate when a tone has been heard or responding when no tone has been heard.
Interfering Factors
•Impacted cerumen or a closed ear canal (possible 35- to 40-dB artifactual conductive hearing loss)
•Patient’s confusion of vibrotactile with auditory sensation or tinnitus with the signal (invalid results)
•Cracked or poorly fitting earphones (low-frequency leakage and false-high thresholds)
•Uncalibrated audiometer or background noise (possible invalidation)
•Presenting extraneous cues to the patient, such as a rhythmic pattern of test tones or hand movement near the attenuator
dial (possible invalidation)
•Patient uncooperative or inattentive (possible invalidation)
•Ear infection
•Audiometer
•Earphone or bone conduction (sound) vibrator
Patient Preparation
•Describe the procedure to the patient and explain that this test determines the presence and degree of hearing loss.
Explain who will perform the test and where it will take place.
•Tell the patient that each ear will be tested, beginning with the ear with the better hearing acuity. Explain that he’ll hear
tones at various intensities and that he should signal (or press the response button) each time he hears the tone. Emphasize
that he should respond even if the tone is faint.
•Just before the test, ask the patient to remove jewelry or apparel that obstructs proper earphone placement.
•Postpone the test if the patient has been exposed to loud noises (loud enough to cause tinnitus or to make face- to-face
communication difficult) within the past 16 hours.
F.) Normal Values
•Normal levels for adults are 0 to 25 dB.
•Normal levels for children are 0 to 15 dB.
the Procedure
o That the test will be performed in a quiet room by a nurse or an audiologist and that it takes about 20
minutes or less, depending on the test
o That each ear will be tested separately by using earphones through which tones of varying intensities

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are delivered, by using a device placed behind the ear, or by using whispered sounds spoken at a specific distance
o That the client will be requested to press a button at the time a tone is heard or to signal when a
whisper is heard
o That no pain is associated with the test
•Prepare for the procedure:
o Obtain a history of known or suspected hearing loss and cause; use of a hearing aid; complaints of
changes in auditory acuity; past auditory testing, procedures, and results; and age of the client.
•The patient’s ear canal is checked with the otoscope for impacted cerumen.
•The examiner presses a finger on the auricle and then the tragus to rule out possible closure of the ear canal under
pressure from the earphones. If the canal tends to close, a stiff -walled plastic tube is carefully inserted into the canal. This
modification is recorded on the audiogram.
•The earphones are positioned properly
•and the headband is tightened.
•A test tone is presented to the patient’s better ear.
•Air conduction testing
o A 1,000-Hz tone is presented to the patient’s better ear. The intensity of the tone is decreased in 10-dB
steps until the patient fails to respond. Then intensity is increased in 5-dB steps until he hears the tone
again. Sequences of 10-dB decrements and 5-dB increments are repeated until the patient responds to at
least two of three presentations at a single level. The threshold level is the lowest decibel level at which
the response rate is at least 50%.
o Using this procedure, tones are presented to the better ear in this order: 1,000 Hz, 2,000 Hz, 4,000 Hz,
8,000 Hz, 1,000 Hz, 500 Hz, and 250 Hz.
o After testing the better ear, the other ear is tested. In each ear, test or retest differences may be + or –5 dB.
If the difference between the first and second threshold at 1,000 Hz is greater than 10 dB, test results are
unreliable; equipment should be checked for malfunction and the patient should be reinstructed and
retested.
o Many audiologists sample hearing only at octave points. Others may prefer the detail resulting from
testing the midoctave frequencies. The American Speech-Language-Hearing Association recommends
testing the better ear first and that mid-octave points be tested when a difference of 20 dB or greater is
seen in the thresholds at adjacent octaves.
• Bone conduction testing
o The earphones are removed and the vibrator is placed on the mastoid process of the better ear (the auricle
shouldn’t touch the vibrator).
o Ascending and descending tones are presented, as in air conduction testing, using 250, 500, 1,000,

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2,000, and 4,000 Hz.
After the Procedure
• Care and assessment after this test include informing the client of the schedule for retesting and instruction
in the use, cleansing, and storing of a hearing aid, if one is used.
• Both tests
o Refer the patient to an audiologist if test results are inconsistent or are confounded by possible crossover.
o Crossover tone: Note and report test tones that cause crossover to the opposite ear during air
conduction testing (over 40 dB or 125 to 750 Hz, 50 dB or 1000 to 8000 Hz) or bone conduction testing.
Mask the ear that is not being tested. (Present a sound to the ear not being tested to ensure that responses
are based on hearing in the ear being tested.)
• In sensorineural hearing loss, both thresholds are depressed.
• In conductive hearing loss, air thresholds are depressed, but bone thresholds are unchanged.
• In mixed hearing loss, both thresholds are abnormal, with air conduction more depressed than bone
conduction.
ACOUSTIC IMMITANCE
TESTS
•Acoustic immittance tests evaluate middle ear function by measuring the flow of sound energy into the ear (admittance).
Not all sound energy that impinges on the tympanic membrane reaches the inner ear; some reflects into the external ear
canal. The relationship between incident and reflected sound energy determines the admittance, which depends on the
resistance, stiffness, and mass of the auditory system. Normally, stiffness is the predominant factor in the middle ear.
•Admittance is commonly measured by two tests: tympanometry and acoustic reflex testing. Each of these tests uses an
electronic tone generator, an air pressure manometer, and a tone probe that delivers sound and air pressure stimuli to the
ear canal and tympanic membrane through an airtight seal. Tympanometry measures middle ear admittance in response to
changes in air pressure in the ear canal; the acoustic reflex test measures the change in admittance produced by
contraction of the stapedius muscle in response to an intense sound. Stapedial contraction stiffens the tympanic
membrane and ossicular chain, causing a measurable reduction in middle ear admittance. Reflex decay, part of the
acoustic reflex test, is a function of the eighth cranial nerve adaptation or fatigue in response to a sustained reflex-eliciting
stimulus.
•Tympanometry helps diagnose middle ear disease and assesses eustachian tube function. Acoustic reflex testing assesses
the seventh (facial) and eighth cranial nerve function and helps establish the site of the lesion. Because admittance tests
require little patient cooperation, they are reliable in testing young children and individuals with physical or mental
challenges.
B.) Purposes Tympanometry
•To assess the continuity and admittance of the middle ear
•To evaluate the status of the tympanic membrane
Acoustic Reflex Testing
•To distinguish between cochlear and retrocochlear lesions

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• To differentiate eighth nerve or peripheral brain stem lesions from intra-axial brain stem lesions
• To locate seventh nerve lesions relative to stapedius muscle innervation
• To confirm conductive hearing loss
• To help confirm nonorganic loss (feigning or exaggerating hearing loss, also called pseudohypoacusis)
C.) Indications
• Tympanometry helps diagnose middle ear pathology and assesses eustachian tube function.
• Acoustic reflex testing assesses the seventh (facial) and eighth cranial nerve function and helps establish the site
of the lesion. Because admittance tests require little patient cooperation, they are reliable in testing young
children and individuals with physical or mental challenges.
D.) Contraindications/Precautions/Interfering Factors Precautions
• Obtain medical clearance before performing admittance tests in the patient with head trauma or a possible
labyrinthine fistula and on one who has recently had middle ear surgery.
• Check equipment carefully. If the probe tip is clogged with cerumen or debris, the measured admittance won’t
change, even when the probe isn’t coupled to the ear. To clean the probe, carefully insert a wire through each
bore, wipe the wire, and then withdraw it.
• If you can’t obtain a seal even though the probe seems well seated, look for leakage elsewhere in the air system.
Check the system by putting the probe in the supplied coupler. If it can’t seal, then the tubing has a leak or the
equipment is malfunctioning.
• While some screening systems permit acoustic reflex measurements, the results aren’t reliable if the probe is
handheld in the ear. Refer to an audiologist, as required.
Interfering Factors
• Interpretation by audiologist of reflex findings in light of audiologic results
• Patient movement resulting in false readings
• Electronic tone generator
• An air pressure manometer
• A tone probe
Patient Preparation
• Ensure that the patient’s ear is free from significant cerumen accumulation.
• Describe the procedure to the patient and explain that acoustic immittance tests evaluate the condition of the
middle ear.
• Tell the patient that he will feel pressure in the ear, but that the test isn’t painful.
• Ask the patient not to move during the test, which takes just a few seconds.
F.) Normal Values Tympanometry
• Four measurements are important on the tympanogram: the ear canal volume, the peak compliance reading, the
peak pressure reading, and the slope gradient. These measures are interpreted along with the shape or “type” of
the tympanogram and together determine the implication of the tympanometric results.
• A type A tympanogram is a normal finding.

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• Acoustic reflexes present at an intensity of 65 to 100 dB hearing level.
• The sensation level of the reflex is computed by subtracting the hearing threshold for the ear by the frequency
receiving the tone. The sensation level of the reflex should be 65 to 100 dB.
Before the Procedure
• Explain to the client:
o That the tests are performed by the audiologist or physician in a quiet room and that each test takes less
than 5 minutes
o That there are no restrictions in food, fluid, or activity before the tests
o That the introduction of air pressure into the ear can cause dizziness that should be reported but that the
dizziness disappears
o That a probe is placed into the ear and that some mild discomfort can be experienced at this time
o That the tests do not harm the ears when the air and sound stimuli are introduced
• Prepare for the procedure:
o Obtain a history of known or suspected hearing loss and type and cause, ear conditions with treatment
regimens, ear surgery procedures, and other tests and procedures to assess and diagnose auditory deficit.
• For tympanometry
o Otoscopic examination is performed to verify that no impacted cerumen or other obstruction is present in
the ear canal.
o The size and shape of the canal are checked to select the appropriate-size probe tip, which is then
attached to the probe.
o The probe tip is inserted into the ear canal while pulling upward and backward on the auricle; a proper
seal can maintain a negative pressure of +200 daPa. Once a hermetic seal is obtained, the pressure in the
ear canal will automatically vary from +200 to –400 daPa.
o A graphic display of the tympanogram is obtained. If the tympanogram has a clear peak, the pressure of
the peak is noted and usually printed with the test results. This indicates the pressure within the middle
ear cavity. The sound admittance through the middle ear system is noted by the height of the
tympanogram, its peak compliance. This value is also typically printed.
o If a flat tympanogram is obtained (no change in admittance), the possibility that the probe tip may have

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rested against the canal wall or that it was clogged with cerumen must be ruled out with ear canal
volume measurements and repeated testing. Measurement error is more likely to be the cause of the flat
tympanogram if the ear canal volume is low (0.3 ml or less). The probe tip is removed, cleaned,
reinserted, and the test is repeated.
• For acoustic reflex testing
o The audiologist positions the immittance probe in the patient’s ear the same as for tympanometry, but
uses a device to fix the probe to the patient’s head to reduce artifacts that can invalidate test results.
o For threshold testing, stimuli of progressively louder levels are presented until a reflex, if present, is
noted.
o Acoustic reflex decay testing involves presentation of a tone, 10 dB above the reflex threshold, at one or
more frequency 1,000 Hz and below, for a 10-second period. The time that the auditory system sustains
the contraction at least half strength is measured. The patient must remain still and quiet during reflex testing.
o Reflexes and reflex decay may be measured ipsilaterally (in the same ear as the probe that measures the
contraction) or contralaterally (the probe measuring the reflex is in the opposite ear from the ear presented
with the loud tone.) Ipsilateral reflexes are also called uncrossed reflexes; contralateral can be called
crossed reflexes.
After the Procedure
• Care and assessment after these tests include removing the probe from the ear canal and gently cleansing
and drying the canal.
H.) Implications of Abnormal Results Tympanometry
• Any evidence that doesn’t reflect a type A tympanogram is considered abnormal.
• If the conductive loss is unilateral, presentation of the reflex tone to the involved ear, with
measurement contralaterally, may reveal a reflex at an elevated hearing level. The calculated
sensation level would be normal in this case. The finding of a reflex when the probe is in an
affected ear is negative for conductive involvement.
• If the cochlea is the site of the lesion, reflexes may be present at normal hearing levels, elevated,
or absent.
• The more severe the loss, the more likely the finding of an absent reflex.
• Most mild to moderately severe hearing losses have present acoustic reflexes. When the
audiologist computes the sensation level of the reflex, it’s noted as being reduced if there’s
significant loss at that frequency.
• Absent acoustic reflexes raise the possibility of a retrocochlear lesion if conductive involvement
or severe cochlear loss isn’t present.
• Acoustic reflex decay (failure to have a sustained reflex for 5 or more seconds) is also an
indicator of possible retrocochlear involvement.

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• The patient with nonorganic loss (or pseudohypoacusis, a feigned hearing loss or exaggeration of
hearing thresholds) may be discovered during immittance testing. Reflexes present below the admitted
threshold are an indicator of a nonorganic problem.
WORD RECOGNITION
TESTS
•The audiologist administers tests that use speech signals to determine the lowest level that the patient is able to hear
words and the ability to correctly recognize words presented above the threshold level. Auditory processing tests also
involve speech materials, but an auditory processing evaluation may use tests with nonspeech material. In auditory
processing speech testing, the speech signal is degraded.
•Interfering speech may be present, the speech may be filtered to remove some frequencies, or the speed of the material is
increased. These tests place greater stress on the auditory processing system to determine the
patient’s function in challenging conditions.
B.) Purposes
•To determine the degree of hearing loss for speech recognition
C.) Indications
•Determining the extent of hearing loss related to speech recognition as revealed by the faintest level at which the spondee
words are correctly repeated
•Differentiating a real hearing loss from pseudohypacusis
•Evaluating clarity of speech sounds or speech discrimination as revealed by word recognition at 40 dB above the spondee
threshold
•Client lack of familiarity with the language the words are presented in or with the words themselves
•Improper placement of the earphones and inconsistency in frequency of word presentation
•A speaker of a foreign language with biased estimates of speech understanding ability if the testing isn’t conducted in the
patient’s native language, by a speaker who can accurately interpret the patient’s responses
•Speech/ non-speech materials
•Earphones
•Audiometer
•Soundproof booth
Patient Preparation
•Explain the procedure to the patient and what the speech test evaluates.
•Review any materials given to the patient by the audiologist.
•Remove any significant cerumen accumulation.
F.) Normal Values
•A normal speech threshold (spondee threshold, SRT) is in the range of –10 to 15 dB HL for children age 2 and over and –

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10 to 25 dB HL for adults.
•Word recognition scores are normally 100%, though typically reduced in the 570 EAR presence of hearing loss. Speech
tests for auditory processing are interpreted by comparing the patient’s score to age -appropriate norms.
the Procedure
o That the test is performed by an audiologist in a specially equipped soundproof booth and that it takes
about 5 to 10 minutes
o That there are no food or fluid restrictions before the test
• That a series of words that change from loud to soft tones will be presented via earphones and
that the client will be requested to repeat them
o That each ear is tested separately
o That no pain is associated with the test
•Prepare for the procedure:
o Obtain a history of known or suspected hearing disorders and results of pure tone audiometry and other
hearing tests, and determine ability to understand English words and sounds.

•To obtain the threshold of speech reception, the audiologist presents two-syllable words (spondee words) to the patient,
decreasing the intensity until the threshold is obtained. Threshold testing results are reported as spondee thresholds, which
is synonymous with speech reception thresholds (SRTs).
•Children may be asked to point to pictures representing the words. Very young children who don’t have the vocabulary to
identify pictures are tested by having them point to body parts, such as eyes, nose, and “Mommy’s” mouth.
•Occasionally, speech awareness thresholds are used in lieu of speech reception threshold testing to assess the lowest level
at which a patient can detect speech (typically 10 dB below the speech reception threshold). The test may be used as a
substitute for the SRT in a young child and for someone who speaks a foreign language.
•To estimate the patient’s ability to understand speech, lists of one-syllable words are presented, typically in quiet and at
an intensity that’s comfortable for the patient. Word understanding testing is referred to as speech discrimination testing or
word recognition testing. This test can be administered at the level of typical conversational speech (40 to 50 dB HL) to
estimate the impact of the hearing loss on communication in ideal environments. A percentage correct score is obtained.
The test can alternatively be administered at an intensity level that’s comfortable for the patient, which provides limited
prognostic information about probable benefit from amplification.
•When there’s a suspicion of cranial nerve VIII or other retrocochlear involvement, the speech understanding testing may
be repeated at a very high intensity. This form of testing is referred to as rollover testing.

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After the Procedure
•No special aftercare or assessment activities are required for this test.
•SRTs higher than 25 dB HL indicate that the patient can’t hear a whispered sound. Thresholds that range up to 40 dB HL
suggest that the patient has difficulty hearing faint or distant speech. If the person doesn’t wear a hearing aid and has a
SRT of 30 to 40 dB HL, make sure that you speak to the patient in a quiet environment from a distance of no more than 6’
(1.8 m). Speech reception thresholds above 40 dB HL indicate increasing difficulty understanding speech. Closer
proximity to the patient, if unaided, is required. When thresholds exceed 50 dB HL, the patient can’t be expected to
understand you without amplification. Health care facilities can obtain portable personal amplification systems to aid in
communicating with this patient.
•The audiologist will compare the SRT with the pure tone average to cross-check test reliability. The patient who doesn’t
have agreement within 10 dB between the SRT and pure tone average may not have understood test instructions. The
patient with nonorganic loss (exaggeration of hearing thresholds) commonly has a better SRT than pure tone testing
would predict. Word understanding scores below 90% indicate that the patient has some degree of communication
difficulty. The audiologist uses the score, interpreted in conjunction with the presentation level and the audiometric
configuration, as a prognostic indicator of potential for success with amplification. Amplification is most successful in the
patient with higher word understanding scores, although a patient with limited word understanding ability may be a
candidate for amplification.
•The audiologist’s finding of decreased word understanding at a high intensity level indicates “rollover,” which, if
significant, is an indicator of possible retrocochlear involvement. The significance of this finding is interpreted along
with the results of immittance tests.
•Abnormal auditory processing test results are those significantly below the expected level when compared to age-
appropriate norms. This test finding indicates difficulty processing auditory information. Auditory processing disorders
are specific to the auditory modality. For example, the patient with attention deficit hyperactivity disorder may function
abnormally if he lacks motivation for completing the task. The patient with an auditory processing disorder may require
language testing/treatment, specific treatments for auditory processing dysfunction, and may need modification of the
classroom environment. Amplification, whether for the entire classroom or using a personal unit for that child, may be
recommended by the audiologist to ensure that the child receives a signal of sufficient quality to permit speech
understanding and learning.
SITE OF LESION
TESTS
•Otoneural lesion site tests are procedures performed to localize the site of lesions and to determine the extent of damage
to the auditory system.
•A battery of tests is administered that includes Békésy automatic audiometry, tone decay, binaural loudness balance and
midplane localization, masking level differences, speech discrimination, and auditory brainstem electric response.

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• Site-of-lesion tests use earphones to present tones of varying intensities that are distinguished from the sensation
level. The intensity is the hearing level, and the sensation level is the number of decibels above the threshold for a
specific tone.
B.) Purposes
• These tests are usually performed when hearing loss audiometry, admittance tests, and presenting signs and
symptoms indicate sensorineural hearing loss.
• Depending on the test performed, lesions of the cochlear nerve, retrocochlear system, and brainstem and lesions
or damage to the cortex, any of which affect hearing acuity, can be located.
• They assist in differentiating between sensory (cochlear) and neural (acoustic nerve) hearing l oss.
C.) Indications
• Dizziness, tinnitus, hearing loss, and other neurological complaints to determine whether they are caused by
sensorineural hearing function
• Determination of the presence and location of lesion sites when conductive hearing loss has bee n previously
tested and ruled out
• Differentiation between sensory (cochlear) and neural (acoustic nerve) hearing loss; differentiation between
cochlear and retrocochlear hearing loss; location of lesions of the retrocochlear system at the acoustic nerve that
can be extraaxial or intra-axial brainstem or cortex lesions
• Determination of the presence, site, and effects of neural lesions of the auditory system
• Diagnosis of Ménière’s disease as revealed by sensory hearing loss
• Improper electrode placement or poor equipment function
• Inability of client to understand or cooperate during the test
• Severe hearing impairment, which can affect the ability of the client to participate in the tests when tones are
presented and responses are expected
• Earphones
Patient Preparation
• No restrictions in foods or fluids or special preparation before the tests
F.) Normal Values
• Normal auditory system and sensorineural hearing; no lesions of the cochlear apparatus, acoustic (eighth) nerve,
or auditory pathways to the brain
• Békésy audiometry: Pulsed and continuous tones overlap on the tracings
• Tone decay: Tone perceived at 0–10 dB above threshold for 1 min
• Binaural loudness balance: Two sounds perceived as being of equal loudness when presented in equal intensity
• Binaural midplane localization: One tone heard at the center of the head when two tones of equal intensitiesare
presented
• Masking level differences: A threshold difference of 12 dB between homophasic and antiphasic conditions
• Auditory brainstem electric response: Acoustic nerve and upper brainstem response wave tracings that follow the

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same pattern
• Explain to the client:
o That the tests are performed by an audiologist in a quiet specially equipped room and that they take up to
90 minutes, depending on the number of tests to be conducted
o That there are no restrictions in foods or fluids or special preparation before the tests
o That each ear can be tested individually and that earphones are used to transmit sounds that the client
responds to verbally or by pushing a button
o That no pain is associated with the tests
• Prepare for the procedure:
o Obtain a history of known or suspected hearing loss and cause; signs and symptoms associated with the
auditory system; and past auditory tests, procedures, and results.
• The client is placed in a quiet environment in a sitting position. The earphones are placed on the head and secured
over both ears.
• Békésy Audiometry. The audiometer is set to record at the desired frequencies (one or across all of them, from
100 to 10,000 Hz). The threshold for a pulsing tone and a continuous tone is determined for this test. The client
is requested to control the intensity by pressing a response button every time a tone is heard until the tone is no
longer heard and then releasing the button. This procedure causes the tone intensity to increase and allows the
client to trace back and forth across his or her threshold. The procedure is repeated for 5 minutes and can be
increased gradually from 100 to 10,000 Hz. The tracings of the frequencies (broken for the pulsed tone and solid
for the continuous tone) are recorded on an audiogram.
• Tone Decay Test. A tone is presented at the client’s threshold and the client is requested to identify the time at
which the tone is audible through the earphones. Tones are increased 5 dB if sounds are inaudible so that a tone
can be heard again. The tone is repeated until it is heard continuously for a minute to determine the presence of
pathological adaptation that is mildly abnormal in sensory lesions and severely abnormal in neural lesions. In
cochlear or retrocochlear lesions a tone is lower or higher than the threshold, respectively.
• Binaural Loudness Balance. A tone is presented to one ear and then the other; the tone at one ear is kept at a
constant intensity of 90 dB, and then a varied tone is used in the other. The client is requested to respond when
the tones sound the same in both ears. This procedure differentiates between cochlear and retrocochlear lesions
by the presence of recruitment (abnormal increase in the perception of loudness or hearing of sounds despite a
hearing loss) or absence of recruitment, respectively.
• Binaural Midplane Localization. A tone is presented to one ear at 90 dB while tones of varied intensities are
presented to the other ear. The client is requested to indicate when a single tone is heard at the center of the head.

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This procedure differentiates between cochlear and retrocochlear lesions by hearing a centered sound or never
hearing the centered sound, respectively.
• Masking Level Differences. A tone of 500 Hz and a masking noise are presented to both ears at a constant
intensity, and the threshold is determined. This determination is followed by a change that cannot be heard by
either ear individually to establish another threshold level. This procedure determines acoustic nerve or
brainstem lesion if no change is noted at different threshold levels.
• Auditory Brainstem Electric Response. Electrodes are placed at the scalp vertex, and the mastoid process of one
ear is tested and then the other. The stimuli are presented in rapid tone times of 1 millisecond at 10 per second
until a desired number of responses are recorded. The responses are recorded as waves at 1-millisecond intervals
at different intensities. Cochlear and retrocochlear lesions are differentiated by normal responses at high
intensities or by absent or late responses at high intensities, respectively.
After the Procedure
• Care after these tests includes removing the devices from the head.
• Tracings reveal movements above and below the client’s threshold, and the types of curves on the tracing identify
the type of auditory lesions as follows:
o Type I: Normal overlapping tracings in which continuous and interrupted tracings are superimposed
o Type II: Superimposed tracings up to 1000 Hz with a separation of tracings of 20 dB above this
frequency, indicative of cochlear loss or Ménière’s disease
o Type III: Separation of the tracings at lower frequencies and decline in the threshold for the continuous
tone, indicative of retrocochlear pathology (neural lesions such as acoustic neurinoma)
o Type IV: Separation of the tracings at all frequencies, indicative of active severe cochlear lesions or early
neural lesions
o Type V: Separation of the tracings with the threshold of the interrupted tracings greater than the threshold
for continuous tracings, indicative of psychogenic hearing loss.
ELECTRONYSTAGMOG
RAPHY
•In electronystagmography(ENG) testing and videonystagmography (VNG) testing, eye movements in response to
specific stimuli are recorded and used to evaluate the interactions of the vestibular system and the muscles
controlling eye movement in what is known as the vestibulo-ocular reflex. Nystagmus, the involuntary back-and- forth
eye movements caused by this reflex, results from the vestibular system’s attempts to maintain visual
function during head movement.
•Nystagmography is a technique for monitoring nystagmus and other eye movements. The eye movements can be
monitored using electrodes placed near the eyes. Traditional ENG records the corneoretinal potential—the difference of 1
mV between the positive charge of the cornea and the negative charge of the retina—to record nystagmus through
electrodes placed near the eyes. In VNG, goggles are placed over the patient’s eyes, and eye movements are recorded with
an infrared camera.
•The tests seek to determine whether the disorder is peripheral (inner ear or related to cranial nerve VIII involvement) or
central (originating from problems of the central nervous system, brain stem, cerebellum, or cerebrum).

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B.) Purposes
•To help identify the cause of dizziness and vertigo
•To confirm the presence and location (central or oculomotor, peripheral, or both) of a lesion
•To assess neurologic disorders
C.) Indications
•Identify the cause of dizziness and vertigo
•Confirm the presence and location (central or oculomotor, peripheral, or both) of a lesion
•Assess neurologic disorders
•Identify abnormal nystagmus
•Back or neck condition that could be aggravated by the procedure
Precautions
•If the patient has a back or neck condition that could be aggravated by rapid changes in position, check with the
physician to determine if any of the positional tests should be omitted.
•Water caloric testing can’t be safely used if the patient has a perforated tympanic membrane. Air caloric test results won’t
be accurate.
•After testing, the audiologist monitors the patient’s status and advises him to remain in a position that reduces dizziness,
if present after the procedure.
•The patient is advised not to drive until all symptoms of imbalance have subsided.
Interfering Factors
•Medication that suppresses or stimulates CNS function
•Poor eyesight or extraocular muscle weakness
•Drowsiness and level of alertness
•Poor patient cooperation E.) Equipment/Patient Preparation Equipment
•Electronystagmogram
•Videonystagmogram
•Goggles
•Light bar
Patient Preparation
•▪ Make sure that the patient’s ear canals are free of cerumen before referring him for ENG testing. The caloric
testing portion of the ENG can’t be conducted safely or accurately if he has cerumen accumulation or a tympanic
membrane perforation.
•Inform the patient that tympanometry will be conducted before caloric testing to ensure tympanic membrane integrity.
•Tell the patient that his dizziness problems will be assessed by recording eye movements.
•Inform the patient that the procedure will require about 11⁄2 hours to complete.
•Reassure the patient that the test isn’t painful and someone will be present to make sure that he doesn’t fall, but explain
that some portions may make him briefly dizzy or nauseated. Because of this, advise him not to eat or drink for 3 to 4

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hours before the test.
•Suggest that someone accompany the patient to the evaluation, as occasionally the patient doesn’t feel well enough to
drive after the appointment. Avoid overemphasizing the risk of discomfort because patient anxiety increases the risk of
nausea and vomiting during the procedure.
•Encourage the patient to wear comfortable clothing. A woman should wear pants.
•If testing involves traditional ENG with attachment of recording electrodes, inform the patient that his skin will need to
be cleaned, so ideally make-up or facial creams shouldn’t be used on the day of the test. VNG testing is compromised by
mascara, so a woman should refrain from wearing make-up on the day of the test.
•Instruct the patient not to smoke or drink caffeinated beverages the day of the test. He should refrain from taking
nonessential medication for 48 hours before the test.
•Ask the patient to bring a list of his medications to the evaluation. He must not use alcoholic beverages, tranquilizers,
sleeping pills, antihistamines, antivertigo agents, or opioids for 48 hours before the test because they prevent accurate
collection and interpretation of the results. Other medications can create dizziness, wh ich include salicylates,
antidepressants, diuretics, stimulants, and certain aminoglycoside antibiotics. ▪ If the patient wears glasses, tell him to
bring them to the test. The patient who wears contact lenses should bring eyeglasses to the examination, if possible.
• Tell the patient that the audiologist will ask for a description of the dizziness and to describe when it began. It’s
helpful if the patient thinks about what situations create or make the dizziness worse. Also, find out about the
progression of the patient’s symptoms by asking him to think about words that might describe the dizziness
other than the word “dizzy,” such as “spinning,” “wobbly,” or “unsteady.”
F.) Normal Values
• Saccadic pursuit testing. Square-wave patterns of differing amplitudes mimicking the target, minimal latency
and good accuracy of eye movements
• Gaze testing. No nystagmus with eyes open, weak or no nystagmus with eyes closed
• Positional testing (head in position). Eyes open, no nystagmus; eyes closed or wearing light-excluding goggles,
no more than weak nystagmus in one or more positions
• Positioning testing (head in movement toward the position). Eyes open, no nystagmus; eyes closed or wearing
light-excluding goggles, no more than weak nystagmus in one or more positions
• Smooth pursuit tracking. Volitional smooth tracking of the target, accuracy within age norms
• Optokinetic testing. Eye movement follows stimulus at speeds to 30 degrees per second; clear triangular wave
pattern; similar pattern for stimuli traveling in both directions
• Caloric testing. Eyes closed, nystagmus occurring in all conditions; suppressed by visual fixation with cold

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stimuli, nystagmus beats to opposite ear; with warm stimuli, it beats to same ear.
• Make sure that the patient’s ear canals are free from cerumen before referring him for ENG testing. The caloric
testing portion of the ENG can’t be conducted safely or accurately if he has cerumen accumulation or a tympanic
membrane perforation.
• Inform the patient that tympanometry will be conducted before caloric testing to ensure tympanic membrane
integrity.
• Tell the patient that his dizziness problems will be assessed by recording eye movements.
• Inform the patient that the procedure will require approximately 11⁄2 hours to complete.
• Reassure the patient that the test isn’t painful and someone will be present to ensure that he doesn’t fall, but that
some portions may briefly make him dizzy. Because of this, advise him not to eat or dri nk for 3 to 4 hours before
the test.
• Suggest that someone accompany the patient to the evaluation, as occasionally the patient doesn’t feel well
enough to drive after the appointment. Avoid overemphazing the risk of discomfort because patient anxiety
increases the risk of nausea and vomiting during the procedure.
• Encourage the patient to wear comfortable clothing. A woman should wear pants.
• If testing involves traditional ENG with attachment of recording electrodes, inform the patient that his skin will
need to be cleaned, so ideally make-up or facial creams shouldn’t be used on the day of the test. VNG testing is
compromised by mascara, so a woman should refrain from wearing make-up on the day of the test.
• Alert the health care facility performing the test if the patient has a history of back or neck problems that would
be exacerbated by head or neck movement.
• If the patient wears glasses, tell him to bring them to the test. The patient who wears contact lenses should bring
eyeglasses to the examination, if possible.
• Tell the patient that the audiologist will ask for a description of the dizziness and to describe when it began. It’s
helpful if the patient thinks about what situations creates or makes the dizziness worse. Additionally, find out
about the progression of the patient’s symptoms by asking him to think about words that might describe the
dizziness other than the word “dizzy.”
• After the device is set up, light bars are connected to the equipment.
• The patient is positioned a calibrated distance from the light source and asked to follow the movement of the
lights using eye movement only. The eye movements are recorded and graphed.
• Oculomotor testing
• Saccade testing
o The patient is asked to watch the movement of a dot on the light bar. The dot position will move varying
amounts, which correspond to eye deviations in degrees. The accuracy and velocity of the eye tracking
of the rapidly moving light is measured. The traces are analyzed to determine if there’s symmetrical (right versus left
and up versus down) eye movement or dysmetria such as excessive overshoot or undershoot. Glissades, a slowing
of the eye movement as it approaches a target, is also ruled out.
• Gaze nystagmus testing
o The patient is asked to look at the light on the light bar and hold the gaze steady. Gaze is directed left,
right, up, and down.

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o The patient is also asked to close his eyes and retain the gaze direction in traditional ENG testing.
When VNG recordings are made, the goggles exclude light and the recordings are made with the eyes
open. Nystagmus shouldn’t occur with the patient’s eyes open while he fixates on the target and should
be minimal with his eyes closed or when goggles exclude light.
• Smooth pursuit (sinusoidal) tracking testing
o The patient watches the dot on the light bar as it moves smoothly back and forth at varying rates.
o The eye movement is observed to determine if the patient can track the target accurately.
o Tracings are analyzed for left/right symmetry and “smoothness” of the eye’s tracking (pursuit) of the
target.
• Optokinetics testing
o The patient is instructed to look at the light bar as a series of dots moves across the screen, first in one
direction (for example, right to left), and then in the other direction.
o The patient’s eyes rapidly move back to center and track another dot. This creates a tracing that looks
like nystagmus: the patient follows a dot for a brief period; the eyes rapidly move back to center and
track another moving dot. This test assesses the CNS’s ability to control rapid eye movement and will be
affected by an existing nystagmus.
• Positional and positioning testing
o The patient’s eye movements are recorded as he’s moved into various body positions and as he remains
in these body positions. Recordings note whether nystagmus is present, and if so, the positions that elicit the
nystagmus are noted and have diagnostic significance.
o In the Dix-Hallpike test, diagnostic for benign paroxysmal positional vertigo (BPPV), the patient is
initially seated. He’s then rapidly moved into a supine, head hanging position, with the head deviated to
the side and then returned to a sitting position.
o If torsional eye movements are observed, time-locked to the subjective report of dizziness, the findings
are positive for BPPV. The test is repeated to establish fatigability, also classic in BPPV. The direction of
the rotational eye movement assists in diagnosing which semicircular canal is involved and helps to
establish the appropriate BPPV repositioning treatment.
• Caloric testing
o The patient lies supine with his head elevated 30 degrees so that the horizontal semicircular canals are
perpendicular to the floor.
o The patient’s ear is irrigated with water or air (depending upon the system used) for approximately 60
seconds per irrigation. Four irrigations are completed (both temperatures for each ear).
o Heating and cooling the outer ear causes a change in temperature of the middle ear. The horizontal
semicircular canal is located behind the medial wall of the middle ear. The fluid in the semicircular canal
moves when the temperature of the fluid is changed, eliciting nystagmus. Thus, for caloric testing,
nystagmus is normal.
o The patient is instructed to open his eyes during one portion of each recording. Visual fixation reduces
nystagmus if the CNS is normal.

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o The symmetry of the nystagmus elicited by irrigation of each ear is assessed. The different temperatures
produce different directions of nystagmus. The symmetry of the left beating nystagmus and the right beating
nystagmus is analyzed.
o If the patient fails to respond to standard caloric stimulation, ice calorics may be used. A small quantity
of ice water or very cold air is introduced into the ear canal to determine if there’s residual functioning of that
ear’s vestibular system.
After the Procedure
• After testing is complete, the patient may resume his usual diet.
• Nystagmus after a head turn is prolonged, or nystagmus occurs when the patient isn’t turning his
head.
• A peripheral lesion may involve the end organ or the vestibular branch of the eighth cranial nerve
and may result from conditions such as Ménière’s disease, multiple sclerosis, ischemic damage
to the cochlea, autoimmune disease, and vestibular ototoxicity and eighth nerve tumors.
• A central lesion may involve the brain stem, cerebellum, cerebrum, or any of the connecting
structures and may result from demyelinating diseases, tumors, or circulatory disorders.
Test Abnormal Findings Usual Underlying Conditions
Ocular dysmetria: significant Central nervous system (CNS)
undershoots, overshoots, glissades, or pathology: possible brain stem,
Saccadic pursuit testing pulsion; reduced eye velocity, cerebellum, or cortex involvement
accuracy, prolonged latency Nonlocalizing, possibly caused by
spontaneous or gaze nystagmus

Spontaneous nystagmus: significant Nonlocalizing abnormality of the
amount noted when eyes are closed or vestibular system: occurs in acute
when tested in complete darkness peripheral disorders, is horizontal and
under goggles while gazing forward initially beats away from the affected
ear; possible CNS involvement if
present with eyes open, or when
viewing a target, or if nystagmus
changes direction
Gaze nystagmus: presence of CNS involvement (peripheral lesions):
Gaze Testing nystagmus only when the eyes are spontaneous nystagmus, stronger
deviated from midline when patient looks in the direction of
the nystagmus fast phase
Up-beating nystagmus: upward Cerebellar or brain stem involvement
deviation of eye movement
Down-beating nystagmus: downward Cerebellar or cervicomedullary

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deviation of eye movement junction involvement
Rotary nystagmus: non-classic benign Brain stem or vestibular nuclei
paroxysmal positional vertigo (BPPV)
Nystagmus: either changes direction Nonlocalizing: suppression with visual
across positions or positioning or fixation suggestive of peripheral
remains in the same direction, but involvement; enhancement of
Positional Testing (Head in Position) isn’t spontaneous nystagmus nystagmus or failure to suppress with
visual fixation suggestive of central
etiology
Transient, fatigable torsional eye BPPV: responds well to repositioning
Positional Testing (Head in Movement movement: during Dix-Hallpike maneuvers
toward the Position) procedure, occurring with subjective
dizziness
Sinusoidal tracking: with Nonlocalizing, possibly caused by
superimposed nystagmus spontaneous or gaze nystagmus
Break-up in tracings or saccades: CNS involvement if peripheral visual
jerking, rather than smooth problems ruled out
Smooth Pursuit Tracking movements; reduced velocity,
accuracy, prolonged latency that isn’t
accounted for by advanced age or poor
cooperation
Significant asymmetry: not explained CNS involvement
by spontaneous or gaze nystagmus
Optokinetic Testing
Reduced eye velocity: when compared CNS involvement if peripheral visual
with age-appropriate norms problems ruled out
Unilateral weakness: over 20% to 30% Peripheral lesion of weaker side
difference in maximum slow-phase
Caloric Testing velocities (averaged across
temperatures) between ears
Bilateral weakness: slow-phase Bilateral peripheral or CNS
velocity of the sum of the four caloric involvement
irrigations reduced, typically below 20
degrees (average of each irrigation ≤ 5
degrees/second)
Directional preponderance: more than Nonlocalizing, usually due to
30% difference in maximum slow- underlying spontaneous nystagmus
phase velocities for right- versus left- CNS involvement
beating nystagmus Failure to suppress
fixation: visual fixation that fails to
reduce nystagmus by at least 40%

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WORKSHEET ON NEUROLOGIC EXAMS
SKULL RADIOGRAPHY
INTRACRANIAL COMPUTED TOMOGRAPHY MAGNETIC RESONANCE IMAGING
ELECTROENCEPHALOGRAPHY EVOKED POTENTIAL STUDIES
COMPUTED TOMOGRAPHY OF THE SPINE
OCULOPLETHYSMOGRAPHY TRANSCRANIAL DOPPLER STUDY CEREBRAL ANGIOGRAPHY
DIGITAL SUBTRACTION ANGIOGRAPHY ELECTROMYOGRAPHY CEREBROSPINAL FLUID ANALYSIS
MYELOGRAPHY
TENSILON TEST
SKULL
RADIOGRAPHY
•Although skull radiography is of limited value in assessing patients with head injuries, skull X-rays are extremely
valuable for studying abnormalities of the skull base and cranial vault, congenital and perinatal anomalies, and systemic
diseases that produce bone defects of the skull. For more accurate assessment of head injuries as well as of skull and
head abnormalities, nonenhanced computed tomography studies of the head are done.
•Skull radiography evaluates the three groups of bones that comprise the skull: the calvaria (vault), the mandible (jaw
bone), and the facial bones. The calvaria and the facial bones are closely connected by immovable joints with irregular
serrated edges called sutures. The skull bones form an anatomic structure so complex that a complete skull examination
requires several radiologic views of each area.
B.) Purposes
•To detect fractures in the patient with head trauma
•To aid in the diagnosis of pituitary tumors
•To detect congenital anomalies
•To detect metabolic and endocrinologic disorders
C.) Indications
•Known or suspected trauma to the face or cranium to reveal a fracture
•Suspected increased intracranial pressure revealed by abnormal markings on the inside of the cranial vault

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•Suspected pituitary tumor revealed by increased size and erosion of the sella turcica
•Suspected metastatic tumor involving the small bones or brain tissue revealed by a shift of intracranial contents
Suspected acromegaly revealed by an enlarged mandible
•Suspected tumor or inflammation involving the paranasal sinuses
•Suspected Paget’s disease revealed by a thickening of the skull bones
•Suspected vascular abnormalities such as chronic subdural hematoma revealed by calcifications in brain tissue
Suspected perinatal injury or congenital defect involving the skull
•Evaluation of thinning of bones, separation of suture lines, widened fontanels, and an enlarged cranium in the diagnosis
of hydrocephalus in infants
•Evaluation of premature closing of the cranial sutures in the diagnosis of craniostenosis in infants
Interfering Factors
•Improper positioning to achieve the desired views
•Limitations in positioning from known or suspected fractures of the cervical vertebrae
•Metal objects such as dentures, hearing aids, and eyeglasses within the x-ray field
Precautions
•Don’t hyperextend or flex the head if cervical injuries are unknown or suspected.
• X-ray machine
• Film
• Table-top
• Sagittal plane
• Folded towel
Patient Preparation
• Explain to the patient that his head will be immobilized and that several X-rays of his skull will be taken from
various angles.
• Tell the patient that skull radiography helps to determine the presence of anomalies and helps establish a
diagnosis.
• Tell the patient who will perform the test and where it will take place.
• Explain to the patient that he doesn’t need to restrict food and fluids and that the test will cause no discomfort.
• Tell the patient to remove glasses, dentures, jewelry, or any metallic objects that would be in the X-ray field.
F.) Normal Values
• The size, shape, thickness, and position of the cranial bones as well as the vascular markings, sinuses, and sutures
are normal for the patient’s age.

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• Explain to the patient that his head will be immobilized and that several X-rays of his skull will be taken from
various angles.
• Tell the patient that skull radiography helps to determine the presence of anomalies and helps establish a
diagnosis.
• Tell the patient who will perform the test and where it will take place.
• Tell the patient to remove glasses, dentures, jewelry, or any metallic objects that would be in the X-ray field.
• Have the patient recline on the X-ray table or sit in a chair.
• Tell the patient to remain still during the procedure.
• Use foam pads, sandbags, or a headband to immobilize the patient’s head and increase comfort.
• Five views of the skull are routinely taken: left and right lateral, anteroposterior Towne’s, posteroanterior
Caldwell, and axial (or base).

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After the Procedure
•Films are developed and checked for quality before the patient leaves the area.
•Report abnormal findings to the practitioner.
•Prepare to educate the patient about his diagnosis.
•Prepare the patient for further testing or surgery, as indicated.
•Provide emotional support to the patient and his family.
•Structural abnormalities suggest possible fractures of the vault or base of the skull or congential anomalies.
•Erosion, enlargement, or decalcification of the sella turcica suggests possible increased intracranial pressure.
•Areas of calcification suggest possible conditions, such as osteomyelitis, or the presence of neoplasm within
the brain substance that contain calcium, such as oligodendrogliomas or meningiomas.
•Midline shifting of a calcified pineal gland suggests a possible spaceoccupying lesion.
•Changes in bone structure suggest possible metabolic disorders, such as acromegaly or Paget’s disease.
INTRACRANIAL COMPUTED
TOMOGRAPHY
•Intracranial computed tomography (CT) provides a series of tomograms, translated by a computer and displayed on a
monitor, representing cross-sectional images of various layers of the brain. This technique can reconstruct crosssectional,
horizontal, sagittal, and coronal plane images.
•In many cases, intracranial CT scanning eliminates the need for painful and hazardous invasive procedures, such as
pneumoencephalographyand cerebral angiography. CT scans, which usually use contrast enhancement, are especially
valuable in assessing a patient with focal neurologic abnormalities and other clinical features that suggest an intracranial
mass. In a patient with a suspected head injury, intracranial CT scans may allow the diagnosis of a subdural hematoma
before characteristic symptoms appear.
B.) Purposes
•To diagnose intracranial lesions and abnormalities
•To monitor the effects of surgery, radiation therapy, or chemotherapy on intracranial tumors
•To serve as a guide for cranial surgery
C.) Indications
•Diagnose intracranial lesions and abnormalities
•Monitorthe effects of surgery, radiation therapy, or chemotherapy on intracranial tumors
•Serve as a guide for cranial surgery
•Intracranial CT scanning with contrast enhancement is contraindicated in the patient who’s hypersensitive to iodine or

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contrast medium.
Precautions
•Iodine or contrast medium may be harmful or fatal to a fetus, especially during the first trimester.
Interfering Factors
•Patient’s head movement (possible poor imaging)
•Failure to remove metal objects from the scanning field (possible poor imaging)
•Hemorrhage (possible false-negative imaging due to change in hematoma)
•CT scanner, oscilloscope, contrast medium (iothalamate meglumine or diatrizoate sodium), 60-ml syringe, 19G to 21G
needle, I.V. tubing and I.V. insertion equipment, if needed
Patient Preparation
•Explain that intracranial CT permits assessment of the brain.
•Unless contrast enhancement is scheduled, inform the patient that there are no food or fluid restrictions. If contrast
enhancement is scheduled, instruct him to fast for 4 hours before the test.
•Tell the patient that a series of X-rays will be taken of his brain. Describe who will perform the test and where it will take
place. Explain that the test will cause minimal discomfort.
•Tell the patient that he’ll be positioned on a moving CT bed with his head immobilized and his face uncovered. The head
of the table will then be moved into the scanner, which rotates around his head and makes loud clacking sounds.
• If a contrast medium is used, tell the patient that he may feel flushed and warm and may experience a transient
headache, a salty or metallic taste, or nausea and vomiting after the contrast medium is injected.
• Instruct the patient to wear a gown (outpatients may wear comfortable clothing) and to remove all metal objects
from the CT scan field.
• If the patient is restless or apprehensive, a sedative may be prescribed.
• Check the patient’s history for hypersensitivity to shellfish, iodine, or contrast media, and mark your findings in
his chart. Inform the practitioner of any sensitivities because he may order prophylactic medications or may
choose not to use contrast enhancement.
F.) Normal Values
• Tissue densities appear as white, black, or shades of gray on the computed image obtained by intracranial CT
scanning.
• Bone, the densest tissue, appears white; ventricular and subarachnoid cerebrospinal fluid, the least dense, appears
black.
• Brain matter appears in shades of gray.
• Structures are evaluated according to their density, size, shape, and position.

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• Explain to the patient that intracranial CT permits assessment of the brain.
• Tell the patient that a series of X-ray films will be taken of his brain. Describe who will perform the test and
where it will take place. Explain that the test will cause minimal discomfort.
• Tell the patient that he’ll be positioned on a moving CT bed with his head immobilized and his face uncovered.
The head of the table will then be moved into the scanner, which rotates around his head and makes loud
clacking sounds.
his chart. Inform the physician of any sensitivities because he may order prophylactic medications or may
• Explain to the patient that intracranial CT permits assessment of the brain.
• Unless contrast enhancement is scheduled, inform the patient that there are no food or fluid restrictions. If
contrast enhancement is scheduled, instruct him to fast for 4 hours before the test.
• Tell the patient that a series of X-ray films will be taken of his brain. Describe who will perform the test and
where it will take place. Explain that the test will cause minimal discomfort.
• Tell the patient that he’ll be positioned on a moving CT bed with his head immobilized and his face uncovered.
The head of the table will then be moved into the scanner, which rotates around his head and makes loud
clacking sounds.
his chart. Inform the physician of any sensitivities because he may order prophylactic medications or may
After the Procedure
• If a contrast medium was used, watch the patient for residual adverse reactions (headache, nausea, and vomiting)
and inform him that he may resume his usual diet.
• Areas of altered density (they may be lighter or darker) or displaced vasculature or other structures may
indicate an intracranial tumor, a hematoma, cerebral atrophy, an infarction, edema, or congenital
anomalies such as hydrocephalus.
• Intracranial tumors vary significantly in appearance and characteristics. Metastatic tumors generally
cause extensive edema in early stages and can usually be defined by contrast enhancement. Primary

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tumors vary in density and in their capacity to cause edema, displace ventricles, and absorb the
contrast medium in contrast enhancement.
• Because the high density of blood contrasts markedly with low-density brain tissue, it’s normally easy
to detect subdural and epidural hematomas and other acute hemorrhages.
• Cerebral atrophy customarily appears as enlarged ventricles with large sulci.
• Cerebral infarction may appear as lowdensity areas at the obstruction site or may not be apparent,
especially within the first 24 hours or if the infarction is small or doesn’t cause edema.
• In the patient with arteriovenous malformation, cerebral vessels may appear with slightly increased
density. Contrast enhancement allows a better view of the abnormal area, but magnetic resonance
imaging is now the preferred procedure for imaging cerebral vessels.
• Another technology for obtaining brain images is positron emission tomography.
MAGNETIC RESONANCE
IMAGING
•Intracranial magnetic resonance imaging (MRI) produces highly detailed, crosssectional images of the brain and spine in
multiple planes. The primary advantage of MRI is its ability to “see through” bone and to delineate fluid- filled soft tissue.
It has proved useful in the diagnosis of cerebral infarction, tumors, abscesses, edema, hemorrhage, nerve fiber
demyelination (as in multiple sclerosis), and other disorders that increase the fluid content of affected tissues. MRI can
show irregularities of the spinal cord with a resolution and detail previously unobtainable. It can also produce images of
organs and vessels in motion.
•MRI technology makes use of magnetic fields and radio-frequency waves, which are imperceptible by the patient; no
harmful effects have been documented. Research continues on the optimal magnetic fields and radio-frequency waves for
each type of tissue.
B.) Purposes
•To help diagnose intracranial and spinal lesions and soft-tissue abnormalities
C.) Indications
•Diagnosing and locating brain tumors, that is, primary and metastatic malignancy, acoustic neuroma, optic nerve tumor,
pituitary microadenoma, lipoma, or benign meningioma
•Determining vascular disorders of the brain, that is, aneurysm, infarcts, intraparenchymal hematoma or hemorrhage, AV
malformations
•Detecting areas of nerve fiber demyelination in the definitive diagnosis of multiple sclerosis
•Determining the cause of cerebrovascular accident, cerebral infarct, or hemorrhage
•Determining cranial bone or face, throat, and neck soft tissue lesions, such as spread of tumor or infection
•Diagnosing intracranial infections, that is, pyogenic abscess, ventriculitis, subdural empyema, toxoplasmosis associated
with acquired immunodeficiency syndrome, or tuberculosis, when procedure is performed in combination with or in place
of CT

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•Determining the cause of seizures, that is, intracranial infection or edema or increased intracranial pressure
•Assessing intracranial vascular integrity in evaluating the predisposition to cerebral atherosclerosis
•Determining cerebral changes associated with dementia
•Evaluating effectiveness of chemotherapy or radiation therapy in tumor treatment
•Evaluating postoperative shunt placement and function performed for hydrocephalus in infants
•Because MRI works through a powerful magnetic field, it can’t be performed on the patient with a pacemaker, an
intracranial aneurysm clip, or other ferrous metal implants or on a patient with gunshot wounds to the head.
•Pregnancy, unless the benefits of performing the study greatly outweigh the possible risks to the fetus
•Extreme obesity Unstable medical status, including confusion or combative demeanor, monitoring of vital signs, use of
cardiopulmonary or other monitoring or assistive life-support equipment, and use of neurological or musculoskeletal
stimulators
•Extreme claustrophobic response that prevents the client from remaining still while enclosed in the scanner, unless
medications are given before the study
•Presence of cardiac pacemaker that can be deactivated by MRI, metallic clips or prostheses, or heart valves that can be
displaced and cause injury to the client during MRI
Precautions
•Because of the strong magnetic field, metallic or computer-based equipment (for example, ventilators and I.V. pumps)
can’t enter the MRI area.
Interfering Factors
• Inability of client to remain still during the procedure

• Metallic objects within the examination field that cause artifacts in the image, such as jewelry; watches; infusion
pumps; metallic or other implants such as heart valves, cochlear or orthopedic prostheses, rods or screws, or
dentures; hairpins or hair clips; pacemaker; or ferromagnetic aneurysm clips
• MRI
• Radioactive contrast dye
Patient Preparation
• Explain that intracranial MRI assesses bone and soft tissue. Tell the patient who will perform the test and where it
will take place.
• Explain that MRI is painless and involves no exposure to radiation from the scanner. A radioactive contrast dye
may be used, depending on the type of tissue being studied.
• Advise the patient that he’ll have to remain still for the entire procedure.
• Inform him that the opening for the head and body is quite small and deep. Tell him that he’ll hear the scanner
clicking, whirring, and thumping as it moves inside its housing.
• Explain to the patient he may receive a sedative if he suffers from claustrophobia or if extensive time is required

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for scanning. As an alternative, an open MRI scanner may be used, which delivers accurate results, but may take
longer to complete.
• Reassure the patient that he’ll be able to communicate with the technician at all times.
• Instruct the patient to remove all metallic objects, including jewelry, hairpins, and watch. Also ask him if he has
any surgically implanted joints, pins, clips, valves, pumps, or pacemakers containing metal that could be
attracted to the strong MRI magnet. If he does, he won’t be able to undergo the test.
F.) Normal Values
• Brain and spinal cord structures appear distinct and sharply defined.
• Tissue color and shading vary, depending on the radio-frequency energy, magnetic strength, and degree of
computer enhancement.
• Explain to the patient that intracranial MRI assesses bone and soft tissue. Tell him who will perform the test and
where it will take place.
• Explain to the patient that MRI is painless and involves no exposure to radiation from the scanner. A radioactive
contrast dye may be used, depending on the type of tissue being studied.
• Advise the patient that he’ll have to remain still for the entire procedure.
• Inform the patient that the opening for the head and body is quite small and deep. Tell him that he’ll hear the
scanner clicking, whirring, and thumping as it moves inside its housing.
• Explain to the patient that sedation may be administered i f he suffers from claustrophobia or if extensive time is
required for scanning. As an alternative, an open MRI scanner may be used, which delivers accurate results, but
may take longer to complete.
• Reassure the patient that he’ll be able to communicate with the technician at all times.
• Instruct the patient to remove all metallic objects, including jewelry, hairpins, and a watch. Also ask him if he has
any surgically implanted joints, pins, clips, valves, pumps, or pacemakers containing metal that could be
attracted to the strong MRI magnet. If he does, he won’t be able to undergo the test.
• The patient is placed in a supine position on a narrow bed, which then slides him to the desired position inside the
scanner, where radio-frequency energyis directed at his head or spine.
• The resulting images are displayed on a monitor and recorded on film or magnetic tape for permanent storage.
• The radiologist may vary radiofrequency waves and use the computer to manipulate and enhance the images.
• During the procedure, the patient must remain still.
After the Procedure
• Tell the patient that he may resume his usual activity after the test.
• If the patient was sedated, ensure that a responsible person drives him home.
• If the test took a long time and the patient was lying flat for an extended period, observe him for orthostatic
hypotension.

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• Structural changes resulting from disorders that increase tissue water content, such as cerebral edema,
demyelinating disease, and pontine and cerebellar tumors, are detected.
• Areas of demyelination appear as curdlike, gray or gray-white areas around the edges of ventricles.
• Tumors appear as changes in normal anatomy, which computer enhancement may further delineate.
ELECTROENCEPHALOG
RAPHY
•Electroencephalography (EEG) is an electrophysiologic study performed to measure the electric activity of the brain
cells. It is conducted to assist in diagnosing and evaluating the course of structural abnormalities involving the brain.
Electrodes are placed at 8 to 16 sites or at pairs of sites on the scalp and connected to an amplifier. Recordings of
waveforms on a moving paper strip during sleep and waking periods reveal patterns characteristic of specific disorders.
Guidelines for electrode placement and the use of a uniform lettering and numbering system to obtain the recordings are
standardized for each client and allow comparison of repeated studies on a single client
•In EEG, electrodes attached to areas of the patient’s scalp record the brain’s electrical activity and transmit this
information to an electroencephalograph, which records the resulting brain waves on recording paper. The procedure may
be performed in a special laboratory or by a portable unit at the bedside. Intracranial electrodes are surgically implanted to
record EEG changes for localization of the seizure focus.
B.) Purposes
•▪ To determine the presence and type of seizure disorder
•To aid in the diagnosis of intracranial lesions, such as abscesses and tumors
•To evaluate the brain’s electrical activity in metabolic disease, cerebral ischemia, head injury, meningitis, encephalitis,
mental retardation, psychological disorders, and drugs
•To evaluate altered states of consciousness or brain death
C.) Indications
•Diagnosis and evaluation of epilepsy and seizure activity
•Suspected intracranial cerebrovascular lesions such as hemorrhages and infarcts
•Suspected intracranial lesions such as tumors (glioblastoma) or abscesses
•Suspected metabolic disorders or inflammatory process (encephalitis)
•Suspected increased intracranial pressure caused by trauma or disease
•Mapping of area of abnormality in dementia, especially Alzheimer’s disease, or of focal irritation in migraine headaches
and psychiatric disorders such as schizophrenia or psychosis
•Evaluation of sleep disorders such as apnea and narcolepsy
•Evaluation of the effect of drug intoxication on the brain
•Detection of cerebral ischemia during endarterectomy
•Determination of brain death in nonresponsive clients D.) Contraindications/Precautions/Interfering Factors
Precautions
•Observe the patient carefully for seizure activity.

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•If seizure activity occurs, record seizure patterns and be prepared to provide assistance. Have suction equipment readily
available.
Interfering Factors
•Interference from extraneous electrical activity; head, body, eye, or tongue movement; or muscle contractions (possible
production of excessive artifact)
•Anticonvulsants, barbiturates, tranquilizers, and other sedatives (possible masking of seizure activity)
•Acute drug intoxication or severe hypothermia, resulting in loss of consciousness (flat EEG)
•Inability of client to remain still and to refrain from moving facial muscles, mouth, head, or eyes during the study
•Medications such as sedatives, anticonvulsants, antiaxolytics, or alcohol
•Caffeine-containing beverages or other stimulants
•Hypoglycemia or hypothermia
•Hair that is dirty, oily, or has had hairspray or other preparations applied can affect electrode placement and contact
Equipment
•EEG
Patient Preparation
•Explain that the EEG records the brain’s electrical activity.
•Describe the procedure to the patient and family members and answer all questions.
• Tell the patient that he must avoid caffeine before the test; other than this, there are no food or fluid restrictions.
Tell him that skipping the meal before the test can cause relative hypoglycemia and alter the brain wave pattern.
• Inform the patient that smoking is prohibited for at least 8 hours before the test.
• Thoroughly wash and dry the patient’s hair to remove hair sprays, creams, and oils.
• Explain to the patient that during the test, he’ll relax in a reclining chair or lie on a bed and that electrodes will be
attached to his scalp with a special paste. Assure him that the electrodes won’t shock him.
• If needle electrodes are used, explain to the patient that he’ll feel a pricking sensation as they’re inserted;
however, flat electrodes are more commonly used.
• Try to allay the patient’s fears because nervousness can affect brain wave patterns.
• Check the patient’s medication history for drugs that may interfere with test results. Anticonvulsants,
tranquilizers, barbiturates, and other sedatives should be withheld for 24 to 48 hours before the test, as ordered
by the practitioner. Infants and very young children occasionally require sedation to prevent crying and
restlessness during the test, but sedation itself may alter test results.
• A patient with a seizure disorder may require a “sleep EEG.” In this case, keep the patient awake the night before
the test and administer a sedative (such as chloral hydrate) to help him sleep during the test.
• If the test is performed to confirm brain death, provide the patient’s family members with emotional support.

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F.) Normal Values
• Alpha waves occur at a frequency of 8 to 11 cycles/second in a regular rhythm; present only in the w aking state
when the patient’s eyes are closed, but he’s mentally alert; usually, they disappear with visual acti vity or mental
concentration.
• Beta waves (13 to 30 cycles/second)— generallyassociated with anxiety, depression, and use of sedatives—are
seen most readily in the frontal and central regions of the brain.
• Theta waves (4 to 7 cycles/second) are most common in children and young adults and appear in the frontal and
temporal regions.
• Delta waves (0.5 to 3.5 cycles/second) normally occur only in young children and during sleep.
• Explain to the patient that the EEG records the brain’s electrical activity.
• Describe the procedure to the patient and family members and answer all her questions.
• Thoroughly wash and dry the patient’s hair to remove hair sprays, creams, and oils.
• Explain to the patient that during the test, he’ll relax in a reclining chair or lie on a bed and that e lectrodes will be
attached to his scalp with a special paste.
• Assure him that the electrodes won’t shock him.
• If needle electrodes are used, explain to the patient that he’ll feel a pricking sensation as they’re inserted;
however, flat electrodes are more commonly used.
• Do your best to allay the patient’s fears because nervousness can affect brain wave patterns.
• Check the patient’s medication history for drugs that may interfere with test results. Anticonvulsants,
tranquilizers, barbiturates, and other sedatives should be withheld for 24 to 48 hours before the test, as ordered
by the physician. Infants and very young children occasionally require sedation to prevent crying and
restlessness during the test, but sedation itself may alter test results.
• A patient with a seizure disorder may require a “sleep EEG.” In this case, keep the patient awake the night before
the test and administer a sedative (such as chloral hydrate) to help him sleep during the test.
• If the test is performed to confirm brain death, provide the patient’s family members with emotional support.
• Position the patient on the bed or in a reclining chair. Reassure him as the electrodes are attached to his scalp.
• Before the recording procedure begins, instruct the patient to close his eyes, relax, and remain still.
• During the recording, observe the patient carefully; note blinking, swallowing, talking, or other movements and
record these findings on the tracing. These activities may cause artifacts on the tracing and be misinterpreted as
an abnormal tracing.
• The recording may be stopped at intervals to let the patient rest or reposition himself. This is important because
restlessness and fatigue can alter brain wave patterns.
• After an initial baseline recording, the patient may be tested under various stress-producing conditions to elicit
patterns not observable while he’s at rest. For example, he may be asked to breathe deeply and rapidly for 3
minutes (hyperventilation), which may elicit brain wave patterns typical of seizure disorders or other
abnormalities. This technique is commonly used to detect absence seizures. Also, photic stimulation tests central
cerebral activity in response to bright light, accentuating abnormal activity in absence or myoclonic

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seizures. In this procedure, a strobe light placed in front of the patient is flashed 1 to 20 times/second; recordings
are made with the patient’s eyes opened and closed.
After the Procedure
• Review carefully the reinstatement of anticonvulsant medication or other drugs withhel d before the test.
• Carefully observe the patient for seizure activity and provide a safe environment.
• Help the patient remove electrode paste from his hair.
• If the patient received a sedative before the test, take safety precautions such as raising the bed’s side rails.
• If brain death is confirmed, provide the patient’s family members with emotional support.
• If clinical events are found to be nonepileptic, a psychological evaluation may be needed.
• In absence seizures, the EEG shows spikes and waves at a frequency of 3 cycles/second.
• In generalized tonic-clonic seizures, it generally shows multiple, high-voltage, spiked waves in both hemispheres.
▪ In temporal lobe epilepsy, the EEG usually shows spiked waves in the affected temporal region.
• In the patient with focal seizures, it usually shows localized, spiked discharges.
• In the patient with an intracranial lesion, such as a tumor or abscess, the EEG may show slow waves (usually
delta waves but possibly unilateral beta waves).
• Vascular lesions, such as cerebral infarcts and intracranial hemorrhages, generally produce focal abnormalitiesin
the injured area.
• Any condition that causes a diminishing level of consciousness alters the EEG pattern in proportion to the degree
of consciousness lost. For example, in a patient with a metabolic disorder, an inflammatory process (such as
meningitis or encephalitis), or increased intracranial pressure, the EEG shows generalized, diffuse, and slow brain
waves.
• The most pathologic finding of all is an absent EEG pattern—a “flat” tracing (except for artifacts), which may
indicate brain death.
EVOKED POTENTIAL
STUDIES
•Evoked potential studies evaluate the integrity of visual, somatosensory, and auditory nerve pathways by measuring
evoked potentials—the brain’s electrical response to stimulation of the sensory organs or peripheral nerves. Evoked
potentials are recorded as electronic impulses by surface electrodes attached to the scalp and skin over various peripheral
sensory nerves. A computer extracts these low-amplitude impulses from background brain wave activity and averages the
signals from repeated stimuli.
•Three types of responses are measured:
o Visual evoked potentials, produced by exposing the eye to a rapidly reversing checkerboard pattern, help
evaluate demyelinating diseases, traumatic injury, and puzzling visual complaints.
o Somatosensory evoked potentials, produced by electrically stimulating a peripheral sensory nerve, help
diagnose peripheral nerve disease and locate brain and spinal cord lesions.

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o Auditory brain stem evoked potentials, produced by delivering clicks to the ear, help locate auditory
lesions and evaluate brain stem integrity.
•Evoked potential studies are also useful for monitoring comatose or anesthetized patients, monitoring spinal cord
function during spinal cord surgery, and evaluating neurologic function in an infant whose sensory system normally can’t
be adequately assessed.
B.) Purposes
•To help diagnose nervous system lesions and abnormalities
•To assess the patient’s neurologic function
C.) Indications
Visual Evoked Potentials
•Diagnosis of neurological disorders such as Parkinson’s disease, Huntington’s chorea, and multiple sclerosis (MS) as
revealed by abnormal bilateral latency resulting from the demyelination of nerve fibers
•Diagnosis of cryptic or past retrobulbar neuritis revealed by abnormal latency or lengthened conduction time along optic
pathways
•Determination of optic pathway lesions and visual cortex defects revealed by abnormal latency
•Diagnosis of lesions of the eye or optic nerves revealed by an extended latency
•Evaluation of binocularity in infants
Auditory Evoked Potentials
•Detection of abnormalities or lesions in the brainstem or auditory nerves that cannot be diagnosed by other diagnostic
methods
• Suspected hearing loss (peripheral) and screening or evaluation of low-birth-weight neonates, infants, children,
and adults for auditory problems
• Early detection of brainstem tumors and acoustic neuromas, revealed by abnormal latency responses
Somatosensory Evoked Potentials
• Evaluation of spinal cord and brain injury and function
• Diagnosis of sensorimotor neuropathies and cervical pathology revealed by abnormal latencies in the upper limb
studies
• Diagnosis of MS and Guillain-Barré syndrome as revealed by abnormal latencies in the lower limb studies
• Monitoring of sensory potentials to determine spinal cord function during a surgical procedure or medical
regimen
Interfering Factors
• Inability of client to understand instructions or to cooperate with requests made during the study
• Improper placement of electrodes
Precautions

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• Know that the patient’s hair should be washed and rinsed before testing. No other hair products should be applied
once the hair is clean.
• Tell the patient that evoked potential studies measure the electrical activity of his nervous system. Explain who
will perform the test and where it will take place.
• Tell the patient that he’ll sit in a reclining chair or lie on a bed. If visual evoked potentials will be measured,
electrodes will be attached to his scalp; if somatosensory evoked potentials will be measured, electrodes will be
placed on his scalp, neck, lower back, wrist, knee, and ankle.
• Assure the patient that the electrodes won’t hurt him. Encourage him to relax; tension can affect neurologic
function and interfere with test results.
• Have the patient remove all jewelry and other metal objects.
F.) Normal Values
• The most significant wave is P100, a positive wave appearing about 100 msec after the pattern-shift stimulus is
applied. Because many physical and technical factors affect P100 latency, normal results vary greatly among
laboratories and patients.
• Waveforms obtained vary, depending on locations of the stimulating and recording electrodes.
Before the test:
• Inform the patient that evoked potential studies measure the electrical activity of his nervous system. Explain who
will perform the test and where it will take place.
• Explain to the patient that he’ll sit in a reclining chair or lie on a bed. If visual evoked potentials will be
measured, electrodes will be attached to his scalp; if somatosensory evoked potentials will be measured,
electrodes will be placed on his scalp, neck, lower back, wrist, knee, and ankle.
• Assure the patient that the electrodes won’t hurt him. Encourage him to relax; tension can affect neurologic
function and interfere with test results
• Let the patient remove all jewelry and other metal objects.
• Instruct the patient to wash and rinse his hair before testing. Tell the patient not to apply any other hair products
after the hair is clean
During the Test:
• For Visual Evoked Potentials
o After the patient is positioned in a reclining chair or on a bed and asked to relax, electrodes are attached
to his scalp at occipital, parietal, and vertex sites; a reference electrode is placed on the mid frontal area or ear
o The patient is positioned 3’ (0.9 m) from the pattern-shift stimulator
o One eye is occluded, and the patient is instructed to fix his gaze on a dot in the center of the screen.
o A checkerboard pattern is projected and then rapidly reversed or shifted 100 times, once or twice per
second.
o A computer amplifies and averages the brain’s response to each stimulus, and the results are plotted as a
waveform
o The procedure is repeated for the other eye.
• For Somatosensory Evoked Potentials

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o After positioning the patient in a reclining chair or on a bed, electrodes are attached to his skin over
somatosensory pathways—typically, the wrist, knee, and ankle—to stimulate peripheral nerves.
o Recording electrodes are placed on the scalp over the sensory cortex of the hemisphere opposite the limb
to be stimulated. Additional electrodes may be placed at Erb’s point (above the clavicle overlying the
brachial plexus), at the second cervical vertebra, and over the lower lumbar vertebrae. Mid frontal or non
– cephalic electrodes are placed for reference.
o Painless electrical stimulation is delivered at a rapid rate to the peripheral nerve through the electrode.
The intensity is adjusted to produce a minor muscle response, such as a thumb twitch on median nerve
stimulation at the wrist.
o Electrical stimuli are delivered 500 or more times at a rate of 5 per second.
o A computer measures and averages the time it takes for the electric current to reach the cortex; the
results, expressed in milliseconds (msec), are recorded as waveforms
o The test is repeated once to verify results, and then the electrodes are repositioned and the entire
procedure is repeated for the other side.
After the Test:
• Assess the patient’s response to testing.
• Information from evoked potential studies is useful but insufficient to confirm a specific
diagnosis. Test data must be interpreted in light of clinical information.
• Extended P100 latencies confined to one eye indicate a visual pathway lesion anterior to the
optic chiasm. A lesion posterior to the optic chiasm usually doesn’t produce abnormal P100
latencies.
• Bilateral abnormal P100 latencies have been found in patients with multiple sclerosis, optic
neuritis, retinopathies, amblyopia (although abnormal latencies don’t correlate well with
impaired visual acuity), spinocerebellar degeneration, adrenoleukodystrophy, sarcoidosis,
Parkinson’s disease, and Huntington’s disease.
• Abnormal interwave latency indicates a conduction defect between the generators of the two
peaks involved. This commonly identifies a precise location of a neurologic lesion.
• Abnormal upper-limb interwave latencies may indicate cervical spondylosis, intracerebral
lesions, or sensorimotor neuropathies.
• Abnormalities in the lower limb demonstrate peripheral nerve and root lesions, such as those in
Guillain-Barré syndrome, compressive myelopathies, multiple sclerosis, transverse myelitis, and
traumatic spinal cord injury.

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COMPUTED TOMOGRAPHY OF
THE SPINE
•Much more versatile than conventional radiography, spinal computed tomography (CT) provides detailed high-
resolution images in the cross-sectional, longitudinal, sagittal, and lateral planes. Multiple X-ray beams from a
computerized body scanner are directed at the spine from different angles; these pass through the body and strike
radiation detectors, producing electrical impulses. A computer then converts these impulses into digital information,
which is displayed as a three-dimensional image on a monitor. Storage of the digital information allows electronic
recreation and manipulation of the image, creating a permanent record of the images to enable reexamination without
repeating the procedure.
•CT scans are helpful in defining the lesions causing spinal cord compression. Metastatic disease and discogenic disease
with osteophyte formation and calcification are examples of pathologic processes diagnosed by CT scans. Since the
advent of magnetic resonance imaging, CT scans are used less frequently to diagnose infection, abscesses, hematomas,
and some disk herniations.
B.) Purposes
•To diagnose spinal lesions and abnormalities
•To monitor the effects of spinal surgery or therapy
C.) Indications
•Diagnosing benign, primary, and metastatic tumors of the spine and their location,revealed by altered density in the areas
of pathology as differentiated normal tissue densities
•Detecting the presence and location of herniated disks,usually in the cervical or lumbar spine,with unilateral or bilateral
nerve root compression
• Diagnosing or evaluating stenosis of the lumbar spine with hypertrophy, causing compression of the cord as the
space within the column is decreased
• Detecting cervical spondylosis with cord compression, caused by structural changes resulting from bone
hypertrophy
• Diagnosing fluid-filled cysts revealed by increased density
• Detecting vascular malformations in adults and congenital spinal malformations, that is, meningocele, myelocele,
or myelomeningocele, in infants
• Monitoring the effectiveness of therapeutic regimen and spinal surgical procedure
• Pregnancy, unless the benefits of performing the study greatly outweigh the risks to the fetus
• Allergy to iodine, if an iodinated contrast medium is to be used
• Extreme obesity
• Extreme claustrophobic response that prevents the client from remaining still during the procedure, unless
medications are given before the study
Interfering Factors

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• Inability of client to remain still during the procedure
• Metallic objects such as jewelry within the examination field
• Barium, feces, or gas in the lower gastrointestinal (LGI) tract, if lumbar spine is to be imaged
Precautions
• The patient may experience strong feelings of claustrophobia or anxiety when inside the CT body scanner. In
such cases, a mild sedative to help reduce anxietymay be ordered.
• For the patient with significant back pain, give prescribed analgesics before the scan.
• CT scan machine
• Oscilloscope
• Recording equipment
• Contrast medium (iothalamate meglumine or diatrizoate sodium)
• 60-ml syringe
• 9G or 20G needle
Patient Preparation
• Explain that spinal CT allows visualization of his spine.
• If contrast medium isn’t ordered, tell the patient that he doesn’t need to restrict food and fluids. If contrast
medium is ordered, instruct him to fast for 4 hours before the test.
• Tell the patient that a series of scans will be taken of his spine. Explain who will perform the procedure and
where it will take place.
• Reassure the patient that the procedure is painless but that he may find having to remain still for a prolonged
period uncomfortable.
• Explain to the patient that he’ll be positioned on an X-ray table inside a CT body scanning unit and he’ll be told
to lie still because movement during the procedure may cause distorted images. The computer-controlled
scanner will revolve around him, taking multiple scans.
headache, a salty taste, and nausea or vomiting after injection of the contrast medium. Reassure him that these
reactions are normal.
• Instruct the patient to wear a radiologic examining gown and to remove all metal objects and jewelry.
• Check the patient’s history for hypersensitivity reactions to iodine, shellfish, or contrast media. If such reactions
have occurred, note them in the patient’s chart and notify the practitioner, who may order prophylactic
medications or choose not to use contrast enhancement.
• If the patient appears restless or apprehensive about the procedure, a mild sedative may be prescribed.
F.) Normal Values
• Spinal tissue appears white, black, or gray, depending on its density.
• Vertebrae, the densest tissues, are white.
• Cerebrospinal fluid is black.
• Soft tissues appear in shades of gray.
Before the Test:

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• Inform the patient that the procedure assesses the spine.
• Inform the patient that the procedure is performed in a radiology department by a technologist and a physician
and takes approximately 30 to 60 minutes.
• Obtain a history of allergies or sensitivities to contrast medium or shellfish.
• Obtain a list of medications the patient is taking.
• Obtain a history of the patient’s spine as well as results of previously performed tests, procedures, trauma,
surgeries, and therapies. For related tests, refer to the musculoskeletal system table.
• Determine previous laboratory abnormalities, especially blood urea nitrogen (BUN) and creatinine, if contrast
medium is to be used.
• Determine date of last menstrual period and the possibility of pregnancy in perimenopausal women.
• Ensure that the results of blood tests are obtained and recorded before the procedure. Patients receiving
metformin (Glucophage) for non–insulin dependent (type 2) diabetes should discontinue the drug on the day of
the test and continue to withhold it for 48 hours after the test. Failure to do so may result in lactic acidosis.
• Inform the patient that he or she may experience nausea, a feeling of warmth, a salty or metallic taste, or a
transient headache after injection of contrast medium, if given. Instruct the patient to take slow, deep breaths if
this occurs.
• Question the patient to ensure that barium studies were performed more than 4 days before the scan.
• Restrict food and fluids for 6 to 8 hours, if contrast medium is to be given
During the Test:
• Administer sedative to a child or to an uncooperative adult, as ordered.
• Administer antianxiety agent, as ordered, if the patient is experiencing claustrophobia.
• Administer an antihistamine or steroid, as ordered by a physician, for patients with a known significant allergic
reaction to the IV contrast medium.
• Place the patient in a supine position on a flat table with foam wedges to help maintain position and
immobilization. Ask the patient to lie still during the procedure because movement produces unclear images.
Make sure jewelry, watches, chains, belts, and any other metallic objects have been removed.
• As the table moves into the scanner, instruct the patient to remain still. The scanner makes noises as it rotates
around the body. The patient may be asked to take deep breaths to facilitate visualization. A number of images
are taken. A computer reconstructs these images so they can be reviewed.
• Administer contrast medium, if ordered. A second series of images is obtained.
• If a CT myelogram is requested, the patient is removed from the scanner, and a lumbar puncture is performed. A
small amount of cerebrospinal fluid is removed and replaced with contrast medium. The patient is pl aced back
into the scanner, and another series of images is obtained
After the Test:
• Instruct the patient to resume normal activity, diet, and previous medication use, unless otherwise indicated.
Renal function should be assessed before metformin is restarted.
• Instruct the patient to increase fluid intake to help eliminate the contrast medium, if used

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• Inform the patient that diarrhea may occur after ingesting oral contrast medium.
• Spinal lesions and abnormalities are present.
• Tumors appear as masses varying in density. Measuring this density and noting the configuration and location
relative to the spinal cord can usually identify the type of tumor. For example, a neurinoma (schwannoma)
appears as a spherical mass dorsal to the cord. A darker, wider mass lying more laterally or ventrally to the cord
may be a meningioma.
• Degenerative processes and structural changes can be seen in detail.
• Herniated nucleus pulposus shows as an obvious herniation of disk material with uni lateral or bilateral nerve root
compression; if the herniation is midline, spinal cord compression will be evident.
• Cervical spondylosis shows as cervical cord compression due to bony hypertrophy of the cervical spine; lumbar
stenosis, as hypertrophy of the lumbar vertebrae, causing cord compression by decreasing space within the spinal
column.
• Facet disorders show as soft-tissue changes, bony overgrowth, and spurring of the vertebrae, which result in nerve
root compression.
• Fluid-filled arachnoidal and other paraspinal cysts show as dark masses displacing the spinal cord. ▪ Vascular
malformations, evident after contrast enhancement, show as masses or clusters, usually on the dorsal aspect of
the spinal cord.
• Congenital spinal malformations, such as meningocele, myelocele, and spina bifida, show as abnormallylarge,
dark gaps between the white vertebrae.
OCULOPLETHYSMOGR
APHY
•Oculoplethysmography is a manometric study to measure blood flow in the ipsilateral orbit of the eye in diagnosing
carotid artery disease. The blood flow in one eye is compared with that in the other eye to determine decreases indicating
pathology. The blood flow of the carotid artery and circulation in the brain are reflected by the blood flow of the
ophthalmic artery because of its connection to the internal carotid artery.
•Oculoplethysmography (OPG) provides an indirect measure of blood flow through the internal carotid artery by
measuring blood flow through the opthalmic artery (the first major branch of the internal carotid). The earlobes receive
their blood supply from the external carotid artery. Pulse arrival times are compared between the eyes and ears and should
be the same. If stenosis of the internal carotid is occurring, then blood flow to the eye will be slower than to the ear. With
oculopneumoplethysmography (OPG-Gee), eye and brachial pressures are compared following application of negative
pressure to the sclera.
•The study can be performed in conjunction with duplex scanning of the carotid arteries and followed by cerebral
angiography to diagnose blood-flow patterns to the brain from the carotid arteries.
B.) Purposes
•To aid in the detection and evaluation of carotid occlusive disease

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C.) Indications
•Determining the cause of transient ischemic attacks (TIAs) and symptoms of neurological disorders, such as syncope and
ataxia
•Diagnosing carotid atherosclerotic stenosis or occlusive disease revealed by a reduced rate of blood flow in the
ophthalmic artery
•Determining the extent of carotid stenosis
•Evaluating carotid artery patency before or after endarterectomy
•Diagnoses carotid athersclerotic stenosis in clients with associated symptoms of dizziness, ataxia, syncope, and carotid
bruits.
•Provides optional follow-up monitoring of clients who have had carotid endarterectomy.
•Eye surgery within last 6 months
•Uncontrolled glaucoma
•Client with one eye
•Cataracts
•Conjunctivitis
•Retinal detachment
•Lens implant
•Allergy to local anesthetic
Interfering Factors
•Client is uncooperative, disoriented, or suffers from uncontrolled movement disorder
•Anticoagulants
•Hypertension
•Specialized ocular pressure measurement equipment Blood pressure equipment
•ECG equipment
Patient Preparation
•Inform the client that the usual medications and eyedrops are not restricted but that additional eyedrops that cause a
slight burning sensation will be administered to anesthetize the eyes.
•Remove contact lenses and store in a safe place. Obtain baseline blood pressure in both arms.
•Attach electrodes for ECG, if one is ordered.
•Obtain a history that includes cardiovascular and neurological status, known or suspected disorders associated with the
carotid artery, and results of associated diagnostic tests and procedures.
F.) Normal Values
•Normal blood flow in the carotid arteries; no atherosclerotic occlusive disease.
•For OPG: All pulses should occur simultaneously.
•For OPG – Gee: The difference between ophthalmic artery pressures should be less than 5 mm Hg. Ophthalmic artery
pressure divided by the higher brachial systolic pressure should be greater than 0.67.

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Test:
•Instruct client that test may be performed by technician, nurse, or doctor and can be done in specified laboratories, the
physician’s office, or a hospital.
•Ascertain that client with glaucoma has taken his usual eye drops.
During Test:
After Test:
•Reassure client that slight burning of the eyes is common.
•Instruct client that after the eyecups are removed, the eyes may appear bloodshot for several hours, and there may be
some blurring of vision for the first half hour.
•Remind client not to insert contact lenses or rub eyes for as long as the eyes are burning (minimum 2 hr posttest).
•Client may use artificial tears to reduce discomfort and should wear sunglasses if experiencing any photophobia.
•Instruct client to report severe burning or pain.
•For OPG: Carotid occlusive disease reduces the rate of blood flow during systole and delays the arrival of a pulse in the
ipsilateral eye or ear. When all pulses are compared, any delay can be measured and the degree of carotid artery stenosis
estimated as mild, moderate, or severe
•For OPG – Gee: A difference between ophthalmic artery pressures of more than 5 mm Hg suggests the presence of
carotid occlusive disease on the side with the lower pressure. A ratio between the ophthalmic artery pressure and the
higher brachial systolic pressure of less than 0.67 reinforces this finding. In other words, the ratio is related to the degree
of stenosis: The lower the ratio, the more severe the stenosis. As with OPG, OPG-Gee only estimates the degree of
stenosis present; angiography may be necessary to provide a precise evaluation.
TRANSCRANIAL DOPPLER
STUDY
•Transcranial Doppler studies provide information about the presence, quality, and changing nature of circulation to an
area of the brain by measuring the velocity of blood flow through cerebral arteries. Narrowed blood vessels produce high
velocities, indicating possible stenosis or vasospasm. High velocities may also indicate an arteriovenous malformation.
B.) Purposes
•To measure the velocity of blood flow through certain cerebral vessels
•To detect and monitor the progression of cerebral vasospasm
•To determine whether collateral blood flow exists before surgical ligation or radiologic occlusion of diseased vessels

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C.) Indications
•Detecting plaque or stenosis of carotid artery revealed by turbulent blood flow or changes i n Doppler signals, indicating
occlusion
•Detecting irregularities in the structure of the carotid arteries
•Diagnosing carotid artery occlusive disease revealed by visualization of blood-flow disruption
•Inability of client to remain still during the procedure
•Incorrect placement of the transducer over the desired test site
•Abnormally large neck that makes direct examination difficult
Precaution
•Make sure to remove turban head dressings or thick dressings over the test site.
•Transcranial Doppler unit
•Probe
•Conductive gel
Patient Preparation:
•Explain the purpose of the transcranial Doppler study to the patient (or to his family).
• Tell the patient that the test will be done while he lies on a bed or stretcher or sits in a reclining chair (or it can
be performed at the bedside if he’s too ill to be moved to the laboratory).
• Describe the procedure. Explain that a small amount of conductive gel will be applied to his skin and that a
probe will be used to transmit a signal to the artery being studied. Tell the patient that it usually takes less than
1 hour, depending on the number of vessels to be examined and any interfering factors.
• Tell the patient that he doesn’t need to restrict food and fluids.
F.) Normal Values
• Waveforms and velocities are normal
Before the Test:
• Explain the purpose of the transcranial Doppler study to the patient (or to his family).
• Describe the procedure. Explain that a small amount of gel will be applied to his skin and that a probe will be
used to transmit a signal to the artery being studied. Tell the patient that it usually takes less than 1 hour,
depending on the number of vessels to be examined and any interfering factors.
During the Test:

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• Have the patient recline in a chair or on a stretcher or bed.
• A small amount of conductive gel is applied to the transcranial window(an area where bone is thin enough to
allow the Doppler signal to enter and be detected); the most common approaches are temporal, transorbital, and
through the foramen magnum.
• The technician directs the signal toward the artery being studied and records the velocities detected. In a
complete study, the middle cerebral arteries, anterior cerebral arteries, posterior cerebral arteries, ophthalmic
arteries, carotid siphon, vertebral arteries, and basilar artery are studied
• The Doppler signal waveforms may be printed for later analysis and can be transmitted to varying depths
(measured in millimeters).
After the Test:
• When the study is completed, wipe away the conductive gel.
• Velocities are high, suggesting that blood flow is too turbulent or the vessel is too narrow
CEREBRAL
ANGIOGRAPHY
•Cerebral angiography involves injecting a contrast medium to allow radiographic examination of the cerebral
vasculature. Possible injection sites include the femoral, carotid, and brachial arteries. Because it allows visualization of
four vessels (the carotid and the vertebral arteries), the femoral artery is used most commonly.

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• Usually, this test is performed on patients with suspected abnormality of the cerebral vasculature; abnormalities
may be suggested by intracranial computed tomography, lumbar puncture, magnetic resonance imaging, or
magnetic resonance angiography.
B.) Purposes
• To detect cerebrovascular abnormalities, such as aneurysm or AVM, thrombosis, narrowing, or occlusion
• To study vascular displacement caused by tumor, hematoma, edema, herniation, vasospasm, increased ICP, or
hydrocephalus
• To locate clips applied to blood vessels during surgery and to evaluate the postoperative status of affected vessels
C.) Indications
• Detecting vascular or nonvascular tumor by vessel displacement
• Detecting spasms, abscess, edema, or hematoma by vascular distortion, displacement, or both
• Detecting abnormalities or interruptions in cerebral circulation through the narrowing or occlusion of vessels
caused by thrombosis or detecting AV malformation
• Detecting vessel wall changes caused by aneurysm
• Detecting atherosclerosis and degree of occlusion of the carotid arteries
• Diagnosing hydrocephalus in an infant or young child
• Determining increased intracranial pressure and possible cause
• Evaluating postoperative placement and status of shunts or clips to vessels
• Pregnancy, unless the benefits of performing the procedure greatly outweigh the risks to the fetus
• Allergy to iodinated contrast medium, unless prophylactic medications are administered or nonionic dye is used
for those suspected of iodine sensitivity
• Presence of a bleeding disorder
• Acute or severe renal or hepatic disease
Interfering Factors
• Inability of client to lie still and keep head immobilized during the procedure
• Atherosclerotic lesions causing narrowing or obstruction of the vessel to be cannulated and difficulty in passage
of the catheter
• Contrast medium
• Automatic contrast injector
• Radiograph machine with rapid biplane cassette changes
• Arterial needles (18G or 19G, 2½ needle for adults; 20G, 1½ needle for children)
• Femoral arterial catheters for femoral injection
• Explain to the patient that cerebral angiography shows blood circulation in the brain.

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• Describe the test, including who will administer it and where it will take place.
• Tell the patient to fast for 8 to 10 hours before the test.
• Make sure that any pretest blood work results are on the chart to determine bleeding tendency or kidney function.
• Explain to the patient that he’ll wear a gown and that he must remove all jewelry, dentures, hairpins, and other
metallic objects in the radiographic field.
• If ordered, administer a sedative and an anticholinergic drug 30 to 45 minutes before the test.
• Make sure the patient voids before leaving his room.
• Explain that a local anesthetic will be administered (some patients — especially children — receive a general
anesthetic).
• Explain to the patient that he’ll feel a transient burning sensation as the medium is injected; a warm, flushed
feeling; a transient headache; a salty or metallic taste in his mouth; or nausea and vomiting after the dye is
injected.
F.) Normal Values
• Cerebral vasculature is normal.
• During the arterial phase of perfusion, the contrast medium f ills and opacifies superficial and deep arteries and
arterioles.
• During the venous phase, the contrast medium opacifies superficial and deep veins
the Test:
•Explain to the patient that cerebral angiography shows blood circulation in the brain
•Describe the test, including who will administer it and where it will take place
•Check the patient’s history for hypersensitivity to iodine, iodine containing substances (such as shellfish), or other
contrast media. Note hypersensitivities on his chart, and report them as appropriate.
•Tell the patient to fast for 8 to 10 hours before the test.
•Make sure that any pretest blood work results are on the chart to determine bleeding tendency or kidney function.
•Ask the patient about his medication use, specificallyanticoagulants. These may need to be discontinued for 3 days
before testing
•Explain to the patient that he’ll wear a gown and that he must remove all jewelry, dentures, hairpins, and other metallic
objects in the radiographic field
•If ordered, administer a sedative and an anticholinergic drug 30 to 45 minutes before the test.
During the Test:
•Have the patient recline on an X-ray table and instruct him to lie still with his arms at his sides

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•Shave the injection site (femoral, carotid, or brachial artery) and clean it with alcohol and povidone -iodine
•A local anesthetic is injected. Then the artery is punctured with the appropriate needle and catheterized.
•In the femoral artery approach, a catheter is threaded to the aortic arch.
•In the brachial artery approach (least common), a blood pressure cuff is placed distal to the puncture site and inflated
before injection to prevent the contrast medium from flowing into the forearm and hand
•After X-rays or fluoroscopy verifies placement of the needle or catheter, the contrast medium is injected. Observe the
patient for an adverse reaction, such as hives, flushing, or laryngeal stridor
•An initial series of lateral and anteroposterior X-rays is taken, developed, and reviewed. Depending on the results, more
contrast medium may be injected and another series taken
•Maintain arterial catheter patency by continuous or periodic flushing. Monitor the patient’s vital and neurologic signs.
After the Test:
•Observe the patient for bleeding, check distal pulses, and apply a pressure bandage.
•Maintain bed rest as ordered. Typically, the patient will be on bed rest for 6 to 8 hours.
•Administer prescribed pain medications, and monitor the patient’s vital signs and neurologic status for 6 hours. The
patient is usually discharged the same day
•Monitor the catheter puncture site frequently and closely for hemorrhage or hematoma formation. If either occurs, notify
the practitioner immediately. If bleeding occurs, apply firm pressure to the puncture site and inform the practitioner. Also
observe the puncture site for signs of extravasation (redness, swelling), and apply an ice bag to ease the patient’s
discomfort and minimize swelling.
•If the brachial approach was used, immobilize the affected arm for 6 hours or longer and routinely check the radial pulse
•Monitor the patient for disorientation and weakness or numbness in the extremities (signs of thrombosis or hematoma)
and for arterial spasms, which may produce symptoms of transient ischemic attacks
•Place a sign near the patient’s bed warning personnel not to take blood.
•Observe the patient’s arm and hand for changes in color, temperature, or sensation. If they become pale, cool, or numb,
report these changes at once
•Tell the patient he may resume his usual diet. Encourage him to drink fluids to help him pass the contrast medium
•Changes in the caliber of vessel lumina suggest vascular disease, possibly due to spasms, plaques, fistulas,
arteriovenous malformation (AVM), or arteriosclerosis.
•Diminished blood flow to vessels may be related to increased intracranial pressure (ICP).
•Vessel displacement may reflect the presence and size of a tumor, areas of edema, or obstruction of the
cerebrospinal fluid pathway.
DIGITAL SUBTRACTION
ANGIOGRAPHY
•Digital subtraction angiography (DSA) is a sophisticated radiographic technique that uses video equipment and
computerassisted image enhancement to examine the vascular systems. As in conventional angiography, X-ray images
are obtained after injecting a contrast medium. However, unlike conventional angiography, in which

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images of bone and soft tissue commonly obscure vascular detail, DSA provides a high-contrast view of blood
vessels without interfering images or shadows.
• This unique view is made possible by digital subtraction, in which fluoroscopic images are taken before and after
injection of a contrast medium. A computer converts these images into digital information and then “subtracts”
the first image from the second, eliminating most information (mainly bone and soft tissue) common to both
images. The result is a better image of the contrastenhanced vasculature.
B.) Purposes
• To visualize extracranial and intracranial cerebral blood flow
• To detect and evaluate cerebrovascular abnormalities
• To aid postoperative evaluation of cerebrovascular surgery, such as arterial grafts and endarterectomies
C.) Indications
• Endovascular aneurysm repair
• Arterial balloon angioplasty
• Arterial stenting
• Endovascular embolization
• Thrombectomy
D.) Contraindications/Precautions/Interfering Factors Contraindication
• Patient with a hypersensitivity to iodine or contrast media
• Poor cardiac function
• Renal, hepatic, or thyroid disease
• Diabetes
• Multiple myeloma.
Interfering Factors
• Patient movement
• Radiopaque objects in the fluoroscopic field
• X-ray machine with biplane cassette changer
• Computer and video monitor
• Video recorder
• I.V. equipment and 250 ml normal saline solution
• Contrast medium
• Automatic contrast medium injector
• Explain to the patient that DSA visualizes cerebral blood vessels
• Tell the patient that he’ll need to fast for 4 hours before the test, but he need not restrict fluids
• Inform the patient that he’ll be positioned on an X-ray table with his head immobilized and will be asked to lie

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still. (Some patients — especially children — may be given a sedative to prevent movement during the
procedure.)
• Instruct the patient to remove all jewelry, dentures, and other radiopaque objects from the X-ray field
• Tell the patient that he’ll probably feel some transient pain from insertion of the needle or catheter and that he
may experience a feeling of warmth, a headache, a metallic taste, and nausea or vomiting after the contrast agent
is injected
F.) Normal Values
• The contrast medium should fill and opacify all superficial and deep arteries, arterioles, and veins, allowing
visualization of normal cerebral vasculature.
Before the Test:
• Check the patient’s history for hyper sensitivity to iodine, substances containing iodine such as shellfish, and
contrast media. If he has had such reactions, note them on the chart and inform the practitioner, who may order
prophylactic medications or choose not to perform the test
• Explain to the patient that he’ll receive an injection of a contrast medium, either by needle or through a venous
catheter inserted in his arm, and that a series of X-rays will be taken of his head. Tell him who will perform the
test, where it will take place, and that it will take 30 to 90 minutes.
During the Test:
• Place the patient in the supine position on an X-ray table and tell him to lie still with his arms at his sides.
• After an initial series of fluoroscopic pictures (mask images) of the patient’s head is taken, the injection site —
most commonly the antecubital basilic or cephalic vein — is shaved and cleaned with an antiseptic solution
• If catheterization is ordered, a local anesthetic is administered, a venipuncture is performed, and a catheter is
inserted and advanced to the superior vena cava
• After placement is verified by X-ray, I.V. lines from a bag of normal saline solution and from an automatic
contrast medium injector are connected. While the saline is administered, the injector delivers the contrast
medium at a rate of about 14 ml/second. If a simple injection of the contrast medium is ordered, a bolus of 40 to
60 ml is administered I.V. by needle.
After the Test
• Because the contrast medium acts as a diuretic, encourage the patient to increase his fluid intake for 24 hours
after this test. Advise him that extra fluid intake will also speed excretion of the contrast medium. Monitor his
intake and output as ordered
• Check the venipuncture site for signs of extravasation, such as redness or swelling. If bleeding occurs, apply firm
pressure and an ice pack to the puncture site. If a hematoma develops, elevate the arm and apply pressure.
• Observe the patient for a delayed hypersensitivity reaction to the contrast medium. A delayed reaction can occur

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up to 18 hours after the procedure
• Inform the patient that he may resume his usual diet.

• Vascular filling defects may indicate arteriovenous occlusion or stenosis, possibly due to vasospasm, vascular
malformation or angiomas, arteriosclerosis, or cerebral embolism or thrombosis.
• Outpouchings in vessel lumina may reflect cerebral aneurysms; such aneurysms frequently rupture, causing
subarachnoid hemorrhage.
• Vessel displacement or vascular masses may indicate an intracranial tumor.
ELECTROMYOGR
APHY
•Electromyography (EMG) records the electrical activity of selected skeletal muscle groups at rest and during voluntary
contraction. It involves percutaneous insertion of a needle electrode into a muscle. The electrical discharge of the muscle
is then measured by an oscilloscope. Nerve conduction time is often measured simultaneously.
B.) Purposes
•To aid in differentiating between primary muscle disorders, such as the muscular dystrophies, and secondary disorders
•To help assess diseases characterized by central neuronal degeneration such as ALS
•To aid in the diagnosis of neuromuscular disorders such as myasthenia gravis
•To aid in the diagnosis of radiculopathies
C.) Indications
•Assess primary muscle diseases affecting striated muscle fibers or cell membrane, such as muscular dystrophy or
myasthenia gravis
•Differentiate secondary muscle disorders caused by polymyositis, sarcoidosis, hypocalcemia, thyroid toxicity, tetanus,
and other disorders
•Detect neuromuscular disorders, such as peripheral neuropathy caused by diabetes or alcoholism, and locate the site of
the abnormality
•Detect muscle disorders caused by diseases of the lower motor neuron involving the motor neuron on the anterior horn of
the spinal cord, such as anterior poliomyelitis, amyotrophic lateral sclerosis, amyotonia, and spinal tumors
•Detect muscle disorders caused by diseases of the lower motor neuron involving the nerve root, such as Guillain-Barré
syndrome, herniated disc, or spinal stenosis
•Differentiate between primary and secondary muscle disorders or between neuropathy and myopathy
•Determine if a muscle abnormality is caused by the toxic effects of drugs (e.g., antibiotics, chemotherapy) or toxins (e.g.,
Clostridium botulinum, snake venom, heavymetals)
•Monitor and evaluate progression of myopathies or neuropathies, including confirmation of diagnosis of carpal tunnel
syndrome
D.) Contraindications/Precautions/Interfering Factors Contraindications:
•Patients with extensive skin infection
•Patients receiving anticoagulant therapy

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• Patients with an infection at the sites of electrode placement
Precautions:
• EMG is contraindicated in the patient with a bleeding disorder.
Interfering Factors:
• Inability of the patient to cooperate or remain still during the procedure because of age, significant pain, or
mental status
• Age-related decreases in electrical activity
• Medications such as muscle relaxants, cholinergics, and anticholinergics
• Improper placement of surface or needle electrodes
• Electrodes
• Attachment cables that link the electrodes to the signal amplifier
• Speaker
• Oscilloscope
• Recorder
• Explain to the patient that EMG measures the electrical activity of his muscles
• Tell the patient that there are usually no restrictions on food and fluids (in some cases, cigarettes, coffee, tea, and
cola may be restricted for 2 to 3 hours before the test).
• Describe the test, including who will perform it and where it will take place.
• Tell the patient that he may wear a hospital gown or comfortable clothing that permits access to the muscles to be
tested.
• Advise the patient that a needle will be inserted into selected muscles and that he may experience discomfort.
Reassure him that adverse effects and complications are rare
• Check the patient’s history for medications that may interfere with the results of the test — for example,
cholinergics, anticholinergics, and skeletal muscle relaxants. If the patient is receiving such medications, note
this on the chart and withhold medications, as ordered
F.) Normal Values
• At rest, a normal muscle exhibits minimal electrical activity.
• During voluntary contraction, electrical activity increases markedly.
• A sustained contraction or one of increasing strength causes a rapid “train” of motor unit potentials that can be
heard as a crescendo of sounds over the audio amplifier.
Before the Test:
• Review the procedure with the patient, indicating that the procedure is performed in a special laboratory by a

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physician and is done to evaluate electrical activity of muscles. This test takes 1 hour to complete, but can take
up to 3 hours depending on the patient’s condition.
• Obtain a list of the medications the patient is taking
• Obtain a history and assessment of neuromuscular and neurosensory status, disease, or conditions that affect
muscle function, level of muscular function and range of motion, traumatic events, and the results of previously
performed tests, surgeries, and procedures. For related tests, refer to the musculoskeletal system table.
• Ensure that the patient has refrained from smoking and caffeine containing beverages for 3 hours before the
procedure.
• Inform the patient that as many as 10 electrodes may be inserted at various locations on the body. Warn the
patient that the procedure may be uncomfortable, but that an analgesic or sedative will be administered
• Ask the patient to remain very still and relaxed and to cooperate with instructions given to contract muscles
during the procedure.
• Ensure that medications such as muscle relaxants, cholinergics, and anticholinergics have been withheld, as
ordered.
• Assess for compliance with directions given for exercising during the test.
• Appropriate hematologic studies should be ordered to assess coagulopathy.
• Obtain a written, informed consent for the procedure from the patient, if necessary
During the Test:
• Have patient remove clothing and any hosiery. Patients may want to wear a gown and void.
• Administer mild analgesic (adult) or sedative (children), as ordered, to promote a restful state before the
procedure.
• Place the patient in a supine or sitting position depending on the location of the muscle to be tested. Ensure that
the area or room is protected from noise or metallic interference that may affect the test results.
• Cleanse the skin thoroughly with alcohol pads, as necessary.
• An electrode is applied to the skin to ground the patient, and then 24- gauge needles containing a fine-wire
electrode are inserted into the muscle. The electrical potentials of the muscle are amplified, displayed on a
screen, and electronically recorded.
• During the test, muscle activity is tested while the patient is at rest, during incremental needle insertion, and
during varying degrees of muscle contraction.
• Ask the patient to alternate between a relaxed and a contracted muscle state, or to perform progressive muscle
contractions while the potentials are being measured.
After the Test:
• When the procedure is complete, remove the electrodes and clean the skin where the electrode was applied.
• Monitor electrode sites for hematoma or inflammation.
• If residual pain is noted after the procedure, instruct the patient to apply warm compresses and to take analgesics,
as ordered.

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• Instruct the patient to resume normal activity, diet, and previous medication use, unless otherwise indicated.
• Evaluate test results in relation to the patient’s symptoms and any related tests performed.
• In primary muscle diseases, such as muscular dystrophy, motor unit potentials are short (low
amplitude), with frequent, irregular discharges.
• In disorders such as amyotrophic lateral sclerosis (ALS) (as well as in peripheral nerve disorders), motor
unit potentials are isolated and irregular, but show increased amplitude and duration.
• In myasthenia gravis, motor unit potentials initially may be normal, but progressively diminish in
amplitude with continuing contractions.
CEREBROSPINAL FLUID
ANALYSIS
•Cerebrospinal fluid (CSF), a clear substance that circulates in the subarachnoid space, has many vital f unctions. It
protects the brain and spinal cord from injury and transports products of neurosecretion, cellular biosynthesis, and
cellular metabolism through the central nervous system (CNS).
•For qualitative analysis, CSF is most commonly obtained by lumbar puncture (usually between the third and fourth
lumbar vertebrae) and, rarely, by cisternal or ventricular puncture. A CSF specimen may also be obtained during other
neurologic tests such as myelography.
B.) Purposes
•To measure CSF pressure as an aid in detecting an obstruction of CSF circulation
•To aid in the diagnosis of viral or bacterial meningitis, subarachnoid or intracranial hemorrhage, tumors, and brain
abscesses
•To aid in the diagnosis of neurosyphilis and chronic CNS infections
•To check for Alzheimer’s disease
C.) Indications
•Assist in the diagnosis and differentiation of subarachnoid or intracranial hemorrhage
•Assist in the diagnosis and differentiation of viral or bacterial meningitis or encephalitis
•Assist in the diagnosis of diseases such as multiple sclerosis, autoimmune disorders, or degenerative brain disease
•Assist in the diagnosis of neurosyphilis and chronic central nervous system (CNS) infections
•Detect obstruction of CSF circulation due to hemorrhage, tumor, or edema
•Establish the presence of any condition decreasing the flow of oxygen to the brain
•Monitor for metastases of cancer into the CNS
•Monitor severe brain injuries
D.) Contraindications/Precautions/Interfering Factors Contraindications:
•Infection at the puncture site contraindicates removal of CSF; in a patient with increased intracranial pressure, CSF
should be removed with extreme caution because the rapid reduction in pressure that follows withdrawal of fluid can
cause cerebellar tonsillar herniation and medullary compression.
Interfering Factors:
•Patient position and activity (possible increase or decrease in CSF pressure)
•Crying, coughing, or straining (possible increase in CSF pressure)

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• Delay between collection time and laboratory testing (possible invalidation of test results, especially cell counts)
• Lumbar puncture tray
• Sterile gloves
• Face mask
• Local anesthetic (usually 1% lidocaine)
• Povidone-iodine solution,
• Small adhesive bandage
• Describe the procedure to the patient and explain that CSF analysis analyzes the fluid around the spinal cord.
• Inform the patient that he need not restrict food and fluids.
• Tell the patient who will perform the procedure and where it will take place.
• Advise the patient that a headache is the most common adverse effect of a lumbar puncture, but reassure him that
his cooperation during the test helps minimize this effect
• Make sure that the patient or a responsible family member has signed an informed consent form.
• If the patient is unusually anxious, assess and report his vital signs.
F.) Normal Values
TEST NORMAL
Pressure 50 to 180 mm H2O
Appearance Clear, colorless
Protein 15 to 50 mg/dl (SI, 0.15 to 0.5 q/L)
Gamma Globulin 3% to 12% of total protein
Glucose 50 to 80 mg/dl (SI, 2.8 to 4.4 mmol/L)
0 to 5 white blood cells
Cell Count
No RBCs
Venereal Disease Research
Laboratories test for syphilis Nonreactive
and other serologic tests
Chloride 118 to 130 mEq/L (SI, 118 to 130 mmol/L)
Gram stain No organisms
Before the Test:
•Obtain a history of the patient’s complaints, including a list of known allergens
•Obtain a history of the patient’s immune and musculoskeletal systems, as well as results of previously performed tests
and procedures. For related tests, refer to the immune and musculoskeletal system tables.

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•Obtain a list of medications the patient is taking, including herbs, nutritional supplements, and nutraceuticals. The
requesting health care practitioner and laboratory should be advised if the patient regularly uses these products so that
their effects can be taken into consideration when reviewing results.
•Note any recent procedures that can interfere with test results.
•There are no food, fluid, or medication restrictions unless by medical direction.
•Review the procedure with the patient
•Inform the patient that the position required may be awkward, but that someone will assist during the procedure. Stress
the importance of remaining still and breathing normally throughout the procedure.
•Inform the patient that a stinging sensation may be felt when the local anesthetic is injected. Tell the patient to report
any pain or other sensations that may require repositioning the spinal needle.
•Assess if the patient has an allergy to local anesthetics, and inform the health care practitioner accordingly.
•Obtain written and informed consent before administering any medications prior to the procedure.
•Inform the patient that the procedure is performed by a health care practitioner and takes about 20 minutes
During the Test:
•Direct the patient to breathe normally and to avoid unnecessary movement.
•Record baseline vital signs.
•To perform a lumbar puncture, position the patient in the knee-chest position at the side of the bed. Provide pillows to
support the spine or for the patient to grasp. The sitting position is an alternative. In this position, the patient must bend
the neck and chest to the knees.
•Observe standard precautions
•Prepare the site—usually between L3 and L4, or between L4 and L5— with povidone-iodine and drape the area.
• A local anesthetic is injected. Using sterile technique, the health care practitioner inserts the spinal needle through
the spinous processes of the vertebrae and into the subarachnoid space. The stylet is removed. If the needle is
properly placed, CSF drips from the needle.
• Attach the stopcock and manometer, and measure initial pressure. Normal pressure for an adult in the lateral
recumbent position is 90 to 180 mm H2O; normal pressure for a child aged 8 years or younger is 10 to 100 mm
H2O. These values depend on the body position and are different in a horizontal or sitting position.
• CSF pressure may be elevated if the patient is anxious, holding his or her breath, or tensing muscles. It may also
be elevated if the patient’s knees are flexed too firmly against the abdomen. CSF pressure may be significantly
elevated in patients with intracranial tumors. If the initial pressure is elevated, the health care practitioner may
perform Queckenstedt’s test. To perform this test, apply pressure to the jugular vein for about 10 seconds. CSF
pressure usually rises rapidly in response to the occlusion, and then returns to the pretest level within 10 seconds
after the pressure is released. Sluggish response may indicate CSF obstruction.
• Obtain four vials of spinal fluid in separate tubes (1 to 3 mL in each), and label them numerically in the order
they were filled.
• A final pressure reading is taken, and the needle is removed. Clean the puncture site with an antiseptic solution

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and apply a small bandage.
• Label the specimen, and promptly transport it to the laboratory.
After the Test:
• If permitted, administer fluids to replace lost CSF and help prevent or relieve headache—a side effect of lumbar
puncture.
• Position the patient flat, either on the back or abdomen; some health care practitioners allow 30° elevation.
Maintain position for 8 hours. Changing position is acceptable as long as the body remains horizontal.
• Check the puncture site for leakage; frequently monitor vital signs such as temperature and blood pressure.
• Observe the patient for neurological changes, such as altered level of consciousness, change in pupils, reports of
tingling or numbness, and irritability.
• Evaluate test results in relation to the patient’s symptoms and other tests performed.
TEST ABNORMAL IMPLICATIONS
Increase Increased intracranial pressure
Pressure Spinal subarachnoid obstruction
Decrease
above puncture site
Cloudy Infection
Subarachnoid, intracerebral, or
intraventricular hemorrhage; spinal
Xanthochromic or bloody cord obstruction; traumatic tap
(usually noted only in initial
Appearance specimen)
Elevated protein levels, red
blood cell (RBC) breakdown
Brown, orange, or yellow (blood present for at least 3 days)
Tumors, trauma, hemorrhage,

Marked increase diabetes mellitus, polyneuritis,
Protein blood in cerebrospinal fluid
Marked decrease (CSF)
Rapid CSF production
Demyelinating disease,
Gamma Globulin Increase neurosyphilis, Guillain-Barré
syndrome
Glucose Increase Systemic hyperglycemia
Systemic hypoglycemia, bacterial
or fungal infection, meningitis,
Decrease mumps, postsubarachnoid
hemorrhage
Active disease: meningitis, acute
infection, onset of chronic illness,
Increase tumor, abscess,
Cell Count
infarction, demyelinating disease

Page 138 of 145
RBCs Hemorrhage or traumatic lumbar
puncture
Venereal Disease
Research Laboratories test
for syphilis and other Positive Neurosyphilis
serologic tests
Chloride Decrease Infected meninges
Gram-positive or gram negative
Gram stain Bacterial meningitis
organisms
MYELOGRA
PHY
•The myelogram allows visualization of the spinal subarachnoid space or the spinal canal to determine abnormalities. A
contrast medium is injected into the spinal canal via a lumbar puncture. Fluoroscopy provides a view of the flow toward
the head as the table is tilted. X-rays are taken at the same time. A cisternal puncture can be performed if a lumbar
puncture is contraindicated.
B.) Purposes
•To evaluate and determine the cause of neurologic symptoms (numbness, pain, weakness)
•To identify lesions, such as tumors and herniated intervertebral disks that partially or totally block the flow of CSF in the
subarachnoid space
•To help detect arachnoiditis, spinal nerve root injury, or tumors in the posterior fossa of the skull
C.) Indications
•Patients who require imaging as a result of a clinical diagnosis of nerve root, thecal sac or spinal cord compression from
disc, tumor or spinal stenosis
•Patients with clinical symptoms and signs of a CSF leak. D.) Contraindications/Precautions/Interfering Factors
Contraindications
•Known allergy to iodine or iodinated contrast media
•Suspected or confirmed increase in intracranial pressure Infection at the puncture site
•Chronic neurological disease such as multiple sclerosis
Interfering Factors
•Inability of client to remain still during the procedure
•Spinal curvatures or other abnormalities that prevent lumbar or cervical puncture for dye injection
•Inaccurate needle placement in the spinal column
•Metal objects within the field E.) Equipment/Patient Preparation Equipment:
•Alcohol, 1% lidocaine solution
•Lumbar puncture tray, contrast medium (iophendylate or metrizamide)

Page 139 of 145
•2 10-ml syringes, spinal needle (18G for iophendylate or 11G for metrizamide)
•X-ray machine capable of fluoroscopy
•Povidone-iodine solution
•Sterile gloves
•Small adhesive bandage
•Explain to the patient that myelography reveals obstructions in the spinal cord
•Tell the patient that his food and fluid intake will be restricted for 8 hours before the test. If the test is scheduled for the
afternoon and facility policy permits, the patient may have clear liquids before the test
•Tell the patient to remove all jewelry and other metallic objects in the X-ray field.
•Tell the patient that the head of his bed must be elevated for 6 to 8 hours after the test and that he’ll remain on bed rest
for an additional 6 to 8 hours. If an oil-based contrast agent is used, inform the patient that it will be
manually removed after the test and that he’ll need to remain flat in bed for 6 to 24 hours
F.) Normal Values
•Normal structure of the subarachnoid spaces of the spinal column; no spinal abnormalities or obstructions
•Contrast medium flowing freely through the subarachnoid space
•No obstruction or structural abnormalities
the Test:
•Describe the test, including who will administer it and where it will take place.
•Explain to the patient that he may feel a transient burning sensation as the contrast medium is injected; a warm, flushed
feeling; transient headache; a salty taste; or nausea and vomiting after the dye is injected. Explain that he may feel some
pain caused by his positioning, needle insertion and, in some cases, removal of the contrast medium.
•Make sure that the patient or a responsible family member has signed an informed consent form.
•Perform pretest procedures and administer prescribed medications. If the puncture is to be performed in the lumbar
region, an enema may be prescribed. A sedative and anticholinergic (such as atropine sulfate) may be prescribed to reduce
swallowing during the procedure. Make sure that pretest laboratory work (may include coagulation and kidney function
studies) is present in the chart.
During the Test:
•Position the patient on his side at the edge of the table with his chin on his chest and his knees drawn up to his abdomen.
(If the patient has a lumbar deformity or an infection at the puncture site, a cisternal puncture may be done.)
•After the lumbar puncture is performed, the fluoroscope is used to verify proper positioning of the needle in the

Page 140 of 145
subarachnoid space. Some CSF may be removed for routine laboratory analysis.
•Turn the patient to the prone position and secure him with straps across his upper back, under his arms, and across his
ankles. Hyperextend his chin to prevent the contrast medium from flowing into the cranium; place a towel under his chin
for comfort.
•If the patient complains of a headache or difficulty swallowing or reports that he isn’t breathing deeply enough, provide
reassurance and explain that he can rest periodically during the procedure.
•The contrast medium is injected and the table tilted so that the dye flows through the subarachnoid space. (In rare
circumstances, air is used as a negative contrast medium; however, this is typically reserved for a patient with suspected
congenital abnormalities such as syringomyelia.)
•The contrast medium flow is observed by fluoroscope, and X-rays are taken. If an obstruction in the subarachnoid space
blocks the upward flow of the contrast medium, a cisternal puncture may be performed.
•The contrast medium is withdrawn, if necessary, after satisfactory X-rays are obtained and the needle is removed. Clean
the puncture site with povidone-iodine solution and apply a small adhesive bandage.
After the Test:
•Based on the contrast medium used during the test, position the patient as follows: If metrizamide was used, tell him to
stay in bed for the next 12 to 16 hours. Keep the head of his bed elevated for at least 8 hours. If an oil- based contrast
medium was used, tell him to remain flat in bed for 24 hours.
•Monitor the patient’s vital signs and neurologic status at least every 15 minutes for the first hour, every 30 minutes for
the next 2 hours, and then every 4 hours for 24 hours, if he isn’t discharged. The patient may be discharged the same day
•Encourage the patient to drink extra fluids to flush the contrast. He should void within 8 hours after returning to his
room.
•If no complications or adverse reactions occur, tell the patient that he may resume his usual diet and activities the day
after the test, as ordered.
•Monitor the patient for radicular pain, fever, back pain, or signs of meningeal irritation, such as headache, irritability, or
stiff neck. If these signs or symptoms occur, keep the room quiet and dark, and administer an analgesic or antipyretic, as
needed
•Myelography can identify and localize lesions within or surrounding the spinal cord or subarachnoid space. Examples of
common extradural lesions include herniated intervertebral disks and metastatic tumors.
•Neurofibromas and meningiomas are common lesions within the subarachnoid space, and ependymomas and
astrocytomas are common within the spinal cord.
•If the test confirms a spinal tumor, the patient may be taken directly to the operating room. Immediate surgery may also
be necessary if the contrast medium causes a total block of the subarachnoid spaceMyelography may help locate or
confirm a ruptured or herniated disk, spinal stenosis, or abscess and, occasionally, confirm the need for surgery. This test
may also detect syringomyelia (a congenital abnormality marked by fluid-filled cavities within the spinal cord and
widening of the cord itself), arachnoiditis, spinal ne rve root injury, and tumors in the posterior fossa of the skull.
•Other findings may include fractures, dislocations, thinning of bones (osteoporosis), deformities in the curvature of the
spine, bone spurs, and vertebral degeneration

Page 141 of 145
TENSILON
TEST
•The Tensilon test involves careful observation of the patient after I.V. administration of Tensilon (edrophonium
chloride), a rapid, short-acting anticholinesterase that improves muscle strength by increasing muscle response to nerve
impulses.
•It’s especially useful in diagnosing myasthenia gravis, an abnormality of the myoneural junction in which nerve
impulses fail to induce normal muscular responses. Patients with myasthenia gravis experience extreme fatigue at the
end of the day and after repetitive activity or stress. Results of other procedures, including electromyography, may
supplement Tensilon test findings in diagnosing this disease.
B.) Purposes
•To aid in the diagnosis of myasthenia gravis
•To aid in differentiating between myasthenic and cholinergic crises
•To monitor oral anticholinesterase therapy
C.) Indications
•Diagnosing myasthenia gravis when fatigue and muscle weakness are present, as revealed by an immediate
improvement after injection of Tensilon
•Monitoring medication regimen of oral anticholinesterase to determine whether increase in dose is advised, as revealed
by an improvement in muscle strength after IV Tensilon
•Determining whether an overdose is present, which can place the client in cholinergic crisis, as reveal ed by an
exaggeration of muscle weakness after IV Tensilon
•Corticosteroids,muscle relaxants,and anticholinergics, which can alter test results by their effect on muscle function or
on the action of Tensilon
Interfering Factors
•Breathing difficulties or apneic conditions, because the disease can cause respiratory difficulties severe enough to
require ventilatory support
•Standard
o 10 mg Tensilon
o 0.4 mg atropine (may be prescribed for the patient with respiratory distress)
o 1 tuberculin and one 3-ml syringe
o I.V. infusion set
o 50-ml bag of I.V. solution (dextrose 5% in water [D5W] or normal saline solution)
o Tape
o Tourniquet
o Alcohol swabs

Page 142 of 145
•Emergency
o 0.5 to 1.0 mg atropine I.V. for cholinergic crisis
o 0.5 to 2.0 mg neostigmine methylsulfate
o I.V. for myasthenic crisis (may be repeated up to a total of 5 mg)
o Extra tuberculin and 3-ml syringes (for atropine or neostigmine injections)
o Resuscitation equipment, including a tracheotomy tray
•Explain that the Tensilon test helps determine the cause of muscle weakness.
•Describe the test, including who will perform it, where it will take place, and how long it will last.
•Don’t describe the exact response that will be evaluated; foreknowledge can affect the test’s objectivity.
•Explain to the patient that a small tube will be inserted into a vein in his arm and that a drug will be administered
periodically. He’ll be asked to make repetitive muscle movements and his reactions will be observed. To ensure
accuracy, the test may be repeated several times.
•Advise the patient that the Tensilon may produce some unpleasant adverse effects, but reassure him that someone will
be with him at all times and that any reactions will quickly disappear.
•Check the patient’s history for medications that affect muscle function, anticholinesterase therapy, drug
hypersensitivities, and respiratory disease. Withhold medications, as ordered. If the patient is receiving
anticholinesterase therapy, note this on the requisition request; include the time of the most recent dose.
F.) Normal Values

•Fasciculations develop.
the Test:
•Explain to the patient that a small tube will be inserted into a vein in his arm and that a drug will be
administered periodically. He’ll be asked to make repetitive muscle movements and his reactions will be observed. To
ensure accuracy, the test may be repeated several times.
•Advise the patient that the Tensilon may produce some unpleasant adverse effects, but reassure him that someone will be
with him at all times and that any reactions will quickly disappear.
•Check the patient’s history for medications that affect muscle function, anticholinesterase therapy, drug
hypersensitivities, and respiratory disease. Withhold medications, as ordered. If the patient is receiving anticholinesterase
therapy, note this on the requisition request; include the time of the most recent dose.
During the Test:
•Begin an I.V. infusion of D5W or normal saline solution

Page 143 of 145
•When performing the test on an adult patient suspected of having myasthenia gravis, 2 mg of Tensilon are administered
initially. Before the rest of the dose is administered, the physician may want to fatigue the muscles by asking the patient
to perform various exercises, such as looking up until ptosis develops, counting to 100 until his voice diminishes, or
holding his arms above his shoulders until they drop. When the muscles are fatigued, the remaining 8 mg of Tensilon are
administered over 30 seconds.
•Some physicians may prefer to begin the test with a placebo injection to evaluate the patient’s muscle response more
accurately. The placebo isn’t necessary if cranial muscles are being tested because cranial strength can’t be simulated
voluntarily
•After Tensilon is administered, the patient is asked to perform repetitive muscle movements, such as opening and closing
his eyes and crossing and uncrossing his legs. Closely observe the patient for improved muscle
strength. If muscle strength doesn’t improve within 3 to 5 minutes, the test may be repeated.
•To differentiate between a myasthenic and cholinergic crisis, 1 to 2 mg of Tensilon is infused. After the infusion,
continually monitor the patient’s vital signs. Watch closely for respiratory distress and be prepared to provide respiratory
assistance.
•If muscle strength doesn’t improve, more Tensilon is infused cautiously — 1 mg at a time up to a maximum of 5 mg —
and the patient is observed for distress.
•Neostigmine is administered immediately if the test demonstrates myasthenic crisis; atropine is administered for
cholinergic crisis
After the Test:
•To evaluate oral anticholinesterase therapy, 2 mg of Tensilon is infused 1 hour after the patient’s last dose of the
anticholinesterase. The patient is observed carefully for adverse effects and muscle response.
•After Tensilon administration, the I.V. line is kept open at a rate of 20 ml/hour until all of the patient’s responses have
been evaluated.
•When the test is complete, discontinue the I.V. and check the patient’s vital signs.
•Check the puncture site for hematoma, excessive bleeding, and swelling.
•Tell the patient that he may resume his usual medications, as ordered
•If the patient has myasthenia gravis, muscle strength should improve promptly after administration of Tensilon.
•A positive response is elicited in motor neuron disease and in some neuropathies and myopathies. The
response is usually less dramatic and less consistent than in myasthenia gravis.
•The patient in myasthenic crisis shows brief improvement in muscle strength after Tensilon administration.
•The patient in cholinergic crisis (anticholinesterase overdose) may experience exaggerated muscle weakness.

Page 144 of 145
Page 145 of 145

Laboratory/Diagnostic Exams: WORKSHEET ON Endocrine System Disorders

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Laboratory/Diagnostic Exams: WORKSHEET ON Endocrine System Disorders

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DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.

WORKSHEET ON endocrine system disorders

CAPILLARY BLOOD GLUCOSE TEST (CBG)

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THYROID STIMULATING HORMONE TEST (TSH)

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• Assess if client is pregnant or nursing.

H.) Implications of Abnormal Results

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• Instruct clients to abstain from intercourse for 72 hr before the test.

ORAL GLUCOSE TOLERANCE TEST

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FIVE – DAY GLUCOSE SENSOR TEST FOR DIABETES

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E.) Equipment/Patient Preparation Equipment

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FINE – NEEDLE ASPIRATION BIOPSY

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DEXAMETHASONE SUPPRESSION TEST

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CRH STIMULATION TEST

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E.) Equipment/Patient Preparation EQUIPMENT

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BONE DENSITY TEST

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ACTH STIMULATION TEST

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24 – HOUR URINE COLLECTION TEST

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D.) Contraindications/Precautions/Interfering Factors PRECAUTIONS

E.) Equipment/Patient Preparation EQUIPMENT

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Components Normal Range

Total • Dopamine: 65 to 400 mcg/24 hours (SI, 425–2610 nmol/24 hours)

Protein • 50 to 80 mg/24 hours (SI, 50–80 mg/ day) (at rest)

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T3 & T4 DIAGNOSTIC EXAM

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https://z-p3-lookaside.fbsbx.com/file/JULY%2006%20DIAGNOSTIC%20EXAMS.ppt?token=AW…Pexh6VidZnhgaPcLDUd9vdpIOj0RZ5s1v2UPKAVXiY4eIhi4WQaSp52n5UzN1Anl3Mi7k74bVmui6 07/07/2020, 2a13 pm

THERE ARE THREE PARTS TO NEWBORN SCREENING:

https://z-p3-lookaside.fbsbx.com/file/JULY%2006%20DIAGNOSTIC%20EXAMS.ppt?token=AW…Pexh6VidZnhgaPcLDUd9vdpIOj0RZ5s1v2UPKAVXiY4eIhi4WQaSp52n5UzN1Anl3Mi7k74bVmui6 07/07/2020, 2a13 pm

https://z-p3-lookaside.fbsbx.com/file/JULY%2006%20DIAGNOSTIC%20EXAMS.ppt?token=AW…Pexh6VidZnhgaPcLDUd9vdpIOj0RZ5s1v2UPKAVXiY4eIhi4WQaSp52n5UzN1Anl3Mi7k74bVmui6 07/07/2020, 2a13 pm

1.) NEWBORN SCREENING TEST LAW (LEGAL BASIS FOR NEWBORN

https://z-p3-lookaside.fbsbx.com/file/JULY%2006%20DIAGNOSTIC%20EXAMS.ppt?token=AW…Pexh6VidZnhgaPcLDUd9vdpIOj0RZ5s1v2UPKAVXiY4eIhi4WQaSp52n5UzN1Anl3Mi7k74bVmui6 07/07/2020, 2a13 pm

https://z-p3-lookaside.fbsbx.com/file/JULY%2006%20DIAGNOSTIC%20EXAMS.ppt?token=AW…Pexh6VidZnhgaPcLDUd9vdpIOj0RZ5s1v2UPKAVXiY4eIhi4WQaSp52n5UzN1Anl3Mi7k74bVmui6 07/07/2020, 2a13 pm