Professional Documents
Culture Documents
Ebook PDF Brunner Suddarths Handbook of Laboratory and Diagnostic Tests Third Edition PDF Docx Full Chapter Chapter Scribd
Ebook PDF Brunner Suddarths Handbook of Laboratory and Diagnostic Tests Third Edition PDF Docx Full Chapter Chapter Scribd
PART
1
Specimen Collection
PART
2
Diagnostic Tests
(in alphabetical order)
Selected References
Index
7
PART
1
Specimen Collection
8
9
INTRODUCTION
The nurse’s prompt and accurate collection of specimens is vital to the
correct diagnosis, treatment, and recovery of the patient. Often, the nurse
alone is responsible for specimen collections; at other times, the nurse’s
responsibility focuses on scheduling the patient’s tests, assisting the health
care provider in performing them, and caring for the patient afterward. Your
clinical setting and your facility’s policies, along with your state’s nurse
practice act, will determine your responsibilities.
Patient Preparation
By thoroughly understanding the diagnostic tests you’ll perform or assist
with, you’ll be better prepared to explain them to the patient with clarity and
compassion, put the patient at ease, gain the patient’s trust and cooperation,
and thus ensure more accurate results. Helping the patient understand a
procedure also paves the way for consent that’s truly informed.
When preparing the patient, your explanations should be clear,
straightforward, and complete. Explain how long the procedure takes, when
the results can be expected, and describe what the patient will experience
during the test. By letting the patient know exactly what to expect, you can
help the patient better tolerate such a procedure.
If you’re assisting the health care provider with a test, speak to the
patient throughout the procedure to offer comfort and encouragement and to
prepare him or her for sensations that may be experienced. Afterward, watch
for adverse reactions or complications, and be prepared to implement
appropriate interventions.
Some tests require detailed instructions to promote cooperation and to
ensure accurate specimen collection. This is especially important when the
patient must modify behavior beforehand or when the patient will personally
collect the specimen. For example, you may need to instruct the patient to
observe a special diet, suspend taking certain medications, or learn a special
collection technique.
Whenever possible, reinforce verbal explanations with appropriate
written instructions and give the patient enough time to read the information
before beginning to prepare for the test or procedure. Many facilities also
have written materials and videos available to augment the patient-teaching
process.
Informed Consent
10
Informed consent is a fundamental patient right. It provides that the patient
(or a responsible family member, if the patient is legally incompetent or a
minor) must fully understand what will be done during a test, surgery, or
medical procedure and must understand its risks and implications before the
patient can legally consent to it.
Explaining a procedure, its purpose, how it will be performed, and its
potential risks are primarily the health care provider’s responsibility. The
nurse typically reinforces the health care provider’s explanation, confirms
that the patient understands it, and verifies that written consent was
obtained, when necessary. Written consent isn’t always needed for a test—
informed consent may be enough—and the patient always retains the legal
right to withdraw oral or written consent at any time and for any reason, and
to refuse care or treatment.
11
PaCO2 shows the lungs’ capacity to eliminate carbon dioxide. ABG samples
can also be analyzed for oxygen content and saturation and for bicarbonate
values.
Typically, ABG analysis is prescribed to assess for adequate oxygenation
and ventilation, assess acid–base balance by measuring the respiratory and
metabolic components, and to monitor effectiveness of treatment for
patients with chronic obstructive pulmonary disease, pulmonary edema,
acute respiratory distress syndrome, myocardial infarction, or pneumonia.
It’s also performed when a patient is in shock and after coronary artery
bypass surgery, resuscitation from cardiac arrest, changes in respiratory
therapy or status, and prolonged anesthesia.
Arterial puncture is contraindicated when the patient:
has a failed Allen’s test result,
has hemophilia or another clotting disorder,
had arterial spasms following previous punctures,
has severe peripheral vascular disease,
exhibits abnormal or infectious skin conditions at or near the puncture site.
In addition, if the patient has a surgical graft, arterial puncture should not
be performed distal to the site. Arterial puncture may also be contraindicated
if the patient is taking anticoagulation therapy.
Most ABG samples can be drawn by a respiratory technician or specially
trained nurse. Collection from the femoral artery, however, usually is
performed by the health care provider. Before attempting a radial puncture,
Allen’s test should be performed. (See the Performing Allen’s Test box.)
Equipment
• 10-mL glass syringe or plastic Luer-Lok syringe specially made for
drawing blood for ABG analysis • 1-mL ampule of aqueous heparin
(1:1,000) • 20G 1-in needle • 22G 1-in needle • gloves • antiseptic pad • two
2 × 2-in gauze pads • rubber cap for syringe hub or rubber stopper for needle
• a clean emesis basin • ice-filled plastic bag • label • laboratory request
form • adhesive bandage • 1% lidocaine solution without epinephrine
(optional)
Many health care facilities use a commercial ABG kit that contains all
the equipment listed above, except the adhesive bandage and ice. If your
facility doesn’t use such a kit, obtain a sterile syringe specially made for
drawing blood for ABG values and use a clean emesis basin filled with ice
instead of the plastic bag to immediately transport the sample to the
laboratory.
12
Performing Allen’s Test
13
Rest the patient’s arm on the mattress or bedside stand and support the wrist
with a rolled towel. Have the patient clench a fist. Then, using your index and
middle fingers, press on the radial and ulnar arteries. Hold this position for a
few seconds.
Without removing your fingers from the patient’s arteries, ask the patient to
unclench the fist and hold the hand in a relaxed position. The palm will be
blanched because pressure from your fingers has impaired the normal blood
flow.
14
Release pressure on the patient’s ulnar artery. If the hand becomes flushed,
which indicates blood filling the vessels, you can safely proceed with the radial
artery puncture. If the hand doesn’t flush, perform the test on the other arm.
Equipment Preparation
Prepare the collection equipment before entering the patient’s room.
Wash your hands thoroughly.
Open the ABG kit and remove the sample label and the plastic bag.
Record the patient’s name and room number on the label, as well as the
date and collection time, and the health care provider’s name.
Fill the plastic bag with ice and set it aside.
Heparinize the syringe, if needed. To do so, attach the 20G needle to the
syringe and open the heparin ampule. Draw all the heparin into the syringe
to prevent the sample from clotting. Hold the syringe upright, and pull the
plunger back slowly to about the 7-mL mark. Rotate the barrel while
pulling the plunger back to allow the heparin to coat the inside surface of
the syringe. Then, slowly force the heparin toward the hub of the syringe
and expel all but about 0.1 mL of it.
Heparinize the needle, if needed. To do so, replace the 20G needle with the
22G needle. Then, hold the syringe upright, tilt it slightly, and eject the
remaining heparin. Excess heparin in the syringe alters blood pH and PaO2
values.
Essential Steps
Confirm the patient’s identity using two patient identifiers and
confirmation of the patient’s identification bracelet according to facility
policy.
Tell the patient that you need to collect an arterial blood sample and
explain the procedure to help ease anxiety and promote cooperation.
Explain that the patient may feel discomfort from the needle stick but must
remain still during the procedure.
15
Wash your hands and put on gloves.
Place a rolled towel under the patient’s wrist for support.
Locate the artery and palpate it for a strong pulse.
Clean the puncture site with antiseptic solution, working outward in a
circular or side-to-side motion.
Allow the skin to dry.
Palpate the artery with the index and middle fingers of one hand while
holding the syringe over the puncture site with the other hand.
Hold the needle bevel up at a 30- to 45-degree angle. When puncturing the
brachial artery, hold the needle at a 60-degree angle. (See the Arterial
Puncture Technique box.)
Check the syringe for air bubbles. If any appear, remove them by holding
the syringe upright and slowly ejecting some of the blood onto a 2 × 2
gauze pad. Air bubble removal devices can also be used to expel air from
the syringe. Air bubbles in the specimen can falsely elevate or decrease
results.
Insert the needle into a rubber stopper or remove the needle and place a
rubber cap directly on the syringe tip. This prevents the sample from
leaking and keeps air out of the syringe.
Put the labeled sample in the ice-filled plastic bag or emesis basin.
Attach a properly completed laboratory request form and send the sample
to the laboratory immediately.
When bleeding stops, apply a small adhesive bandage to the site.
Discard syringes, needles, and gloves in the appropriate containers.
16
Arterial Puncture Technique
The needle penetration angle in ABG sampling varies depending on the artery
being used for the sample. For the radial artery, the most commonly used, the
needle should enter bevel-up at a 30- to 45-degree angle.
Puncture the skin and the arterial wall in one motion, following the artery
path.
Watch for blood backflow in the syringe. Don’t pull back on the plunger.
Allow arterial pulsations to pump blood into the syringe automatically.
Fill the syringe to the 3-mL mark.
After collecting the sample, press a gauze pad firmly over and proximal to
the puncture site. Maintain continuous pressure for 5 to 10 minutes, until the
bleeding stops. Visually inspect the site for hematoma formation.
Monitor the patient’s vital signs and observe for signs of circulatory
impairment, such as swelling, discoloration, pain, numbness, or tingling in
the arm or leg.
Watch for bleeding and hematoma formation at the puncture site.
Special Considerations
If the patient is receiving oxygen, make sure that therapy has been under
way for at least 15 minutes before collecting an arterial blood sample.
Unless prescribed, don’t turn off existing oxygen therapy before collecting
arterial blood samples.
Indicate on the laboratory request slip the amount and type of oxygen
therapy the patient is receiving.
If the patient isn’t receiving oxygen, indicate that he’s breathing room air.
If the patient has been recently suctioned or placed on a ventilator, wait at
least 15 minutes before drawing the sample.
17
Quality and Safety Nursing Alert
If the patient has received a nebulizer treatment, wait about 20 minutes before
collecting the sample.
Complications
If too much force is used when attempting an arterial puncture, the needle
may touch the periosteum of the bone, causing the patient considerable pain,
or the needle may pass through the artery’s opposite wall. If this happens,
slowly pull the needle back a short distance and check to see if you obtain a
blood return. If blood still fails to enter the syringe, withdraw the needle
completely and start with a fresh heparinized needle.
If arterial spasm occurs, blood won’t flow into the syringe, and you won’t
be able to collect the sample. If this happens, replace the needle with a
smaller one and try the puncture again. A smaller bore needle is less likely
to cause arterial spasm.
18
Documentation
Record:
Allen’s test results,
time the sample was drawn,
patient’s temperature,
type and amount of oxygen therapy the patient was receiving,
location of arterial puncture site,
length of time that pressure was applied to the site to control bleeding,
patient’s tolerance of the procedure.
Blood Culture
Normally bacteria-free blood can be infected through infusion lines, as well
as from thrombophlebitis, infected shunts, or bacterial endocarditis from
prosthetic heart valve replacements. Bacteria may also invade the vascular
system from local tissue infections through the lymphatic system and the
thoracic duct.
Blood cultures are done to detect bacterial invasion (bacteremia) and the
systemic spread of an infection (septicemia) through the bloodstream.
Samples may be taken by the laboratory technician, health care provider, or
nurse through venipuncture at the patient’s bedside; they’re transferred into
two bottles: one containing an anaerobic medium and the other an aerobic
medium. The bottles are incubated to encourage any organisms in the
sample to grow in the media. Blood cultures identify about 67% of
pathogens within 24 hours and up to 90% within 72 hours. (See the Isolator
Blood-Culturing System box.)
19
Isolator Blood-Culturing System
Equipment
• Tourniquet • gloves • antiseptic swabs • 10-mL syringe for an adult, 6-mL
syringe for a child • three or four 20G 1½-in needles • two or three blood
culture bottles (50-mL bottles for adults, 20-mL bottles for infants and
children) with sodium polyethanol sulfonate added (one aerobic bottle
containing a suitable medium, such as Trypticase soy broth with 10% carbon
dioxide atmosphere; one anaerobic bottle with prereduced medium; and,
possibly, one hyperosmotic bottle with 10% sucrose medium) • laboratory
request form • 2 × 2-in gauze pads • small adhesive bandages • labels
Essential Steps
20
Check the expiration dates on the culture bottles and replace outdated
bottles.
Confirm the patient’s identity using two patient identifiers and
confirmation of the patient’s identification bracelet according to facility
policy.
Tell the patient that you need to collect a series of blood samples to check
for infection.
Explain the procedure to ease anxiety and promote cooperation. Explain
that the procedure usually requires three blood samples collected at
different times and different sites.
Wash your hands and put on gloves.
Tie a tourniquet 2 in (5 cm) proximal to the area chosen. (See
Venipuncture, page 22.)
Clean the venipuncture site with an antiseptic swab, with the first swab
moving back and forth on the horizontal plane, the second swab moving
back and forth on the vertical plane, and the last swab moving in a circular
motion from the site outward. Wait 30 to 60 seconds for the skin to dry
completely.
Perform a venipuncture, drawing 10 mL of blood from an adult.
Special Considerations
21
Obtain each set of cultures from a different site. Infants will rarely have
three separate blood cultures run; they will usually have one.
Avoid using existing blood lines for cultures unless the sample is drawn
when the line is inserted or catheter sepsis is suspected.
Complications
Hematomas are the most common venipuncture complication. If a
hematoma develops, apply direct pressure to the site.
Documentation
Record:
blood sample collection date and time,
test name,
amount of blood collected,
number of bottles used,
patient’s temperature,
adverse reactions to the procedure.
Sputum Collection
Secreted by mucous membranes lining the bronchioles, bronchi, and
trachea, sputum helps protect the respiratory tract from infection. When
expelled, sputum carries saliva, nasal and sinus secretions, dead cells, and
normal oral bacteria from the respiratory tract.
Sputum may be cultured to identify respiratory pathogens. Expectoration,
the usual sputum collection method, may require ultrasonic nebulization,
hydration, or chest percussion and postural drainage. Less common methods
include tracheal suctioning and, rarely, bronchoscopy. Tracheal suctioning
provides a more reliable diagnostic specimen, but generally isn’t used,
unless expectoration fails to provide a sample.
Tracheal suctioning is contraindicated within 1 hour of eating and in
patients with esophageal varices, nausea, facial or basilar skull fractures,
laryngospasm, or bronchospasm. It should be performed cautiously in
patients with heart disease because it may precipitate arrhythmias.
Equipment
For Expectoration
• Sterile specimen container with tight-fitting cap • gloves • label laboratory
request form • aerosol (10% sodium chloride, propylene glycol,
acetylcysteine, or sterile or distilled water)
22
For Tracheal Suctioning
No. 12 to 14 French sterile suction catheter • water-soluble lubricant •
laboratory request form • sterile gloves • mask • goggles • sterile in-line
specimen trap (Lukens trap) • normal saline solution • portable suction
machine, if wall suction is unavailable • oxygen therapy equipment
Commercial suction kits have all equipment except the suction machine
and an in-line specimen container.
Essential Steps
Collecting by Expectoration
Confirm the patient’s identity using two patient id entifiers and
confirmation of the patient’s identification bracelet according to facility
policy.
Inform the patient that you need to collect a sputum specimen by
expectoration.
Explain the procedure.
Plan to collect the specimen early in the morning, before breakfast.
Instruct the patient to sit on a chair or at the edge of the bed. If unable to sit
up, place the patient in high Fowler position.
Ask the patient to rinse mouth with water to reduce specimen
contamination. Avoid mouthwash or toothpaste because they may affect
the mobility of organisms in the sputum sample.
Then tell the patient to cough deeply and expectorate directly into the
specimen container.
Ask the patient to produce at least 5 to 10 mL of sputum, not saliva. Check
the specimen carefully to make sure it includes thick mucus.
If the patient is unable to hold the specimen container, put on gloves and
place it near the patient’s mouth.
Cap the container and, if necessary, clean its exterior.
Remove and discard your gloves, then wash your hands thoroughly.
Label the container with the patient’s name and room number, the health
care provider’s name, date and time of collection, and initial diagnosis.
Include on the laboratory request form whether the patient was febrile or
taking antibiotics and whether sputum was induced.
Send the specimen to the laboratory immediately.
Collecting by Tracheal Suctioning
Collect a specimen by suctioning if the patient can’t produce an adequate
specimen by coughing.
23
Explain the suctioning procedure to the patient. Explain that the patient
may cough, gag, or feel short of breath during the procedure.
Check the suction equipment to be sure it’s functioning properly.
Place the patient in high Fowler or semi-Fowler position.
Administer oxygen to the patient before beginning the procedure.
Wash your hands thoroughly.
Position a mask and goggles over your face.
Put on sterile gloves. Consider one hand sterile and the other hand clean to
prevent cross-contamination.
Connect the suction tubing to the male adapter of the in-line specimen trap.
Attach the sterile suction catheter to the rubber tubing of the trap. (See the
Attaching a Specimen Trap to a Suction Catheter box.)
Tell the patient to tilt the head back slightly.
Lubricate the catheter with normal saline solution.
Gently pass the catheter through the patient’s nostril without suction. When
the catheter reaches the larynx, the patient will cough. As the patient
coughs, quickly advance the catheter into the trachea.
Tell the patient to take several deep breaths through the mouth.
Apply suction for 5 to 10 seconds, but never longer than 15 seconds.
(Prolonged suction can cause hypoxia.)
If the procedure must be repeated, let the patient rest for four to six breaths.
When collection is completed, discontinue the suction.
Gently remove the catheter.
Administer oxygen.
Detach the catheter from the in-line trap and gather it in your dominant
hand.
Pull the glove cuff inside-out and down around the used catheter to enclose
it for disposal. Remove and discard the other glove, your mask, and
goggles.
Detach the trap from the tubing connected to the suction machine.
24
Another random document with
no related content on Scribd:
body; a projection from the thoracic side-pieces, forming a long
pouch, into which a fold on the inner side of the elytra fits, the two
being subsequently locked by the action of some special projections.
This arrangement is similar to that which exists in the anomalous
family of water-beetles Pelobiidae. In order to make this mechanism
more perfect the side-pieces in Belostoma form free processes.
Martin has informed us that the young have the metasternal
episternum prolonged to form a lamella that he thinks may be for
respiratory purposes.[499] About twelve genera and upwards of fifty
species of Belostomidae are known. None exist in our isles, but
several species extend their range to Southern Europe. In the waters
of the warm regions of the continents of both the Old and New
Worlds they are common Insects, but as yet they have not been
found in Australia.
Song.—Cicadas are the most noisy of the Insect world; the shrilling
of grasshoppers and even of crickets being insignificant in
comparison with the voice of Cicada. Darwin heard them in South
America when the Beagle was anchored a quarter of a mile from the
shore; and Tympanoterpes gigas, from the same region, is said to
make a noise equal to the whistle of a locomotive.[503] A curious
difference of opinion prevails as to whether their song is agreeable
or not; in some countries they are kept in cages, while in others they
are considered a nuisance. The Greeks are said to have decided in
favour of their performances, the Latins against them. Only the
males sing, the females being completely dumb; this has given rise
to a saying by a Greek poet (so often repeated that it bids fair to
become immortal) "Happy the Cicadas' lives, for they all have
voiceless wives."[504] The writer considers the songs of the
European species he has heard far from unpleasant, but he is an
entomologist, and therefore favourably prepossessed; and he admits
that Riley's description of the performances of the seventeen-year
Cicada is far from a satisfactory testimonial to the good taste of that
Insect; Riley says, "The general noise, on approaching the infested
woods, is a combination of that of a distant threshing-machine and a
distant frog-pond. That which they make when disturbed, mimics a
nest of young snakes or young birds under similar circumstances—a
sort of scream. They can also produce a chirp somewhat like that of
a cricket and a very loud, shrill screech prolonged for fifteen or
twenty seconds, and gradually increasing in force and then
decreasing." The object, or use of the noise is very doubtful; it is said
that it attracts the females to the males. "De gustibus non est
disputandum!" perhaps, however, there may be some tender notes
that we fail to perceive; and it may be that the absence of any
definite organs of hearing reduces the result of a steam-engine
whistle to the equivalent of an agreeable whisper. No special
auditory organs have been detected[505] as we have already
intimated; and certain naturalists, amongst whom we may mention
Giard, think that the Insects do not hear in our sense of the word, but
feel rhythmical vibrations; it is also recorded that though very shy the
Insects may be induced to approach any one who will stand still and
clap his hands—in good measure—within the range of their
sensibilities. There is a good deal of support to the idea that the
males sing in rivalry.