Reduction of Risk Potential – 1

Reduction of risk potential in nursing refers to the set of nursing actions and responsibilities aimed at minimizing or preventing harm, complications, and adverse events in patients receiving healthcare services. This includes activities such as monitoring vital signs, conducting diagnostic tests, obtaining specimens, safely managing medical devices (e.g., catheters, IV lines), recognizing changes in patient condition, and providing education to patients. Nurses play a critical role in identifying and mitigating risks associated with medical procedures, treatments, and interventions, ultimately ensuring the safety and well-being of patients.

Reduction of Risk Potential

Assess and Respond to Changes and Trends in Client Vital Signs: 

Procedure Steps: 

  • Gather necessary equipment, including a blood pressure cuff, stethoscope, thermometer, and pulse oximeter. 
  • Explain the procedure to the patient and ensure their comfort and cooperation. 
  • Measure and document the following vital signs: 
  • Record trends in intervals specified by physician orders such as 1,2, or 4 hours to monitor for changes that can indicate a change in health status.   
  • Blood Pressure: The normal range is typically 90/60 mm Hg to 120/80 mm Hg for adults. 
  • Heart Rate (Pulse): Normal resting heart rate is 60-100 beats. per minute (bpm) for adults. 
  • Respiratory Rate: The normal range is 12-20 breaths per minute for adults. 
  • Temperature: Normal oral temperature range is 97.8°F to 99.1°F (36.5°C to 37.3°C). 
  • Oxygen Saturation (SpO2): Normal range is 95% to 100%. 

GUIDELINES: MEASURING VITAL SIGNS:

  • Purpose: The process of measuring vital signs, including temperature, pulse, respiration, blood pressure, and oxygen saturation, is essential for assessing a client’s health status. It provides baseline data and helps identify changes in their condition.
  • Responsibility: While assistive personnel may be involved in vital sign measurement, the nurse is ultimately responsible for interpreting the findings. The nurse collaborates with the primary healthcare provider to determine the frequency of vital sign assessments but can also make independent decisions based on the client’s status.
  • Documentation: Accurate documentation of vital sign measurements is crucial. Any abnormal findings should be reported promptly to the primary healthcare provider.

WHEN VITAL SIGNS ARE MEASURED: Vital signs should be measured in various clinical situations, including:

  • Initial Contact: When a client is admitted to a healthcare facility.
  • Physical Assessment: As part of a comprehensive physical assessment.
  • Before and After Invasive Procedures: Both before and after invasive diagnostic procedures or surgical procedures.
  • Medication Administration: Particularly before, during, and after the administration of medications that affect cardiac, respiratory, or temperature-controlling functions.
  • Blood Transfusion: Before, during, and after a blood transfusion.
  • Condition Changes: Whenever a client’s condition changes, indicating a need for assessment.
  • Interventions: Whenever an intervention (e.g., ambulation) may affect a client’s condition.
  • Fever or Infection: In cases of fever or known infection, vital signs may need to be measured every 2 to 4 hours.

TEMPERATURE:

  • Normal Range: Normal body temperature ranges from 97.5°F to 99.5°F (36.4°C to 37.5°C), with an average of 98.6°F (37.0°C) in healthy young adults.
  • Measurement Sites: Temperature can be measured at various sites, including the mouth, rectum, axilla, ear, and temporal artery, using electronic measuring devices.
  • Conversion: A simple formula can be used to convert temperatures between Fahrenheit and Celsius: °C = (F-32)×5/9 and °F = (9/5×°C)+32.

TEMPERATURE Nursing Considerations:

  • Time of Day: Temperature can vary throughout the day, being lower in the morning and higher in the afternoon.
  • Environmental Temperature: Body temperature can be affected by external temperature conditions.
  • Age: Infants may have fluctuating temperatures during their first year due to an immature heat-regulating system.
  • Physical Exercise: Exercise generates heat and can increase body temperature.
  • Menstrual Cycle: Temperature may decrease before ovulation and increase during ovulation in menstruating individuals.
  • Pregnancy: Metabolic rate changes in pregnancy can result in consistently elevated temperatures.
  • Stress: Emotional stress can stimulate hormonal release and raise body temperature.
  • Illness: Infections and inflammatory responses often cause fever and increased body temperature.

TEMPERATURE Nursing Considerations for Different Measurement Sites:

  • Oral: Ensure the client hasn’t consumed hot or cold substances, smoked, or chewed gum within the last 15 to 30 minutes. Place the thermometer under the tongue, instructing the client to keep the mouth closed without biting down.
  • Rectal: Provide privacy and position the client in the modified left lateral recumbent position. Avoid rectal measurements in certain conditions, such as cardiac clients, recent rectal surgery, diarrhea, fecal impaction, rectal bleeding, or risk of bleeding.
  • Axillary: Used when oral or rectal measurements are contraindicated. Place the thermometer in the dry axilla and ensure the client holds the arm tightly against the chest.
  • Tympanic/Temporal Artery: Assess the auditory canal for any inflammation or discharge before using the tympanic thermometer. For temporal artery measurements, ensure the client’s forehead is dry, and slide the probe across the forehead or behind the earlobe if diaphoretic.

PULSE:

  • Normal Range: The average adult pulse rate falls between 60 and 100 beats per minute.
  • Evaluation: Pulse rate changes are valuable in assessing a client’s response to interventions such as ambulation, bathing, dressing changes, or exercise.

Assessing Pulse Qualities: When measuring the pulse, assess the rate, rhythm, and strength (force or amplitude) of the pulse. Use a grading scale for pulses to classify their qualities:

  • 4+ = strong and bounding.
  • 3+ = full pulse, increased.
  • 2+ = normal, easily palpable.
  • 1+ = weak, barely palpable.
  • 0 = absent, not palpable.

Pulse Points and Locations: Pulse points are found at various locations on the body, including:

  • Temporal artery
  • Carotid artery
  • Apical pulse
  • Brachial pulse
  • Femoral pulse
  • Popliteal pulse
  • Posterior tibial pulse
  • Dorsalis pedis pulse

Pulse Deficit: Pulse deficit occurs when the peripheral pulse rate (e.g., radial pulse) is less than the ventricular contraction rate (apical pulse). This indicates a lack of peripheral perfusion and may result from ineffective cardiac contractions or dysrhythmias. Two techniques, one-examiner and two-examiner, can be used to identify pulse deficit. Notifying the primary healthcare provider is essential in such cases.

RESPIRATIONS:

  • Normal Range: The normal adult respiratory rate is 12 to 20 breaths per minute.
  • Factors Affecting Respiratory Rate: Many factors that affect the pulse rate, such as changes in carbon dioxide or oxygen levels in the blood, head injuries, increased intracranial pressure, and certain medications (e.g., opioid analgesics), can also affect the respiratory rate.
  • Assessing Respiratory Rate: Count the client’s respirations after measuring the radial pulse. Each respiratory cycle includes one inhalation and one exhalation. In most cases, you can count respirations for 30 seconds and then multiply by 2, except in clients who are very ill or exhibit irregular respirations, where a full 1-minute count is necessary. When assessing respirations, note the rate, depth, pattern, and any abnormal sounds.

OXYGEN SATURATION:

  • Measurement Method: Oxygen saturation is indirectly measured using a pulse oximeter. The device calculates the percentage of hemoglobin bound to oxygen in the blood.
  • Normal Range: The normal oxygen saturation reading is 95% to 100%.
  • Factors Affecting Measurement: Several factors can affect oxygen saturation measurements, including outside light sources, client movement, jaundice, carbon monoxide poisoning, peripheral vascular disease, medications with vasoconstrictive properties, hypotension, hypothermia at the assessment site, dark nail polish or acrylic nails (with some oximeters), low hemoglobin levels (anemia), and living in elevated locations (e.g., high-altitude areas).

Measuring Oxygen Saturation:

  1. Select the most appropriate site for sensor probe placement, ensuring it’s free of edema or compromised skin integrity.
  2. Avoid using hypothermic fingers.
  3. Use the earlobe, bridge of the nose (for adults), or palm or sole (for infants) if peripheral vascular disease is a concern.
  4. Be cautious about latex allergies if using disposable adhesive probes.
  5. In some cases, remove fingernail polish according to agency procedures.
  6. Do not place the sensor on the same extremity as an electronic blood pressure cuff, as it can temporarily interrupt blood flow.
  7. Attach the sensor probe to the monitoring site and power on the oximeter.
  8. Wait for the oximeter readout to stabilize (usually 10 to 30 seconds).
  9. If continuous monitoring is planned, set alarm limits (typically 85% to 100%), assess skin integrity under the sensor probe, and relocate the probe every 4 hours.
  10. While the normal oxygen saturation range is 95% to 100%, acceptable levels can range from 90% to 100%, with levels of 85% to 89% being acceptable in certain chronic disease conditions. Oxygen saturation below 85% is considered abnormal and should be reported.

BLOOD PRESSURE:

  • Definition: Blood pressure (BP) is the force exerted by the blood on the walls of arteries, measured in millimeters of mercury (mm Hg).
  • Components: BP consists of two measurements: systolic pressure (the maximum pressure during heart contraction) and diastolic pressure (the pressure when the heart is at rest between beats).
  • Normal Range: For adults (age 18 and older), normal BP is defined as a systolic pressure below 120 mm Hg and a diastolic pressure below 80 mm Hg.
  • Hypertension Classifications: Hypertension is classified as prehypertension (systolic BP 120-139 mm Hg or diastolic BP 80-89 mm Hg), stage 1 hypertension (systolic BP 140-159 mm Hg or diastolic BP 90-99 mm Hg), and stage 2 hypertension (systolic BP 160 mm Hg or higher or diastolic BP 100 mm Hg or higher).
  • Postural (Orthostatic) Hypotension: This occurs when a normotensive client experiences low blood pressure and accompanying signs and symptoms upon transitioning from a lying to a sitting or standing position. Orthostatic vital sign measurements involve checking blood pressure and pulse while the client is supine, sitting, and standing.

Factors Affecting Blood Pressure:

  • Blood pressure tends to increase with age.
  • Stress can stimulate the sympathetic nervous system, leading to increased blood pressure.
  • Some populations, such as African-Americans, have a higher incidence of high blood pressure.
  • Medications like antihypertensives and opioid analgesics can affect blood pressure.
  • Blood pressure follows a diurnal pattern, typically being lowest in the early morning and highest in the late afternoon and evening.
  • Gender differences in blood pressure may exist, with males generally having higher blood pressure post-puberty and females having higher blood pressure post-menopause.

Guidelines for Measuring Blood Pressure:

  1. Choose an appropriate assessment site, avoiding areas with intravenous infusions, arteriovenous shunts, recent breast or axillary surgery, trauma, or disease. The leg can be used if the brachial artery is inaccessible.
  2. Select the right cuff size to ensure accurate readings.
  3. Clients should avoid smoking or exercising within 30 minutes before measurement.
  4. Clients should rest for at least 5 minutes in a sitting or lying position before measurement, refraining from speaking.
  5. Ensure that the cuff is fully deflated, wrap it snugly around the extremity, and use an appropriately sized stethoscope.
  6. Document the systolic and diastolic pressures based on Korotkoff phases, with phase 1 representing systolic pressure and phase 5 indicating diastolic pressure.

It is important to also understand what is “normal” for each individual patient and watch for trends outside of their normal range. For instance, an athlete who runs marathons may have a resting heart rate in the 40s and this will be normal for him and not a cause for alarm. However, a patient who has a resting heart rate in the 80s suddenly drops to a rate in the 40s would be abnormal.

Also– always LOOK AT THE PATIENT when assessing vital signs, accompanying symptoms such as changing skin color or diaphoresis, appearing short of breath, or changes in mentation in addition to changes in vital signs are cause for concern and should be quickly investigated and brought to the attention of the rest of the health care team!

Guidelines for Diagnostic Tests, Treatments, and Procedures:

  • Explain the Procedure: Before any medical test or procedure, healthcare professionals should provide a thorough explanation to the patient. This helps the patient understand what to expect and alleviates anxiety.
  • Obtain Informed Consent: For invasive procedures, obtaining informed consent is crucial. It ensures that the patient understands the procedure’s risks, benefits, and alternatives, and voluntarily agrees to proceed.
  • Maintain Precautions: Healthcare providers should adhere to standard precautions, which include measures like hand hygiene, wearing personal protective equipment, and proper disposal of medical waste. Additional precautions may be necessary depending on the specific procedure, such as radiography precautions when using radiation.
  • Aseptic Technique: In invasive procedures, maintaining an aseptic (sterile) technique is essential to prevent infections. This involves using sterile equipment and ensuring that the procedure area remains free from contaminants.
  • Pregnancy Consideration: It’s important to determine whether a diagnostic test or procedure is safe for a pregnant patient. Some tests, especially those involving radiation or contrast dyes, may pose risks to the developing fetus.
  • Pre-Procedure Vital Signs: Assessing vital signs (temperature, pulse, respiration, blood pressure) before a procedure establishes baseline data. This baseline helps healthcare providers identify any changes or complications that may arise during or after the procedure.
  • Fasting and Medication: Depending on the procedure, patients may need to fast (refrain from eating and drinking) before midnight on the night before the test. Medications may also need to be temporarily withheld, especially if they could interfere with test results.
  • Post-Biopsy Care: After a biopsy, it’s crucial to apply light pressure to the biopsy site to prevent bleeding and monitor the site for signs of infection. Proper post-procedure care is vital for patient recovery.
  • Culture and Sensitivity Testing: When collecting specimens for culture and sensitivity testing, strict asepsis must be maintained to prevent contamination. It’s important to send the specimen to the laboratory promptly for accurate results.
  • Patient Education: Patients should be educated about post-procedure care and any necessary lifestyle adjustments. Clear instructions can help patients recover more effectively.
  • Monitoring and Documentation: Continuous monitoring of patients during and after procedures is essential to ensure their well-being and detect any complications. Detailed documentation of the procedure and the patient’s response is vital for medical records.

Vital Signs:

  • Interpreting Results: Healthcare providers are responsible for interpreting vital sign measurements. Comparing the findings to the patient’s baseline readings helps identify abnormalities and guide further assessment or treatment.
  • Temperature Considerations: Rectal temperature measurement is avoided in certain situations, such as in patients with cardiac conditions, diarrhea, or rectal surgery, as it may pose risks.
  • Pulse Rate Changes: Changes in pulse rate can indicate a patient’s tolerance to interventions like ambulation, exercise, or medication administration. They can also signal underlying conditions or reactions to medications.
  • Apical Heartbeat: Assessing the apical heartbeat is important in patients with irregular radial pulses, heart conditions, and children under two years of age.
  • Respiration Monitoring: Respiratory rate is counted after measuring the pulse. Monitoring respiration is crucial for evaluating a patient’s respiratory status and response to interventions.
  • Oxygen Saturation: Oxygen saturation readings below 85% are considered abnormal and should be reported. This measurement helps assess the patient’s oxygen levels.
  • Orthostatic Vital Signs: Obtaining orthostatic vital sign measurements involves checking blood pressure and pulse while the patient changes position from supine to sitting and standing. This helps detect conditions like postural hypotension.

Specific Precautions for Radiography:

  • Radiopaque Objects: Radiopaque objects like jewelry should be removed before radiography to prevent interference with imaging.
  • Pregnancy Assessment: For female patients, especially of childbearing age, inquiring about pregnancy status is important. If pregnant, certain radiographic procedures may need to be postponed or modified to minimize fetal exposure to radiation.
  • Radiation Exposure: Patients should be informed that the exposure to radiation during radiography is minimal and generally not harmful. Protective shielding may be used to further minimize exposure.
  • Lead Apron: Healthcare providers may wear lead aprons when staying in the room with the patient during the procedure to protect themselves from radiation.
  • Post-Radiograph Privacy: After the radiograph, patients should be provided with privacy for dressing or assisted with dressing as needed.

Specific Precautions for Contrast Dye Injection:

  • Allergy Assessment: Healthcare providers should determine if the patient has allergies to iodine, seafood, or radiopaque dye before injecting contrast dye.
  • Informing Patients: Patients should be informed about possible side effects of contrast dye injection, which may include throat irritation, flushing of the face, a warm sensation, or a salty taste during the test.
  • Fluid Intake: Encouraging fluid intake after the procedure is usually recommended unless contraindicated. Monitoring urine output can help ensure the dye is efficiently eliminated.
  • Venipuncture Site: The site of venipuncture for contrast dye injection should be assessed for any bleeding or complications.

Obtaining a Blood Specimen:

  1. Explain any necessary preparations for the test to the patient.
  2. Use strict aseptic technique when collecting blood specimens.
  3. Adhere to standard and other precautions as necessary, following agency guidelines when handling hazardous and infectious materials.
  4. Assess the patient’s risks associated with venipuncture, such as low platelet count, anticoagulant use, bleeding disorder, or low white blood cell count that increases the risk of infection.
  5. Check for allergies, including latex allergies, and contraindicated venipuncture sites (e.g., extremities with intravenous infusions, arms with a history of mastectomy, or arms with hemodialysis access devices).
  6. Begin venipuncture with the most distal sites of an extremity first.
  7. Avoid the use of a tourniquet and clenching and unclenching the hand before venous sampling, as they can falsely increase the measured value.
  8. If the patient is receiving an anticoagulant, apply pressure to the venipuncture site for 3 to 5 minutes after withdrawing the needle.
  9. Send specimens for culture to the laboratory immediately.
  10. Follow agency procedures for specific guidelines on specimen collection.
  11. Note deviations from normal ranges and report these results.
  12. Be familiar with the procedure for drawing blood from a central venous access device.

Steps for Drawing Blood from a Central Venous Access Device:

  1. Cleanse the injection cap with an agency-approved solution and allow it to dry.
  2. Stop the IV infusion and flush the catheter port with 5 mL of normal saline.
  3. Attach a 5-mL syringe, aspirate 3 to 5 mL of blood, and discard it.
  4. Attach the appropriate syringe and withdraw the required amount of blood into it.
  5. Flush the catheter with 10 mL of normal saline.
  6. Flush the catheter port with the agency-approved amount and type of heparin solution.
  7. Clamp the lumen, remove the cap, cleanse the catheter port and allow it to dry, attach the new cap, unclamp the lumen, and resume the IV infusion.

Electrolytes:

  • Normal adult ranges:
    • Sodium: 135 to 145 mEq/L (mmol/L)
    • Potassium: 3.5 to 5.1 mEq/L (mmol/L)
    • Chloride: 98 to 107 mEq/L (mmol/L)
    • Bicarbonate (venous): 22 to 29 mEq/L (mmol/L).

Activated Partial Thromboplastin Time (aPTT):

  • Used to monitor heparin therapy and screen for coagulation disorders.
  • Normal range: 20 to 36 seconds.
  • Nursing Considerations:
    • Draw blood samples 1 hour before the next heparin dose.
    • Do not draw samples from the arm with heparin infusion.
    • Transport specimens to the laboratory immediately.
    • Prolonged aPTT (>90 seconds) during heparin therapy requires bleeding precautions.

Prothrombin Time (PT) and International Normalized Ratio (INR):

  • PT measures clot formation time and can be used to monitor warfarin therapy.
  • INR is used to measure the effects of oral anticoagulants.
  • Normal PT range (adult male): 9.6 to 11.8 seconds.
  • Normal PT range (adult female): 9.5 to 11.3 seconds.
  • Normal INR range: 1.00 to 1.30; therapeutic ranges vary.
  • Nursing Considerations:
    • Concurrent warfarin and heparin therapy can affect PT.
    • Diets high in green leafy vegetables can alter PT.
    • Therapeutic PT varies based on the purpose of anticoagulation therapy.

Bleeding Time and Platelet Count:

  • Bleeding time measures vascular and platelet activity during hemostasis.
  • Normal bleeding time range: 1 to 9 minutes.
  • Platelets play a role in hemostasis.
  • Normal platelet count range: 150,000 to 400,000 cells/mm3 (150 to 400 x 109/L).
  • Nursing Considerations:
    • High altitudes, cold weather, and exercise can temporarily increase platelet counts.
    • Low platelet count may necessitate bleeding precautions.

 

Erythrocyte Sedimentation Rate (ESR):

  • ESR measures the rate at which erythrocytes settle out of anticoagulated blood in 1 hour.
  • It is a nonspecific test used to detect various illnesses, including infection, inflammation, neoplasm, tissue necrosis, or infarction.
  • Normal values range from 0 to 30 mm/hr, depending on the client’s age.
  • Fasting is not necessary before an ESR determination, but a fatty meal may cause plasma alterations.

Hemoglobin and Hematocrit:

  • Hemoglobin is the main component of erythrocytes and carries oxygen and carbon dioxide. It is essential in identifying anemia.
  • Normal hemoglobin values:
    • Males: 14 to 16.5 g/dL (140 to 165 mmol/L)
    • Females: 12 to 15 g/dL (120 to 150 mmol/L)
  • Hematocrit represents red blood cell (RBC) mass and helps identify anemia or polycythemia.
  • Normal hematocrit values:
    • Males: 42% to 52%
    • Females: 35% to 47%
  • Fasting is not required before either test.

Troponins:

  • Troponin is a regulatory protein found in striated muscle, and increased troponin levels are indicative of myocardial injury, such as a heart attack (MI).
  • Troponin T concentration: Usually <0.1 ng/dL (<0.1 mcg/L); higher values are consistent with MI.
  • Troponin I value: Usually <0.6 ng/mL (<0.6 mcg/L); readings >1.5 ng/mL (1.5 mcg/L) are consistent with MI.
  • Troponin levels increase as soon as 3 hours after myocardial injury and may remain elevated for 7 to 14 days.
  • Serial measurements are important for comparison with baseline findings.
  • Fasting is not required before this test.

Natriuretic Peptides:

  • Natriuretic peptides, such as B-type natriuretic peptide (BNP), are used to identify congestive heart failure (CHF).
  • BNP, synthesized in cardiac ventricle muscle, is the primary marker for identifying CHF as the cause of dyspnea.
  • BNP level should be <100 pg/mL (<100 ng/L). Higher levels indicate more severe CHF.
  • Fasting is not necessary before the test.

Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST), and Ammonia:

  • ALT is used to identify hepatocellular disease of the liver and monitor its progression.
  • Normal ALT value: 4 to 6 units/L.
  • AST may be used to evaluate hepatocellular disease and coronary artery occlusive disease.
  • Normal AST range: 0 to 35 units/L.
  • Ammonia is metabolized by the liver and excreted by the kidneys; elevated levels may lead to encephalopathy.
  • Normal ammonia values: 10 to 80 mcg/dL.
  • Fasting for 8 to 20 hours (except water) is required before ammonia testing, and smoking should be avoided for 8 to 10 hours before the test.
  • Specimens should be placed in an ice water bath and transported to the laboratory immediately.

Amylase and Lipase:

  • In acute pancreatitis, amylase levels significantly increase. The rise starts 3 to 6 hours after the onset of pain, peaks at approximately 24 hours, and returns to normal 2 to 3 days after the onset of pain.
  • Normal amylase range: 25 to 151 units/L.
  • Increased lipase levels are observed in pancreatic disorders, and this elevation may not occur until 24 to 36 hours after the onset of illness. Lipase levels can remain elevated for up to 14 days.
  • Normal lipase range: 10 to 140 units/L.
  • It’s important to list the medications the client has taken in the 24 hours before an amylase test, as many medications can affect the results. The result may be invalidated if the specimen for amylase was obtained less than 72 hours after cholecystography with radiopaque dyes.
  • Endoscopic retrograde cholangiopancreatography may increase lipase activity.

Bilirubin, Lipids, and Protein:

  • Bilirubin is a byproduct of hemoglobin breakdown and is produced by the liver, spleen, and bone marrow. It can be classified as direct (excreted primarily through the intestinal tract) or indirect (circulating mainly in the bloodstream). Total bilirubin levels increase with any type of jaundice.
  • Normal bilirubin values:
    • Direct: 0 to 0.3 mg/dL (0 to 5.1 mcmol/L)
    • Indirect: 0.1 to 1.0 mg/dL (1.7 to 17 mcmol/L)
    • Total: <1.5 mg/dL (25.7 mcmol/L).
  • Lipid assessment includes total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), and triglycerides.
  • Normal lipid values:
    • Cholesterol: 140 to 199 mg/dL (3.6 to 5.1 mmol/L)
    • LDL: <130 mg/dL (3.4 mmol/L)
    • HDL: 30 to 70 mg/dL (0.8 to 1.8 mmol/L)
    • Triglycerides: <200 mg/dL (2.3 mmol/L).
  • Protein reading reflects the total amount of albumin and globulins in the serum. It can be increased in conditions like Addison disease, autoimmune collagen disorders, chronic infection, and Crohn disease, and decreased in conditions like burns, cirrhosis, edema, and severe hepatic disease.
  • Normal protein values range from 6.0 to 8.0 g/dL (60 to 80 g/L).

Nursing Considerations for Bilirubin, Lipids, and Protein:

  • For bilirubin testing, instruct the client to avoid yellow foods (e.g., carrots, yams, yellow beans, pumpkin) for 3 to 4 days before the blood draw and to fast for 4 hours before the test.
  • Note that bilirubin readings can be affected if the client has ingested alcohol or certain medications before the test.
  • Bilirubin results are invalidated if the client has undergone a radioactive scan in the 24 hours before the test.
  • For lipid testing, instruct the client to fast for 10 to 14 hours (except for water) and to abstain from alcohol for 24 hours before the test. The evening meal before the test should be free of high-cholesterol foods.
  • For protein testing, instruct the client to avoid high-fat foods for 8 hours before the test.

Fasting Blood Glucose:

  • Fasting blood glucose levels are used to diagnose conditions like diabetes mellitus and hypoglycemia.
  • Normal fasting glucose concentration: 70 to 110 mg/dL (3.9 to 6.1 mmol/L).
  • Normal range for glucose monitoring with capillary blood: 60 to 110 mg/dL (3.3 to 6.1 mmol/L).
  • Clients should fast for 8 to 12 hours before the fasting blood glucose test.
  • Clients with diabetes mellitus should withhold the morning insulin dose or oral hypoglycemic medication until after blood has been drawn.

Diabetes Mellitus:

  • Chronic disorder characterized by glucose intolerance and impaired carbohydrate, protein, and lipid metabolism.
  • Results from a deficiency of insulin or resistance to the action of insulin.
  • Deficiency of effective insulin leads to hyperglycemia.

Hypoglycemia:

  • Defined as a blood glucose level lower than 70 mg/dL (3.9 mmol/L).
  • Often caused by too much insulin, inadequate food intake, or excessive physical activity.

Glycosylated Hemoglobin (HbA1c):

  • Reflects how well blood glucose levels have been controlled in the previous 3 months.
  • In diabetic individuals:
    • Good control: HbA1c ≤ 7%
    • Fair control: HbA1c 7% to 8%
    • Poor control: HbA1c ≥ 8%
  • No fasting is required before the test.

Hyperglycemia:

  • Defined as a blood glucose level higher than 250 mg/dL (13.9 mmol/L).

Serum Creatinine and Blood Urea Nitrogen (BUN):

  • Serum creatinine is a specific indicator of renal function. Elevated creatinine levels indicate a slowing of the glomerular filtration rate.
  • Normal creatinine values: 0.6 to 1.3 mg/dL (53 to 115 mcmol/L).
  • Blood urea nitrogen (BUN) is the nitrogen portion of urea, and increased levels indicate a slowing of the glomerular filtration rate.
  • Normal BUN values: 8 to 25 mg/dL (2.9 to 8.9 mmol/L).
  • Both creatinine and BUN should be analyzed when evaluating renal function.
  • Before a creatinine test, clients should avoid excessive exercise for 8 hours and excessive consumption of red meat for 24 hours.

Calcium, Phosphorus (Phosphate), and Magnesium:

  • Calcium: Functions in bone formation, nerve impulse transmission, muscle contraction (including myocardial and skeletal muscles), and blood clotting.
    • Normal calcium values: 8.6 to 10.0 mg/dL (2.15 to 2.5 mmol/L).
  • Phosphorus (Phosphate): Important in bone formation, energy storage and release, urinary acid-base buffering, and carbohydrate metabolism.
    • Normal phosphorus values: 2.7 to 4.5 mg/dL (0.87 to 1.45 mmol/L).
  • Magnesium: Required in the blood-clotting mechanism, regulates neuromuscular activity, acts as a cofactor for many enzymes, and affects calcium metabolism.
    • Normal magnesium values: 1.6 to 2.6 mg/dL (0.66 to 1.07 mmol/L).

Nursing Considerations:

  • For calcium testing, instruct the client to consume a normal calcium diet (800 mg/day) for 3 days before the test.
  • Fasting may be required for 8 hours before a calcium test.
  • Fasting for 8 hours is necessary before a phosphorus test.
  • Prolonged use of magnesium products can increase magnesium levels.
  • Long-term parenteral nutrition therapy or excessive fluid loss may decrease magnesium levels.

White Blood Cell Count (WBC):

  • WBCs are involved in the body’s immune defense system.
  • Normal WBC count: 4500 to 11,000 cells/mm3 (4.5 to 11 x 10^9/L).
  • The WBC count assesses the distribution of leukocytes.

Nursing Considerations:

  • A “shift to the left” indicates an increased number of immature neutrophils in the peripheral blood. It can be seen in conditions like recovery from bone marrow depression or severe infections.
  • A “shift to the right” (less common) is found in liver disease, Down’s syndrome, megaloblastic and pernicious anemia, indicating cells with more nuclear segments.

Normal Adult White Blood Cell Differential Count:

  • Neutrophils: 56% or 1800 to 7800 cells/mm3 (0.18 to 0.78 x 10^9/L).
  • Bands: 3% or 0 to 700 cells/mm3 (0 to 0.07 x 10^9/L).
  • Eosinophils: 2.7% or 0 to 430 cells/mm3 (0 to 0.04 x 10^9/L).
  • Basophils: 0.3% or 0 to 200 cells/mm3 (0 to 0.02 x 10^9/L).
  • Lymphocytes: 34% or 1000 to 4800 cells/mm3 (0.1 to 0.48 x 10^9/L).
  • Monocytes: 4% or 0 to 800 cells/mm3 (0 to 0.08 x 10^9/L).
  • The bone marrow releases more neutrophils into circulation to meet the increased demand during infections.
  • This leads to an elevated white blood cell (WBC) count, particularly in neutrophils.
  • In severe infections, immature neutrophils called “bands” may be released into circulation.
  • An increased number of band neutrophils in the blood is known as a “shift to the left.”
  • A shift to the left is commonly observed in patients with acute bacterial infections.
  • Eosinophils:
    • Account for 0% to 4% of all white blood cells (WBCs).
    • Have reduced phagocytic ability.
    • Primary function includes engulfing antigen-antibody complexes during allergic responses.
    • Elevated eosinophil levels can be seen in neoplastic disorders (e.g., Hodgkin’s lymphoma), skin diseases, connective tissue disorders, and parasitic infections.

    Basophils:

    • Make up less than 2% of all leukocytes.
    • Contain cytoplasmic granules with chemical mediators like heparin and histamine.
    • When stimulated by antigens or tissue injury, they release substances from their granules.
    • This release is part of the response in allergic and inflammatory reactions.

Lymphocytes:

  • Constitute 20% to 40% of white blood cells (WBCs).
  • Central to cellular and humoral immune responses.
  • Two main subtypes: B cells and T cells.
  • T cell precursors originate in the bone marrow, then migrate to the thymus gland for further differentiation.
  • Natural killer (NK) cells are lymphocytes that can kill virus-infected cells, activate T cells, and phagocytes.
  • Lymphocytes circulate in the blood and also reside in lymphoid tissues.

Monocytes:

  • Account for approximately 4% to 8% of total WBCs.
  • Potent phagocytic cells that ingest various materials, including bacteria, dead cells, tissue debris, and old or defective red blood cells (RBCs).
  • Monocytes briefly circulate in the blood before migrating into tissues and becoming macrophages.
  • Tissues also contain resident macrophages (e.g., Kupffer cells in the liver, osteoclasts in bone, alveolar macrophages in the lung).
  • Macrophages protect the body from pathogens at entry points and support immune responses.

Thrombocytes (Platelets):

  • Primary function is to initiate the clotting process by forming an initial platelet plug at sites of injury.
  • Platelets are essential for blood clotting and must be structurally and metabolically sound.
  • Platelet activation occurs at sites of capillary damage.
  • Platelets accumulate to form an initial platelet plug, stabilized with clotting factors.
  • Platelets are also involved in clot shrinkage and retraction.
  • Originate from stem cells in the bone marrow and differentiate from megakaryocytes.
  • About one third of platelets reside in the spleen.
  • Platelet production is regulated by thrombopoietin, a growth factor produced in various organs.
  • Platelets typically have a short lifespan of 8 to 10 days.

Here’s the information about urinalysis and laboratory values summarized in bullet points:

Urinalysis:

  • Color: Pale yellow.
  • Odor: Specific aromatic odor, similar to ammonia.
  • Turbidity: Clear.
  • pH: 4.5 to 7.8.
  • Specific gravity: 1.016 to 1.022.
  • Glucose: Less than 0.5 g/day.
  • Ketones: None.
  • Protein: None.
  • Bilirubin: None.
  • Casts: None to few.
  • Crystals: None.
  • Bacteria: None or fewer than 1000/mL.
  • RBCs: Fewer than 3 cells/HPF.
  • WBCs: 4 cells/HPF or fewer.
  • Chloride: 110 to 250 mEq/24 hr.
  • Magnesium: 7.3 to 12.2 HPF.
  • Potassium: 25 to 125 mEq/24 hr.
  • Sodium: 40 to 220 mEq/24 hr.
  • Uric acid: 250 to 750 mg/24 hr.
  • Urinalysis helps diagnose urological or renal disorders.
  • Best to collect the specimen in the morning during the first or second voiding.

Important to Recall:

  • Maintain strict aseptic technique and use standard precautions when drawing blood.
  • Follow agency guidelines for collecting specimens.
  • Educate the client about the test and its preparation.
  • Be familiar with normal ranges for common laboratory parameters.
  • Normal values may vary based on agency standards.
  • Review and recognize deviations from normal laboratory results.
  • Report test results to the primary healthcare provider.

Integumentary System Procedures:

  • Skin Biopsy: Involves the surgical excision of a small piece of skin tissue for histopathologic examination. Patients are instructed to keep the adhesive bandage on for at least eight hours and to clean and treat the site daily as prescribed.
  • Skin Culture: A noninvasive procedure where a sterile applicator and appropriate culture tubes are used to obtain skin samples. Specimens for viral cultures are placed on ice immediately.
  • Wood’s Light Examination: Skin is viewed under ultraviolet light to identify superficial skin infections. The examination is typically done in a darkened room.
  • Dermatoscopy: This involves examining the skin using a lighted instrument with optical magnification.

Skin Testing to Reveal Allergies (Scratch Test):

  • Preparation: Before this invasive procedure, patients are often advised to discontinue systemic corticosteroids or antihistamine therapy for 48 hours.
  • Safety Measures: Scratch tests can sometimes induce an anaphylactic reaction, so healthcare providers should have resuscitation equipment available.
  • Post-Test Care: Patients are instructed to keep the skin testing patch dry and avoid activities that may induce sweating. The site is carefully inspected for reactions, and patients receive information about antigens to which they react.

ONCOLOGICAL DISORDERS Procedures

  • Used for cancer diagnosis and staging.
  • Tests include Biopsy, Bone marrow examination, Chest radiography, Complete blood count, Computed tomography, Cytologic studies, Serum tumor marker evaluation, Liver function studies, Magnetic resonance imaging, Proctoscopic examination, and Radionuclide imaging.

Staging

  • Method of classifying malignancies based on invasion.

Cancer

  • Neoplastic disorder affecting organs, causing uncontrolled cell growth.

Metastasis

  • Transfer of disease to anatomically distant places.

Biopsy:

an invasive procedure involving the surgical excision of a small piece of tissue for microscopic examination to obtain histologic proof of malignancy.

  • Diagnostic Methods: Two common diagnostic methods for examining the tissue specimen obtained from a biopsy are the frozen section and permanent paraffin section.
  • Frozen Section: This method allows for rapid diagnosis, often within minutes of tissue excision. It is especially valuable in situations where immediate diagnosis is crucial for treatment decisions.
  • Permanent Paraffin Section: In this method, the tissue specimen is embedded in paraffin wax, which provides clearer details during microscopic examination. However, it typically takes about 24 hours to prepare the specimen for analysis.

Types of Biopsies

  • Needle, Incisional, Excisional, Staging.
  • Nursing Considerations:
    • Provide specific preparation for each type.
    • Monitor for complications.

THE ENDOCRINE SYSTEM Procedures

  • Involves scanning and blood laboratory studies.

TESTS OF THE THYROID GLAND

Nursing Considerations for Thyroid Scan:

  • Contrast Agent History: Prior to the thyroid scan, assess whether the client has received any radiographic contrast agents within the past 3 months. This information is crucial, as recent contrast agent administration could potentially invalidate the scan results.
  • NPO Status: Instruct the client to maintain a nothing-by-mouth (NPO) status after midnight on the day of the thyroid scan. This ensures an empty stomach, which can be important for some diagnostic procedures.

Nursing Considerations for Thyroid Needle Aspiration:

    • Client Preparation: Unlike the thyroid scan, no specific client preparation is necessary for thyroid needle aspiration. However, it’s essential to ensure the client’s understanding of the procedure and address any questions or concerns they may have.

THE GASTROINTESTINAL SYSTEM Procedures

  • Includes upper GI tract study, upper GI endoscopy, and virtual colonoscopy.
  • Nursing considerations for Upper Gastrointestinal Tract Study (Barium Swallow): fluoroscopic examination of the upper GI tract is performed after the client has drunk barium sulfate.
    • Preparation: Instruct the client not to eat or drink after midnight on the day of the test to ensure an empty stomach for the procedure.
    • Fluid Intake: After the procedure, advise the client to increase fluid intake. This helps in passing the barium through the GI tract.
    • Stool Monitoring: Monitor the client’s stools for the presence of barium, indicated by chalky whiteness. This is important as barium can potentially cause bowel obstruction.
    • Laxative Use: If necessary, a laxative may be prescribed to assist the client in passing the barium, and the administration should be carried out as ordered.

    Nursing considerations for Upper Gastrointestinal Endoscopy (Esophagogastroduodenoscopy):

    • Pre-Procedure Fasting: Instruct the client not to eat or drink for 6 to 12 hours before the test to ensure an empty stomach for the procedure.
    • Anesthetic and Sedation: Explain to the client that a local anesthetic (spray or gargle) may be administered before the procedure for comfort, and a sedating medication will be given. Ensure the client understands the purpose of these medications.
    • Positioning: Position the client on their left side to facilitate saliva drainage and provide better access for the endoscope insertion.
    • Airway Monitoring: Continuously monitor the client’s airway patency during the test to ensure unobstructed breathing. Use pulse oximetry to monitor oxygen saturation levels. Keep emergency equipment readily available in case of complications.
    • Post-Procedure Care: After the procedure, prevent the client from eating or drinking until the gag reflex has fully returned to avoid the risk of aspiration. Monitor the client for any signs or symptoms of perforation, such as pain, bleeding, unusual difficulty in swallowing, or increased temperature.
    • Bedrest and Recovery: Maintain bedrest for the sedated client until they have regained full alertness. Provide comfort measures such as lozenges, saline gargles, or oral analgesics to relieve any minor sore throat discomfort resulting from the procedure.

Virtual Colonoscopy

  • Combines CT or MRI with virtual reality software.Nursing Considerations for Virtual Colonoscopy:
    • Bowel Preparation: Instruct the client to follow a bowel preparation regimen similar to that of a traditional colonoscopy. This typically involves consuming a clear liquid diet, taking laxatives, and thoroughly emptying the colon before the procedure.
    • Client Education: Explain to the client the details of the virtual colonoscopy procedure, including the use of computed tomography (CT) scanning or magnetic resonance imaging (MRI) combined with virtual reality software to visualize the colon and detect diseases. Emphasize that no sedatives are required, and no traditional scope will be used, which may alleviate anxiety.
    • Air Introduction: Inform the client that during the procedure, air will be introduced into the colon via a tube placed in the rectum. This air insufflation is necessary to expand the colon for better visualization.
    • Comfort and Support: Provide emotional support and reassurance to the client throughout the process, as the procedure can be uncomfortable due to the introduction of air and the need to maintain specific positions.
    • Monitoring: Continuously monitor the client’s vital signs and overall comfort during the procedure, addressing any discomfort or concerns promptly.
    • Post-Procedure Care: After the virtual colonoscopy, monitor the client for any adverse effects, such as abdominal discomfort or bloating, and provide appropriate care and interventions as needed.
    • Follow-Up: Ensure that the client receives any necessary post-procedure instructions, including when they can resume a regular diet and activities.

    Hepatobiliary Procedures

  • Encompasses ERCP and percutaneous transhepatic cholangiography.
  • Nursing Considerations:
    • Pre-Procedure Fasting: Ensure that the client refrains from eating or drinking for several hours before the procedure to minimize the risk of aspiration during sedation.
    • Sedation Administration: Administer sedation as prescribed to keep the client comfortable and relaxed during the procedure.
    • Vital Sign Monitoring: Continuously monitor the client’s vital signs, including heart rate, blood pressure, and oxygen saturation, throughout the ERCP procedure.
    • Gag Reflex Assessment: Monitor for the return of the gag reflex after the procedure, as this is an important indicator of the client’s readiness to resume oral intake safely.
    • Perforation or Peritonitis Monitoring: Closely observe the client for any signs or symptoms of potential complications such as perforation or peritonitis, which may include abdominal pain, distension, fever, or other relevant symptoms.

Paracentesis

  • Transabdominal removal of peritoneal fluid.Nursing considerations for Paracentesis:
      1. Voiding Preparation: Ensure that the client empties their bladder before the procedure to facilitate the paracentesis and avoid interference with the needle insertion.
      2. Baseline Assessments:
        • Measure the client’s abdominal girth, weight, and baseline vital signs before initiating the paracentesis procedure. These measurements serve as essential baseline data.
      3. Proper Positioning:
        • Position the client upright on the edge of the bed with their back well-supported and feet resting on a stool. The semi-Fowler position should be used if the client is bed-confined. This positioning optimizes access and comfort during the procedure.
      4. Fluid Collection:
        • During the procedure, carefully collect the ascitic fluid and accurately measure the amount obtained. Additionally, describe the characteristics of the fluid, such as color and clarity, and record these findings.
      5. Fluid Sample Handling:
        • Label the collected fluid samples accurately to ensure proper identification and analysis. These samples may be sent to the laboratory for further examination.
      6. Site Care:
        • After completing the paracentesis, apply a dry sterile dressing to the insertion site to reduce the risk of infection and provide wound protection.
      7. Monitoring for Bleeding:
        • Continuously monitor the insertion site for any signs of bleeding, hematoma formation, or other complications. Timely detection and intervention are critical.
      8. Post-Procedure Assessments:
        • Measure the client’s abdominal girth and weight again after the procedure to assess the immediate impact of fluid removal.
      9. Hematuria Monitoring:
        • Be vigilant for any signs of hematuria, which could result from bladder trauma during the procedure. Monitor the client’s urine output and characteristics closely.

      Semi-Fowler Position

  • Supine with a 30-degree elevated head.

Liver Biopsy

  • Involves needle insertion into the liver.
  • Nursing Considerations:
      • Assess coagulation tests (i.e., prothrombin time, partial thromboplastin time, platelet count) to determine bleeding risk.
      • Administer a sedative as prescribed to ensure the client’s comfort during the procedure.
      • Position the client in the supine or left lateral position to expose the right side of the upper abdomen for the biopsy.
      • Continuously assess the biopsy site for any signs of bleeding or hematoma formation.
      • Monitor the client closely for signs and symptoms of peritonitis, such as abdominal pain, tenderness, or guarding.
      • Following the procedure, restrict the client to bed rest for the specified duration as prescribed by the healthcare provider.
      • Ensure that the client is placed on the right side with a pillow under the costal margin to provide support and splint the puncture site.
      • Educate the client on the importance of avoiding coughing or straining after the procedure to minimize the risk of bleeding.
      • Advise the client to refrain from heavy lifting and strenuous exercise for a period of one week to promote proper healing and prevent complications.

Stool Specimens

  • Inspected for various components.
  • Nursing Considerations:
    • Keep quantitative 24- to 72-hour collections refrigerated until taken to the laboratory.
    • Check agency guidelines for specific procedures regarding diet and medication.

Perform Testing Within Scope of Practice (e.g., Electrocardiogram, Glucose Monitoring): 

  Procedure Steps: 

  • Verify the healthcare provider’s orders for the specific diagnostic test. 
  • Verify the patient identification with at least 2 identifiers (not room number) as per JAHCO standards.
  • Prepare the equipment and ensure it is in proper working condition. 
  • Explain the procedure to the patient, addressing any questions or concerns. 
  • Perform the test according to established protocols. 
  • Include any cultural preferences when it comes to privacy–sometimes it may be important to have a specific gender perform the test or be present due to respecting these cultural concerns.

Interpret the test results—Nurses can explain the results and educate the patient as to how they may pertain to their health status, however, “Direct interpretation and DIAGNOSIS” are only for physicians to do and discuss with the patient–as nurses we have to be extremely careful that we do not “interpret results” beyond our scope of practice or diagnose health conditions….we make nursing diagnoses based on medical status and patient observations and document them accurately. 

Compare the results to reference ranges provided by the laboratory or healthcare facility. 

EKG RhythmInterpretationTreatment
Normal Sinus Rhythm (NSR)Regular rhythm with a rate of 60-100 bpm. P-wave before each QRS complex.No specific treatment required.
Sinus BradycardiaRegular rhythm with a rate less than 60 bpm.Treat underlying
causes, consider.
atropine if
symptomatic.
Sinus TachycardiaRegular rhythm with a rate greater than 100 bpm.Treat underlying
causes, manage.
symptoms if
necessary.
Atrial Fibrillation (AFib)Irregular rhythm with no discernible P
waves. Rapid, chaotic atrial activity.
Rate control (e.g.,
beta-blockers, calcium channel blockers) and anticoagulation to
prevent stroke.
Atrial FlutterRegular or irregular rhythm with
"sawtooth" P-wave pattern.
Rate control,
anticoagulation, and possible cardioversion.
Ventricular
Tachycardia (VTach)
Regular rhythm with a rate greater than 100 bpm originating in the ventricles.Immediate
cardioversion (if
pulseless) or
antiarrhythmics (e.g., amiodarone) and
oxygen.
Ventricular Fibrillation (VFib)Chaotic, irregular
rhythm with no
identifiable waves.
Immediate
defibrillation, CPR, and advanced life support.
First-Degree AV BlockPR interval prolonged (>0.20 seconds).Usually no treatment required; monitor for progression.
Second-Degree AV Block, Type I
(Wenckebach)
PR interval
progressively
lengthens until a QRS complex is dropped.
Often no treatment required; monitor for progression.
Second-Degree AV Block, Type IIConsistent PR interval with intermittent
dropped QRS
complexes.
May require a
pacemaker if
symptomatic.
Third-Degree AV Block (Complete Heart
Block)
Atria and ventricles beat independently, resulting in no
correlation between P waves and QRS
complexes.
Urgent placement of a pacemaker.
Third-Degree AV Block (Complete Heart
Block)
Atria and ventricles beat independently, resulting in no
correlation between P waves and QRS
complexes.
Urgent placement of a pacemaker.

The above EKG interpretations are good for educational purposes and can help as the nurse is trying to understand the health condition of the patient HOWEVER it is HIGHLY recommended that nurses who are wanting to know more about emergent treatment of cardiac conditions take ACLS (Advance Cardiac Life Support) and continue to make the distinction of making NURSING diagnosis versus MEDICAL diagnosis.

 

All medication administration and other actions listed should be directly overseen and ordered by a physician.

Monitor the Results of Diagnostic Testing and Intervene as Needed: 

  Procedure Steps: 

  • Routinely check for the availability of diagnostic test results. 
  • Collaborate with the laboratory or diagnostic imaging department to expedite critical results Report critical results within the timeframe specified by facility protocols. 
  • Analyze test results in the context of the patient’s clinical status and history. 
  • Communicate findings promptly to the healthcare provider. 
  • Implement interventions as directed by the provider, such as administering medications or preparing for additional procedures.
Diagnostic TestIndicationsInterpretationNursing
Considerations
Blood Pressure (BP)Hypertension, Hypotension,
Monitoring
Normal: Systolic < 120 mm Hg, Diastolic < 80 mm Hg- Use the
appropriate cuff size.
Hypertension: Systolic ≥ 130 mm Hg,
Diastolic ≥ 80 mm Hg
- Ensure patient is relaxed and seated.
Hypotension:
Systolic < 90
mm Hg
- Assess for
orthostatic
changes if
necessary.
Blood Glucose (BG)Diabetes
management, Hypoglycemia, Hyperglycemia
Normal: 70-99 mg/dL (fasting), 70-140 mg/dL (postprandial)- Educate on
fasting
requirements if needed.
Hypoglycemia: < 70 mg/dL- Properly label and handle samples.
Hyperglycemia: > 140 mg/dL
(postprandial)
- Monitor for
symptoms
during testing.
Hypoglycemia: < 70 mg/dL- Properly label and handle
samples.
Hyperglycemia: > 140 mg/dL
(postprandial)
- Monitor for
symptoms
during testing.
Complete Blood CountAnemia,
Infection, Blood disorders
Hemoglobin
(Hb): Normal
varies by age.
and gender
- Confirm
patient identity.
(CBC)White Blood Cell Count (WBC): Normal varies by age- Assess for risk of bleeding or infection.
Platelet Count: Normal range typically
150,000-450,00 0/µL
- Explain
potential side effects (e.g.,
bruising).
UrinalysisKidney function, Urinary tract
infection (UTI)
pH: Normal
range 4.5-8.0
- Ensure sterile collection
technique.
Protein:
Negative (trace amounts may be normal)
- Provide
instructions for clean catch or catheter
sample.
Leukocytes:
Negative
(Presence
suggests UTI)
- Document
color, clarity,
and odor of
urine.
Electrocardiogram mCardiac
assessment,
Arrhythmias,
Chest pain
Sinus Rhythm: Normal PQRST pattern- Prepare the
patient for the procedure.
(ECG/EKG)Atrial
Fibrillation:
Irregular rhythm, absent P-waves
- Ensure proper lead placement.
Ventricular
Tachycardia:
Wide QRS
complexes,
rapid rate
- Monitor for
signs of
discomfort
during the test.
Ventricular
Tachycardia:
Wide QRS
complexes,
rapid rate
- Monitor for
signs of
discomfort
during the test.
Chest X-rayPulmonary
conditions,
Cardiac
assessment
Normal: Clear lung fields,
cardiac
silhouette within normal limits
- Explain the
procedure and its purpose.
Abnormal
findings depend on the specific condition being assessed
- Use radiation protection for patient and
staff.
- Assess for
allergies to
contrast dye if used.
Pulmonary
Function Tests
Respiratory
conditions, Lung function
assessment
Spirometry:
Measures lung volumes and
airflow
- Explain the
procedure and its purpose to the patient.
(PFTs)Normal values vary by age,
height, and
gender
- Ensure proper technique for
maximal effort during the test.
Abnormal
results may
indicate lung.
disease
- Assess for
allergies to
bronchodilators if used.
ElectroencephalogramSeizure
disorders, Brain injury
assessment
Normal EEG:
Shows specific wave patterns
- Educate the patient on the need for a
sleep-deprived EEG if required.
(EEG)Abnormal EEG: Irregular or
epileptiform
activity
- Ensure the
patient is.
relaxed and
comfortable.
- Remove any hair products or accessories.
Magnetic
Resonance Imaging (MRI)
Neurological
conditions, Soft tissue imaging
Normal MRI:
Clear and
detailed images
- Assess for
contraindication s (e.g., metal
implants).
Imaging (MRI)Abnormal
findings depend on the specific condition being assessed
- Inform the
patient of the
need to lie still during the
procedure.
Computed
Tomography (CT)
Various medical conditions,
Detailed
imaging
Normal CT:
Clear and
detailed images
- Explain the
procedure and potential use of contrast dye.
(CT Scan)Abnormal
findings depend on the specific condition being assessed
- Ensure the
patient's safety during the scan (e.g., radiation protection).
Bone
Densitometry
Osteoporosis
assessment,
Bone density
measurement
T-Score:
Compares bone density to a
young adult
reference
- Educate on
preparation
(e.g., avoid
calcium
supplements).
(DEXA Scan)Normal: T-score within normal range- Assess for
contraindication s (e.g.,
pregnancy).
Abnormal T
score may
indicate
osteoporosis
- Ensure proper positioning and comfort during the scan.
Arterial Blood Gas (ABG)Respiratory and metabolic
disorders,
Oxygen status
Normal ABG
values vary by age and clinical context
- Ensure the
patient is.
relaxed and
breathing
normally.
Abnormal values indicate acid.
base imbalance
- Explain the
potential risks and benefits of the test.
Holter MonitorCardiac
arrhythmias,
Long-term EKG monitoring
Records
continuous EKG over 24-48
hours
- Teach the
patient to keep a symptom diary during
monitoring.
Identifies
abnormal heart rhythms
- Instruct the
patient to avoid water and
magnets.
Glucose
Tolerance Test (GTT)
Diabetes
diagnosis and monitoring,
Gestational
diabetes
Normal: Blood glucose levels return to
baseline after 2 hours
- Explain the
fasting
requirement to the patient.
Abnormal:
Elevated blood glucose levels post-glucose
load
- Monitor the
patient for
symptoms of
hypoglycemia.
Urine Culture
and Sensitivity
Suspected
urinary tract
infection (UTI), Monitoring UTI treatment
Normal: No
significant
bacterial growth in urine culture
- Properly
collect a clean catch urine.
sample.
Abnormal:
Presence of
significant
bacterial growth
- Ensure
accurate
labeling of the specimen.
Thyroid
Function Tests
Thyroid
disorders (e.g., hypothyroidism, hyperthyroidism)
TSH, T3, and T4 levels within
reference
ranges
- Educate the patient on
fasting
requirements (if needed).
Abnormal levels indicate thyroid dysfunction- Assess for
potential
contraindication s to iodine
based contrast agents.
Liver Function Tests (LFTs)Assess liver.
health and
function
Normal LFTs:
AST, ALT, ALP, bilirubin,
albumin within reference
ranges
- Inform the
patient of the
need to fast.
before the test.
Abnormal LFTs may indicate.
liver disease or dysfunction
- Ensure proper labeling and
handling of
specimens.
Coagulation
Profile
Monitoring
anticoagulant therapy,
Bleeding
disorders
PT (Prothrombin Time) and INR within
therapeutic
range
- Verify patient’s recent
medication and treatment
history.
Abnormal PT
and INR may
indicate
increased
bleeding risk
- Educate on
potential risks and benefits of anticoagulation therapy.
C-Reactive
Protein (CRP)
Inflammatory
conditions,
Infection
Normal CRP
levels: Low or undetectable
- Explain the
procedure and purpose to the patient.
Elevated CRP
levels may
indicate
inflammation or infection
- Ensure
accurate
specimen
collection and handling.
Creatinine
Clearance
Renal function assessment,
Kidney disease
Normal
clearance rate varies by age.
and gender
- Educate the patient to
collect a timed urine sample.
Reduced
clearance may indicate.
impaired kidney function
- Monitor fluid intake and
output during the test.
Erythrocyte
Sedimentation Rate (ESR)
Inflammatory
conditions,
Infection
Normal ESR:
Low
sedimentation rate
- Explain the
procedure and potential for
needle stick.
Elevated ESR
may indicate.
inflammation or infection
- Educate on the need for fasting before the test.
Serum
Electrolytes
Electrolyte
imbalances,
Fluid balance
assessment
Normal ranges vary by specific electrolyte- Educate the patient on
fasting
requirements if necessary.
Abnormal levels indicate.
electrolyte
imbalance
- Ensure proper specimen
labeling and
handling.
Renal PanelKidney function assessment,
Electrolyte
balance
Normal BUN
(Blood Urea
Nitrogen) and Creatinine levels
- Assess for
allergies to
iodine-based
contrast agents (if used).
Elevated BUN and Creatinine may indicate.
impaired kidney function
- Monitor the
patient for signs of contrast
induced
nephropathy (if applicable).
TroponinCardiac injury assessment,
Myocardial
infarction (MI)
Normal troponin levels: Low or undetectable- Explain the
purpose of the test and
potential cardiac symptoms.
Elevated
troponin levels may indicate.
cardiac injury or MI
- Assess for
factors that may interfere with
test accuracy.
D-DimerSuspected
blood clot or
thrombosis
Normal D-Dimer levels: Low or undetectable- Educate the patient on
fasting
requirements if needed.
Elevated D
Dimer levels
may indicate.
clot formation
- Monitor for
potential
contraindication s (e.g., recent surgery).
Prostate
Specific Antigen (PSA)
Prostate cancer screening,
Prostate health
Normal PSA
levels vary by age and clinical context
- Discuss
potential
benefits and
limitations of
the PSA tests.
with the patient.
Elevated PSA
levels may
indicate
prostate
abnormalities
- Ensure proper patient
positioning
during the blood draw.
Sputum Culture and SensitivityRespiratory
infections,
Pneumonia
Normal result: No significant bacterial growth- Educate the patient on
proper sputum collection
techniques.
Abnormal result: Presence of
specific
bacterial
pathogens
- Ensure
accurate
labeling and
handling of
specimens.
Erythropoietin (EPO)Anemia, Kidney diseaseNormal EPO
levels: Within
reference
ranges
- Explain the
purpose of the test to the
patient.
Elevated EPO
levels may
indicate anemia or kidney.
dysfunction
- Monitor for
signs of
bleeding or
hematoma at
the injection
site.
Serum Lipid
Profile
Cardiovascular risk assessment, Cholesterol
levels
Normal lipid
levels: Varies by specific lipid.
component
- Educate the patient on
fasting
requirements
prior to the test.
Elevated LDL
cholesterol may indicate.
increased
cardiovascular risk
- Inform the
patient about
dietary and
lifestyle
modifications.
Diagnostic TestIndicationsInterpretationNursing
Considerations
Arterial Blood Gas (ABG)Respiratory and metabolic
disorders,
Oxygen status
Normal ABG
values vary by age and clinical context
- Ensure the
patient is.
relaxed and
breathing
normally.
Abnormal values indicate acid.
base imbalance
- Explain the
potential risks and benefits of the test.
Carotid
Ultrasound
Evaluation of
carotid artery disease, Stroke risk
Normal: No
significant
narrowing or
plaque in carotid arteries
- Instruct the
patient to avoid neck jewelry.
and tight
collars.
Abnormal
findings may
indicate carotid artery stenosis
- Assess for
potential
contraindication s (e.g., recent neck surgery).
HbA1cDiabetes
management, Long-term
glucose control
Normal HbA1c: < 5.7% (non
diabetic)
- Educate the patient on
fasting
requirements (if applicable).
Elevated HbA1c indicates poor long-term.
glucose control
- Ensure
accurate
specimen
labeling and
handling.
Synovial Fluid AnalysisJoint pain,
Arthritis,
Infection
Normal synovial fluid: Clear and viscous- Explain the
purpose of the test and
potential
discomfort.
Abnormal fluid may show signs of inflammation, infection, or
crystal deposits
- Educate the patient about
proper joint
aspiration
technique.
Transcranial
Doppler (TCD)
Brain blood flow assessment,
Stroke risk
Normal TCD:
Consistent
blood flow
patterns
- Inform the
patient about
the procedure and its non
invasive nature.
Abnormal TCD may indicate.
changes in
cerebral blood flow
- Ensure proper probe
placement and positioning.
Midstream Urine CultureSuspected
urinary tract
infection (UTI)
Normal: No
significant
bacterial growth in urine culture
- Teach the
patient proper midstream urine collection
technique.
and SensitivityAbnormal:
Presence of
specific
bacterial
pathogens
- Ensure
accurate
labeling and
timely delivery of the
specimen.
Troponin I (cTnI)Cardiac injury assessment,
Myocardial
infarction (MI)
Normal cTnI
levels: Low or undetectable
- Explain the
purpose of the test and
potential cardiac symptoms.
Elevated cTnI
levels may
indicate cardiac injury or MI
- Assess for
factors that may interfere with
test accuracy.
Genetic TestingHereditary
diseases,
Genetic risk
assessment
Normal result: Absence of
specific genetic mutations
- Discuss the
implications of the genetic test with the patient.
Abnormal result: Presence of
specific genetic mutations
- Provide
genetic
counseling and emotional
support as
needed.

Obtain Blood Specimens: 

   Procedure Steps: 

  • Gather equipment, including a tourniquet, sterile needle, collection tubes, and alcohol swabs. 
  • Confirm patient identity (Using two identifiers as per JAHCO standards and room number is not an identifier) and obtain informed consent. 
  • Explain the procedure to the patient, and allow for any culturally necessary provisions.
  • Choose an appropriate venipuncture site (e.g., antecubital vein) and apply a tourniquet. 
  • Cleanse the site with an alcohol swab and allow it to dry.
  • Perform venipuncture using proper technique, collecting the required amount of blood in the appropriate tubes. Remove the tourniquet, withdraw the needle, and apply pressure and a bandage to the puncture site. 
  • Label specimens accurately with patient identification and other required information. 
  • Transport specimens promptly to the laboratory for analysis. 

Obtain Specimens Other Than Blood for Diagnostic Testing: 

 Procedure Steps:

  • Educate the patient on the collection process for the specific specimen (e.g., urine, sputum, wound swabs) and provide clear instructions.
  • Use appropriate collection containers and techniques to maintain specimen integrity. 
  • Label specimens accurately and securely to prevent sample mix-up. –Label specimens at the bedside while still in the presence of the patient –ALWAYS try to keep this practice to avoid mislabeling specimens. — Use at least 2 patient identifiers when labeling specimens
  • Ensure prompt transport of specimens to the laboratory for analysis. 
  • Monitor the patient for any discomfort or complications associated with specimen collection.
  • Apply pressure to the venipuncture site for at least 30 seconds. For patients who are on anticoagulant therapy a full one to two minutes may be required to stop bleeding or prevent a bruise.
  • If a wrap-around style dressing (Co-ban, Co-flex) is put around the venipuncture site BE SURE to remind the patient to REMOVE it after a couple hours to avoid it becoming a potential ligature.

Insert, Maintain, or Remove a Nasal/Oral Gastrointestinal Tube: 

 Procedure Steps: 

  • Assess the patient’s PHYSICIAN ORDER need for the tube and provide education and support. 
  • Insert the tube using the appropriate method (e.g., nasogastric or orogastric) and confirm correct placement via imaging or pH testing. 
  • Refer to the facility or State-approved procedure guide before performing any procedures such as this in that facility. Also, keep patient safety, individuality, and cultural awareness in mind when performing any nursing procedure.
  • It is VITALLY important to have a method of Pulse Oximetry available when performing NG or OG tube insertion as the tube may end up in the lungs—most often if this happens, the patient will immediately be in distress and short of breath or be unable to talk. However, a continuous good pulse oximetry reading in addition to pH can assure you that the NG/OG tube is NOT in the lungs.
  • Secure the tube in place to prevent accidental removal or displacement. Many places now have a specific securement device that goes on the nose for securing this tube. If the patient is conscious and able to move around, it may be very difficult for them to tolerate the tube. Take extra time and care as those particular patients may need extra support and should also be elevated in acuity on their unit if possible.
  • DO NOT ATTEMPT TO INSERT these tubes for anyone that has any type of facial injury or possible fractures within the skull. Take extra caution with trauma patients as the fractures may not be easily apparent at first presentation.
  • Monitor and document tube function, including intake and output and assess for complications like aspiration or tube dislodgement. 
  • The Administrator prescribed medications or nutrition through the tube as ordered. 
  • When removing the tube, ensure patient comfort and follow aseptic technique to minimize the risk of infection. 

Orogastric Tube (OG Tube) Insertion: 

  • The steps for OG tube insertion are similar to NG tube insertion, but the tube is inserted through the mouth instead of the nose. 
  • Prepare Equipment: Same as for NG tube insertion

Explain the Procedure: Same as for NG tube insertion. 

Position the Patient: Same as for NG tube insertion

Measure and Mark: Same as for NG tube insertion. 

Prepare the Tube: Same as for NG tube insertion. 

Insert the Tube: Gently insert the lubricated OG tube through the patient’s mouth toward the back of the throat, following the same principles of slow and steady advancement. Confirm Placement: Same as for NG tube insertion.

Secure the Tube: Same as for NG tube insertion. 

Check Residual Volume (if applicable): Same as for NG tube insertion. 

Residual Volume Assessment

Before each enteral feeding or medication administration, aspirate any gastric contents from the NG or OG tube using a syringe. Measure the volume of aspirated gastric contents. 

Interpretation of Residual Volume: 

A residual volume of less than 100 mL is generally considered acceptable in most cases. If the residual volume exceeds 100 mL or the facility’s specified threshold, it may indicate delayed gastric emptying, a potential risk for aspiration, or other gastrointestinal issues. 

Always follow institutional policies and healthcare provider orders regarding the acceptable range for residual volumes. 

Actions for Elevated Residual Volume: 

If the residual volume is elevated beyond the acceptable range, notify the healthcare provider for further assessment and guidance. The healthcare provider may adjust feeding rates, change the enteral formula, or prescribe medications to facilitate gastric emptying. Continue to monitor the patient for signs of gastric distress, abdominal pain, nausea, or vomiting, and report any changes promptly. 

Other notes about NG/OG tubes—the same lidocaine jelly that is commonly used for catheter insertion can be very helpful for comfort, also lidocaine spray may be available in some places. Try to make the procedure as comfortable as possible if the patient is conscious.

ALL tube feedings need orders, should have specific pumps, etc. and nurses who use these should be trained in how to use them– if a patient has NG/OG and is receiving nutrition they need to keep the head of the bed elevated at all times to avoid aspiration.

If they are using the NG/OG for suction –due to intestinal blockage, etc., be sure that there is INTERMITTENT suction available, a constant suction is OK for the initial drainage of a blockage, however it should then be changed to intermittent to avoid damaging the wall of the stomach.

Otito-Umoren